About the USMLE® Step 1 Exam New

Discover key details about the USMLE® Step 1 exam, including content, exam format, and test-day procedures.
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The United States Medical Licensing Examination (USMLE) Step 1 is a critical milestone in your medical education, designed to assess your ability to apply basic science concepts to medical practice. It is part of the 3-exam USMLE series, which is required for medical licensure in the United States.1

USMLE Step 1 Exam Overview

Step 1 plays a crucial role in verifying your readiness for clinical training and ensuring you have the foundational knowledge needed to begin rotations and practice medicine under supervision. As a nationally standardized exam, it provides a consistent measure of students' medical knowledge across different schools and educational programs.2

For most students, Step 1 is taken after the preclinical years, typically at the end of the second year of medical school, once core foundational coursework is complete. However, since Step 1 transitioned to pass/fail in January 2022, some students now opt to take it earlier in their second year, depending on their school’s curriculum and personal readiness. Your testing timeline is up to you and your individual needs.

Exam Content: Topics Tested on Step 1

The Step 1 exam content is developed by the National Board of Medical Examiners (NBME) and is regularly reviewed to ensure it reflects current medical knowledge and best practices. 

The USMLE Step 1 covers the foundational medical sciences essential for clinical practice. According to the December 2024 review by the USMLE Management Committee, no major changes were made to the exam content itself, meaning the core topics remain consistent. The exam continues to assess your ability to integrate basic science concepts and apply them to clinical scenarios.1

Rather than testing subjects in isolation, Step 1 presents case-based questions requiring you to draw from multiple disciplines simultaneously. Mastering these topics will help you pass Step 1 and strengthen your critical thinking ability in clinical settings.3

Here’s a breakdown of the key subjects covered on Step 1:

Foundational Sciences:

  • Anatomy: Gross anatomy, histology, and neuroanatomy
  • Physiology: Organ systems, homeostasis, and regulatory mechanisms
  • Biochemistry: Metabolism, molecular biology, and genetics

Pathophysiology & Disease Mechanisms:

  • Pathology: Disease processes, inflammation, and neoplasia
  • Microbiology: Bacteria, viruses, fungi, and parasites
  • Immunology: Immune responses, hypersensitivity, and autoimmunity
  • Pharmacology: Drug mechanisms, side effects, and interactions

Interdisciplinary Concepts:

  • Behavioral Sciences: Patient communication, ethics, and psychology
  • Public Health Sciences: Epidemiology, biostatistics, and preventive medicine
  • Genetics, Aging, and Nutrition: Key concepts in disease prevention and management

Rather than simply memorizing facts, you’ll need to understand how these subjects relate to clinical decision-making. The best way to prepare is to practice case-based questions with a QBank that mirrors the complexity of the exam.

Exam Structure: Step 1 Exam Format*

Step 1 follows a structured format to test your ability to apply foundational medical knowledge under timed conditions. Understanding the exam’s layout will help you develop an effective pacing strategy and avoid surprises on test day. The table below outlines the key components of the exam, including its duration, question format, and break allowances.

Total Duration: 8 hours
Number of Blocks: 14 blocks
Questions per Block: Up to 20 questions
Total Questions: No more than 280
Break Time: 45 minutes (can be extended to 60 minutes by skipping the tutorial)
Question Format: Single best answer (some may include images, histology slides, or audio clips)
Test Interface: Digital
*Beginning May 14, 2026, the USMLE Step 1 exam will follow this updated testing format. 

Source4

USMLE Step 1 Eligibility

To take Step 1, you must fall into 1 of the 3 following categories when you apply and on your exam date:

  1. U.S. and Canadian Students: You must be officially enrolled in, or a graduate of, a U.S. or Canadian medical school program that leads to an MD degree and is accredited by the Liaison Committee on Medical Education (LCME®).
  2. DO Students: You must be officially enrolled in, or a graduate of, a U.S. medical school that leads to a DO degree and is accredited by the Commission on Osteopathic College Accreditation (COCA®).
  3. International Students: You must be officially enrolled in, or a graduate of, a medical school outside the U.S. and Canada that is listed in the World Directory of Medical Schools as meeting the Educational Commission for Foreign Medical Graduates (ECFMG®) eligibility requirements and meets other ECFMG eligibility criteria.

What if My Eligibility Status Changes?

If your eligibility to take Step 1 changes after you submit your application and before your test date, notify the organization that registered your exam as soon as possible. Failure to meet eligibility requirements may result in your score being canceled — determined at the discretion of the USMLE program. For example, if you are dismissed or withdraw from medical school, you are not eligible to take the USMLE, even if your status is being contested.

Effective July 1, 2025, students who graduate from Canadian medical schools will be considered international medical graduates (IMGs) when applying to U.S. graduate programs. To enroll in a residency program accredited by the Accreditation Council for Graduate Medical Education (ACGME®), you will need to obtain ECFMG certification or hold a full and unrestricted license to practice medicine in the program’s licensing jurisdiction. Check the USMLE website for updates.

How to Register for USMLE Step 1

On March 10, 2025, the USMLE program launched the MyUSMLESM Portal to handle Step 1 registration for students and graduates of LCME- or COCA-accredited medical programs.

  1. Create a MyUSMLE account using your legal name, medical school, and other personal details. You will be emailed your USMLE ID and a temporary password.
  2. Start an exam application in the portal using your new login. Follow the instructions and enter your personal information as it appears on your government-issued ID. Select a 3-month eligibility period.
  3. Pay your registration fee to conclude the online portion of your application.
  4. Submit your Certification of Identification and Authorization Form to your school based on its requirements.
  5. Wait for the NBME to review your application. You will usually receive your scheduling permit within 2 to 4 weeks after submitting your certification form to your school.
  6. Book your exam through the Prometric website up to 6 months in advance using your scheduling permit. It must fall within your 3-month eligibility period, excluding major holidays.

Selecting Your Step 1 Test Date

The Step 1 exam is available to take throughout the year. The only requirement is that it falls within your 3-month eligibility period. You can schedule through the Prometric website up to 6 months in advance. Their ProScheduler tool will help you locate a testing center near you that has available time slots in your selected date range. Appointments tend to fill up quickly, so schedule at your preferred location as soon as you receive your scheduling permit. Remember, Step 1 is not offered on major local holidays.

Step 1 Registration for International Students

Students and graduates of medical programs that are not LCME- or COCA-accredited need to register for Step 1 through the ECFMG’s IWA portal.

  1. Obtain a USMLE/ECFMG Identification Number, complete the application for ECFMG Certification, and read the ECFMG Information Booklet and USMLE Bulletin of Information (see eligibility section above).
  2. Start an exam application in the IWA portal using your USMLE/ECFMG Identification Number. Follow the instructions and enter your personal information as it appears on your government-issued ID. Select a 3-month eligibility period and enter other requested information. Pay your registration fee to conclude the online portion of your application.
  3. Submit requested documentation to be used in eligibility verification. The ECFMG will confirm with your medical school if you are a currently enrolled student or graduate. All credentials and documentation must be received by the ECFMG within 4 weeks of the date you submit the online portion of your application.
  4. Book your exam through Prometric once you have received your scheduling permit. Processing typically takes up to 3 weeks once the ECFMG has received all of your materials.

Step 1 Cost & Fees

If you are a student or graduate of an LCME- or COCA-accredited medical program in the U.S. or Canada, you will apply for Step 1 through the NBME. Other students and graduates must apply through the ECFMG.

Organization Exam/Service Cost (USD)
NBME Step 1 Registration $680
Eligibility Extension $70
ECFMG ECFMG Certification $160
Step 1 Registration $1,020*
Eligibility Extension $100
Test Region Change $90

*If you select a testing region outside the U.S. and Canada, you will be subject to an additional $205 international test delivery surcharge.

Rescheduling Fee

If you need to reschedule your exam date or change your test center location within your 3-month eligibility period, you are subject to Prometric’s rescheduling fee chart:

Change Date Testing Region Cost (USD)
46+ days before (but not including) the first test day All None
31-45 days before (but not including) the first test day All $35
6-30 days before (but not including) the first test day All $100
≤5 days before (but not including) the first test day U.S. and Canada $140
≤5 days before (but not including) the first test day Outside the U.S. and Canada $358

USMLE Step 1 Testing Policies

Understanding the USMLE Step 1 testing policies is helpful for a smoother exam experience. From eligibility requirements to test-day procedures and retake policies, knowing what to expect can help you avoid delays and feel more prepared on exam day. By familiarizing yourself with these policies in advance, you can be ready to perform your best on exam day.

Eligibility Requirements

To take the USMLE Step 1, you must meet certain eligibility requirements based on your medical school enrollment and accreditation status. The specific requirements vary for U.S. medical students and international medical graduates (IMGs).

If you are a U.S. medical student, you must be officially enrolled in or have graduated from a medical school accredited by the Liaison Committee on Medical Education (LCME) or the Commission on Osteopathic College Accreditation (COCA).5

If you are an international medical graduate (IMG), your medical school must be listed in the World Directory of Medical Schools (WDOMS) and meet Educational Commission for Foreign Medical Graduates (ECFMG) certification requirements. Since eligibility policies may change, always check the official USMLE website for the latest updates before registering.6

Exam Day Preparation

Being fully prepared for the USMLE Step 1 test day means understanding what to bring, what to expect, and how to manage your time. Since the exam is administered at Prometric testing centers under strict security protocols, it's essential to be familiar with the process to ensure a smooth experience. With the right materials and a solid game plan, you can stay focused and at ease, knowing you're set up for success.

Step 1 Test Day Essentials:

  • Government-issued photo ID (that matches the name you registered with)
  • Snacks and water (must be kept in provided lockers)
  • Comfortable clothing (layering recommended for warmth)
  • Approved medical items (must be pre-approved by the facility)

Arriving prepared ensures you can focus without distractions. Plan to arrive at least 30 minutes early for check-in, and dress in layers for comfort. Use breaks wisely — hydrate, eat a snack, and reset your focus. With the right preparation, you’ll walk in ready to pass.7

Retake Policy

If you do not pass Step 1, you may retake the exam; however, limits apply to both the number of attempts and testing frequency. You may take Step 1 up to 4 times total and are limited to no more than 3 attempts within a 12-month period. If you require a fourth (final) attempt, you must wait at least 12 months from your first attempt and 6 months from your most recent attempt before retesting. 

Failing Step 1 can feel discouraging, but it does not mean the end of your medical career by any means. Many students successfully pass on a second or third attempt by adjusting their study strategies and focusing on their weak areas.

The key to passing on your next attempt is identifying where you struggled the first time and refining your approach. Open your QBank and use the performance-tracking tools to pinpoint the topics that challenged you. Even if your subscription has ended, your progress is saved — so when you renew, your metrics will be there. Use those insights, along with what you learned from your first Step 1 attempt, to let the algorithm create a personalized study plan that guides you toward a passing score.

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Frequently Asked Questions (FAQs)

Step 1 can be taken 3 times within a 12-month period. The fourth attempt must be taken at least 12 months after your first attempt and at least 6 months after your most recent attempt. This includes incomplete attempts. If you’ve made 4 attempts and have not passed, you are ineligible to apply for any Step in the USMLE sequence.
Yes, the USMLE offers reasonable accommodations for examinees with disabilities as defined by the Americans with Disabilities Act (ADA). Learn more on their test accommodations page. You can also request additional break time for medical conditions, such as diabetes or lactation, with appropriate documentation.
Yes, you can reschedule your exam or change your test center location within your 3-month eligibility period. Doing so 46 or more days before (but not including) the first test day is free. Change requests made closer to the exam date are subject to Prometric’s rescheduling fee chart.

Contact the organization that registered your Step 1 exam to ask about a 1-time, contiguous eligibility period extension. You will be charged a fee for this service. If you do not take the exam in either period, you must reapply with a new application and fees.

When preparing for the USMLE Step 1 exam, many students have common concerns about exam policies, scoring, eligibility, and logistics. Below, we’ve answered some of the most frequently asked questions to help you stay informed.8

Yes, the USMLE Step 1 exam transitioned to a pass/fail scoring system for all administrations on or after January 26, 2022. To pass, you must achieve a score of 196 or higher.
With the transition to pass/fail, Step 1 no longer directly impacts residency applications. However, passing is still essential, and programs now focus more on Step 2 CK scores, clinical evaluations, research experience, and personal statements.

IMGs can take Step 1 if they attended a medical school listed in the World Directory of Medical Schools and meet ECFMG certification requirements. Since Step 1 is now pass/fail, IMGs must strengthen other aspects of their application to remain competitive.

Yes, you can reschedule your exam, but fees and policies vary. It’s best to check with the USMLE program or Prometric testing center for the latest rescheduling procedures.
If you miss your Step 1 exam, you will need to reapply and pay the required fees to reschedule. A new application cannot be processed until at least 4 weeks after the end of your missed eligibility period.
While most students take Step 1 during medical school (typically at the end of their second year), it is possible to take it after graduation. However, taking it during medical school is recommended to align with your curriculum and preparation.

References

  1. United States Medical Licensing Examination. (n.d.). Step 1. USMLE.https://www.usmle.org/step-exams/step-1
  2. National Board of Medical Examiners. (n.d.). Comprehensive Basic Science Self-Assessment (CBSSA). NBME.https://www.nbme.org/examinees/nbme-self-assessments/comprehensive-basic-science-self-assessment
  3. American Medical Association. (n.d.). What is the USMLE? AMA.https://www.ama-assn.org/medical-students/usmle-step-1-2/what-usmle
  4. United States Medical Licensing Examination. (n.d.). Step 1 exam content. https://www.usmle.org/step-exams/step-1/step-1-exam-content
  5. Harvard Medical School. (n.d.). Licensure & USMLE: United States Medical Licensing Examination. Harvard Medical Student Handbook.https://medstudenthandbook.hms.harvard.edu/206-licensure-usmle-united-states-medical-licensing-examination
  6. United States Medical Licensing Examination. (n.d.). Eligibility. USMLE.https://www.usmle.org/bulletin-information/eligibility
  7. United States Medical Licensing Examination. (n.d.). Exam day information: Personal belongings. USMLE.https://www.usmle.org/what-to-know/exam-day-information/personal-belongings
  8. United States Medical Licensing Examination. (n.d.). Common questions. USMLE.https://www.usmle.org/common-questions
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