Late spring and early summer mark Step 2 season for many medical students. While Step 1 of the United States Medical Licensing Examination (USMLE), largely covers clinical knowledge, basic science knowledge and how the body works and why conditions develop, USMLE Step 2 is a clinical knowledge exam of test-takers’ knowledge base of diagnosis and management. Most students take the test at the conclusion of their clinical rotations, so that information is fresh.
Medical education experts shared their insights about how to prepare and how residency programs may view Step 2 scores differently in the era after the USMLE Step 1 exam moved to pass-fail scoring.
How much should you study?
The answer to this question is going to be highly individualized. Historically, students have studied less for Step 2 than Step 1.
As associate assistant director of counseling and education services at the at the University of Kansas Medical Center (KUMC), Jen Dolson, MEd, has helped medical students prepare for the Step exams for more than a decade. In post-exam surveys KUMC of medical students who took Step 2—after Step 1 moved to pass fail—the average dedicated study window they took to prep was about three to four weeks. During that time, the average amount of time those students spent studying was about eight hours a day.
“When comparing it to Step 1, Step 2 is a different beast,” said Dolson. “The questions are much more about actually working with patients, not as much about the basic science behind it, which is the focus of Step 1. Our students take Step 2 at the end of their third year. At that point, students have been preparing to practice medicine all day long, every day, through of… their clinical rotations.”
The University of Kansas School of Medicine is a subscriber to the AMA UME Curricular Enrichment Program, which offers institutions a series of engaging, high-quality and interactive modules developed to easily fill emerging curricular gaps and support tracking of medical student progress.
Who should help you assess your weaknesses?
Since Step 2 is largely rooted in your knowledge of clinical medicine, your performance on National Board of Medical Examiners Subject Exams, commonly referred to as shelf exams, is probably a good place to start when it comes to knowing your deficiencies.
Beyond that, seek guidance from your medical school’s office of academic support.
“They should talk to the people who understand learning approaches, testing approaches, cognitive skills development,” said Joanna C. Arnold, PhD, director of the office of student learning and educational resources at the University of California, Davis, School of Medicine (UC Davis). “It's well-documented that peers—who are probably the people that they often talk to—while very well-intentioned, typically relay their own experience rather than the evidence and data about learning.
What do changes to Step 1 mean for Step 2?
One idea behind moving Step 1 to pass-fail is to lower the emphasis on high-stakes exams in the residency-selection process. Still, there are many concerns that for medical students who don’t have a numerical Step 1 score—those who took the exam after January 2022—that a numerical score on Step 2 may simply replace Step 1 as a sorting metric for interview slots, and, ultimately, residency positions.
According to a 2022 survey of residency program directors—prior to the switch in Step 1 scoring affected residency applicants—32% of programs required medical student to surpass a threshold Step 2 score on in order for applicants from U.S. allopathic medical schools to secure a residency interview position.
In his role as vice chair for education in internal medicine at UC Davis, Mark C. Henderson, MD, is heavily involved in the residency-selection process. His program has moved away from using Step 1 or Step 2 as a key metric in sorting for interviews or residency positions. Other than an applicant’s having passed, Davis doesn’t have a cutoff score, unlike other schools.
Instead, Dr. Henderson and his colleagues are trying to gauge other attributes, such as “resilience, work ethic or dedication, and capacity for improvement, things that make them good physicians, at least for internal medicine,” he said.
What common mistakes should you avoid?
Formerly the chief medical officer at Kaplan Medical, Christopher Cimino, MD, has extensive experience working with medical students on Step exam preparation. He advised test-takers not to overthink it when it comes to Step 2 exam day.
“The USMLE does not write trick questions,” he said. “There's a lot of feeling among students that if you didn't get that question right, it was because it was a trick question. That happens sometimes with practice questions just because faculty are prone to writing trick questions, but the USMLE throws those out and tries to avoid them. So, if something feels like a trick question, it may be because you're overthinking it, and it may be the question is simpler than you thought.”
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How does Step 2 prep differ from Step 1?
During Step 1 preparation, students tend to review content before turning their focus to practice questions and practice tests. For Step 2, with most students coming off their clinical rotations, they tend to need less time building their knowledge base.
“It's pretty common for a medical student to go straight to practice questions and then they let those questions determine their weaknesses. At that point, a student is likely to consult content resources to gain that knowledge,” Dolson said. “Whereas with Step 1, the content review portion where you’re building your knowledge base is a major part of the process.”
Which topics are high-yield?
When formulating a study plan, the first question many students want to know is: What’s on the test? While it’s going to vary with each unique version of the Step 2 exam, the areas that offer the most return on investment—often referred to as high-yield topics—tend to be fairly consistent.
For Step 2, "the dominant area is going to be internal medicine. Even for things like the surgery questions, a fair number of them have internal medicine principles,” Dr. Cimino said.
“For example, things like nutrition are in the surgical domain. They are surgical principles, but because they don’t involve cutting students tend to think of them as internal medicine. So the internal medicine aspects of all the disciplines are probably a good place to focus.”
What happens if you fail?
The Step 2 pass rate has been well over 90% for test-takers from MD and DO schools in recent years, according to the USMLE. But if you fail, USMLE policy allows up to four total attempts to pass any of the Step exams.
As far as the impact of that failure on your residency prospects, a Step 2 fail is not a deal-breaker. But it’s likely going to require some explanation from an applicant during the selection process.
