In the fall of 2018, Pauline Huynh, MD, was a third-year medical student at the Johns Hopkins School of Medicine. At that time, like thousands of medical students before her, she was facing down a notable milestone: Step 1 of the United States Medical Licensing Examination (USMLE).
Since she took the exam and moved on to residency, a few things have changed. A global pandemic upended years of USMLE testing cycles and a significant switch to a pass-fail scoring format—a change to make the exam less burdensome for medical students—has taken hold. What hasn’t changed is the exam’s difficulty and that it can be a source of consternation for medical students.
Still, the importance of passing the exam, a requisite for medical licensure, remains. Dr. Huynh reflected on the time she spent studying for the exam, the toll it can take on medical student well-being, and the significance of exam performance in the residency-selection process.
As a new cohort of medical students approach dedicated study time, Dr. Huynh offers up her insight on what she wishes she knew in medical school about USMLE Step 1 prep. She also acknowledged the experience of her colleagues who had taken or are also studying to take the Comprehensive Osteopathic Medical Licensing Examination of the United States (COMLEX-USA) series, often in tandem with the USMLE exams.
Prioritize your well-being
“I took Step 1 back when it was scored, so take everything I say with that context, but even now that it is pass-fail, the study period is still … intense,” Dr. Huynh said. “You will have moments where you feel a lot of panic, anxiety imposter syndrome—when you will spend a stupid amount of time fixating or ruminating on a factoid you didn’t remember or feel as though you are ‘falling behind.’ Looking back, that was so much unnecessary stress and pressure that I didn’t need to put on myself, and something I should have been more thoughtful about addressing.
“This will be a long and intense period of your life—whether it be two, four, or six weeks—however long your institution allots. It's important to recognize that, and during that period, you need to take a breather. Do so—and then just dive back in when you’re ready. Your health and well-being–including your mental well-being—should come first.”
Ask for help
“If you know how you can be supported during that study period, feel free to let folks know,” said Dr. Huynh, an AMA member who is now a third-year otolaryngology resident at Kaiser Permanente Northern California. “It’s OK to ask or be specific. This goes beyond group study sessions.
“I know folks who chose to fly or drive home to their families during their study period so that they don’t have to worry about cooking or doing laundry while studying for 10 to 14 hours a day. Not everyone is that fortunate, but you can probably come up with one or two things that would give you immense relief to know that it’s taken care of. It’s okay to let your loved ones know how they can support you, because chances are they want to but aren’t sure how.”
It’s doesn’t determine your future
“Your residency application is you—as a person—and that’s so much more than one or two exams,” Dr. Huynh said. “It's what you've been involved with. It's your interests, it's your hobbies, it's how you plan on making an impact for your patients, for your families, for your society. And that’s going to be more the case now that it’s pass-fail.”
She hopes that the transition from scores to pass-fail in Step 1 is helping to alleviate some of this stress, as a topic of discussion in residency or even the application cycle. “I can't imagine that I got into residency based off of my Step 1 or Step 2 scores,” she noted.
”Even as a resident now, no one has spoken to me about my Step 3 score. To my knowledge, that has not been used at all in the evaluation of how I am performing clinically as a resident. When I work with students on subinternships or away rotations, it’s not a thing I ask or think about.”
Step 1 prep is ultimately personal
“It is easy to get drawn into the hubbub that swirls about from people who have completed it and are offering 1,000 strategies,” she said. “You need to find something that works for you—and you've done it before, when you studied for the MCAT [Medical College Admission Test], when you studied for the SAT or ACT.
“So you know that there is something, intrinsically, that works for you. Be confident in it,” said Dr. Huynh, chair of the AMA Resident and Fellow Section’s Governing Council. “For example, I learned early on that I study better in a coffee shop … away from my bed.”
Take it on your timetable
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“One of my lowest moments was about a week before the exam,” Dr. Huynh said. “I didn’t get the practice score I wanted—that I thought I needed—and it caused a moment of panic. I was torn between whether or not to proceed with the test date I had signed up for or push it back.
“I remember being, like, super nervous about it. My parents knew my test date. I would have to tell them that I wanted to push it back.”
Dr. Huynh ultimately decided to postpone by a week or two.
“And I 100% stand by that decision,” she said.
“Again, this was in the context of scored exams—and I made a decision based on a hypothetical ‘predicted’ result. My hope is that in today’s context, with the exam now being pass-fail, these moments are no longer as common. In the even that you do not feel ready to take an exam, work with your administrators and mentors to find a schedule that works best for you.”
Be ready for the Step 1 hangover
“I was warned about—but wasn't fully prepared for—how much you feel like absolute garbage when the exam is done,” Dr. Huynh said. “It's like a whirlwind of eight hours, and you feel like you failed. Everyone tells you that this will be the case, but it's another thing to actually go through it.
“Plan something for when you're done. For me, that was going to a nice dinner afterward. You might feel exhausted but celebrate the fact that you're done. Go back and resume the activities that you've loved and enjoyed and had to put off for however many weeks.”
Trust the process
“Even with this exam now being pass-fail, I’m not going to lie—it’s still a huge amount of material to cover, and this will be one of the most stressful periods of your career,” she said. “However, trust the process and understand that the pass rate is still extremely high.
“You spent one, two or even three years in medical school before taking the exam. Instructors taught you well. You’ve taken so many standardized tests to get to this point. This is just one more on the long list of exams you’ve taken, and you will take more in the future.”
