An Overview of the USMLE Step 1 Examination for Foreign Medical Graduates


As a foreign medical graduate, your application process for a U.S. medical residency differs slightly from that of a student who completed their education in the United States. Most importantly, before you can apply for a residency, you must get certification from the Educational Commission for Foreign Medical Graduates (ECFMG). In another blog post, we covered the basic requirements for ECFMG certification, but today, we are going to focus on one of the most important aspects of the process — passing the USMLE Step 1. After you submit your initial application for ECFMG certification, passing the USMLE Step 1 becomes the next task on your list of things to do. Read on to learn more about what you can expect from this essential examination.

About the USMLE Step 1

The United States Medical Licensing Examination (USMLE) consists of three steps. The first test is the USMLE Step 1. You might also hear it simply referred to as “Step 1.” The USMLE Step 1 is a joint program of the Federation of State Medical Boards of the United States, Inc and the National Board of Medical Examiners. Although you do not need to pass the USMLE Step 1 before taking the USMLE Step 2, you must achieve a passing score on both exams before you become eligible to take the USMLE Step 3. Also, you must pass USMLE Step 1 Step 2, AND Step 3 before your ECFMG certification becomes official.

The Format of the USMLE Step 1

The USMLE Step 1 is a one-day examination, lasting a total of eight hours. It is divided into seven blocks, each of which is 60 minutes long, and there are short breaks between each one of the blocks. There is no set number of questions on each block of the test — instead, the USMLE guarantees that there will be no more than 40 questions per block and no more than 280 questions on the exam as a whole.

All of the questions on the USMLE Step 1 are single-item multiple choice questions. That means that each question consists of a short vignette followed by four or more lettered response options (labeled A, B, C, D, E, etc). From these options, you must choose the best answer. Only one answer is correct.

The Content of the USMLE Step 1

The USMLE covers the basics of medical science. In general, you will be tested on the information that you would learn in the first two years of medical school in the United States. During these years, the training for U.S. medical students consists primarily of didactic coursework and laboratory exercises (as opposed to clinical training). However, you should be aware that in some countries, the medical training does not align with that of the United States — in terms of timing and/or content — so you need to tailor your study efforts specifically for the USMLE, not necessarily reviewing everything you learned in medical school.

That’s because the questions on the USMLE are created by examination committees made up of medical experts from institutions in only two countries: the United States and Canada. These experts — including medical school faculty members, teachers, research investigators, and clinicians — come together to decide what it is important for future U.S. medical residents to know about basic medical science.

In general, the USMLE Step 1 covers the broad principles of basic science and the functioning of human organs and organ systems. More specifically, it includes questions within 8 traditionally defined disciplines and 5 interdisciplinary areas.

The traditionally defined disciplines are:

  • Anatomy
  • Behavioral Sciences
  • Biochemistry
  • Biostatistics and Epidemiology
  • Microbiology
  • Pathology
  • Pharmacology
  • Physiology

The interdisciplinary areas are:

  • Aging
  • Genetics
  • Immunology
  • Molecular and Cellular biology
  • Nutritional sciences

Not only do you need to be able to recall information on these subjects but you also need to be able to read and interpret relevant graphs and tables, identify pathologic and normal specimens (including both microscopic and pathologic specimens), apply your knowledge to specific clinical problem-solving questions.

You should also be aware that there is a heavy emphasis on how these topics apply to organ systems — these types of questions typically make up between 60 and 70 percent of the total content of the test. The following organ systems are covered on the USMLE Step 1:

  • Blood and Lymphoreticular System
  • Behavioral Health
  • Cardiovascular System
  • Endocrine System
  • Gastrointestinal System
  • Nervous System and Special Senses
  • Renal and Urinary System
  • Reproductive System (Male and Female)
  • Respiratory System
  • Skin and Subcutaneous Tissue
  • Musculoskeletal System

Clearly, the USMLE Step 1 covers a lot of academic territory, so if you are hoping to get matched to a U.S. medical residency program in the future, be sure to study! While in medical school, you might also want to consider broadening your knowledge on particular topic areas of interest by completing a student elective program in the United States. A student elective can help you decide what specialty area you want to pursue in your residency, and it can also connect you with physicians in the United States who may be able to provide letters of reference for your future residency application.

FMG Portal offers lots of resources for foreign medical students and graduates who are interested in U.S. medical residency programs. Contact us today for more information!