USMLE Step 1 is the first of three exams required for medical licensure in the United States. Sponsored by the Federation of State Medical Boards (FSMB) and the National Board of Medical Examiners (NBME), it tests whether medical students understand the basic sciences that underpin clinical medicine. Since January 26, 2022, Step 1 has been scored as pass/fail only, a major shift from the three-digit numeric score it previously reported.
What Step 1 Actually Tests
Step 1 focuses on your understanding of foundational science concepts and your ability to apply them to medicine. That includes anatomy, physiology, biochemistry, pharmacology, pathology, and microbiology, along with the principles behind how diseases develop and how treatments work. The exam doesn’t just ask you to recall isolated facts. Questions typically present a clinical scenario and require you to connect basic science knowledge to a patient’s symptoms, lab findings, or treatment plan.
Most medical students take Step 1 after completing their preclinical years (typically the first two years of medical school), before they begin full-time clinical rotations. It’s a high-stakes checkpoint: passing is a requirement to continue toward licensure, and failing can delay your training timeline significantly.
The Shift to Pass/Fail Scoring
Before 2022, Step 1 reported a three-digit score that ranged roughly from 1 to 300, and that number carried enormous weight in residency applications. Competitive specialties like dermatology or orthopedic surgery often used Step 1 scores as a primary screening tool. The transition to pass/fail, which took effect for exams taken on or after January 26, 2022, was intended to reduce student stress and refocus medical education away from board-score optimization.
If you fail, you won’t receive a numeric score, but you will get feedback on how far you were from the passing threshold along with content-area breakdowns to guide your studying for a retake.
Who Can Take Step 1
Three groups of people are eligible. You must be either a student enrolled in (or graduate of) a U.S. medical school accredited by the LCME (the body that oversees MD programs), a student or graduate of a U.S. osteopathic school accredited by COCA (the DO equivalent), or a student or graduate of an international medical school listed in the World Directory of Medical Schools that meets the eligibility requirements of the ECFMG, the credentialing body for international medical graduates.
In practical terms, if you’re studying medicine at an accredited school in the U.S. or at a recognized school abroad, you’re eligible. International medical graduates apply through the ECFMG rather than directly through the NBME.
Registration and Cost
The application fee for Step 1 is $695 for the 2026 testing year. International students taking the exam outside the U.S. and Canada may face additional regional fees. For exams taken in India, an 18% tax is collected on top of the base fee and sent to the Indian government. There is no separate late-scheduling surcharge listed, but exam seats at Prometric testing centers fill up quickly during peak periods (especially spring and early summer), so applying early gives you more flexibility in choosing your test date.
Retake Rules If You Don’t Pass
You’re allowed a maximum of four attempts to pass Step 1. Within any 12-month window, you can sit for the exam up to three times. If you need a fourth attempt, it must be at least 12 months after your first attempt and at least six months after your most recent one. These waiting periods mean that multiple failures can push your timeline back considerably, potentially delaying clinical rotations or graduation.
How Step 1 Affects Residency Applications
Even under pass/fail scoring, Step 1 still matters. In the 2024 survey of residency program directors conducted by the National Resident Matching Program (NRMP), 86% of programs said they consider whether an applicant has passed Step 1 when deciding who to interview. That made it the single most frequently cited factor, ahead of the dean’s letter (85%), specialty-specific letters of recommendation (84%), the Step 2 CK score (83%), and the personal statement (81%).
Failing Step 1 carries a real cost beyond the delay. In that same survey, 77% of program directors said they consider failed attempts on either Step exam when screening applicants. A failed attempt on your record doesn’t automatically disqualify you, but it does raise a flag that many programs weigh during the selection process.
Step 2 CK Has Gained Importance
With Step 1 no longer producing a numeric score, much of the differentiating power has shifted to USMLE Step 2 Clinical Knowledge (CK), which still reports a three-digit score. In the 2024 NRMP survey, 30% of programs required MD applicants to hit a target Step 2 CK score just to be offered an interview. That figure was 36% for international medical graduates and 22% for DO graduates. If you’re early in medical school, the practical takeaway is that strong Step 2 CK performance now carries the competitive weight that Step 1 scores once did.
How Students Typically Prepare
Most students dedicate a focused study period of four to eight weeks exclusively to Step 1 preparation, usually scheduled between their second and third years. The most common resources include large question banks (UWorld is the dominant one), review books like First Aid for the USMLE Step 1, and spaced-repetition flashcard systems like Anki for memorizing high-yield facts over time. Many schools now build a dedicated “study block” into the curriculum specifically for Step 1 preparation.
Because the exam is pass/fail, the preparation calculus has shifted. Students no longer need to chase a score above 250 to be competitive for top specialties. The goal is straightforward: pass comfortably and move on. That said, the material you learn for Step 1 forms the backbone of clinical reasoning you’ll use throughout rotations and residency, so the studying isn’t wasted effort even beyond the exam itself.