Similarities Between Step 1 and Step 2:
Both exams are multiple-choice and are administered in 60-minute blocks that contain approximately 40 questions.
Both exams will assess the presentation, diagnosis, and pharmacotherapy of disease processes.
Differences Between Step 1 and Step 2:
Step 2 is a longer exam with eight 60-minute blocks, while Step 1 has seven 60-minute blocks.
Step 1 is pass/fail, while Step 2 is scored.
Step 1 focuses broadly on the basic science of medicine and asks questions such as:
- What is the diagnosis of this patient with these findings?
- Which physiological/pathological process is responsible for this patient's symptoms?
- What is the mechanism of action and the side effects of the pharmacological therapy?
- Which anatomical location is affected by this patient's condition?
- What is the histopathological finding associated with this patient's condition?
Step 2 will emphasize disease management and will ask questions such as:
- What is the appropriate next step in the evaluation/management of this condition?
- What are the risk factors associated with this patient's condition?
- What is the best test to establish the diagnosis?
- What is the most likely diagnosis or the causative organism?
- Which tests are best for monitoring the progress of this patient's condition or treatment?
- What are the complications of this disease/medication?
- Which screening tests are indicated for this patient?
USMLE Step 1 or USMLE Step 2: Which Is Harder?
Step 1 has traditionally been considered harder because it is the first exam in the series and students often struggle with some of the basic science concepts that are tested in detail. In addition, many students may find that the Step 2 concepts are learned more easily during the clinical clerkship or medical practice, unlike learning through lectures, books, flashcards, and questions, which is typically emphasized before Step 1.
According to public USMLE data, in 2023, students from outside the United States and Canada (International Medical Graduates) had a pass rate of 72% on Step 1 compared to 88% on Step 2. Although Step 1 is pass/fail, a passing score on the three-digit scale is 196. A three-digit passing score for Step 2 is 214.
Changing Your Mindset
Since Step 1 is no longer scored, more emphasis is being placed on Step 2 as the only scored metric that residency programs have to compare candidates. When planning to take the exam, it is important to reflect on your goals and how well you want to do on the exam. In addition, it is worth considering your career interests and the average Step 2 scores of candidates matched in your field of interest.
Additionally, the transition from basic-science-centered questions to clinical management can be tricky for students. In addition to asking "what caused this disease," you should also begin to ask "what is the best test to screen or diagnose this condition," "what are the treatment options for this condition and the risks and benefits of each?" and "what are the complications of this disease that the patient needs to be monitored for?". Thinking about these questions during the clinical clerkship or your general medical practice while studying will help you prepare well for Step 2.