Step 1 / Level 1
Draft · not yet reviewed by AlexStep 1 / Level 1: what it is, how to prepare and what matters now
The short answer
Step 1/Level 1 is the foundations exam most students take at the end of second year. It is reported pass/fail, but the knowledge it tests comes back on Step 2 CK/Level 2, shelf exams and the wards. Prepare during second year with questions and spaced repetition, then use a structured dedicated period of about a month to sharpen it.
What is Step 1 / Level 1?
Step 1 (USMLE, written by the NBME) and Level 1 (COMLEX, written by the NBOME) test the foundational science of medicine: physiology, pathology, pharmacology, microbiology, biochemistry and how they connect in the body. MD students take Step 1. DO students take Level 1 and often Step 1 as well.
Both are long, single-day, computer-based exams split into timed blocks. The exact number of blocks, questions and break time changes over time, so check the official sites when you register.
DO students need COMLEX Level 1 to graduate. The topics are nearly the same as Step 1, but COMLEX questions are shorter, lean more on recall and include osteopathic manipulation. I studied primarily for the USMLE and took Level 1 a few days after Step 1. If you do the same, mix COMLEX-style questions into dedicated rather than saving them for the end. Start with the COMLEX guide.
Does it still matter now that it's pass/fail?
Yes, but for a different reason than it used to. Your score is no longer on an application. What carries forward is what you learned.
Everything on Step 1 comes back. The concepts show up again on Step 2 CK/Level 2, on every shelf exam and on rounds. Treat Step 1 as a dress rehearsal for the exam that does get scored. The full argument is in Step 1 is pass/fail: here's why it still matters.
How should I prepare during second year?
The worst thing you can do is walk into dedicated without a foundation. Cramming two years of material into a few weeks does not work, and material you crammed the night before a class exam probably never made it into long-term memory.
What helped me most during the school year:
- Board resources as your main material. I switched from class notes to board materials early in medical school and my scores went up. See how to study for Step 1.
- Questions early and often. You don't need to finish UWorld before dedicated, but you should be doing questions all through second year. See how to use UWorld.
- Spaced repetition. A board Anki deck done daily over a long period is far more effective than a burst of it. See Anki for medical school.
Keep your resource list short. My non-negotiables were First Aid, Pathoma and UWorld. Sketchy for pharmacology and microbiology and Boards and Beyond for video review came next. Past three to five resources during the school year, you start getting diminishing returns. The full list is on the resources hub.
What does dedicated look like?
Dedicated is a full-time job. Mine was about a month, and I averaged about 180 UWorld questions a day, with some days closer to 220 or 250. Mornings were questions in practice mode, afternoons were content review, and practice exams were the checkpoints.
The day-by-day version, including how I spaced practice exams, is in the Step 1 dedicated schedule.
Try the tool
Dedicated Planner
Build your Step 1 or Step 2 calendar backward from test day, with rest built in.
What will the end of second year feel like?
Weird, honestly. By the end of second year you've finally figured medical school out. You know how to study and what to expect from your exams. Then everything is about to change: your first major standardized test, the loss of your flexible schedule when rotations start, and a new environment where you don't know the rules yet.
You'll still have class exams, but it's hard to care about them with dedicated around the corner. That stretch is a mental grind. For me it was one of the lowest points of medical school, and Becca watched me be far harder on myself than I needed to be. If that sounds familiar, dedicated anxiety is written for you.
When should I take it?
Leave yourself a week or two off before rotations start. If you are choosing between more study days and a real break before third year, I would take the break. More in when should I schedule Step 1.
Key takeaways
- Pass/fail changed how Step 1 is reported, not how much it teaches you.
- Second year is when you build the foundation. Dedicated is when you sharpen it.
- Questions and spaced repetition beat passive reading every time.
- Keep your resource list short: three to five during the year.
- Protect a break before rotations. You can patch gaps in third year; you can't easily undo burnout.
Everyone also asks
When do most students take Step 1/Level 1?
Most take it at the end of second year, after a dedicated study period and before third-year rotations begin. Your school's calendar sets the real window.
How long should I study for Step 1?
Think of it as all of second year plus a dedicated period. My dedicated was about a month. If you have been doing questions and spaced repetition all year, dedicated is for sharpening, not starting.
Do I need to take both Step 1 and Level 1?
DO students need COMLEX Level 1. Whether to also take USMLE Step 1 depends on your goals. See the COMLEX section of this site for how I decided.