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USMLE Step 1 Practice Question Types

College students taking the USMLE Step 1.


Types of Questions You’ll See on USMLE Step 1


There are many different types of USMLE Step 1 questions, and preparing for each type of question can help students gain confidence in their question approach and test-taking strategy. Before preparing for various question types, understanding the test’s content areas is helpful. In this post, we’ll delve into USMLE Step 1 question types, focus, and crucial practice questions for effective learning.



Shifting UMLE Step 1 Practice Question Approach Based on the Changing Focus of the Exam


The change to pass/fail grading in early 2022 brought with it some changes to the exam. These changes include increased questions about applying basic science concepts and communication competencies. Systems-based practice and patient safety questions are decreasing, while diagnosis and management questions have been eliminated from Step 1 and moved to USMLE Step 2. These changes are likely related to the soon-to-be pass-fail grading system of USMLE Step 1, and demonstrate that USMLE Step 1 is pre-clinical exam, primarily testing application of basic science concepts, as well as communication skills.


Consider this focus shift in USMLE Step 1 questions when choosing practice tests. Note that older NBME forms available online in PDF format do not consider these changes. Using the most up-to-date NBME forms is best to make sure your focus is in line with the current exam.


Students often deprioritize studying communication, perceiving it as “common sense” or “low yield.” While communications can often be answered with a gut feeling, spending a limited amount of time preparing for this content can be helpful, particularly as they constitute 6-9% of the Step 1 exams according to the USMLE testing outline. Empathetic statements, obtaining more information or prior medical records, open-ended questions, and statements that avoid judgment or declarative statements are often the best answer in communication-style questions.



USMLE Sample Question Categories 


The USMLE Step 1 asks basic science concepts in multiple ways, categorizing each question into one of three types: most likely, multimedia questions, and chart questions. It is important to note that negatively phrased questions (LEAST likely?; all of the following EXCEPT?; which is NOT?) are no longer present on USMLE Step 1, to the relief of many students. Questions that were phrased in this way were often confusing and added a layer of complexity that detracted from the subject matter at hand and were therefore eliminated from USMLE Step 1.


Most Likely Step 1 Questions 


The most likely question students will encounter on the USMLE Step 1 exam is a “most likely” question (eg. Which of the following is the most likely diagnosis?)! Often, “most likely” questions will be asked in the context of a long clinical case. To approach these long cases, it is important for students to put together all the pieces of the puzzle. To do this quickly and efficiently, students should read the actual question of the stem first. This is important so students know if they will need to focus on diagnosis, a biochemical correlate, anatomy, etc. while they read through the question.


Often, a brief 1-2 second skim through the answer choices will help students put together a framework for what they should be looking for in the stem. While reading, highlighting between 3-5 clues can help students put together the mental puzzle. Frequently, a clinical case includes one or two extra distracting details, relevant to incorrect answer choices. Due to these distractors, assembling all the clues and treating the case as a whole is crucial.


Multimedia Step 1 Questions


Multimedia questions encompass questions that contain radiologic or pathologic findings, or videos or audio of physical exam maneuvers. These questions often stress students and trigger panic when they press the “play” button for the daunting cardiac physical exam. The first thing to do with any multimedia question is to keep calm and carry on. Reading the stem alone can answer many multimedia questions.


Therefore, the best approach to these types of questions is reading the actual question first. Afterward, skim the answer choices, briefly view the image for 15 seconds, then read the stem. Sometimes, you will recognize the physical exam finding or the image easily, in which case, great! Use it as one of the clues in the question stem. Sometimes, the multimedia may be harder to interpret – is that a rumbling diastolic murmur? Is it a fixed split S2? Is it a loud S4? In these instances, students should assemble as many stem clues as possible before delving into answer choices.


Chart Step 1 Questions


The last type of question that is commonly seen on USMLE Step 1 is a chart question. This means that students find a large chart instead of sentences comprising the answer choices. This chart is often dominated by an assortment of up, down, and sideways arrows, with a sprinkling of urine findings (different types of casts, for example), CSF findings (protein, glucose levels), or pretty much anything else.


Like multimedia questions, students often get easily overwhelmed by the charts and can slip up. The best way to approach a chart question is to start with the column you are most familiar with and use the process of elimination wisely. It is also important to remember which aspect is the cause, and which aspect may be a consequence. It is extremely easy to get mixed up with all the up and down arrows. Students should take their time and approach chart questions methodically.


As always, if you need additional help or want to incorporate 1-on-1 tutoring into your study schedule, you can contact us here.

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About the Author

Karolina Woroniecka, MD/PhD

As a former Howard Hughes Medical Institute Student Fellow, Karolina Woroniecka graduated Phi Beta Kappa from Brown University with a B.S. in Biology and Hispanic…

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