Questions You Should Know about Step-in Post

General Common Questions

Eligibility

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The total number of attempts allowed per Step is four (4).

If you have attempted a Step four or more times, including incomplete attempts, and have not passed, you are ineligible to apply for any Step in the USMLE exam sequence. Attempts at the formerly administered Step 2 CS count toward the limit.

The USMLE Composite Committee, which oversees the USMLE, considers all aspects of the examination to ensure the program fulfills its mission to support medical licensing authorities in the United States. The committee has voted to change the number of allowed attempts to safeguard the integrity of the exam and to align more closely with the USMLE attempt limits imposed by most state medical boards.

During this review, the committee was presented with data indicating that it is quite rare for individuals with more than four repeated attempts on USMLE Steps to successfully complete the examination sequence, gain access to postgraduate training, and ultimately receive a license to practice medicine in the United States.

The policy change is effective for all applications submitted on or after July 1.

You must pass Step 1 and Step 2 before you are eligible to take Step 3. In LCME-accredited medical schools, while Step 1 and Step 2 can be taken in any order, most students will take Step 1 at the end of their second year and Step 2 in their fourth year; Step 3 is typically taken during the first or second year of postgraduate training.

Students and graduates of medical schools outside the United States and Canada should contact the ECFMG for information regarding ECFMG Certification and Step 1 and Step 2 eligibility.

Most medical licensing authorities require completion of USMLE Steps 1, 2, and 3 within a seven-year timeframe, which starts from when you pass your first Step. For additional details on these requirements, consult the FSMB website.

If you already hold a physician license from a US medical licensing authority, you may not be eligible to take the USMLE. Please reach out to the relevant registration organization for inquiries about your eligibility.

The Educational Commission for Foreign Medical Graduates (ECFMG) provides pertinent information. Through its Certification program, ECFMG evaluates the readiness of graduates from medical schools outside the United States and Canada to enter residency or fellowship programs in the United States. The ECFMG® Certification Fact Sheet offers an overview of ECFMG Certification and preliminary guidance on entry into US graduate medical education programs. For detailed information on these subjects, including eligibility to take the USMLE, refer to the ECFMG Information Booklet. Both publications are accessible on the ECFMG website.

Step 1 Sample Test Questions

Sample Test Questions

The Step 1 examination continues to encompass content related to the discipline of pharmacology. However, the primary emphasis will be on mechanisms of drug action rather than specific pharmacotherapy, drug-drug interactions, adverse effects, or contraindications of medications.

A 27-year-old woman visits the office for counseling prior to conception. She mentions that a friend recently gave birth to a baby with a neural tube defect and wants to minimize her risk of having a child with this condition. She has no significant medical history and takes no medications. Physical examination shows no abnormalities. It is most suitable to recommend that this patient start supplementation with a vitamin that is a cofactor in which of the following processes?

(A) Biosynthesis of nucleotides

(B) Protein gamma glutamate carboxylation

(C) Scavenging of free radicals

(D) Transketolation

(E) Triglyceride lipolysis

(Answer: A)

The Step 1 examination includes questions regarding the principles of biostatistics and epidemiology, covering topics of research ethics and regulatory issues.

A study aims to assess the feasibility of acupuncture in children with chronic headaches. Sixty children experiencing chronic headaches are selected for the study. Besides their typical treatment, all children undergo acupuncture three times a week for two months. Which of the following best describes this study design?

(A) Case-control

(B) Case series

(C) Crossover

(D) Cross-sectional

(E) Historical cohort

(F) Randomized clinical trial

(Answer: B)

A 26-year-old woman visits the physician with her husband for preconception counseling. Her mother and three of her five siblings have type 2 diabetes mellitus. She is 170 cm (5 ft 7 in) tall and weighs 82 kg (180 lb); BMI is 28 kg/m2. Her blood pressure measures 148/84 mm Hg. Physical examination reveals no other abnormalities. Her fasting serum glucose concentration is 110 mg/dL. What is the most appropriate initial statement by the physician?

(A) "Let's discuss how you can enhance your health before attempting to conceive."

(B) "We should test you for islet cell antibodies prior to conception."

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(C) "You can conceive immediately since you are in good health."

(D) "You should avoid gaining weight during pregnancy as you are already overweight and at risk for type 2 diabetes mellitus."

(E) "You should face no issues with your pregnancy if you start insulin therapy."

(Answer: A)

A 42-year-old nulligravid woman arrives at the office due to a one-year history of progressively irregular vaginal bleeding and menstrual cramps. Previously, her menstrual cycles were regular at 28-day intervals lasting 3 days with minimal cramping. Over the past year, menstrual periods have occurred at 21- to 28-day intervals and have lasted 10 to 12 days with increasingly severe pain. Using acetaminophen and ibuprofen has yielded little relief. She used an oral contraceptive from ages 17 to 40 but discontinued after being diagnosed with deep venous thrombosis of the right lower extremity. She reports no other significant health history and takes no medications. Her mother and sister underwent hysterectomy at ages 39 and 43, respectively, due to abnormal uterine bleeding. The patient stands at 163 cm (5 ft 4 in) and weighs 75 kg (165 lb); BMI is 28 kg/m2. Vital signs are normal. Physical examination indicates an enlarged, irregularly shaped uterus with nodularity. What is the most likely cause of the patient's symptoms?

(A) Benign monoclonal tumors arising from smooth muscle cells

(B) Endometrium growing into myometrium

(C) Endometrium growing outside the uterus

(D) Failure of functional ovarian cysts to regress post-ovulation

(E) Rapid division and proliferation of ovarian stromal cells

Patient Information
Age: 6 years
Sex Assigned at Birth: M
Race/Ethnicity: unspecified
Site of Care: office

The patient is accompanied by his mother due to a one-month history of bleeding gums after tooth brushing, increasingly severe muscle and joint pain, fatigue, and easy bruising. His mother mentions that he has lost six baby teeth and has shown irritability during this time. The use of acetaminophen has provided minimal pain relief. The patient has autism spectrum disorder, is not toilet-trained, and has only a 10-word vocabulary. Vital signs and oxygen saturation on room air are normal. The patient appears alert but does not engage in eye contact or verbal communication. Skin assessment reveals paleness and coarseness. Scalp examination shows erythematous hair follicles. He displays poor dentition, with gingivae bleeding easily when touched. Multiple ecchymoses and petechiae are observed over the trunk and extremities. Marked swelling and tenderness can be palpated in the elbow, wrist, knee, and ankle joints, and he moves all limbs cautiously. Deep tendon reflexes are absent throughout. It is most appropriate to gather specific additional history regarding which of the following in this patient?

(A) Diet

(B) Evidence of pica

(C) Herbal supplementation

(D) Lead exposure

(E) Self-injurious behaviors

(Answer: A)

Patient Information
Age: 82 years
Gender: F, self-identified
Race/Ethnicity: Chinese, self-identified
Site of Care: urgent treatment center

History
Reason for Visit/Chief Concern: "My lower left side hurts."

History of Present Illness:
' 2-day history of moderate left lower quadrant abdominal pain
' Pain associated with fever, chills, nausea, and decreased appetite
' No diarrhea or constipation reported
' No history of similar symptoms
Past Medical History:
' Hypertension
' Hypercholesterolemia
' Most recent colonoscopy 10 years ago showed no abnormalities
Medications:
' Lisinopril
' Atorvastatin
Allergies:
' No known drug allergies
Family History:
' Father: deceased from stroke at age 78 years
' Mother: deceased, had hypertension
Psychosocial History:
' Does not smoke cigarettes, drink alcoholic beverages, or use other substances

Physical Examination:

Temp: 38.5°C (101.3°F)
Pulse: 100/min
Resp: 22/min
BP: 164/72 mm Hg
O2 Sat: 98% on RA
Ht: 155 cm (5 ft 1 in)
Wt: 54 kg (119 lb)
BMI: 23 kg/m2

Appearance: anxious due to pain
Pulmonary: clear to auscultation
Cardiac: regular rhythm without murmurs, rubs, or gallops
Abdominal: hypoactive bowel sounds; tenderness in the left lower quadrant
Rectal: normal anal sphincter tone; no masses or lesions; stool test for occult blood negative

Diagnostic Studies

Serum:
' Na+: 148 mEq/L
' K+: 4.2 mEq/L
' Cl-: 99 mEq/L
' HCO3-: 30 mEq/L
' Urea nitrogen: 20 mg/dL
' Creatinine: 1.4 mg/dL
' Glucose, non-fasting: 100 mg/dL
' ALT: 20 U/L
' AST: 18 U/L
Blood:
' Hematocrit: 36%
' Hemoglobin: 13.0 g/dL
' WBC: 12,000/mm3
' Neutrophils, segmented: 60%
' Neutrophils, bands: 6%
' Lymphocytes: 30%
' Monocytes: 4%
' Platelet count: 350,000/mm3
Urine:
' Leukocyte esterase: Negative
' Nitrite: Negative
' WBCs: 2/hpf
' RBCs: 0/hpf

CT scan of abdomen and pelvis: obtained; results pending

Question: Which of the following is the most likely diagnosis?

A) Appendicitis

B) Colorectal cancer

C) Crohn disease

D) Diverticulitis

E) Pseudomembranous colitis

(Answer: D)

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