Most physicians who took USMLE Step 1 over 5 years ago have no clue what’s actually on the exam.

Don’t believe me?

For those of you who’ve forgotten what Step 1 really tests, hop on board for a little refresher.

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The USMLE provides a set of sample Step 1 questions.

For your enjoyment, I compiled some highlights from Block 1 (questions 1-40). But if you really wanna have fun, the whole thing is online here:

https://www.usmle.org/pdfs/step-1/samples_step1.pdf

Here’s your first question:

Now, you might think that a licensing examination would be interested in evaluating a physician’s ability to help this poor guy before he died.

Nah. Not Step 1.

Instead, let’s figure out who knows how this cell got *here*.

(The correct answer, if you’re wondering, is B.)

Next question:

What I love about this question is how it lures you in with a totally-believable clinical vignette. Is it gonna be a question about wound care? Indications for debridement or antibiotics? Nope. Hope you remembered your cytokines!

Correct answer: E.

On to question 3:

Look, I actually evaluate children with polyuria/suspected diabetes insipidus. And never once has ever occurred to me to look up this information (much less carry it around in my head).

But perhaps your DI workup differs from my own. If so, the correct answer is A.

Question 4:

You’ve got to respect this question’s lack of pretense. No foreplay at all. It goes straight for the basic science.

And just in case it’s been a while since you ordered a Southern blot on the digestion products of your patient’s cerebellum or pancreas, the correct answer is C.

Had enough? Or should we keep going?

Okay, okay - just one more.

Is it really the case that all doctors must know, as a condition of licensure, that RSV has a linear, negative-sense RNA genome?

I guessed E, hoping that the USMLE was trying to test a clinically-useful point which I had been heretofore unaware. They weren't. Correct answer: D.

Are these questions cherry-picked? Sure. Most of them weren’t that bad.

But I only looked at the first 40 questions - so these 5 represent 12.5% of the total.

Remember this: #Step1Mania is an arms race. Students must score higher than their peers to gain an advantage in residency selection.

Yet as Step 1 scores rise higher, the questions that serve as discriminators become more and more esoteric.

For program directors who use Step 1 scores for candidate selection, this is the kind of stuff that your residents are memorizing to get that shiny score.

Think on that for a moment.

And if the reason you use Step 1 scores is not because of the material, but because you think it reflects the candidate’s hard work, time management, dedication, etc. - then can we not measure those things using tests or tasks that actually make you a better doctor?

And please, spare me the comments about how these questions weren’t that bad because you knew some of them. I did, too. It doesn’t keep me from being able to discern that the facts they test are only peripherally relevant to the actual practice of clinical medicine.

Please also spare me the argument that these are good questions because they are distantly related to a topic with some clinical utility (like VEGF inhibitors or C5a receptor inhibitors).

If so, why not test the information that is important (i.e., indications for or side effects of VEGF inhibitors)? Just because the answer to some of these questions relates to something that's useful doesn't mean that they're good questions.

And please please please, spare me the argument that students need to learn this because some of them might go on to become basic scientists.

Cause here’s the thing: Step 1 is a licensing exam. Not an “explore different career pathways” exam.

Licensure exists to protect the public.

It’s hard for me to conceive of a situation in which a patient could be harmed by a physician because she didn’t know the answers to the questions above.

It’s even harder for me to think of a case where a patient could be helped.

So the next time you are debating the value of the Step 1 score, please think back to this little exercise, and remember what’s actually on the test - and what that number reflects.

#USMLEPassFail

For anyone who prefers a prose version: https://thesheriffofsodium.com/2019/04/02/whats-on-usmle-step-1/