Late spring and early summer mark Step 2 season for many medical students. While Step 1 of the United States Medical Licensing Examination (USMLE®), largely covers clinical knowledge and how the body works and why conditions develop, Step 2 is a clinical knowledge exam of test-takers’ knowledge base of diagnosis and management. Most students take the test at the conclusion of their clinical rotations, so that information is fresh.

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Some experts shared their insights about how to prepare, how it might change with Step 1 moving to pass-fail scoring, and how residency programs may view Step 2 scores.

The answer to this question is going to be highly individualized. Historically, students have studied less for Step 2 than Step 1.

Christopher Cimino, MD, is chief medical officer at Kaplan Medical. He has seen medical students study for Step 2 about one-quarter of the time that they do for Step 1. When Step 1 goes pass-fail and Step 2 has a numerical score, he expects the emphasis on Step 2 studying to increase. As far as what a good study plan looks like, he said it’s tied to your clerkship learning.

“Part of the reason that people felt studying wasn't as needed is because a lot of what's on Step 2 is so clinically relevant that you're covering it while you do your clinical rotations,” Dr. Cimino said. “So, based on patients you see in a given day, do a deep dive on their problems in a way that will help you shine on both rounds and Step 2.”

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Since Step 2 is largely rooted in your knowledge of clinical medicine, your performance on National Board of Medical Examiners Subject Exams, commonly referred to as shelf exams, is probably a good place to start when it comes to knowing your deficiencies.

Beyond that, seek guidance from your medical school’s office of academic support.

“They should talk to the people who understand learning approaches, testing approaches, cognitive skills development,” said Joanna C. Arnold, PhD, director of the office of student learning and educational resources at the University of California, Davis, School of Medicine. “It's well-documented that peers—who are probably the people that they often talk to—while very well-intentioned, typically relay their own experience rather than the evidence and data about learning.”

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Get information on COMLEX Level 1 going pass-fail.

One idea behind moving Step 1 to pass-fail is to lower the emphasis on high-stakes exams in the residency-selection process. Still, there are many concerns that for medical students who don’t have a numerical Step 1 score—those who took the exam after January 2022—that a numerical score on Step 2 may simply replace Step 1 as a sorting metric for interview slots, and, ultimately, residency positions.

According to a 2021 survey of residency program directors (PDF), Step 2 score was already among the top criteria in selecting which candidates to interview.

In his role as vice chair for education in internal medicine at UC Davis, Mark C. Henderson, MD, is heavily in involved in the residency-selection process. His program has moved away from using Step 1 or Step 2 as a key metric in sorting for interviews or residency positions. Other than an applicant’s having passed, Davis doesn’t have a cutoff score, unlike other schools.

Instead, Dr. Henderson and his colleagues are trying to gauge other attributes, such as “resilience, work ethic or dedication, and capacity for improvement, things that make them good physicians, at least for internal medicine,” he said.

Dr. Henderson, an AMA member, advised medical students “to think about the other elements of their application that would be viewed favorably in such a holistic process. ... for example, leadership of an organization or activity that they might be freed up to do because the shackles of Step 1 are released in a way.”

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Dr. Cimino said not to overthink it when it comes to exam day. “The USMLE does not write trick questions,” he said. “There's a lot of feeling among students that if you didn't get that question right, it was because it was a trick question. That happens sometimes with practice questions just because faculty are prone to writing trick questions, but the USMLE throws those out and tries to avoid them. So, if something feels like a trick question, it may be because you're overthinking it, and it may be the question is simpler than you thought.”

That same 2021 residency program director survey indicated that a failed attempt at any Step exam is one of the top factors considered deciding whom to interview; it should be noted that the Step 2 pass rate was well over 90% for test-takers from MD and DO schools in recent years, according to the USMLE. But if you fail, you still have a shot at earning a residency position. “A Step 1 or Step 2 failure would get our attention,” Dr. Henderson said. “We have seen individuals who have had some kind of event in their life or an extenuating circumstance, in which case we'll look at what their subsequent score to get a sense of trajectory. We don't exclude people for a failure, but I do think it gets more attention than, let's say, getting a high score does.”

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