Taking Practice Exams the Right Way

Chapter 08

Practice exams may seem like one of the best ways to gauge your readiness for Step 1, but they simply aren’t. One of the reasons why is because the content distribution for most practice exams do not align with the content distribution for Step 1. As a result, they are not a reliable metric for assessing readiness for STEP1. Yet, you can’t not take a practice exam because there can be some valuable insights from the experience. Therefore, they need to be used strategically. This chapter explains how to schedule your practice exams, analyze your performance, and adjust your study plan based on your results. I also share tips for building endurance for the long exam day.

Why Practice Exams Matter

Taking practice exams is one of the most important parts of Step 1 preparation. Not only do they provide a snapshot of your current knowledge, but they also simulate the actual exam experience. If used correctly, practice exams can help you refine your test-taking strategy, build endurance, and identify weak areas that need more attention.

However, there’s a right and wrong way to use practice exams. Simply taking them isn’t enough—you need to approach them strategically to get the most benefit.

Choose the Right Practice Exams

There are several options when it comes to practice exams, but not all are created equal. Here’s how I ranked the most useful exams for Step 1:

• UWorld Self-Assessments: These are the closest in format and question style to the real Step 1 exam. UWorld’s interface and question types are similar to what you’ll see on test day, making these practice exams ideal for refining your skills.
• NBME Exams (Form 25, 26, etc.): While not as representative in terms of the testing interface, NBME exams are still essential because they provide a good benchmark for where you stand to an extent. Since NBME creates the actual Step 1, these exams will help you gauge your readiness even if most of them are outdated.
• AMBOSS Self-Assessment Week: This annual event offers a great opportunity to assess your Step 1 readiness for free. The AMBOSS Self-Assessment Week includes a full-length exam with a detailed analysis of your performance. While it’s a solid option to get familiar with clinical reasoning, AMBOSS generally does not mimic the interface of the real exam as closely as UWorld does. However, it provides high-quality questions that challenge your clinical knowledge, and the results analysis can help pinpoint areas to improve. Keep in mind that while the content coverage is good, it's not as representative of the biostatistics and communications-heavy nature of Step 1.
• USMLE-Rx: USMLE-Rx is another solid practice tool that offers a full set of Step 1 questions designed to correlate with First Aid for the USMLE Step 1. The key strength of USMLE-Rx is its heavy integration with First Aid, which helps reinforce key concepts while testing your knowledge. However, the interface and question style may not be as reflective of the real Step 1 exam compared to UWorld. USMLE-Rx is a good supplementary resource for solidifying foundational knowledge, but for exam simulation, it doesn't quite match UWorld's realism.
• Free 120: The official 120-question sample exam from USMLE. It’s shorter than a full exam but highly representative of the content and style of Step 1 questions.

When to Take Practice Exams

It’s important to space out your practice exams in a way that allows you to measure progress without burning out. Here’s the general schedule I recommend:

• Start with a practice exam early: Ideally, take your first full-length practice exam during your first week of dedicated study. This will give you a baseline score and a sense of where you stand.
• Take one every 2-3 weeks: After the initial exam, schedule practice exams every 2-3 weeks. This gives you enough time to improve based on your previous performance without overwhelming yourself with constant testing.
• Final weeks before the exam: During the last 2 weeks, I recommend taking at least 1-2 practice exams to fine-tune your strategy. These should be used to assess your readiness, identify any lingering weak areas, and build confidence.

How to Analyze Your Results

Taking a practice exam is only half the battle—you need to spend just as much time analyzing your performance to get the most value. Here’s how to break down your results:

• Focus on categories, not just overall scores: While your overall score is important, pay close attention to how you performed in specific categories. Did you perform poorly in biochemistry but excel in anatomy? Use this information to guide your study plan moving forward.
• Identify patterns in wrong answers: Look for patterns in the questions you missed. Were they mostly due to knowledge gaps, misinterpretation of the question, or timing issues? Understanding why you got questions wrong will help you tailor your review and practice more effectively.
• Target weak areas: Based on your analysis, refocus your study efforts on the areas where you’re consistently underperforming. This might mean creating more focused question blocks in UWorld or adding specific Anki cards for reinforcement.

Build Endurance

Step 1 is not just a mental test—it’s a physical and emotional one. The exam lasts 8 hours, and you’ll be answering 280 questions in total. One of the key benefits of practice exams is that they help you build the endurance necessary to get through the real test without losing focus or energy.

Here’s how to use practice exams to build endurance:

• Simulate exam conditions: When you take practice exams, do them under conditions that mirror the actual exam. Sit down for the full duration, take breaks according to the rules, and limit distractions. This will help you get used to the mental and physical demands of the day.
• Pace yourself: One of the most important aspects of Step 1 is time management. Practice pacing yourself by sticking to the 60-minute time limit for each block and managing your breaks carefully.
• Train your brain for stamina: Just like training for a marathon, gradually build up your stamina by practicing with full-length exams rather than just individual question blocks. This will help you maintain focus and prevent fatigue on test day.

Don’t Chase a Perfect Score

It’s easy to get caught up in the idea of achieving a high score on your practice exams, but it’s important to remember that Step 1 is now pass/fail. Your goal is to pass, not to achieve perfection. Here’s why:

• Passing is all that matters: Step 1 is pass/fail, so focus on getting the knowledge and skills you need to cross that passing threshold. Overworking yourself in pursuit of a higher score is counterproductive, especially if it leads to burnout.
• Use practice exams for learning, not validation: The purpose of practice exams is to help you identify weak areas and improve—not to validate your knowledge. A lower score on a practice exam is an opportunity to adjust your approach and fill in gaps before test day.

Assessing Practice Exam Relevance for Step 1

While practice exams are valuable for building endurance and testing your knowledge, they can be misleading. After taking every available NBME form (25 through 31) and all three UWorld Self-Assessments, plus sitting for Step 1 twice, I realized that the question distribution on practice exams doesn't always match the real exam.

Step 1 Question Breakdown by System

Step 1 Question Breakdown by Discipline

UWorld Practice Exam Question Analysis (out of 160):

NBME Practice Exam Question Analysis (out of 200):

From my experience, the most recent exams—NBME 31 and UWorld Self-Assessment 3—are the closest to the actual Step 1 exam. Why? Because they include a much larger proportion of multisystem and communication questions, which make up a significant chunk of the actual test. Older practice exams, in contrast, often underrepresent these topics, which can give you a false sense of what the real Step 1 will emphasize.

If you compare the question breakdown on these newer practice exams to the official USMLE content distribution, they align more closely with what you can expect on test day. Older forms don’t reflect the same balance of topics, so relying too heavily on them can skew your preparation. Always keep the official content breakdown in mind and be aware that not all practice exams will be an accurate reflection of your Step 1 experience.

Adjusting Your Study Plan Based on Practice Exam Results

The beauty of practice exams is that they provide concrete data you can use to tweak your study plan. Here’s how to adjust your schedule after each exam:

• Reassess weak areas: After each practice exam, review your weakest categories and focus your study sessions on those areas. For example, if biostatistics is a consistent weak spot, prioritize it in your next week’s study schedule.
• Refine your question blocks: Instead of doing random question sets, tailor your UWorld blocks to focus on weak areas. If you missed a lot of questions in pharmacology, do an 80-question block solely focused on drugs and mechanisms.
• Increase review of challenging topics: If a certain category consistently drags your score down, add extra Anki cards or cribsheets to reinforce your knowledge in that area. Use the feedback from your exams to guide your review sessions.

Let me break it down for you like this:

Practice Exams Aren’t Just for Kicks: Every 2-3 weeks, take one. Not every week—not every day. You’re building a strategy here, not auditioning for burnout.

Don’t Freak Over Scores: You’re aiming to pass, not win gold medals. Use the exams to figure out what you don’t know, then fill those gaps. That’s the whole game.

Go Deep on Mistakes: Got something wrong? Great. That’s a clue, not a failure. Dig into why and use it to sharpen your sword.

Train for the Main Event: Practice like it’s fight night. Sit down, no distractions, no snacks, and crush it in one go. Build that endurance so you’re not wiped out by Block 7 on game day.

Passing is Winning: Step 1 isn’t about perfection. Once you hit that passing mark, it’s all gravy. Don’t overthink it—get over the line, then move on.

Bottom Line: Practice exams are your dress rehearsals. Use them to find your weak spots, tighten up your strategy, and get ready to deliver on game day. Don’t overdo it—quality over quantity. You’re here to pass, not burn out chasing a perfect score.

In Chapter 09, we’ll talk about you. Self-care isn’t a luxury—it’s a necessity. We’ll cover how to balance studying with recovery, so you don’t break down before exam day. Stay tuned.

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