The United States Medical Licensing Examination (USMLE) Step 1 is the first of three exams required for physician licensure and focuses on the basic sciences. In 2022, the exam shifted from numeric scoring to a pass/fail system, accompanied by a higher passing threshold. Pass rates among U.S. MD students declined from 95-97% during 2020-2021 to 89-91% during 2022-2024, effectively doubling the failure rates.
Contributing factors may include gaps in study resources, grading changes, and COVID-19-related challenges. Although prior academic performance and study habits are known predictors of success, limited research has examined readiness during dedicated study periods. Identifying risk factors is crucial for supporting the timely exam completion, preventing delays, and guiding effective institutional strategies. A recent survey published in Medical Science Educator aimed to detect study habits and student metrics associated with passing the USMLE Step 1 within a six-week dedicated study period (August-October 2024) and to inform strategies for timely success.
In this survey, a total of 93 respondents (median age = 25 years [interquartile range {IQR}: 2.0], female = 67.7%, male = 31.2%) were included. Participants consisted of MD/PhD (class of 2023) and MD (class of 2026) students from a single institution who took the USMLE Step 1 in spring 2024. Students who tested before the dedicated study period were excluded from this study. The survey was distributed via institutional emailing, individualized links, and remained open for 6 weeks, with reminders and incentives to improve response rates. Data collected included comprehensive basic science examination (CBSE) scores, medical college admission test (MCAT) scores, and all-preclerkship course averages. The primary endpoint was on-time passing (OTP), defined as passing step 1 within the 6-week study period. Statistical analyses included chi-square test, Fisher’s exact test, Wilcoxon test, and t-test, which were conducted using R version 4.4.1.
Among the 93 respondents (response rate = 50.3%), 27 students (29%) did not achieve OTP on USMLE Step 1. Only three failed initially; the rest passed after extending their study period. Median study duration was significantly shorter in the OTP group (n = 66, 42 days, IQR: 35-46) compared to the non-OTP group (n = 27, 62 days, IQR: 55.75-68.5) with p = 2.0 × 10− 10. There was no difference in the number of study days per week between the groups.
Results showed significant associations between OTP and all preclerkship course average (odds ratio [OR]: 1.32, 95% confidence interval [CI]: 1.17-1.54), first-year CBSE score (OR = 1.15, 95% CI: 1.12–1.34), highest MCAT score (OR = 1.18, 95% CI: 1.03–1.39), second year CBSE score (OR = 1.21, 95% CI: 1.12–1.34), final practice exam score (OR = 1.39, 95% CI: 1.18–1.77), prior question bank use (OR = 4.11, 95% CI: 1.62–10.86), and pre-dedicated course review (OR = 4.69, 95% CI: 1.80-13.43). No association was found with summer studying, taking ≥4 consecutive days off, daily question blocks, or peer tutoring.
In multivariable analysis, second-year CBSE score and preclinical course average remained significant predictors. The odds of OTP increased with higher second-year CBSE scores (OR: 1.14, 95% CI: 1.03-1.28) and higher course averages (OR: 1.21, 95% CI: 1.03-1.45). Question bank use before the dedicated period showed a positive but non-significant trend with an OR of 2.73 (95% CI: 0.77-10.17).
Among those delaying the exam (n = 27), common reasons included insufficient question bank use (40.7%), lack of confidence despite passing scores (48.1%), need for additional content review (37%), mental health issues/burnout (51.8%), and low-passing scores (44.4%). This study’s limitations include non-response bias, recall bias due to a six-month delay, and limited generalizability due to its single-institution design.
In conclusion, this study found that early study habits and prior academic performance were the strongest predictors of OTP of USMLE Step 1. Mental health challenges were a common cause of delays, highlighting the need for both academic and psychological support.
Reference: Spier E, Yamron E, Frohlich BA, et al. Student-specific factors associated with passing the USMLE Step 1 examination within an institution-allotted dedicated study period. Med Sci Educ. 2026. doi:10.1007/s40670-025-02636-w
