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How many Practice Questions before Step 1: How to score >250

That magic number, I think it used to be a 240, but now a days it seems like it has moved even higher and the expectations are moving higher each year. A common question that comes from those who want to score high, is how many practice questions before Step 1? Which can really be a bummer for medical students since Step 1 is an absolute beast of an exam. There is so much riding on the USMLE Step 1, and so much stress for us as medical students to do well on it.

Looking back on my experience with this exam it is no secret that I was crazy nervous about the test and how to get ready for it. More specifically I was uncommitted at first on what resources to use, how many questions to do, how should I do those questions, were my practice tests good representation of my knowledge, and what score I needed to land me a spot in my number one choice residency.

Before we dive into all of that I want to introduce myself.

About Me

My name is Sean Kiesel, as I write this I am a 4th year Osteopathic Medical Student in the midst of residency interview season. I got into medical school with a 50th percentile MCAT score… yup I didn’t really study at all for that exam.

So, this poor score meant that I wasn’t picky with medical school admissions. This means that my wife and I landed 2,000 miles from home in rural Kentucky/rural Tennessee for the first two years of medical school.

Long story short, my wife cried when we got to the place we would call home in Kentucky (the home/town wasn’t what we expected), so I put on my big boy pants and got to work the first day of medical school.

I made an agreement with myself that I would never score that low on an exam again, because I wanted choices the next time I went through a similar process, or in other words I wanted choices for residency!

Long story short, I am on track to have a 4.0 in medical school and I scored in the 97th percentile on the COMLEX Level 1, as well as the 91st percentile on the USMLE Step 1. That is a 704 COMLEX 1 and a 256 USMLE Step 1.

Now, I don’t tell you that to brag, I just tell you to show that I actually came quite a ways and do know what I am talking about when it comes to USMLE Step 1.

How about we dive in now and talk about:

  • my favorite type of resources
  • how many questions should you do
  • what mode you should do questions in
  • how to use practice tests


My Favorite type of resources:

Q-Bank practice questions are absolutely the best resource out there. I always like to make this reference for students… You wouldn’t get ready for a basketball game by reading the rule book right, or by reading how the game works? You will get out on the court and practice!

This is exactly how getting ready for USMLE Step 1 is. Don’t sit and read through the highlights that are review books. Just do questions from the get go.

These Q-Banks are great for learning, because they force you to recall information and then they give you first hand explanations of what you were just forced to critically think about.

How to use practice questions

Some people will say that they are “saving” their questions for when they know more. Please don’t do this!

Questions are the most efficient way to learn the material! Do questions early and often.

So in summary, practice questions are the absolute best resource for your Step 1 prep.

How many questions should you do:

This is so key to your success. This point is really two fold, because you don’t just want to do questions for the sake of doing questions. Your effort really needs to be 100% and you need to be all in with every single question.

So this point means there is a specific amount you need to do, as well as you need to put all your effort into every question.

Don’t look up answers to the questions, or just randomly guess because you don’t want to get it wrong or don’t know it. Give each question all of your attention and try to get it right everytime meaning, treat it like you are testing.

The perfect amount of questions really depends on how many you ultimately want to get through.

I did 15 per day starting the first day of second year. So, from July to December of second year I did 15 questions per day, the only exception was during the 4 days leading up to a block exam. I stopped doing practice questions and focused entirely on lectures for the test.

COM PREP MED - Practice Questions infographic

For example, my block tests were on Mondays. So I did my last practice questions on Wednesday before an exam. This left me Thursday through Sunday night to focus 100% on the block exam. I did this because I needed to make sure I passed all my classes first. If I didn’t pass all the classes then there was no way that I could actually sit for Step 1. So, I kept the horse before the carriage and made sure to pass classes.

Those few days before exams and then Thanksgiving and Christmas are the only days I didn’t do questions during second year.

Then starting in January I upped the amount of questions to 20 questions per day. This was enough that it gave me plenty of time to get through the explanations, but it also pushed me timewise to do them.

When I was about 3 weeks out from test day and I had done my first pass of my best Q-Bank (UWorld), I started my second run through. I did 120 questions a day to simulate the exam. I will get into what modes I did the questions in below.

I came up with the numbers I did because I wanted to get through one decent Q-Bank in the fall of second year, as well as have time to go through one of the best Q-Banks two times. I was able to accomplish this.

What mode you should do questions in:

Tutor untimed mode is the absolute best way to do questions early on.

This is how I did questions up until about three weeks before my exam. The reason I did questions this way is because it is the most efficient way to learn in my opinion.

It is a great way to use your review books along side the Q-Bank, or to maximize your use of the AMBOSS platform is to look up the topic that you just did a question on, after you do the question.

What I mean is if you do a question on aortic stenosis. After you read the question explanation, then you pull out your review book or find that learning card in the AMBOSS library. Then you read up on the topic, but not only on aortic stenosis. You should also read up on all other valvular issues. This is because questions like to compare similar things to each other. So, if you know the subtle differences between each of those valvular abnormalities then, my friend, you just became a valvular champion.

COM PREP MED - Why amboss rocks infographic

Do this every single time you get a question. So, the next time you get an aortic stenosis question go and do the exact same thing. This repetition is so key, and it can be thought of as a form of spaced repetition. Doing questions this way takes a lot longer, but is an incredible way for you to efficiently learn the material.

As your exam day gets closer,you will start to worry about fatigue on exam day right? Well, if not you should be thinking about it.

The best way to deal with that during your prep time is to do questions that simulate exam day. This comes in two forms, practice tests (which I will talk about in a minute), and then using your Q-Bank to set up a situation that resembles exam day.

Using your Q-Bank to mimic test day is pretty easy. In the three weeks leading up to exam day I focused on doing 120 questions a day from my second pass of my good Q-Bank.

What this looked like was 3 one hour sessions back to back to back. I did these in timed mode and made a set of 40 questions. This is because USMLE doesn’t ever do more than 40 questions in an hour block.

So, I spent three weeks doing 3 hours every morning that was exactly like test day. I would leave my phone out of the room, not allow interruptions, no snacks or drinks in the room, put my ear plugs in and go to town on the three separate blocks of 40 questions.

Another key to this though, is that I didn’t look at what I got right and wrong after I did the block. I would quickly click through to start the next block without taking a break or looking at the answers.

Once again, this simulates test day. On test day you won’t know what you got right or wrong and this can mess with your head a little bit. So, I taught myself to trust myself on each and every question by not knowing what I got right or wrong in those three weeks leading up to the exam.

Now, after I did my three separate blocks I would spend the afternoon looking at what I got right and wrong and reviewing it, but this was after the fact.

This brings me to another point about these three hour blocks of questions. I took  breaks every two hours during test day. This means that since I trained myself to sit and do questions for three hours, so that two hours was a walk in the park for me, and it was. I was not fatigued at all on test day and I credit it mainly to how I was prepping the three weeks before the exam.

There was another way I built stamina that involved practice tests, I talk about that under the practice test section.

In summary, do tutor mode early on and then timed mode later on with a focus on simulating exam day.

How to use practice tests:

You would be surprised at how many people I know that would do a practice test with food around, a drink on the table, no ear plugs in, and taking random breaks throughout, or even worse using their books and notes to look up answers during the test. Then they would be surprised when their actual test score is lower than their test average.

It really should come as no surprise though, that the way you prep is the way you perform. So, if you get serious about your practice tests and treat them like the real deal then they will not only be reliable score predictors for you, but they will help you get a feel for what test day will be like.

Here are my few tips about how to use practice tests to increase your score.

First you need to do at least 3 practice tests. One at the start of your board prep to get a baseline, one in the middle of your board prep and then one a week or two before exam day. Spacing them like this will give you a good idea as to your progression.

I personally did 8 practice tests. Mine were spaced out like this: I did a baseline one in January, since we had most pathology done at that point. Then I did another one in March, then the rest of them were once dedicated prep started in April. I did one every two weeks for the first month of dedicated board prep, then I did a test weekly the month before my exam.

I did this many tests for two reasons; one, to mimic test day as much as I could, and two, to continually gauge where my knowledge was at.

Now you may be asking how I went about sitting down and taking these practice tests.

That is a great question, let me explain.

I would leave my phone in the other room, block out a time of 4 hours on a Saturday at the same time that I would be testing. This means I sat down from 8 am to noon because I knew that this time is when I would be testing for the real deal.

I treated practice test day like real test day. So the night before I stopped studying earlier, I woke up and ate the same thing I was planning to eat on test day. I had the computer all ready to rock and the test pulled up so that at 8 am I could shut the door, put in my ear plugs and just go to town and test for 4 hours straight.

I removed all textbooks from the room just to take away any temptation to look at them.

Basically I sat down and did questions for 4 hours and treated it exactly like a real exam.

My philosophy around practice tests and questions was that if I could sit down and do questions for 3-4 hours straight, then I would have no problem come test day because I would be taking a break every 2 hours. This was so true, I was not fatigued at all after Step 1.

For those of you wondering which practice exams I used, here ya go.

I used a mix of the UWorld exams as well as the NBME exams.

There are all the details of how I used practice questions to get my step 1 score of 256.

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