USMLE Step 1 Strategy: How to Pick the Best Answers

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The USMLE is a very unique test with three very different Steps. Step 1 features the traditional multiple choice format, but has no shortage of tricky questions and answers. However, if you are prepared and know the “tricks of the trade” the test makers use, you will be able to identify and pick the best answers to USMLE Step 1 questions.

One Best Choice Answers


Step 1 includes only multiple-choice questions with one best answer. This is the traditional, most frequently used multiple-choice format, except that USMLE questions can have up to 11 answer choices. USMLE test items consist of a statement or question followed by 3 to 11 response options arranged in alphabetical or logical order. Some of the questions require interpretation of graphic or pictorial materials. The response options for all questions are lettered (A, B, C, D, E, etc.). Your job is to select the best answer to the question. Other options may be partially correct, but there is only one best answer.
The most important thing to remember is that these questions require you to select not only a good answer, but the best answer from the choices given. One answer is always better than the others. Therefore, it is critical that you read through all of the options before making your choice. Remember, you don’t get any points for selecting the second best answer. If an answer choice seems partially correct, then it is entirely wrong.

Understanding Distractors


To deal most effectively with exam questions, you need to have some understanding of how the questions are constructed. Getting a question correct means selecting the best answer. Incorrect options are called “distractors.” Their purpose is to distract; that is, to get you to pick them rather than the best answer. Each distractor will be selected by some examinees, or it would not be included as an option. Every option fools somebody. Your job is to not be misled.
In general, distractors will seem plausible and few will stand out as obviously incorrect. Distractors may be partially right answers but not the best answer. Common misconceptions, incomplete knowledge, and faulty reasoning will cause you to select a distractor.
The test maker tells his or her question writers that their distractors must follow these five rules:

  • They must be homogeneous.

    For example, they will be all laboratory tests or all therapies, not a mix of the two.

  • They must be incorrect or definitely inferior to the correct answer.

    There will be enough of a difference between the right answer and the distractors to allow a distinction. For example, if estimating the percentage of a population with a disease, the options will differ by more than 5 percent.

  • They must not contain any hints as to the right answer.

    Distractors are meant to induce you to an incorrect choice, not give you clues as to the correct one.

  • They must seem plausible and attractive to the uninformed.

    If you are not sufficiently familiar with a topic, you may well find that all of the options look good.

  • They must be similar to the correct answer in construction and length.

    Thus, trying to “psych out” the question by looking for flaws in its construction is not a useful strategy. Answer choices that do not adhere to these rules are not used on the exam.


All options are meant to distract you, but often one of the distractors will seem better than the others, the so-called “preferred distractor.” While still incorrect, this is the wrong answer chosen most often. Preferred distractors are why you can often get yourself down to two choices: the correct answer versus the preferred distractor.
Selecting the correct answer is not a matter of splitting hairs. The correct answer will be clearly correct. If you think two answers are so close that you cannot reasonably choose between them, then the odds are that neither one is correct; you need to look carefully at a different option.


Test-taking Strategies to Avoid


Many students have learned test-wise strategies and used them effectively on their medical school exams. These strategies will not help you on the USMLE. Worse, focusing on these test-wise strategies actually hurts you because it distracts you from doing the mental work you need to do to recall the proper content and think through the question.
This means that you should break yourself of the habit of looking for:

  1. Grammatical cues: where one or more distractors does not follow grammatically from the stem. For example, a stem ends in “an” and only some options begin with a vowel.
  2. Logical cues: where a subset of options is logically exhaustive, indicating that the answer is one of the subset. For example, including the three options: “greater than,” “same as,” and” less than” in a five-option question. You will also not find logically exhaustive options when one of the options is nonsensical.
  3. Absolute terms: terms such as “always” and “never,” which wise test-takers avoid, will not be used in this exam.
  4. Long correct answers: options will be the same in construction and level of detail. Efforts are made to ensure that the correct answer is not longer, more specific, or more complex than the other options.
  5. Word repeats: where the same word or phrase is included in both the stem and the correct answer.
  6. Word association links: where the correct answer can be arrived at by simple word association without a deeper understanding of the topic. For example, Vietnam veteran and post-traumatic stress can be associated. However, in a diagnostic stem about a Vietnam veteran, the correct answer may well be some other condition.
  7. Convergence strategy: where the correct answer includes most of the elements in common with the other options. For example, consider the following question:

The 16th president of the United States was

A. Julius Lincoln

B. Abraham Smith

C. Abraham Lincoln

D. Vladimir Lenin

E. Andrew Jackson

By the convergence strategy, the correct answer is “C” (two Lincolns and two Abrahams).
The USMLE will no longer feature the types of flaws mentioned above. If you’re thinking of using these strategies, don’t. Tricks don’t work on the USMLE. They distract you from the high-power cognitive strategies that are much more likely to lead to a correct answer.