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Ah, the infamous argument. Do I take Step 1 before or after clerkships? What does the data say? The data suggests students generally perform better on Step 1 after clerkships, as stated here, and there isn't too much left to debate after that, right? Wrong. Here, we break down the argument for and against taking Step 1 after third year.

Pro: Step 1 scores, on average, go up.

Many schools who have made this change stand by it, as detailed above, and it makes sense. A year of clerkships, shelf exams, and the knowledge of both medicine and test prep that come with it can only help you.

Pro: You get to focus on the clerkships, freely exploring all your options without being limited by your Step 1 score.

This happens an uncomfortable amount to students; they want to do a specific specialty, get a Step 1 score that doesn’t meet that specialty’s threshold, and rule it out immediately. Thus, not taking Step 1 before clerkships allows you to really find yourself in clerkships, knowing that you can make a decision about what you want to do before Step 1, and that might provide added motivation to then do well on the exam!

Pro: You probably have more time to study.

The time between second and third year is usually finite, as the core third-year clerkships need to be finished on a school’s schedule. As a result, taking it after third-year is over (when there is much less restriction on your time) can give you a few extra weeks to study.

Con: The data should be taken with a grain of salt.

The data that Step 1 scores increased when students took them after third year suggest increases of anywhere from 3-20 points on the USMLE Step 1, but this does not account for things such as curriculum changes, increases in Step 1 averages over time annually, and the fact that students may respond differently to these changes. Of course, a randomized, controlled study will never be performed here, so this may be the best data we get.

Con: You don’t know what you can apply into until you get your Step 1 score.

It might be difficult to schedule fourth year electives (or even decide on what to apply into) without knowing what your Step 1 score qualifies you (or disqualifies you) for. Thus, you might be better served knowing what your score is earlier to make a decision about residency.

Con: You forget all the knowledge from first and second year.

There is no question that pre-clinical and clinical knowledge differ vastly. The knowledge you use in pre-clinicals is applied infrequently at best in clinicals, and after a year of only clerkships, you will likely forget all your pre-clinical knowledge and end up needing to re-learn much of it from scratch.

Con: Your shelf exam scores and clinical performances might suffer.

Although the data is not yet out there, there is reason to think that taking Step 1 might actually improve your shelf exam and clinical performances, assisting in the consolidation of knowledge from your first two years of medical school.

Con: You want a break after clerkships!

Burnout in clerkship is a real thing and taking Step 1 (arguably the most important exam in medical school) is not something anyone looks forward to after clerkships (arguably the toughest year in medical school). Rewarding yourself for finishing clerkships by not having to take Step 1 could be one of the best decisions you make for yourself in medical school!

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