Stress and Step 1: One Medical Student’s Perspective

by Sukhjot Sandher

During the basic science instruction of our first and second years of medical school, we are rigorously tested on whether we are prepared to complete our third and fourth year clinical rotations. The USMLE Step 1 examination, taken by most medical students at the end of their second year, is one of the most significant assessment metrics. Your “Step 1” results largely determine your options in both the residency program and specialty choices. The performance pressures surrounding the Step 1 lead many students to undertake a grueling study regime filled with sleepless nights to cram in every last bit of knowledge. However, this may actually end up doing more harm than good. Research has shown that intense amounts of stress may be counterproductive in learning and academic performance, suggesting that an essential part of performing well is to develop a healthy mindset leading up to the test.

At the end of your first year in medical school, life is pretty sweet. The weather is changing and summer vacation is just around the corner. However, for second years there is no summer vacation ahead, only the looming prospect of an examination that will influence their future medical careers. For some, the test is merely a formality, no more important than any other test. For others, it is an exam that dictates not only their specialty but also the residency programs open to them. Some level of anxiety is intrinsically wrapped up in such an event, and healthy levels of stress can be useful in terms of focus, motivation and goal-setting. For most people, stress is simply that response that allows your body to keep moving, regardless of the pressures put on it.

However, long-term levels of chronic stress can be maladaptive, especially in the area of academic performance. One study conducted in a cohort of dental students found that exam scores were negatively associated with stress levels, measured by a test called Perceived Stress Scale 4 (Crego, Carrillo-Diaz, Armfield, & Romero, 2016). In this particular survey, students were asked a number of questions regarding particular events as stressful, on a scale of 1-4. 1 was indicative of an event never being stressful, whereas 4 were indicative of an event that was very often stressful. Their academic performances were correlated with the survey results, and the authors found a higher stress score was correlated with poorer academic performance. More interestingly, the researchers found another component more important than stress levels in predicting academic performance: self-efficacy, or the belief that one can accomplish a task. In fact, when integrating the effects of both of these two factors, they found that self-efficacy to be more predictive of improved academic performance (Crego et al., 2016). In another study conducted at Saint Louis University School of Medicine, student performance in five unique categories (MCAT, USMLE Step 1, NBME Subject Exam Total, Preclinical performance and Clerkship Evaluation Total) were compared with results from health and wellbeing surveys. Stress and/or depression were negatively correlated with preclinical performance, the NBME subject exam total, and clerkship evaluation total (Haight, Chibnall, Schindler, & Slavin, 2012).

Clearly, finding healthy ways to deal with stress is critical to get through this ordeal. Rather than setting one huge overarching goal (e.g. “I have to learn all of microbiology in the next 3 days”) instead set a series of small incremental goals to give yourself more manageable and frequent targets (“the goal of the next 6 hours is to learn all of the gram negative bacteria”). Intermittent feelings of accomplishment make it easier to get excited about moving to a new section. Avoid snacking while studying, but instead make large batches of meals that can be frozen into aliquots – lasagna, stews, chicken and lentils, etc. – and thawed out when you need to eat something healthy and filling. Empty carbs can lead to sugar highs and crashes that interfere with studying. Finally, allow time for exercise (even a quick 15 minute walk to clear your head can release beneficial endorphins that increase blood-flow to the brain), and get 5-6 hours of quality sleep each night (8 hours of groggy disengaged studying is less effective than 6 hours of alert, active studying).

Many of my classmates may say stress doesn’t matter. They may cite research that has not shown a link between stress and Step 1 performance (Tucker, Jeon-Slaughter, Sener, Arvidson, & Khalafian, 2015).  Others have already decided on their desired specialties, in competitive fields such as Plastic Surgery, Otolaryngology, and Ophthalmology, and feel that a suboptimal Step 1 score may ruin their future career prospects. However medical students frequently change their minds about what specialty they want to pursue throughout medical school. According to a study published in Academic Medicine, only 20% of graduating medical student (between years 1991 and 1994) kept their specialty choice when they entered medical school, based on a pre-matriculation and post-graduation survey: “Approximately 80% of the graduates in both classes rejected the specialty intentions they had declared when they began medical school” (Kassebaum & Szenas, 1995). Similar results were found in a smaller but more recent study, which reported that 20-45% of medical students changed their specialty choice between their first and senior year of medical school (Compton, Frank, Elon, & Carrera, 2008). While these results suggest post-Step 1 flexibility, perhaps the reason for many deciding on another specialty was due to their Step 1 scores themselves. While this is probable, another study challenges that hypothesis as it showed that approximately 54% of medical students changed their specialty choice between freshmen and sophomore year; whereas approximately 58% switched between second and senior year (Held & Zimet, 1975). An additional study conducted in the 1990’s found that between the completion of second year to graduation, approximately 53% of students changed their specialty choice (McLaughlin, Daugherty, Rose, & Goodman, 1993)  Thus, even with a step 1 score in hand, switching specialties seems to be fairly common.

Reasons behind choosing different specialties are complex and numerous. One current study conducted in Canada suggests that an important factor in deciding whether individuals change their intended specialty (and indeed which specialty they switch to) is the prospective lifestyle they will lead. Desire for a better lifestyle steered individuals into family medicine, whereas a positive clinical experience encouraged individuals to go into a specialty (Scott, Gowans, Wright, & Brenneis, 2007). Another potential reason for change is direct exposure to the hands-on work in a given specialty, which may completely change the impressions that a student may have had before working in a clinical setting.

Regardless of the reasons, it is clear that many of us will switch from specialty option to specialty option throughout medical school. The overwhelming visage of the all-important Step 1 scores will soon be merely one data point among average board scores, mean number of publications, and extracurricular involvement. Maintaining a clear perspective about the importance of this exam, while not being overwhelmed by unhelpful stress, is one of the most important preparations you can take.



Compton, M. T., Frank, E., Elon, L., & Carrera, J. (2008). Changes in U.S. Medical Students’ Specialty Interests over the Course of Medical School. Journal of General Internal Medicine, 23(7), 1095-1100.

Crego, A., Carrillo-Diaz, M., Armfield, J. M., & Romero, M. (2016). Stress and Academic Performance in Dental Students: The Role of Coping Strategies and Examination-Related Self-Efficacy. Journal of Dental Education, 80(2), 165-172.

Haight, S. J., Chibnall, J. T., Schindler, D. L., & Slavin, S. J. (2012). Associations of Medical Student Personality and Health/Wellness Characteristics With Their Medical School Performance Across the Curriculum. Academic Medicine, 87(4), 476-485.

Held, M. L., & Zimet, C. N. (1975). A Longitudinal Study of Medical Specialty Choice and Certainty Level. Journal of Medical Education, 50(11), 1044-1051.

Kassebaum, D. G., & Szenas, P. L. (1995). Medical students’ career indecision and specialty rejection: roads not taken. Academic Medicine, 70(10), 937-943.

McLaughlin, M. A., Daugherty, S. R., Rose, W. H., & Goodman, L. J. (1993). Specialty choice during the clinical years: a prospective study. Academic Medicine, 68(10), S55-57.

Scott, I., Gowans, M. C., Wright, B., & Brenneis, F. (2007). Why medical students switch careers: Changing course during the preclinical years of medical school. Canadian Family Physician, 53(1), 94-95.

Tucker, P., Jeon-Slaughter, H., Sener, U., Arvidson, M., & Khalafian, A. (2015). Do Medical Student Stress, Health, or Quality of Life Foretell Step 1 Scores? A Comparison of Students in Traditional and Revised Preclinical Curricula. Teaching and Learning in Medicine, 27(1), 63-70.

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