USMLE Step 1 Is Now Fourteen 30-Minute Blocks: Format, Content, Registration and Pass Rates (2026)

Published 25 October 2026 · Luke, co-founder of OET BANK and USMLE BANK · 9 min read

If you are reading Step 1 experiences written before May 2026, one detail in them is now wrong: the day is no longer seven one-hour blocks. Step 1 has moved to fourteen 30-minute blocks, with the same number of questions and the same length of day. This article sets out what the exam looks like now, what it tests and in what proportions, how graduates of medical schools outside the US and Canada register (through FSMB since January 2026), what the pass rates say, and the preparation material the exam's own sponsors publish.

1. Three Steps, and the two you need first

• Step 1 asks you to apply the basic sciences to clinical situations. It is reported as pass or fail only.
• Step 2 CK tests clinical knowledge: diagnosis and management. The passing score is 218.
• Step 3 is a two-day exam on unsupervised practice. The passing score is 200, and it is offered only in the US and its territories.

For a graduate of a medical school outside the US and Canada, the exams that count towards ECFMG Certification are Step 1 and Step 2 CK, together with the English requirement, OET Medicine. The two Steps can be taken in either order, and you can apply for both at once. Step 3 needs passes in both and a valid ECFMG certificate.

2. What changed in May 2026: 30-minute blocks

A new test-delivery program cut the day into shorter blocks. The number of questions and the length of the day stayed the same. The change reached Step 3 on 10 March, Step 2 CK on 7 May and Step 1 on 14 May 2026.

Two practical consequences. When you read someone's account of the exam, check the date first: "seven blocks of forty" describes an exam that no longer exists. And with twice as many blocks, the way you split your break time between them needs planning again.

3. What Step 1 tests, in percentages

The USMLE publishes the share of Step 1 that each organ system takes:

By discipline, pathology (45–55%) and physiology (30–40%) dominate, followed by nutrition (15–20%) and gross anatomy and embryology, microbiology and pharmacology at 10–20% each. Every question sits in a system and a discipline at once, so the columns add up to more than 100%. Nutrition content was increased across all three Steps from June 2026, and score reports now give feedback on it.

For comparison, Step 2 CK is weighted by specialty — medicine 55–65%, paediatrics 17–27%, obstetrics and gynaecology 10–20%, psychiatry 10–15%, surgery 5–15% — and by task, led by diagnosis (16–20%), laboratory and diagnostic studies (13–17%) and mixed management (12–16%). Step 1 asks why something happens; Step 2 CK asks what you do next.

4. How international graduates register: FSMB since 2026

Since 12 January 2026, students and graduates of medical schools outside the US and Canada apply for Step 1 and Step 2 CK through FSMB, not ECFMG. The order is:

1. Open your ECFMG file

   Create a MyIntealth account and have your application for ECFMG Certification accepted. That has to happen before your first exam application.

2. Create an FSMB account

   If FSMB cannot match you to an existing record, identity verification costs $75, which stays on your account as credit for a later FSMB service.

3. Apply for the Step and pay

   The exam fee is $695. Testing outside the US and Canada adds a regional fee: $210 for Step 1 and $235 for Step 2 CK.

4. Receive your scheduling permit

   It arrives by email. Allow at least two weeks for the application to be processed.

5. Book a date at Prometric

   Choose the date and the test centre with the permit.

5. Choosing a three-month window, and the cost of moving your date

When you apply, you choose a three-month eligibility period — April to June, for example. Permits and Prometric bookings open six months before the period starts, and seats go to whoever books first.

• Extending the period: once only, for the next three months, $70, non-refundable, requested within 25 days of the period ending.
• Moving to an earlier period: you have to cancel and apply again. Cancel after approval and the whole fee is lost; cancel before approval and you get it back minus $100.

Prometric's fees for changing or cancelling a booking have been the same in every region since 1 July 2026:

Results usually arrive within four weeks and are released on Wednesdays. FSMB advises allowing up to eight weeks.

6. Where you sit it

Step 1 and Step 2 CK are taken at Prometric test centres, and the USMLE says there are about 100 Prometric centres outside the US. The official site does not currently publish a list of countries, so whether a seat is available in your city is something you find out when you book with your permit. You choose a testing region on the application and can change it after the permit is issued. Step 3 is only offered in the US.

7. How hard it is: pass rates and attempt limits

The USMLE's figures for 2025, first-time takers:

For international graduates, Step 1 is the steepest of the three, and after a failure the pass rate falls to little more than half. From 2025, examinees from Canadian schools are counted with the schools outside the US and Canada.

The number of attempts is limited too:

• Four or more unsuccessful attempts at any Step make you ineligible for every Step. An incomplete attempt counts.
• The same Step can be taken at most three times in 12 months. A fourth attempt needs 12 months since the first and six months since the most recent.
• A Step you have passed cannot be retaken.
• For ECFMG Certification, the exam requirements must all be met within seven years of the first exam you pass.

8. The official preparation material

Plenty of courses and question banks exist. These are only the materials published by the exam's sponsors:

• Free sample questions: 119 for Step 1 (six blocks, updated April 2026), 120 for Step 2 CK, 137 for Step 3, with a practice version of the new test software.
• Prometric practice session: once you have a permit, in the region of your exam. $155 outside the US. The questions come from the free samples.
• NBME self-assessments: CBSSA for Step 1 and CCSSA for Step 2 CK, from $62, seven forms, four sections of 50 questions, with a score report that estimates your likelihood of passing.

Sitting the free samples under exam conditions first, and using the NBME self-assessments to check where you stand as you go, is the framework you can build from official material alone.

9. If you are aiming at the 2027 Match

• Take the OET by its last sitting in December 2026. Your Pathway application and OET score must reach ECFMG by 31 January 2027.
• 29 January 2027: NRMP standard registration deadline (a $50 late fee after that).
• 3 March 2027, 9 p.m. US Eastern: rank order list deadline. Step 1, Step 2 CK and your Pathway must all be complete by then.
• 19 March 2027: Match Day.

ERAS applications for this season opened on 2 September 2026. If you are starting Step 1 now, a realistic target is the following year or later; the 2028 Match calendar has not been published.

Frequently asked questions

How many questions are on USMLE Step 1 in 2026?

About 280, in fourteen 30-minute blocks of up to 20 questions each, over a testing day of about eight hours with at least 55 minutes of break time. This format started on 14 May 2026; before that, Step 1 was seven 60-minute blocks of up to 40 questions.

Is USMLE Step 1 still pass/fail?

Yes. Step 1 has reported only pass or fail since 26 January 2022. Step 2 CK still has a three-digit score, with a passing score of 218, and Step 3's passing score is 200.

How do international medical graduates register for Step 1 now?

Through FSMB, since 12 January 2026. Your application for ECFMG Certification has to be accepted first (through a MyIntealth account). Then you create an FSMB account, apply and pay $695 plus a $210 regional fee if you test outside the US and Canada, receive a scheduling permit by email, and book at Prometric.

What is the Step 1 pass rate for international medical graduates?

In 2025, 75% of first-time takers from medical schools outside the US and Canada passed (22,066 examinees), against 93% for US MD schools. Repeat takers from schools outside the US and Canada passed at 54%.

How many times can I take USMLE Step 1?

At most three times in any 12 months, and four or more unsuccessful attempts at any Step make you ineligible for all of them. A fourth attempt at the same Step requires 12 months since your first and six months since your most recent attempt. You cannot retake a Step you have passed.