Table 5. Conventional content analysis of narrative comments on the costs and values of USMLE Step 1 exam preparation.

USMLE: United States Medical Licensing Examination

Theme	N	Representative Examples:
Step 1 studying was important preparation for the clinical years of medical school and residency	13	“While the problems with Step 1 are absolutely endless, they at least provided a basic framework to hang information off of- knowing what kind of basic science knowledge has relevance to the practice of medicine.  This is contrasted to lectures from some basic scientists, who either do not know or do not have interest in making sure the information presented serves a role in informing the practice of medicine later in our careers”   “I think that the score on Step 1 forced me to study far more in depth than I would have if it was pass/fail, and I processed/integrated information at a higher level- as a result I was FAR more prepared for clinical work”   “While there are clearly mixed feelings about Step 1, I do believe that the time and focus spent studying for this exam forced me to learn, re-learn, and enhance my understanding of so many different topics.  It was the time where I cemented a number of subjects/topics from the didactics that I simply did not have the ability to consolidate during the first 1.5 years”
Our preclinical curriculum interferes with Step 1 studying or posed a barrier to my career goals	12	“I wish we had an organized lecture/presentation outlining the long-term importance of Step 1 and what ramifications certain scores might have on our realistic opportunity to be accepted into certain specialties…. I wish someone had urged me to use Step-focused resources to study throughout my first 2 years, rather than using lectures which are often times NOT high yield”   “Because [of] the impact Step 1 had on residency, I was only interested in learning that content during the first two years regardless of what was being taught in the lectures”   “The course load was too much to study for Step 1 and we were told not to study for Step 1 during the first year of medical school because [the later preclinical curriculum] would be so great… had Step 1 been emphasized earlier on, and had we been encouraged to start studying from day 1, my score would probably not have been so terrible”
Step 1 studying adversely affected my mental or physical health or other aspects of my wellbeing	12	“I was honestly afraid I was not going to physically survive the first two years of medical school because I was so anxious about scoring well on Step 1…. The pressure to perform well on Step 1 exacerbated my depression. When I finally got my score and realized it wasn’t a good score, I didn’t even care because I was just shocked that I had survived”   “I did not eat well and skipped several meals a week while preparing for USMLE Step 1. I did not exercise at all during dedicated preparation for USMLE Step 1. I did not see my significant other or family members for 3+ weeks at a time during the preclinical years, especially during dedicated preparation for USMLE Step 1”   “The survey only asked about sacrifices made to volunteerism/community service, leadership/advocacy, direct patient care, and medical research activities… however, I also sacrificed wellness activities to study more for Step 1 (orchestra rehearsals, writing club sessions, tennis league) because I didn’t feel I could spare the time”
Step 1 studying is a barrier to learning how to be a good doctor or is not an adequate measure of students’ clinical potential	12	“I felt USMLE Step 1 was focused on a lot of things I never saw or used in actual clinical practice and I wasted a lot of time studying. It did help reinforce/consolidate some information, but I think that could’ve been accomplished in a different, less stressful manner.”   “I spent too much time during my preclinical years memorizing intricate details of systems that don’t actually affect patient care. I frequently found that I had missed the “big picture” so often during my preclinical years that I felt ashamed of my medical knowledge during my clinical years. Even though I’ll graduate at the top of my class, I feel like I lack the meaningful medical background knowledge I need to care for patients that I should have solidly learned in my preclinical years (anatomy, relevant physiology). I regret that I spent so much time learning to do well on my exams instead of finding ways to make the clinically relevant information we learned ‘stick.’”   “It was difficult to focus on the content of our lectures knowing that more weight was put on our Step 1 score when it comes to matching. However, I believe our clinical lectures would have helped us in preparing to become better and more well-rounded physicians than studying for Step 1 has.”