Purpose
This research describes the challenges medical students face with English as a Second Language (ESL) when preparing for the United States Medical Licensing Examination (USMLE) Step 1. The purpose was to identify factors determining language barriers and proficiency affecting Step 1 readiness. This will lead to proposing strategies to support students pursuing a bilingual medical education to succeed in Step 1.

Method
A 23-item scale, from strongly affected to not at all, measured the ESL impact in preparation and performance in Step 1 among bilingual medical students. It examined how ESL challenges impact confidence in lectures and in-class discussions, reading comprehension, and overall preparation for Step 1. Additionally, interviews were held with students enrolled in a remedial course to gather deeper insights into their specific linguistic obstacles. The data were analyzed to identify trends and propose targeted support strategies to address ESL barriers to succeed in Step 1.

Results
Findings revealed that 39% of students expressed a lack of confidence in participating in lectures due to language barriers, and 28% reported difficulty with reading comprehension, a critical skill for interpreting exams. Forty-two percent (42%) expressed that confidence in participating in class discussion is affected, meanwhile 35% struggle with understanding medical terminology. These challenges not only increased anxiety in 80% of students but also limited their ability to engage fully with Step 1 preparation and performance.

Conclusion
Addressing ESL barriers is essential for improving Step 1 performance among ESL medical students. By integrating language support into Step 1 preparation, medical schools can help ESL students overcome these barriers. Based on the results, new strategies will be identified, fostering a more inclusive and equitable learning environment to make them succeed in Step 1.