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Many medical students experience test anxiety, which may impair their performance in examinations. We examined the relationship between test anxiety and United States Medical Licensing Examination (USMLE) step-1 scores and determined the effect of a test-taking course on anxiety and USMLE scores.We randomly chose second-year students to take a test-taking strategies course (cases) from among volunteers. The remainder of the class served as controls. We measured test anxiety with the Westside Test Anxiety Scale (with possible scores of 1–5). The cases completed the Westside Test Anxiety scale at baseline, after completing the course (4 weeks) and again after taking the USLME step 1 (10 weeks). The controls completed the instrument at baseline and after taking the USMLE step 1 (10 weeks).Ninety-three of 101 (92%) students participated in the study. The baseline test anxiety score for all students was 2.48 (SD 0.63). Test anxiety was inversely correlated with USMLE step 1 (β = –0.24, p = 0.01), adjusting for Medical College Admission Test (MCAT) scores. The test anxiety score of the participants decreased from 2.79 to 2.61 after the course (p = 0.09), and decreased further to 2.53 after the USMLE (p = 0.02), whereas the scores of the controls increased. The mean USMLE step-1 score was 234 for the cases and 243 for the controls (p = 0.03).Many medical students experience test anxiety, which may impair their performance in examinationsTest anxiety is modestly inversely correlated with USMLE step-1 scores. A test-taking strategy course modestly reduced anxiety, but did not improve USMLE scores. More robust interventions that achieve greater reductions in text anxiety may improve test scores.