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Running Out of Time to Pass Step 1? Here Are Your Options

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by Alec Palmerton, MD in Plan, Step 1 Pass-Fail
USMLE Step 1 Running Out of Time

There is nothing worse than needing to take a test we’re not ready for. Even worse is when it is Step 1, a test we may have underestimated now that it’s pass-fail. (Or maybe you even failed). Finally, we may feel overwhelmed – there is way too much to do and too little time.

If you are struggling to pass Step 1, know that you are not alone. It may feel like the end of the world. You may feel incompetent. You may even feel like you are the only one. However, that would be wrong on all counts.

In this article, you will learn:

  • Why so many people have underestimated the difficulty of a pass-fail Step 1,
  • How you can turn your despair into tangible hope,
  • Your options if you struggle to pass Step 1, including one that might even let you graduate on time, and
  • Much, much more

Table of Contents

The Kubler Ross Stages of Step 1 Struggles

For those of us struggling to pass Step 1, many cycle through the Kubler-Ross stages of grief:

  • Denial – no way! Things will be ok – I just had a dud of a practice test. I know a lot more than my practice scores show.
  • Anger – what the $&!@ did my school teach me? I did everything right, passed all my classes, and this is the position I’m in?
  • Bargaining – there has to be a way. There is the perfect solution where I can do everything I need and still make it to clerkships on time. I just need to look at one more Reddit post…
  • Grieving – this is horrible. What will happen to my residency application? Will I be a doctor?

Ultimately, we may be struggling to get to the point of acceptance. But, unfortunately, too intense is the panic and raw emotions.

Anyone who has been in this position knows the guilt of feeling like they should have known better. The joy has long since evaporated from our lives, only for panic and despair to settle in.

Why Is Passing Step 1 So Difficult Now That It is Pass-Fail?

Many people are finding that Step 1 is harder to pass than expected. But why?

We’ve discussed why Step 1 is so hard to pass in this article. For our purposes here, suffice to say that most med schools – both in the US and abroad – test minutiae and the recall of facts. Rarely do they move students to apply concepts. This focus on cramming and memorizing details hurts on exams like the USMLEs that test your ability to USE knowledge rather than regurgitate it.

See this article for more on why Step 1 pass-fail is so hard to pass.

What Are Your Options?

What do you do if you find yourself struggling to pass Step 1 or want to prevent such struggles in the future? In particular, how can you navigate a system that encourages the memorization of facts – even if that approach hurts you for Step 1 and Step 2 CK?

First: Take a Time-Out

Bad decisions multiply like rabbits. Once I’ve made one wrong decision, I will often compound that by making another bad one. For example, if I stay up too late the night before, I may wake up late. Being late will lead me to rush, maybe driving too fast and narrowly avoiding an accident. But while I’m ruminating about my near-miss, I miss my exit and become even more late.

A similar process happens to those of us who are struggling to pass Step 1. We feel unprepared, have low NBME scores, and rush to make up the difference.

What is the natural response when we have too much to do and too little time? We try to cram everything we think we need to do into the time we think we need to do it in.

USMLE Step 1 Running Out of Time

Does studying feel like you’re rushing against time? Take a deep breath.

Do you find yourself rushing but paradoxically making little to no progress? If so, the best thing to do is stop and take a deep breath. Slow down, so you learn the material well and don’t have to repeat it. Doing 200 UWorld questions in a day without giving yourself the time to master it does you no good. Rushing through a topic to “cover” it means you’ll have to repeat it later and minimizes the chances of getting questions on that topic correct.

Instead, use the process that I call “slow is fast.” In other words, taking things slowly paradoxically lets you accomplish things faster, because you do not have to redo everything. For more on how slow is fast, you may want to read this article. Next, consider your options:

Option #1: Take Your Test as Planned (Not Recommended)

You will feel very tempted to take your test on the original date. It is a (minor) pain to move your exam. In addition, you may have misgivings about delaying clerkships and/or taking your test after your first clinical year.

Most importantly, schools will NOT like it when students delay their tests. Most do not actively advertise that postponing Step 1 is an option. Some go so far as to say that students CAN’T push back their tests. Some schools may not be able to offer delays to all the students who want them.

Why? I’m speculating, but I’d imagine that delaying clerkships is a substantial administrative headache. If 25% of the class pushes back their first required clerkship, it creates enormous imbalances later on when they all need to finish their requirements.

However, doing the convenient thing (taking your test) when you’re not ready can backfire. In particular, if you fail, there are lasting consequences – many residency programs will reject an applicant with ANY failure of a USMLE.

Because Step 1 is unscored, there will likely be a greater emphasis on clerkship grades. Shelf exams are very similar to Step 1 in style and even content. Taking Step 1 unprepared will also lead to problems a few months later when you start taking your shelf exams.

Option #2: Delay Clerkships and Take Your Step 1 Later

If you need more time to prepare for Step 1, one obvious option is to delay your clerkships. Here are the pros and cons of this approach:

Advantages of Delaying Clerkships

Postponing clerkships gives you more time to study for Step 1. If time is the problem – you are learning things well, and more time is all you need – delaying makes a lot of sense. You would know this if when you learn something, you understand it well, and your QBank/NBME scores improve. Moving your clerkships back will give you more time to build a stronger foundation for shelf exams.

Disadvantages of Delaying Clerkships

As noted above, postponing rotations may be logistically challenging. In addition, schools may not be in a position to let many students delay their clerkships, given a limited number of students associated hospitals can accommodate.

Most importantly, many students who aren’t ready to take Step 1 need more than just time. Often, they need a different approach. If you’ve been cramming/memorizing for two years, don’t expect an extra month of skimming 100+ UWorld questions/day to make up the gap. To re-learn the material well, we need a lot more time AND an approach that allows us to master – not memorize – medicine.

Did you learn the material well previously and just need to refresh it? If so, delaying your test by a month or two can give you the cushion you need to pass.

However, if you’ve been cramming for most of med school and struggle to pass Step 1, I’d recommend Option #3, below.

Option #3: Change Your Approach, Delay Step 1, and Take It After Your First Clinical Year

Thinking of taking Step 1 after your first clerkship year? Here are the advantages and disadvantages:

Advantages of Taking Step 1 After Your First Clinical Year

For many people, taking Step 1 after their first clinical year makes a lot of sense. Why? Because for many students struggling to pass, the amount of material they will need to cover is more than they can reasonably do in a month or two.

In addition, clerkships are excellent preparation for Step 1. Why? Because the format – and even content – of shelf exams overlaps hugely with Step 1 material. Don’t believe me? Many schools have students take Step 1 after their first clinical year by default. (E.g., University of Pennsylvania, Harvard, Duke, NYU Long Island, etc.). My guess is that trend will continue to grow.

Disadvantages of Taking Step 1 After Your First Clinical Year

The con of taking Step 1 later in ANY form is that having more time isn’t a guarantee you’ll be ready. Specifically, if you have more time but don’t change the approach that caused the problem in the first place, you’ll be back to where you started.

Shelf exams are often an excellent way to get in a Step 1 mindset. These tests you take after every clerkship come from the NBME – the same organization that writes Step 1 and Step 2 CK. So students will get multiple opportunities to learn how to take a USMLE-style test.

See this article for more on the best way to prepare for Step 1 during clerkships.

Concluding Thoughts

Is passing Step 1 harder than you expected? If so, you’re not alone. But you are left trying to determine what the best next step is. The most critical question is, “why am I struggling to pass Step 1?” The answer to that question will help you decide the best next step to take.

Did you learn the material well the first time? If so, another few weeks may be all you need to get back what you’ve mastered before.

However, for many students, the issue runs deeper. Unfortunately, the system of medical school education doesn’t encourage students to learn well. Why? Because of the emphasis on factoids rather than application of concepts. Instead, we get by through cramming and memorizing random facts/details. When faced with actual tests of our understanding (e.g., USMLEs, real patients, etc.), our mind often fails us.

Regardless of the reasons for struggles about passing Step 1, there is hope. If you’d like help navigating your options, consider a free consultation. We have helped numerous students who previously struggled to pass Step 1. Often the reasons for their struggles are more straightforward than they thought. Never is it that the student is just incapable.

Sign up for a free consultation to learn more about how you can turn your Step 1 struggles into meaningful progress.

Photo by Milad Fakurian

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Want FREE Cardiology Flashcards?

Cardiology is key for impressive USMLE scores. Master cardiology from a Harvard-trained anesthesiologist who scored USMLE 270 with these 130+ high-yield flash cards. You’ll be begging for cardio questions - even if vitals make you queasy.