Did you fail Step 1, or are you struggling to pass? If so, you may be feeling depressed or even hopeless. You may be wondering:
- What are my residency chances?
- What do I do next? Or even,
- Do I even deserve to be a doctor?
Right now, it may feel like the world is ending. But with the right approach, failing Step 1 can also be the springboard for career-altering change. We’ve helped a student go from failing Step 1 to scoring in the 97%ile (the equivalent of a 262) in less than two months. (An insane 32% improvement).
Look back on your life and you’ll probably see that the most meaningful changes happened during the most challenging times. Why? Because most people rarely make important changes during good times. In fact, with perspective, many students tell us that failing a USMLE was the best thing that could have happened to them. In this article, you will learn:
- How bad is it to fail Step 1, and how many people fail every year?
- Statistics on how often people match after failing Step 1
- Concrete reasons why the problem is NOT you, but your approach – and what to do
- Research-based strategies to helping you calm the gnawing sense of dread you may be feeling, and
- Much more
Summary:
- Failing Step 1 feels like one of the lowest points in many people’s medical careers
- However, not passing Step 1 can be a career-changing wake-up call
- Step 1 fails are increasingly common now that Step 1 is pass-fail
- From 2020 to 2022, the overall Step 1 fail rate more than doubled, from 8% to 18%
- Not passing Step 1 hurts your residency chances, but not as much as you might fear
- To be safe, give yourself ~1 month dedicated studying for every 5% Step 1 NBME improvement you’re looking for
NOTE: this article was updated 7/1/2024, and includes:
- The most up-to-date Step 1 passing rate information (2023),
- USMLE attempts for each Step being limited to four times (rather than six) as of July 2021, and
- Advice given Step 1 being pass-fail
Table of Contents
How Bad Is It to Fail Step 1?
You’re probably asking, “can you get a residency if you fail Step 1?” The short answer: yes! A JAMA study found > 99% of graduates entered GME/practice in the US within six years of graduation. In other words, even though roughly 3% of people didn’t match in a given year, most ended up in residency/practice. In one US allopathic school, 92% of students (59 of 64) who had failed the USMLE matched.
Am I the Only One Who Didn’t Pass Step 1? How Many People Fail
Another thing to know is that you are not alone. Every year, thousands of people fail the USMLEs. Here is how many people fail Step 1 every year.
| Step 1 Passing Rates | 2019 | 2020 | 2021 | 2022 | 2023 |
|---|---|---|---|---|---|
| MD Degree Examinations | 22,146 | 20,343 | 23,078 | 24,251 | 25,146 |
| MD Degree Passing % | 96% | 97% | 95% | 91% | 90% |
| MD Fails* | 886 | 610 | 1,154 | 2,183 | 2515 |
| DO Degree Examinations | 4,837 | 5,274 | 5,365 | 4,722 | 4,913 |
| DO Degree Passing % | 96% | 95% | 94% | 89% | 86% |
| DO Fails* | 193 | 264 | 322 | 519 | 688 |
| IMGs Examinations | 16,065 | 13,117 | 19,210 | 24,956 | 26,141 |
| IMGs Passing % | 78% | 83% | 77% | 71% | 68% |
| IMG Fails* | 3,534 | 2,230 | 4,418 | 7,237 | 8365 |
| Total Step 1 Exams | 43,048 | 38,734 | 47,653 | 53,929 | 56,200 |
| Overall Step 1 Pass Rate | 89% | 92% | 88% | 82% | 79% |
| Total Step 1 Fails | 4,614 | 3,104 | 5,894 | 9,939 | 11,568 |
The passing rate of people who are re-taking Step 1 is lower. However, despite that, the majority of people who take Step 1 again will pass. For example, in 2020, of the 1985 re-takes of Step 1, 55% passed.
How Many Times Can I Re-Take Step 1?
Before July 2021, you could attempt Step 1 up to six times. However, per USMLE.org:
The total number of attempts allowed per Step is four (4). Examinees who have attempted any USMLE Step (including Step 2 CS) four or more times and have not passed are ineligible to apply for USMLE Steps.
Regardless of how many times you can take it, remember, your next attempt is the most important. The more times you fail Step 1, the more complex the residency match process will become.
What Do Residency Programs Do When You Fail Step 1
I won’t sugar-coat it. There are a fair number of programs that will reject an application that has a USMLE fail. That said, many programs will still consider you if you do better on a subsequent attempt. Here are the results of the 2018 Program Director Survey. (Note the results are broadly similar to the 2021 Survey. However, many more program directors participated in the 2018 survey, so the results are reproduced here. In addition, this question was no longer asked in the 2022 survey). “Would your program consider applicants who fail Step 1 on the first attempt?”
| Never | Seldom | Often | |
|---|---|---|---|
| Anesthesiology (N = 58) | 34% | 66% | 0% |
| Child Neurology (N = 33) | 27% | 70% | 3% |
| Dermatology (18) | 50% | 50% | 0% |
| Emergency Medicine (84) | 37% | 61% | 2% |
| Family Medicine (141) | 3% | 47% | 50% |
| Internal Medicine (163) | 23% | 66% | 11% |
| Internal Medicine/Pediatrics (26) | 35% | 62% | 4% |
| Interventional Radiology (14) | 64% | 36% | 0% |
| Neurological Sugery (24) | 58% | 38% | 4% |
| Neurology (37) | 27% | 59% | 14% |
| Obstetrics and Gynecology (79) | 34% | 65% | 1% |
| Orthopaedic Surgery (46) | 65% | 35% | 0% |
| Otolaryngology (32) | 56% | 44% | 0% |
| Pathology (40) | 28% | 68% | 5% |
| Pediatrics (73) | 4% | 79% | 16% |
| Physical Medicine and Rehabilitation (24) | 8% | 79% | 13% |
| Plastic Surgery (20) | 80% | 20% | 0% |
| Psychiatry (58) | 3% | 62% | 34% |
| Radiation Oncology (25) | 52% | 40% | 8% |
| Radiology-Diagnostic (42) | 43% | 52% | 5% |
| Surgery (97) | 46% | 53% | 1% |
| Thoracic Surgery (8) | 30% | 70% | 0% |
| Transitional Year (27) | 44% | 52% | 4% |
| Vascular Surgery (13) | 23% | 77% | 0% |
What Should I Do If I Failed Step 1?
If you’ve failed Step 1, you may feel overwhelmed by what you must do. Here are some concrete steps you can take to help you make your next attempt maximally successful.
Grieve and Reach Out to Others
If you failed Step 1, you might be feeling numb right now. You may want to bury your panic, shame, and horror, then curl into a fetal position in the corner. Delving into your thoughts and feelings is probably the last thing you want to do right now. You may be afraid of what you find when you open what feels like Pandora’s box of emotions. However, research strongly suggests you SHOULD grieve. When we put words to our emotions – “terrified,” “angry,” “lonely” – we start to calm down almost immediately. Researchers call this putting of feelings into words “affect labeling.” Specifically, Matthew Lieberman of UCLA has shown that naming our emotions calms down our amygdala, our brain’s threat sensor. At the same time, our prefrontal cortex – the rational brain – kicks in. With a functioning prefrontal cortex and calm amygdala, you can coolly reflect on what happened. You will need to objectively think about what went wrong so you can address it the next time. (More on this below). Another essential thing to do is to reach out to others. You may be feeling incredibly alone right now. Grieving, particularly with those who love and support us is important. Under the best of circumstances, social isolation is bad for your well-being. It’s even worse when you’re undergoing adversity. Plus, adversity often tears down our masks and allows for genuine connection. Indeed, some of my darkest hours have forged some of my closest friendships.
Current Med Students: Contact Your Administration
Current med students need to contact their administration. Your point of contact may be an academic advisor or dean. Whatever you do, it’s essential to let your school know. (Note: often your school will already know). Why is it important to keep your school in the loop? There are practical and administrative consequences you’ll need help navigating. If you failed Step 1, often, students will have to delay/pull out of clerkships. This clerkship interruption is because some schools require students to pass Step 1 to be in clerkships. Other schools may want to give you dedicated time to pass your exam. Either way, letting your school know is critical.
Take an NBME Self-Assessment
Next, you’ll want to take an NBME Self-Assessment. NBME self-assessments allow you to:
- Assess your problem areas
- Figure out patterns in questions you’re missing
- Establish a baseline from which you can measure your progress
You should NOT be surprised if your NBME is below your last Step 1 score. It may have been months of not studying since taking your test.
Give Yourself Enough Time and Stop Rushing
One of the most common reasons people fail Step 1 is that they rush. Rushing usually follows this course:
- Begin studying for Step 1
- Take practice test / realize I’m not nearly where I wanted to be yet
- Feel pressed for time since I “need” to take my test by a particular date
- Compress what I feel I need to do (a lot) into a timeframe I think I have (a little)
- Rush through the material and not be able to learn anything well
- Continue to get disappointing results, rush more, and repeat the cycle
There is strong psychology behind rushing. Research on scarcity – in this case, of time – is illuminating. When we have too little time, we “tunnel” and ignore the long-term effects of our actions. For example, when we rush, we’ll stay up late into the night studying. We ignore the long-term consequences (being groggy and unproductive for days afterward) because we tunnel on what is in front of us (maximizing the day’s work). Interestingly, these adverse effects of scarcity have little to do with “mindset.” In other words, simply trying to have an “abundance mindset” is less important than giving yourself enough time to study.
Re-Think Your Strategy and Learn Things Well
Having enough time is only part of the equation. How you use that time is critical. Specifically, one of the most common reasons people fail Step 1 is that they don’t learn the material well. The tendency to memorize – rather than master the material – is pervasive in medical education. We cram lists of facts with little understanding of context. Because the pace of content is like drinking from a firehose, we feel there is little time to slow down and learn it well. Step 1 is usually people’s first wake-up call that memorizing is a poor strategy. The USMLEs, unlike many med school exams, focus on the application of concepts – not cramming disembodied facts. Memorization may have been an effective strategy previously when learning details by memory was all we needed. However, if you failed Step 1, I highly recommend giving yourself time to master the material. You can see an example of how you can master material – rather than memorize it – to make sure your next Step 1 attempt is your best one.
Address Burnout and Anxiety
If you find yourself “studying” without learning anything, you may be burned out and/or anxious. Both correlate with poor Step 1 performance. In this study, anxiety had a strong negative correlation with students’ Step 1 scores. It’s not hard to understand why anxiety or burnout can make a Step 1 failure more likely. Stress and burnout can derail the best strategies and intentions. Both burnout and anxiety can make you feel like a shell when you’re studying. How often do your eyes move across a page, but you don’t comprehend anything? How often do you need to re-read a paragraph before understanding it? If you suffer from burnout or anxiety, you may want to consider professional help. As someone who has struggled with worry for many years, I know how debilitating it can be for high-stakes exams. The good news is that if burnout or anxiety are holding you back, professionals can help you develop ways for dealing with them. There is nothing wrong with asking for help – it is just an additional avenue for improving your score on a subsequent Step 1 attempt.
When Should I Schedule My Step 1 Re-Take?
You may be asking, “when should I schedule my Step 1 re-take?” While there is no one-size-fits-all answer, I can offer some guidelines.
NBME Scaled Scores for a 95% vs. 99% Chance of Passing Step 1
First, what is the likelihood of passing based on your NBME scores?
- For a ≥87% chance of passing Step 1, aim for an NBME scaled score of 60% or higher
- For a ≥95% chance of passing Step 1, aim for an NBME scaled score of 65% or higher
- For a ≥99% chance of passing Step 1, aim for an NBME scaled score of 70% or higher
**Note: these are estimates based on large samples of predicted chances of passing across more than 100 individual datapoints
How Fast Can I Expect My Step 1 NBME Scores to Improve?
Next, how much of a score improvement can you expect? Much depends on how well you can address the reasons you failed in the first place. That said, we’ve found that students studying well can expect ~5% monthly improvement with effective, full-time studying. That means focusing on mastering material as opposed to memorizing. Note: can you improve by MORE than 5% per month? Sure! This is especially true if you’ve done few questions before. If you haven’t studied much previously, then there is still a lot of “low hanging fruit” left to pick. However, we’ve found that for those who had studied long enough to make a first Step 1 attempt, most of the “easy points” have been taken. Plus, while we’ve certainly helped students improve by more than 5%/month, we wouldn’t bet our next Step 1 attempt on our ability to do so. With our 5%/month target, here are some rough guidelines for how to schedule your Step 1 re-take:
Step 1 NBME Scaled Score ≤ 50%
Scores this low will need a deep re-think of the approach. You likely feel as if there is a lot that you “know” without truly understanding it. Memorization will be rampant at this level. You’ll likely need at least 4-6 months before you feel comfortable retaking your test. However, much will depend on how well you can address why you failed in the first place.
Step 1 NBME Scaled Score 50-60%
You are likely still dealing with memorization, rushing, anxiety, and/or burnout at this level. However, you may have specific areas you feel stronger on than others – things you can use as a springboard for learning other things. An optimistic timeline would put you at 2-4 months to be at a comfortable passing range.
Step 1 NBME Scaled Score 60+%
In this category, you may have known that failing Step 1 was possible. However, the final score may still have come as a surprise. If your NBMEs are still within the 60% range, you may only need a month or two to prepare. Note that, like everything, HOW you get ready will be critical.
Concluding Thoughts
Failing Step 1 may feel like the end of your chances at matching. It’s not. Not passing Step 1 may close some doors. However, it opens many opportunities for self-reflection and changes you may never have made. Many students we’ve worked with have told us afterward that it was the best thing that could have happened to them. Here’s a student who failed Step 1 only to transform her approach and score 28 points (~14%) higher (and pass) several months later. Here is Rosa: [wonderplugin_video iframe=”https://vimeo.com/732492521″ lightbox=0 lightboxsize=1 lightboxwidth=960 lightboxheight=540 autoopen=0 autoopendelay=0 autoclose=0 lightboxtitle=”” lightboxgroup=”” lightboxshownavigation=0 showimage=”” lightboxoptions=”” videowidth=600 videoheight=400 keepaspectratio=1 autoplay=0 loop=0 videocss=”position:relative;display:block;background-color:#000;overflow:hidden;max-width:100%;margin:0 auto;” playbutton=”https://www.yousmle.com/wp-content/plugins/wonderplugin-video-embed/engine/playvideo-64-64-0.png”]
If you’re feeling lost and want guidance on the best next steps, we can help you. We’ve worked with many students who pass their USMLEs after failing and are thrilled to see them match. Sign up for a free consultation here if you want help passing Step 1 – and doing even better on Step 2 CK.
