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Will Failing Step 1 Be the Best Thing That Could Have Happened?

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by Alec Palmerton, MD in Plan, Step 1 Pass-Fail

Did you fail Step 1, or are you struggling to pass? If so, you may be feeling hopeless. You may be wondering:

  • Is residency even a possibility now?
  • Do I even deserve to be a doctor?
  • Will that pit in my stomach from failing Step 1 ever go away?

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. Those things that you knew that you should be doing that you kept putting off? You will have renewed motivation and purpose in addressing them.

Look back on your life and you’ll probably see that the most meaningful changes happened during the most difficult 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

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. (https://www.yousmle.com/fail-step/)

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 Rates2017201820192020
MD Degree Examinations21,38221,61122,14620,343
MD Degree Passing %94%95%96%97%
MD Fails*1,2831,081886610
DO Degree Examinations3,8354,1364,8375,274
DO Degree Passing %95%96%96%95%
DO Fails*192165193264
IMGs Examinations17,20316,44316,06513,117
IMGs Passing %73%75%78%83%
IMG Fails*4,6454,1113,5342,230
Total Step 1 Exams42,42042,19043,04838,734
Overall Step 1 Pass Rate86%87%89%92%
Total Step 1 Fails6,1195,3574,6143,104

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 2020 Survey. However, many more program directors participated in the 2018 survey, so the results are reproduced here).

“Would your program consider applicants who fail Step 1 on the first attempt?”

 NeverSeldomOften
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 need to here. 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. It is important to grieve, particularly with those who love and support us.
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 the masks we put up 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 actually 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 were 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 many times do you need to re-read a paragraph before you understand 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?

The question you may be asking is, “when should I schedule my Step 1 re-take?” While there is no one-size-fits-all answer, I can offer some guidelines.

First of all, 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 ~10 points/month of effective, full-time studying. That means focusing on mastering material as opposed to memorizing.

Note: can you improve by MORE than 10 points 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 10 points/month, we wouldn’t bet our next Step 1 attempt on our ability to do so.

With our ~10 points/month target, here are some rough guidelines for how to schedule your Step 1 re-take:

Step 1 Score < 170

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 at a minimum before you will feel comfortable retaking your test. However, much will depend on how well you can address why you failed in the first place.

170-180

You are likely still dealing with memorization, rushing, anxiety, and/or burnout at this level. However, you may have specific areas that you feel stronger on than others – things that 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.

180-193

In this category, you may have known that failing Step 1 was a possibility. However, the final score may still have come as a surprise.

If your NBMEs are still within the 180s-190s 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 higher (and pass) several months later. Here is Rosa:


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 we are thrilled to see them match. If you want help passing Step 1 – and doing even better on Step 2 CK – sign up for a free consultation here.

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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.

Subscribe
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