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Struggling To Pass Step 1? You’re Not Alone

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by Alec Palmerton, MD in Step 1 Pass-Fail

We offer free consultations for students preparing for the USMLEs. In previous years, we’d hear from a trickle of US MD students who had failed their Step 1 or struggled to pass. The passing rate has never been 100% for Step 1, although it was always relatively high – typically in the 96-98% for first-time test-takers of US MD schools.

We are hearing more and more anecdotes about how many students struggle to pass the USMLEs, particularly Step 1. In previous years, the focus was always on scoring higher. However, now that Step 1 is pass-fail, there seem to be substantially more students who are struggling to pass. It’s not an exaggeration to say that the Step 1 failure rate may end up being 3-5x (or more) previous years’ rates.

In this article, you’ll learn:

  • Why so many students are struggling to pass Step 1,
  • How there could be as much as a 5x (or more) failure rate bump this year,
  • A stark reminder that correlation ≠ causation,
  • If you’re struggling to pass Step 1, you’re not alone (and there’s hope!), and
  • Much more

Table of Contents

Why Are So Many People Struggling to Pass Step 1?

The stories of students struggling to pass Step 1 are all unique. However, they share several commonalities, which fall into three stages.

Stage 1: Schools and Students Underemphasizing Step 1 Prep

First, schools and students are preparing much less for Step 1. For students, this is because they are focused on extracurriculars and research to set themselves apart in the residency rat race. Schools rely on experience, which implies that passing should be a low bar to attain.

Stage 2: Overemphasizing Rote Memorization for School

Next, students focus on their school exams. In many cases, schools explicitly tell their students they should concentrate on doing well in their classes. Why? Because in prior years, students who did well on those exams passed Step 1 without a problem.

Note the potential logical fallacy here, however. We are assuming a correlation equals causation. In other words, the correlation (students doing well in class also passing Step 1) does NOT prove the causation (students passed Step 1 BECAUSE they had done well in classes). We’ll discuss this more in depth below.

This distinction between correlation and causation is essential. Why? Because Step 1 and school exams emphasize different things. Most school exams focus on memorizing minutiae over conceptual mastery. Step 1, in contrast, focuses on the application of foundational concepts in medicine.

Students who focus solely on med school classes are encouraged to take a memorization-heavy approach until they reach…

Stage 3: Realizing that Step 1 is Nothing Like Med School Exams

When students finally begin their dedicated study, they realize that their classes have woefully underprepared them for Step 1. They panic, try and follow the plans of prior students – usually, a heavy dose of multiple UWorld / UFAP passes – and find that their scores are still not comfortably above the passing threshold.

Many of these students struggling to pass say the same thing: they lack a foundation. The number of people who come to our site looking for “relearning everything during Step 1 study” is staggering.

Faced with the prospect of delaying their graduation by a year, many students still take their tests without being fully prepared. From an individual standpoint, a 70% chance of passing may seem like a reasonable wager. However, when hundreds (or thousands) of students take a similar gamble, the results are predictable – many more fails than in prior years.

Correlation ≠ Causation

What does this “just do what worked for students in past years” mentality, miss? Before Step 1 pass-fail, students did much MORE than just prep for their school exams. They often began preparing for Step 1 as early as their first year. Many pre-Step 1 pass-fail students went as far as NOT going to class and learning exclusively for Step 1. It even had a term – “Step 1 Mania.”

It’s hard not to wonder if Step 1 Mania had the unintended consequence of papering over deficiencies in medical education. For example, did early exposure to Step 1 material – and the application of concepts – allow students to see beyond memorizing the body as a series of facts?

During this period, their class material was deprioritized or even ignored – remember the complaints that Step 1 was ruining medical education? Plus, many of these early preparers used techniques like spaced repetition, so they weren’t left relearning everything for Step 1.

Did Step 1 Mania Paper Over Deficiencies in Medical Education?

Someone suggested this simplified model, and I can’t disagree:

Step 1 Mania: Students study hard for Step 1, de-emphasizing class material. They pass the memorization-heavy school exams while teaching themselves medicine.

Students think: I passed my classes because I had to. I did well on Step 1 material because I studied it early and often.

Schools think: Students are doing well and passing Step 1 because our classes prepared them well. See, they didn’t need to study Step 1 material!

Post-Step 1 Pass-Fail: Students don’t study for Step 1 because the previous failure rate had been so low. They memorize and pass the class tests without developing a solid foundation.

Students think: I passed my classes. Why am I struggling so much with Step 1? Is there something wrong with me?

Schools think: How are students struggling so much with Step 1? Is there something different about these students?

In other words, everyone has been confusing correlation with causation.

Correlation: students who did well on class material are doing well on Step 1

Causation: students did well on Step 1 BECAUSE they did well on class material

It’s hard not to think that the reverse was more likely. Students who had prepared well for Step 1 had done well in classes – NOT those who had prepared well for school exams had done well on Step 1. The alarmingly low pass rates we’re hearing from US MD schools suggest that the causation may go oppositely.

You’re Not the Only One Struggling: How Many People Are Failing the Pass-Fail Step 1?

As we’ve discussed, some unofficial estimates are trickling out that the problem is pretty broad. For example, one highly regarded medical school told their students that 25% had delayed their Step 1 date. Delaying meant students pushed back the start of clerkships or may even have taken an entire year off for more time.

Early reports of Step 1 passing rates from schools – relayed by students – tell an even more sobering picture. Several prominent US MD schools reportedly have pass rates of near 90% – implying a failure rate of 2-5x a typical year previously. Most other schools we have heard about seem to have passing rates in the 80s, sometimes in the low 80s.

What’s worse is that these passing rates don’t include many students who haven’t even taken their test yet. If even a portion of those delayers had taken their test and failed, the passing rates would likely be lower.

What does this mean? If you’re struggling with Step 1, you’re not the only one. And most of it isn’t your fault.

Concluding Thoughts

We aren’t prescribing what you should do or how things should change. Instead, if you’re struggling, I want you to know you’re not alone. And frankly, while I’m sure you can find many reasons why you could have/should have done better, most of this isn’t your fault. It’s also not the fault of your professors or the administrators at your school. Instead, it’s the system – having 100 lecturers teaching 100 lectures while not being trained, paid, or incentivized to do a good job.

And the uncomfortable, unfortunate truth is that whereas it’s not anyone’s fault, you are left feeling lost, disempowered, and struggling.

I’d like to offer you a free consultation if you’ve read this far. I can’t promise to change the system or to make everything instantly better. However, we will do our best to listen and understand your situation and offer suggestions for the best plan and resources to move forward.

And if you’re curious, we’ve been building a medical education system in parallel for years. An approach that emphasizes concepts over rote memorization. One that helps you learn things well – and never forget them. If you’d like to learn more, we’d love to hear from you.

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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.