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*This post was updated July 2019.*  There’s no sugar-coating it — opening your Step 1 score report to find the word “Fail” plastered in that little grey box is an awful feeling. You just spent several weeks studying for one of the most difficult exams you will ever face, endured the 8-hour marathon of exam questions, and spent the weeks anxiously awaiting for your results. Now, you are beyond disappointed. You may be tempted to individually hunt down every NBME question writer and have a Carrie Underwood moment with their cars, or crawl into bed and sleep until you can’t sleep anymore or you die – whichever comes first. Please resist both of these impulses and take the following steps:

First things first: Contact your school.

First and foremost, you need to contact your medical school. This cannot be avoided, and should not be delayed! It can be embarrassing to call your academic advisor to tell them you just failed Step 1, but it is imperative. Your school isn’t out to get you, and they’re not looking for a reason to throw you out. It’s always good to have someone in your corner, and your advisor can be that someone. The truth is, even if you have had some academic struggles in the past, the fact that your school has stuck with you through the first two academic years is a good sign that they are going to continue to stick with you through this.

This may be the first time you are dealing with a failing Step 1, but I guarantee your medical school has helped other students through this same situation in the past. Not only are they a resource to help you plan and execute your next attempt, but there will undoubtedly be logistics to work out regarding delaying clinical rotations and authorizing a second attempt. Your school will need to get these things rolling pronto.

Also, believe it or not, you will feel better. It is never fun to go through something difficult by yourself. You will likely have a more positive outlook on the situation, knowing you have support. Your school is not there to wag a finger at you, rather they are going to help you through this.

Ask for help.

Your initial approach to tackling Step 1 did not work. You should seek out people who have done well on Step 1, find out how they did it, and ask them for advice. Your medical school can likely help identify and contact upperclassmen who may have tips for you, especially since schools are very intimately aware of their students’ academic performance. There may even be some upperclassman who have worked with other students who failed Step 1 in the past. Your school will know these things.

Remember, there is no one-size-fits-all approach to being successful on Step 1, but there are general trends among successful students. As you ask people what they have done, identify these trends, and then compare them to your first approach to studying for Step 1. Stick with the strategies that seem to work for other students, and cut out things successful students did not do.

This may seem obvious, but make sure the people you’re talking to actually did well on Step 1. Do not have your roommate or best friend mentor you through this tough time, even though they got a 204, just because it is easier. Choose people to talk to based on what they scored. Put more stock in the advice of high-scorers.

Try different study tactics.

Like I already said, your first approach to Step 1 did not work. You cannot afford to try the same thing twice. You need to re-evaluate what resources you used (see below), how you utilized your question bank, and how you spent your study time. This is an area where having someone experienced in studying for Step 1 will be invaluable.

You likely either did not take any NBME practice exams, or did not have a passing score on those tests before you took Step 1. I cannot stress this enough – do NOT retake Step 1 without passing an NBME practice exam. I find that some students get close to passing their NBMEs and decide to go for a hail mary on test day. This is not a good choice. Those practice tests are very accurate predictors, so what you see on those is likely what you will get on test day.

Avoid common mistakes while studying for Step 1.

One of the most common mistakes I see among students who fail Step 1 is resource overload. These students look at the enormous exam they are up against, see the thousands of Step 1 resources commercially available, and mistakenly think they need a resource for each topic that may show up on the exam. This is not the case. You simply do not have the time to go through every book in the BRS series. Your big-ticket items for Step 1 are physiology, pathology, microbiology, pharmacology, and biostatistics. You can get excellent coverage of these topics by sticking with UWorld, Pathoma, BRS physiology, and First Aid. Look no further!

Another mistake I often see is students focusing on low-yield topics. For example, these students see a single UWorld explanation that mentions the different anatomic locations of erythropoiesis during fetal life, and become anxious because they are not familiar with that topic. They then flip to the page in First Aid containing that information, and spend the next hour writing and re-writing the graph on fetal erythropoiesis, until they feel like they have it down. Well the truth is, they probably will never see a question on that topic on their Step 1 exam. Even if they do, the depth of knowledge needed to answer that question will be cursory at best. They just wasted an hour of study time on a topic they saw once in a UWorld explanation, when they could have been learning something else that comes up over and over again in the question bank (e.g. hemochromatosis, cardiac tamponade, sickle cell disease, emphysema, etc.). Let the frequency at which you see questions on a given topic be your guide as to how high-yield it is. If you have incorrectly answered six questions on type 1 hypersensitivities, it would be worth your time to spend an hour on that topic.

Be realistic when planning your next attempt at Step 1.

When planning what it will take to remediate your Step 1 failure, you need to take into account what you scored on your first attempt. If you got a 188, then you can likely set aside another several weeks to study for the test, and pass. If you landed at 165, you may strongly need to consider repeating some of your medical coursework. A low failure shows a fundamental lack of knowledge that will be difficult to remediate in a short Step 1 study period, which is more suited to reviewing and refreshing information previously learned.

Lastly, you cannot take a year off to study and then comeback to cover up your failure with a 270+ score. This just does not happen. It is possible, however, to take time off and end up with an average-to-above-average score. You will not be able to match neurosurgery, but many specialties will see your hard work in a positive light.

Toughen up.

Studying and taking Step 1 the first time was mentally, physically, and emotionally draining. You will need to muster even more determination to endure a second helping of Step 1. Take care of yourself, stay determined, and work hard every single day. You can do this! You may be down, but you are not out. Go get ‘em!

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Daniel Good

Daniel Good

Dan was born and raised in the great state of Texas. He completed an undergraduate degree at Texas Christian University, followed by a Master’s degree at The University of North Texas Health Science Center. He began his medical education at St. George’s University, and was inducted into the international medical honors society Iota Epsilon Alpha. He has since transferred to Northeast Ohio Medical University, where he continues his record of academic excellence, including a score above 270 on USMLE Step 1. Dan enjoys teaching and loves helping his students realize their full potential.
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