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Dr. Tzvi Doron contributed to this post.
 
Every year, students from America's top medical schools fail USMLE Step 1. We know because many of them come to us, and we have helped students from most of the top 25 medical schools in the country. Whether you are a U.S. MD medical student, an IMG, or a DO student, it is possible to fail the USMLE. It is also possible to bounce back and conquer it. 
 
Failure is always a difficult experience, but failing a high stakes exam like USMLE Step 1 can be particularly devastating. It is difficult to get up and dust yourself off in preparation to start the process over again. You may have all kinds of negative thoughts swirling through your head. “Was that my only chance? Did I just ruin my career? What will happen with my student loans? Do people ever recover from something like this? Will I still be able to match into a solid residency program?”

Rest assured: You are not alone, and you can prevail. What's important is how you deal with failure and what you do to improve your chances of succeeding the next time around. Let's get to work!

What to Do if You Fail Step 1:

Look within. Many people will reflexively find reasons outside of themselves for why they failed Step 1. Things like, “My school didn’t prepare me well,” or, “The exam was heavy on my only weak areas” may enter your mind. Some medical students will blame others for giving them bad advice on how to study for the exam.

Even if these things are partly true, we advise that you take responsibility for your decisions and situation so you can change them for the better. Excuses and blame won’t help your cause. It is absolutely essential to take ownership of your failure so that you can take control of your future.

Your success is within your control. You are the master of your own destiny — as long as you are ready to be honest and brave.

Start with a soul-searching appraisal of your previous Step 1 attempt. Ask yourself questions like:

  • Did I really give the test 110% effort? Or did I study too much without time to breathe, rest, and retain information?
  • Did I confront my weaknesses head on? 
  • Was I using only the most important resources and nothing extra?
  • Was I making an effective and honest use of assessment tools? Was I adapting to the results?
  • Was I willing to ask for help when I was lost? Did I ask the right person?
  • Was I leveraging the power of USMLE flash cards
  • Were my timeline and study plan appropriate? Did I choose my test date wisely?

The answers to these questions will point you toward the changes that need to be made to succeed this time around.

NRMP Program Director Survey Results, 2021

The National Resident Matching Program (NRMP) performs a "biennial survey of the directors of all programs participating in the Main Residency Match." From this year's data (see Figure PD_I2 on pg. 10)1, the Education and Academic Performance Characteristics that were ranked by the program directors to be of greatest importance "in selecting applicants to interview" are (in descending order):

  • Failed USMLE attempts
  • Failed COMLEX attempts
  • Med school accreditation status
  • Clerkship grades in preferred specialty
  • Medical Student Performance Evaluation (MSPE)
  • Grades in required clerkships
  • Grade consistency
  • USMLE Step 2 CK score
  • COMLEX Level 2 CE score
  • Awards/honors, clerkship in preferred specialty
  • Medical school reputation
  • Passing COMLEX Level 2 PE
  • Class ranking

So, yes — a failed attempt at the USMLE or COMLEX is indeed at the top of the list of the top factors that program directors consider.

However, pull back and look at the larger picture of these top ranking factors: There are many other areas that go into the decision making process, many of which are within your control.

The Most Important Thing You Can Do After Failing Step 1:

The most important thing for you to do after failing Step 1 or Level 1 is to talk to your academic advisor and get a solid plan of attack together.

To state the obvious, you want to put Step 1 behind you once and for all, and we assure you that it can be done. We have worked with countless students who recovered from a prior failure to go on to be successful.

Once you've talked with your advisor, it's critical that you set yourself up for success this time around on your Step 1 exam.

We want to stress that the number one factor we've seen contribute to a repeat Step 1 failure is students rushing to take the next attempt without giving themselves the proper amount of time to prepare.

According to the 2020 Step 1 Administrations Performance Data from the NBME®2, 67% of US MD testers, 74% of DO, and 50% of International repeat testers passed.

Assessment: The Key to Moving Forward to Pass Step 1

The last essential element to passing Step 1 after a failed attempt is a specific assessment of your current status. Before diving in once more, you must figure out what your strengths and weaknesses are so you know what to concentrate on for your next try. 

The best way to do this is with an NBME self-assessment exam. Since it has been at least a few weeks since you’ve sat for Step 1, you will likely score 10-20 points lower than you did on your actual exam. This can be disconcerting. However, it is very important that you do this before you begin your new study plan because this initial assessment will serve a few key purposes:

  • To gauge how much time you need to reach your Step 1 goal
  • As a baseline to assess your progress on subsequent NBMEs
  • To assess which subjects you are weakest in and need the most work (Hint: it is also worth comparing the NBME self-assessment score report with your official USMLE score report to see if there are any patterns worth taking note of as you assign priority to different subjects and systems)

How much time do you need to prepare for your Step 1 retake?

These guidelines assume you've made constructive changes to your preparations to avoid previous mistakes and correct habits that did not set you up for success.

If you scored 180+, y
our Step 1 foundation is mostly solid. Depending on your target score, you will likely need an additional 2-4 weeks of dedicated study.

If you scored in the 170s, your Step 1 foundation is wobbly. You will likely need four to six weeks of dedicated study. Strongly consider working with a tutor to cover as much ground as efficiently and quickly as possible.

If you scored in the 160s or below, this demonstrates a fundamental lack of knowledge that will be difficult to remediate in a short Step 1 study period. In this case, a review course or remediation are the best steps to take.

Note: You cannot take a year off and come back with a 270+ score on USMLE Step 1.

Regular Step 1 Reassessment: Make Sure You Are on Track

One of the biggest mistakes that leads to a failed Step 1 is fear of NBME practice tests. If you really want to conquer the USMLE, it is necessary to face this fear and get the most from each and every available NBME test. 

Taking NBME practice tests regularly and adapting according to your performance can make the difference between failure and success. This is what allows you to face weaknesses head on and fix them by fine tuning your study plan and schedule as you progress. Your initial plan may be very well thought out on paper, but how will you know if you need to switch directions mid way, or even just make small adjustments, if you don’t reassess? Don’t take any chances. Reassess your progress and your plan early and often. 

What Step 1 Scores Specialties Look For

The chances of matching into the most competitive fields — such as dermatology, orthopedics, etc. — are the primary place a failure on Step 1 or Level 1 can be detrimental. If you haven't reviewed the NRMP's "Charting the Outcomes in the Match" data, now's a good time to do so. (There are different data sets by MD students, DO students and International Medical Graduates.)

For example, if you look at the NRMP's Chart 6 for US Allopathic applicants3, you can see ranges of Step 1 scores by specialty — both by those of accepted applicants and those who were not accepted.

Remember What You Are Fighting For

As we said before, we have helped countless students through this process, so remember that you are not alone and this can be done. The path you anticipated taking through med school may look a little different, but if you take the right steps to set yourself up for success, and — most importantly — you believe in your ability to succeed, you will be well on your way.

You are not your score. It is only one factor in the bigger picture of your role as a future physician. See this test for what it is: a necessary box to check on the way to your career, and remind yourself of why you got into medicine in the first place. 

The USMLE is not just a test, it’s a means to the end of becoming a physician. Often this is lost in the process of retaking the USMLE, and it is important that you keep that special end in mind. Try to envision yourself practicing medicine in the future. Imagine yourself helping patients to heal and lead healthy lives. Picture their faces and try to feel the gratification you will experience.

Moreover, we know that when students prepare well for the USMLE they strengthen their clinical reasoning skills in ways that truly make them better doctors. Our students are not only better prepared to take the USMLE; they are also ready to impress their attendings during clinical rotations. Use your USMLE preparation as a chance to raise your clinical aptitude so you can be a more effective physician.

Do Whatever It Takes to Prevail

As long as it’s legal, healthy, and ethical, we encourage our students to do whatever it takes, and pour their entire beings into studying for one to two months to achieve their goals. Whether we like it or not, and whether it is fair or not, that is what the USMLE demands. 

Sometimes this means knowing when to ask for help. In general, we physicians and aspiring physicians tend to be a stubborn group. We like to think of ourselves as hard-working, intelligent, resourceful, and successful individuals. While these are all excellent character traits, they also can make it difficult for us to ask for help when needed. With that said, it takes great strength of character, honesty and humility to realize when you need help to get you where you want to go.

 

Sources:

1) National Resident Matching Program, Data Release and Research Committee: Results of the 2021 NRMP Program Director Survey. National Resident Matching Program, Washington, DC. 2021. 

2) Copyright © 1996-2021 Federation of State Medical Boards (FSMB) and National Board of Medical Examiners (NBME). All rights reserved. The United States Medical Licensing Examination® (USMLE®) is a joint program of the FSMB and NBME.

3) National Resident Matching Program, Charting Outcomes in the Match: Senior Students of U.S. MD Schools

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