If you have recently failed Step 1, please know that you are not alone, as failure rates for Step 1 have increased significantly in the last several years. While a failure may be disappointing, it’s important to spend some time considering how a Step 1 failure will affect you and what you can do to ensure you pass Step 1 on your next attempt.
Take a Moment to Process Your Emotions
The most important thing you can do after failing USMLE Step 1 is to take a deep breath. You are likely feeling all sorts of emotions from frustrated to anxious to flat out angry. It is incredibly difficult to spend so much time and effort working towards a goal to achieve the result you didn’t want. It’s important to take time to allow yourself to feel these emotions. Some students may only need a few days and others may need a few weeks. It’s normal to feel the emotions your feeling and you don’t want to suppress these feelings or push through them. As you attempt to process your frustration/anxiety/anger/etc., it may be helpful to reach out to your support group. Take the time to vent to your family or significant other.
Remember that failure on one standardized exam does not define you. You have many admirable qualities that are worth celebrating and you’ve worked incredibly hard to get to this point. While failing Step 1 is not the result you wanted, you can use it as motivation. I have found that I learned so much from different failures throughout my life if you are willing to embrace it. The times where I have grown the most and been most proud of myself are typically after I have failed at something. Think about this as you process your emotions and begin to think about retaking the exam.
Understand the Impact of Step 1 Failure on Residency Prospects
While failing Step 1 could affect your chances of matching in to residency, it’s not a guarantee. USMLE exams are one component of a comprehensive application to residency and there are MANY other ways to stand out including extracurricular activities, research and letters of recommendation. Remember that you don’t need 15 interviews to match into most residencies. You can always apply to a greater number of programs to increase your chances of receiving interviews if you feel that your Step 1 failure is going to hurt your application. Once you receive interviews for residency, you can also discuss what you learned from a failing Step 1. Like I mentioned above, failure can be a powerful driver of growth and programs will be impressed by your maturity if you reflected on your experience and learned from it. In addition, you can demonstrate that you learned from your mistakes by scoring very well on Step 2 CK.
The chart below was taken from a survey of residency program directors in 2022 and shows the use of USMLE exams in the application process. For graduates of US MD programs, 23% of programs require a passing score which means they likely wouldn’t consider an individual who had failed Step 1. This number is very similar for IMG’s and DO’s.
23% may sound like a lot of programs, but keep in mind this is across all specialties. I encourage you to check out the full report here to learn more about the specific specialties you are interested in. The bottom line is that failing Step 1 will not eliminate you from contention at most places, but you need to make sure you take the necessary steps to pass on your next attempt.
Assess Your Proximity to Passing Step 1
The first thing you should do once you feel ready to consider your next move after a Step 1 Fail is to figure out how close you were to passing. While the USMLE no longer gives you a 3-digit score, they do offer bar graphs that can be a helpful tool for figuring out how close you were. Below is an example score report from someone who recently took the exam.
The histogram contains six blue rectangles that show the frequency of where student’s scores fall. I have added the numbers for each rectangle to aid in this discussion. There are very small rectangles at both ends of the histogram that were not labeled. Most scores fall in the middle rectangles (3-5) and the overall distribution is relatively similar to a bell curve. The student’s score (yellow marker) sits very close to the passing score (black marker) and both scores lie in Rectangle 2. This student was extremely close to passing the exam and may only need small adjustments to pass on his or her next attempt. Below is an example of a different scenario.
This individual is still in Rectangle 2 but is further away from the minimum passing score (black marker). Again, we don’t have numbers to quantify this exactly but there is a decent gap between where the student is and where they need to be. This student might require more significant adjustments to their study schedule. Any score at the in Rectangle 1 or the low end of Rectangle 2 likely needs a more thorough evaluation and may require more significant additional study time.
Assess Strengths and Weaknesses
You need to have a good idea of which topics your strengths and weaknesses so that you can target your weaknesses effectively. This can be done in several different ways. The most important tool for this will be your USMLE Score report.
This report shows your strengths relative to a low pass. Any areas where you score Lower than the Low Pass need to be your priorities. In this particular example, this student should focus on General Principles, Multisystem Processes & Disorders, Cardiovascular, Pathology, Physiology, Biochemistry & Nutrition, Pharmacology, Histology & Cell Biology and Genetics. While some of these areas such as General Principles, Multisystem Processes & Disorders, Pathology and Physiology are somewhat vague, other areas such as Cardiovascular, Biochemistry & Nutrition, Histology & Cell Biology and Genetics are more concrete and easier to focus your time on. You can also use recent NBME’s taken before your Step 1 exam to see if certain subject areas are showing up on both exams.
Get an Outside Perspective
If you’ve failed Step 1 it’s important to acknowledge that you may have made some mistakes in the way you studied leading up to this exam. This can be difficult and requires a certain degree of vulnerability but the students who can acknowledge their mistakes tend to make greater improvements when they try again. It’s one thing to admit you made mistakes but it’s another thing to identify what those mistakes were. Sometimes speaking with someone can help you gain an outside perspective so that you are better able to identify mistakes. Many schools offer some level of educational support services and these individuals can offer a useful, unbiased assessment of your study approach and techniques. Utilize these resources and don’t try to do it all on your own. If you have the financial means, you could also consider a tutor. Click here for an entire article discussing USMLE tutoring options if this is something you are interested in. If a tutor isn’t an option then speaking to one or multiple fellow students who have passed the exam can also be very useful. The most important thing is to find people who can be objective so that you can take an honest look at your approach and make changes if necessary.
Develop a Plan to Retake Step 1
If you are thinking of retaking Step 1, the first thing you should consider is your timeline. Typically, USMLE score reports are released within 4 weeks of your test date. If you fail, you have to consider that you haven’t been studying Step 1 content for roughly 4 weeks so you have probably forgotten at least some of the content in that timeframe. You can use your proximity to passing that we discussed above to start to figure out how much more time you might need. If you were very close to passing then you will need less time than if you were further from passing. However, trying to estimate the exact number of days or weeks is very difficult because of individual variability. It is helpful to look at how rapidly you were improving during your dedicated study period to get an estimate of how long you think it will take to improve the necessary amount.
I can’t stress enough that you shouldn’t rush to retake your exam. I know that you want to put this test in your rearview so that you can move on with your medical training. I want that for you, but you can’t rush to get there. I have seen far too many students rush in to retaking because they want the test over with or they don’t want to fall behind on clinical rotations. Then, they fail a second time and they are further behind. In the grand scheme of things, taking an additional 4-6 weeks to study is not the end of the world. I understand that students don’t want to delay the start of residency which is very valid. However, if you take 4-6 weeks between preclinical and clinical rotations, you still have 2-2.5 years to make up those 4-6 weeks. You may have to complete some clinical rotations over break or take less time off for interviews, but it can be done. Have a discussion with your program before you schedule your retake so that you know what ALL of the potential options are.
Assess Your Readiness to Retake Step 1
As you start to put together your plan for retaking Step 1, make sure you have built in practice exams to provide a bench mark so you know if you are ready. You may have used most or all of the NBME’s during your dedicated but if you have any unused NBME’s, make sure you schedule these close to when you think you want to take the exam. I would not advise retaking previous NBME’s. Students tend to think that if enough time has elapsed since they previously took an NBME then it won’t affect their score very much. With my students I have found this to be an inaccurate assumption and retaking an NBME can give you a false sense of security when the score overestimates your chances of passing.
If you have also used UWSA’s already, then you can consider doing simulated exams with 4-7 blocks of 40 questions from a resource like UWorld or Amboss. While using multiple blocks from one of these question banks won’t give you a prognostic score, you can use the data in a different way. If you took 7 blocks of Amboss in a simulated exam and your average was 72%, then you can compare this average to your weekly Amboss average. Weekly Amboss average is basically the average of all question blocks taken in a given week during dedicated. It provides a one-week slice of where you are performing and can be much more helpful than looking at your cumulative question bank average, particularly as you progress through dedicated and get closer to your test. The cumulative average may be weighed down by lower performance earlier in your Step 1 preparations. You want to see your weekly averages and your average on simulated exams trending up over time. If your averages on simulated exams aren’t slowly rising, then you may not be making the improvements necessary to justify retaking the exam.
I know that some students will have to decide when to take the exam even though their practice exam scores may not be where they want them to be. While progressing beyond the “Low Pass” zone affords students a very high degree of certainty about passing, it is impossible for all students to achieve this. If you are uncertain about whether you should proceed with taking or retaking the exam, then it may be beneficial to discuss this with an academic advisor or a tutor. These individuals will have seen multiple individuals in similar situations and can probably offer some quality advice about how much uncertainty is acceptable. I would advise you to avoid hanging your hat on anecdotal posts on Reddit. Of course there are examples of individuals who passed with scores below the “Low Pass” zone but you can’t afford to rely on anecdotes.
Summary
It can be very frustrating and disappointing to fail Step 1. It is very important to take a thorough look at your study process and consider what you can change with your study approach to pass Step 1 on your next try. The steps in this article should help you reflect and develop a plan for retaking your Step 1 exam.