Medicine From The Trenches

Experiences from medical school and residency.

Failing USMLE Step I and how to get beyond it.

For many second year medical students, the prospect of taking USMLE Step 1 is looming “large” on the horizon. You have completed three semesters of pre-clinical science and the first step toward licensure as a physician rapidly approaches. Along with the exam and its preparation comes the thought of what will happen if you fail this exam. Statistics show that somewhere around 1/4th of people who take this exam, will not pass on the first try. While failing this exam happens, it’s better to consider that 3/4ths of the people who take this exam will pass.

So what happens if I fail?

If you fail, you generally have the option of re-taking the exam. Most medical schools in this country will have you do some remedial work and will have you sit for the exam a second time with little consequences (from the school’s standpoint) other than damage to your ego. If you fail Step I once, you can still practice medicine and you can still graduate from medical school. You have likely knocked yourself out of the moderately competitive to competitive specialties but you can still have a very satisfying career in the less competitive specialties.

The first thing that you have to do, if you open your test score report and find that you have not passed, is immediately figure out where you were deficient. The USMLE score report comes with a breakdown of where you lost points. You should immediately start your review in your weakest subjects/items. The next thing that you want to do is speak with your Dean of Education so that you can get an idea of the time frame that you have to submit a passing score. Some schools want a passing score on Step I before you can begin third year clinical rotations and some will allow you to complete a rotation that you have started.

Don’t make the grave mistake of attempting to do clinicals and study for Step I. If you failed this exam once, you need to put your entire attention into a thorough and adequate preparation for this exam. You can’t afford two failing scores here and thus, drop/delay your clinical rotations until you have passed Step I. It’s not going to be easy or quick in terms of preparing for a retake so don’t try to rush this process. As bad as one failing score looks, two failing scores can really kill your chances for a solid residency match.

Get the idea out of your head that you “are not good at standardized tests” or “that your career in medicine” is over. You just cannot afford this type of thinking. Your whole attitude needs to be focused on the task at hand, which is, passing Step I. If you cannot focus for a couple of days, then take that time to relax and let yourself come to terms with your circumstances but, depending on your school’s schedule, you likely need to get back into the study mode fairly quickly. Take some time to come to terms with your non-passing score but don’t let a non-pass set you into a “tail-spin” that prevents you from doing your best on a second attempt.

The other mistake that many medical students will make is believing that because they were able to do well in their medical school coursework, they are a “cinch” to pass Step I. This is not always the case for as I have been involved in academic medicine, it’s not always the students with the weaker academic records that fail but those who have a “false sense of security” because of their academic record. Make no mistake, Step I takes some preparation and review no matter how you scored in your coursework. Be prepared to give Step I, the attention that it needs no matter how much you want to enjoy your time off from coursework.

Another thing that you likely need to do is enlist the assistance of your Dean of Academic Affairs. There is no medical school in this country that has never had a student fail Step I. Your Dean of Academic Affairs can offer some assistance in getting your study methods on track. There may be great resources available at your school that you will be able to access since you have a failure on Step I. Be sure to find every resource (many likely free) that is available to you.

Another mistake that many students make is looking at the pass rates of a previous class and thinking that there is no way that you can fail. If the Class of 2008 has a 100% pass rate and you are the only member of the Class of 2009 that fails, that 2008 pass rate hasn’t helped you much. Passing or failing Step I is a personal matter and not class (or school) dependent. Either you have prepared well and performed well or you have not. These are individual characteristics and not school characteristics.

What kind of residency can I get with a failure on Step I?

If you pass on the second try, score some solid performances in your clinical rotations and perform well on Step II, you have a shot at a very good residency. No, you are likely not going to match into Derm, Ortho, Rads and Ophtho but you have a shot at solid programs in just about everything else if you post a good performance in things after your failure. Sure, it’s not the best situation that you have failed this very important exam but your career is not over. There is still a substantial amount of “medical school” in front of you that will provide an ample opportunity to show that a non-pass on Step I (on your first attempt) was an aberration rather than a characteristic of how you perform. Some options may not be there for you but more options exist than you would believe. You simply have to get this behind you and move on with what you have left.

Getting and keeping your head together

Again, your first priority is to do whatever you need to do to pass this exam. You cannot afford to wallow in blame but need to gather your reserves and get busy. Sure, it seems like everyone you know passed without difficulty but you didn’t pass and you have to pass this exam. The thing “is what it is”. The reality is that while this hurts; it’s not fatal. You can take this opportunity to learn what kind of reserve you have and how to thrive in adversity. These are characteristics that any residency program director would be happy to have in an incoming resident. Get your thinking together; enlist the help of your Deans and get this exam behind you.  Performance on one license exam does not define your entire medical career unless you allow this performance to define your and your career. Sure, it’s important but in terms of percentages, most people pass comfortably on the next try and move on to good clinical rotations and residency spots.

Final Thoughts

If you find that you failed Step I, get your resolve together to:

  • Get in contact with your academic Dean and Dean of Students.
  • Find out what options are there for you to allow you to focus on getting ready for your retake.
  • Put that non-pass into perspective and behind you; what have you learned “not” to do?
  • Get the idea that your “medical career is over” and that you can’t match into a good residency program out of your head.
  • Prepare efficiently and properly so that you do not find yourself failing your re-take (or any other licence step ) exam.

This is not about you as a person, physician or anything else. You simply didn’t pass Step I and you resolve to prepare and pass with a significantly better score on the retake.

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22 November, 2008 - Posted by | academics, medical school, residency

429 Comments »

  1. Hello, I got an email from you but my email is still ‘awaiting moderation’ I hope you got my last message. I am looking forward to your reply dr.

    Comment by hopestrings | 24 July, 2014 | Reply

  2. To drnjbmd
    Hello, I got my usmle step1 score last week, 187. Please I would like to know what my chances are

    Comment by hopestrings | 24 July, 2014 | Reply

    • To hopestrings:
      I do not understand your question. What kind of chances are you inquiring about? Look at previous questions and answers. If you are an IMG, your chances for entering residency in the United States depend on: specialty desired, specialty program (university-based versus community- based), whether or not you meet the requirements for entering said program (score minimums + no failures) and your other academics.

      Comment by drnjbmd | 24 July, 2014 | Reply

      • Thank you very much for your reply and sorry to have not made myself properly understood. Yes I am an IMG and what I meant was given that score, what chances do I have of getting into a residency program here in the US and what are possible boosters I would need for competitive ones? I believe I may need to re-write it.

        Comment by hopestrings | 24 July, 2014

      • To Heartstrings:
        What specialty are you interested in pursuing? There is a huge difference in terms of competitiveness in surgical specialties versus non-surgical specialties. The other thing that you need to do once you decide on a specialty is to look at individual programs and their requirements for international medical graduates. Many specialty programs have specific score cut-offs for IMGs, thus you need to look at individual programs. Some programs will want you to take Step II (CK and CS) before application, thus you will want to take and pass both of those with the best scores possible since your Step I score is under 200. Since you do not have a passing score on Step I, will need to retake it ( I believe the minimum passing score is 192). If you want to improve your USMLE transcript, post very strong scores on your remaining steps (Step II CK, a Pass on Step II CS and Step III). Observerships in places with faculty that are well-known and can evaluate you in terms of your clinical knowledge/performance are also good things to make yourself more competitive. In general, most residency programs have websites where you can get an idea of your competitiveness and things that they look for in terms of applicants. Do some research into programs in the specialties of interest and get a list in programs where your 187i.e., a failure, isn’t a liability. Good luck.

        Comment by drnjbmd | 24 July, 2014

      • Thank you very much, your analysis exceeded my expectation and good luck

        Comment by hopestrings | 24 July, 2014

  3. Dr. drnjbmd,

    I was admitted at a US medical school in August 2009 and completed the first two years of basic science medical education. I took the USMLE Step 1 three times but was unable to pass it. My last unsuccessfuly Step 1 attempt was in June 2012 and I was subsequently dismissed from my medical school. I really do want to pursue medicine despite my failed USMLE scores. Can you please suggest what other alternative routes I can take to fulfill my goal?

    I’ve been toying around with the idea of taking MCAT and re-applying to a medical school. What do you think my chances are to get accepted into medical school again? Do you think that admission committees will have access to my USMLE scores? I’m worried that my USMLE history will follow me around everywhere that I even look for a possibility of getting back into medicine. Do you think I have a better shot at applying to a DO school instead of an MD school? I would sincerely appreciate your honest feedback.

    Comment by drdean | 17 July, 2014 | Reply

    • To drdean:
      It isn’t likely that you will be admitted to a medical school in the United States (DO or MD) because you were dismissed from medical school for academic reasons. Unless you are ready to lie on an application which will ask if you have previously attended medical school in the US or overseas, it’s going to be very difficult for you to just “do over” your academic problems. You have numbers AAMC and USMLE that are linked to you which means that though it may take some time, your previous academic history will catch up with you at some point even if you lied. If you did retake the Medical College Admissions Test, you would still have to apply to medical school (DO or MD) using your undergraduate transcript which is linked to you by numbers (Social Security and AAMC). It’s not your USMLE transcripts but the fact that you were dismissed from a US medical school that is the most damaging aspect of attempting to “do over” as applications are electronic and you are in the AAMC/USMLE system.

      Options would be to attempt medical school offshore but even with that option, your USMLE attempts are going to follow you unless your identity is changed completely (very difficult to do outside of a witness-protection program in all honesty). You would have to look for a state that would overlook your three failures on USMLE (fewer and fewer each year) which is a problem. If you were able to attend medical school offshore and started from the beginning, some states would allow you to start over with Step I (USMLE) since you would not have passed all steps within a seven-year period. The problem with that plan becomes that when you apply for license, you have to state that it took you more than 4 years to complete medical school (they are going to want to know why) and you would have to disclose that you were dismissed for academic reasons. There is also alarmingly increasing difficulty for FMGs to get into residency in this country with the increased numbers of American medical graduates. Couple this with your three USMLE failures (these never go away) and you would have additional difficulty even with stellar coursework performance from an overseas school and passage of USMLE (all steps). All residency applications ask for AAMC and USMLE numbers in addition to state licensure application which asks for these numbers which might mean, depending on the state, that you could not obtain even a training license for residency.

      Another option would be to find a career in another medical profession where your academics from medical school would not make much difference. This has been done by people who were not able to pass USMLE in the past. No, you would not be a physician but you can look for a career that can offer you satisfaction. There are many options in healthcare that are available which do not involve being a physician (which is not a profession for everyone either by desire or ability). Good luck and do some research into other careers out there.

      Comment by drnjbmd | 17 July, 2014 | Reply

  4. Dr. drnjbmd,

    Let me tell you upfront that I will have uphill battle to even secure one interview call based on my current situation. Let me explain: I am US citizen and going to US medical school and will graduating in AUG 2014. I started med school in Aug 2008 and did not repeat a class, clerkships or electives through my medical school tenure except for psych shelf and ob/gyn shelf but did not require repeating the clerkships because i passed them on retake. However I failed my board exam four times: step1 failed once and passed it with minimum score, step2 clinical knowledge no failure but passed with minimum score, step2 clinical skills failed it 3 times before passing it a week ago with accommodations of my learning disability( the score has been flagged as passing with accommodation( no standard environment). This CS exam failures have caused me to be dismissed and then reinstated after appealing and which i believe will also be on my dean’s letter.

    on top of all poor performances, the worst damaging or career ending has been the honor code violation( USMLE irregular behavior), which has been permanently entered on my USMLE transcripts and referred to national data bank for states authorities to see. This means residency programs that I will apply to will be able to see it and will make a decision that might be potentially detrimental to me. Also the state licensing authorities will see it as well to make a decision about it. My 3 failures on CS exam have left me with limited number of states that I can seek resident initial license, 15 states won’t give me an initial license.

    I’m about 300,000 $ worth of loans from med school education and don’t know which other jobs can pay these loans beside physician job. I’m asking for your wisdom here from your experience. I have no money and no job. The only job I had, they fired me when they came to know of my irregular behavior with usmle. Little money that i made through that job has been spent largely to pay lawyers to defend me against usmle charge, which was unsuccessful. If I have to go through match in September 2014 I will have to use credit cards and I am only licensable on 34/50 states based on 3 failures rules. if you were on my shoes what would you do? Currently the school might not be aware of my irregular behavior because i have not told dean office yet or they might know it but waiting only for me to disclose it. I would strongly appreciate your honest wisdom opinion for me to move forward as I’m facing career ending decision.

    thank you,

    ww

    Comment by WW | 8 July, 2014 | Reply

  5. Hello!
    I am a caribbean IMG and i took my step 1this year. I got my score… 204. Knowing its not good in what possition do i stand? What can i do to ‘get-in’? Does the advise to my other collegues (given in this page) apply to me as well?
    Thank you very much!

    Comment by Isabel | 20 March, 2014 | Reply

    • To Isabel:
      You need to look at the specific application requirements for specific residency programs (for IMGs). Most, but not all, residency programs have Step I score requirements for IMGs. These will be listed on their webpages along with any other IMG requirements. You need to do your homework in terms of finding programs for which you would be competitive/compatible. Once the MATCH process has completely ended (next week or so), you might contact some residency program directors of specialties that you meet the IMG requirements for to ask what you can do to make yourself more competitive. With the increase in American graduates and the changes in the regulations for programs participating in the MATCH (all in for example), it’s going to be tougher for IMGs. You can make sure that you score extremely high on Step II which can help your cause but the number-crunch is going to be there. Good luck.

      Comment by drnjbmd | 20 March, 2014 | Reply

      • Thank you very much for your advise. I will do as you say. Thank you!

        Comment by Isabel | 21 March, 2014

  6. My school doesn’t allow me to retake step 1 and dismiss from school. Can I get admission in other school

    Comment by Ketan | 25 February, 2014 | Reply

    • To Ketan:
      If you are in the USA, most medical schools will not take a student who is not in “good standing” from another school. If you are dismissed, then you would not be in “good standing”. If you are not in the USA, you would have to check with prospective schools. Most USA medical schools will not take a student who wants to “start over” if they have been dismissed from another medical school. Most schools in the USA have a limited number of retakes before dismissal (usually two retakes-must pass on third try). Outside of the USA, it’s school-dependent.

      Comment by drnjbmd | 25 February, 2014 | Reply

  7. What should I do I short three point to meat the step1 exam ,do I pass the exam or not ,I’m doing rotation right ,what can I do

    Comment by W | 7 February, 2014 | Reply

    • To W:
      I am not sure what you are asking but you can’t afford to fail any USMLE Steps. If you are going to be an IMG or FMG, you have to pass all steps of USMLE with the highest score possible to be competitive for residency in this country. If you are going to be and AMG, you will knock yourself out of university programs in all specialties and the surgical specialties + the ROADs if you fail a USMLE Step. In short, don’t take the USMLE unless you are sure that you can pass well. This is not an exam to take for practice.

      Comment by drnjbmd | 7 February, 2014 | Reply

  8. hi,
    I am an indian medical graduate. I completed my MBBS in jan 2013. i gave my usmle step 1 in december and got my results 2 weeks back. I failed my step 1 with a score of 177. it came as a huge shock as I was doing considerably well on my Uworld questions and nbme tests. I seriously have no idea what went wrong on the test day. Now I’m planning to take the step again. I am really interested in getting into paediatrics and would like an honest opinion on what my chances are to match into a good paeds program? and any other advice would be much much appreciated since currently I am quite pessimistic about the whole scenario.

    thank you.

    Comment by him | 31 January, 2014 | Reply

    • To him:
      You are going to face an uphill battle getting into residency in this country with that Step I failure. Your best chance will be programs that will match you outside of the match because they know you. These are harder to find because of the “all in” rule that went into effect last year. You might look into community-based pediatric programs (university-based are probably out of reach) who might not care about your failure. Do some research and apply to the highest number of programs that you can afford that do not have a “pass on one take” rule for USMLE steps. The most important thing to remember is that you can’t fail any more USMLE Steps period. Figure out what went wrong and correct it before your retake. Relying on scores from practice tests might not be a good idea as clearly you were missing the understanding of some concepts, hence your failure. Peds is a non-competitive specialty but the university-based programs are very competitive especially for an IMG. You might also look into Family Medicine (likely to be more forgiving of a Step I failure and allow treatment of pediatric patients) but again, steer clear of university-based programs which are going to be competitive.

      Comment by drnjbmd | 31 January, 2014 | Reply

      • Thanks for the insight. I really needed a real answer to my queries. I guess I will give it one more shot. I’m not interested to settle for anything other than paediatrics. The branch I choose to specialise in is my only priority. Also, since I need to complete at least my step 2 by sept this year to be eligible for the 2015 match, implies ill probably have to retake my step 1 around march – April which is just a few weeks away. Do you have any advice as to how I could maximise my efforts in this period? And what all study material will be most beneficial?

        Comment by Him | 31 January, 2014

      • To Him:
        Without out looking at your diagnostics, I can’t recommend maximization strategies. I do know that people who are conceptual learners as opposed to memorizers do better on USMLE. There are simply too many things to memorize. If you can find the Board Simulator Series (might be able to get these 5 books on E-Bay because they are out of print), you might work with that resource. The problems with question banks is that many people start to memorize those questions and lose sight of the concepts being tested. Good luck.

        Comment by drnjbmd | 1 February, 2014


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