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 it 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 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 as since 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.
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 on the retake.
Thank you very much for the wonderful article.. Could you plz tell me what effects does it have if an IMG fails in his 1st attempt in the steps 1,2CK, 2CS or 3? Does it lessen the chances of getting into good residencies?
To Dr. Ahkhan,
It depends on what specialty you are attempting to enter. As you know, some specialties (the surgical specialties) can be difficult for an IMG to enter and failing a step could be problematic in that case. The primary care specialties and psychiatry may not be a problem as long as there is a solid pass on the second attempt. A failure on one step isn’t going to make you more competitive but it likely isn’t going to totally ruin your application especially if you pass the other steps well in addition to a solid pass on the second attempt.
In general, I have seen the most failures on Step I. It seems that the Step IIs and Step III are not as problematic for IMGs. In any event, do your best not to have another failure and see what happens. You might have to set your sights on something non-surgical but there are plenty of primary care slots out there that go unfilled every year. Good luck to you.
Dear Dr,
I have written to you before & I thankyou for replying to me each time. I am looking for some serious career guidance & I knew that you would be the best person coz I relate so much with you through youre writings.
I am an IMG & having completed step1 & step 2 CS, I am wondering how to proceed now with my career. I know it is very tough to get into residency now a days & having american work experince has become a big criteria. having jut completed a basic medical degree I was thinking of working some more in my home country, getting a diploma here in the field of my choice (pediatrics) & then pursuing residecy in the US. most people have advised me against this because they say it is a waste of time & by my age people usually finish residency & yet I am only starting. plus any degree here would not be valued by the amrican system.
I am so confused as to which path to take coz on the other hand if I do apply for 2010 & dont get accepted it would break me. it would be such waste of the 2 years & the money I already spent preparing for usmle. Please do advise me as to what would you see as the best option & can you give me some tips on how to strengthen my position for being accepted into residency. I had tried at a few places for shadowing but never got any reply.
thanks so much.
To Tina,
I don’t know how to advise you since I don’t know much about how having a residency from another country affects getting into a residency here. I know that being a IMG here makes the road tougher but not impossible. If you are intent on getting into residency here, then you don’t get “broken” by not being accepted after one try. You keep on trying and you get what you need to obtain what you want. Good luck.
Dear Dr
I am an IMG and unfortunately I failed in my step2 ck exam on my first attempt. I have been graduated from medical school 3 years ago and I want to study Ob & Gyn or surgery. Does my failure affects my chance?
Thanks for your advices in advance.
To Leiza,
Yes, failure of any Step of USMLE will affect you getting into a residency. This does not mean that you won’t get into a residency but it will have effects. You need to get this exam passed as soon as you can but don’t attempt a retake until you are sure that you CAN pass. You don’t want another failure on any other USMLE if you have one already.
Figure out your weaknesses and make them strengths. Figure out how this failure will affect your application time line and make plans to minimize those effects. It’s not easy for an IMG to get into residency programs in the USA but it’s not impossible. Be sure that you have done an observership and performed well in every clinical aspect. Be sure that your clinical knowledge is excellent and that your clinical skills are excellent. Above all, make sure that your communication skills are excellent. Good luck.
Dear Dr NJBMD
Thanks alot for all your advices.
Regards.
Leiza
Looking around the net I ran into this webpage. I am a US born doctor that graduated from a Caribbean med school. I failed step1 on the first attempt. 174 first attempt then a 196 on the second. Failed Step 2 first attempt with a 163 then a 200 on second. I did not get one interview after appling to 189 programs. Mainly FP and prelim surgery spots. Did not get one interview anywhere. I have Sallie Mae calling my phone every day wanting $1500/month which I do not have. Wife is talking about leaving with the 2 kids now. Lordy….
Anyway, this is my terrible story and wanted to share to let people know “it’s not going to be alright” if you fail a board exam. That’s a statement that only moms have a right too. Good luck to everyone.
BT
To DrNoJob:
Failing one Board exam isn’t fatal. You failed two which does not bode well. You could try to get a Masters of Public Heath and then apply for Preventive Medicine. The loan companies would get off your back and you would at least be able to head into some kind of residency that could lead to board certification. Preventive Medicine is going to be a hot field and the the MPH is the entry for these residency programs. Another option would be to see if you can get a prelim medicine (not surgery) work hard and see if you can slide into a second year FP or IM.
Your offshore degree along with your two failures is quite problematic as you have found out. Now you need to do some serous “damage-control” and try to get into any type of residency program. FP wasn’t the answer for many people this year because of the increased enrollment/graduation rate here in th United States. There were very few vacancies in anything.
After trying Step 1 twice, I have given up on medicine. I studied years ago then went back to medicine and studied again. So I have invested almost 10 years towards my MD. Now I have come to a point where attempting Step 1 is pointless for me. I would like suggestions as to what kind of jobs I could go into? I need to figure out a new career. I have a Masters in Medical Science and working on a Doctorate in Health Science. I would appreciate some ideas…I am at a standstill.
I got my Step 1 score today. I didn’t fail but i scored really low – i got 200/82. do you think I have sum chance to get into a decent residency?
i know im sorry this forum is about failing the step 1. but you seem like you do have lots of experiences in this
To Skan:
What do you want to go into? If you are thinking Derm, Optho, Ortho, EM and other competitive specialties, you may face an uphill battle unless your grades are outstanding. If you passed USMLE Step I and you are a graduate of a US medical school, you stand a good shot at solid programs in Ped, IM, FM and the less competitive specialties. This doesn’t mean that you are a “shoo-in” for top university programs but it does mean that you have a good shot at a match into a good program if the rest of your application is solid. Surgery and the surgical subspecialties are going to be a long-shot but not impossible again, if your grades are good and letters are solid. Good luck!
Dear Dr,
i am an IMG, i failed my step1 two years ago,i passed my cs, and now i am intending to sit for my step1 in 2 months from no. i did a internal medicine clerckship 2 years ago, and an OBGYN observeship one yaer ago. i will apply fro rsidency this year. what are my chances to match if i pass the usmle step1 and 2.
sincerly,
To Ali:
Your chances of matching are difficult to determine for a couple of reasons. First, the number of americans applying for match increased and will increase in the next year because American schools are graduating more students to cover the projected physician shortage. It’s always going to be difficult for an FMG to match if the number of applicants to a particular specialty are high but even some previously non-competitive specialties became more competitive because of the numbers. Second, some specialties are more difficult to enter than others. You may have a shot at something like Family Medicine in a community program but even these slots were scarce this year. Third, you need to be very sure that you don’t fail any other USMLE steps period. Programs are getting pretty unforgiving of FMGs who have difficulty with these exams. Good luck!
My USMLE step 1 score is 206 which I guess equals an 85%. I have had an elective in Surgery at MASS GENERAL. How would you rate my chances of success? Any advice?
To Bilal:
The question is ” What are you trying to become successful at?” Are you trying to get into a top-ranked university surgical residency? You are likely going to be a stretch at a Duke, Louisville or BID but you certainly could look at some of the less competitive university programs like University of West Virginia, The SUNYs, Rochester and some good communities like New Hanover in NC. If your coursework was done at a US school and you have passed your pre-clinical classes along with honors in your Surgery and Medicine clerkships, that 206 should be fine. You broke 200 and you are close to the mean. You should also have some good letters of recommendation such as from your Mass General rotation.
If you are an FMG, you should look at community programs and try to make sure that your other USMLE steps (especially 2) are very high. Surgery is pretty competitive for FMGs and some university programs will not take FMGs at all. Still, the community programs can give solid training and experience. Good luck!
Thank you for your article, and for being frank and inspirational at the same time. I failed step 1 and am interested in getting into a med/peds residency. What are my chances of getting into a residency and how many applications will I have to submit? I am in a US medical school. Thank you for your response.
To mddream:
You likely need to apply to more rather than less programs. I don’t think that you are going to have a difficult time as long as you take Step II early and do well (no failures here). You need to have at least one of your letter writers say that your failure of Step I was a total “fluke” for you because you are a good student and would make an excellent resident. Do well in your clinical rotations and do an audition-rotation at the program that interests you most. Needless to say, work at your highest level. My guess is that if you do a good job with Step II, have good letters and do well in your clinicals, you will be fine. Just make sure that you apply to enough programs to have at least 10 interviews so you can match. You don’t want to scramble. If you find that you are not getting enough interviews, add some prelim programs, do well and re-enter the Match next year with excellent letters.
Hello, Im an IMG and I failed my USMLE Step 1, I got 174/72 and I was wondering if there is still hope to get in a General Surgery or OB /GYN residency? Im not interested in Public Health or Family practice.
Thanks for you reply
To Dra Cristina:
General Surgery is going to be a steep climb for you with a Step I failure and being an IMG. OB/Gyn might also be a hurdle in strong community and university programs. Unfortunatly, things are getting tighter for IMGs rather than easier. You may want to look into doing a prelim in Surgery and going from there. Many PGY-2 spots open as folks find out after one year that surgery is not for them. I would advise applying for a good cross section of prelim surgery slots, entering one of these and working very strong. Also, do well on ABSITE too. Good luck!
I just got my step 1 scores, and I just barely passed with a 187. I was considering emergency medicine, but now i’m concerned about getting a residency at all, in any field. I’m in school in NYC and my wife is 2 years into a 5 year degree, so having to leave the tri-state area for residency would mean us having to live apart for a year or so. what do you think my chances are. any advice on improving those? Frankly, I’m also becoming more disillusioned by the whole world of medicine, and in the back of my mind I kind of want to look into alternatives to doing a residency (I’d do an internship year and get board certified). Any ideas for alternatives where an MD would count for anything?
Thank you so much. This site has already given me some hope.
To DJM:
You passed Step I and you have a score that you don’t like but the good thing is that you passed. You are not out of the running for most specialties (Derm, Opthamo, and Ortho might be a stretch) except the most competitive. There are other things that make a huge contribution into getting into a somewhat competitive residency like EM. First, plan on honoring your Internal Medicine, Peds and Surgery clerkships. Honors in these clerkships will greatly enhance your chances of matching into EM. Second, take Step II as early as you can and do well. Most people go up significantly on Step II anyway but you want a very strong score. This makes your Step I score look more like a fluke rather than a pattern. Finally, get a strong letter from the EM chair at your school. Have him/her make some phone calls for you if at all possible. He/She also knows the programs that would be a good match for you. You can do an audition rotation early at a program that interest you and do well. Again, program directors want solid people that they know.
Step I is part of the equation but there are other parts that you can control (read make excellent). Decide that you are going to have a strong clinical year and make it happen. Decide that you are going to do well on Step II and make it happen. Set your mind to what you want and get the job done. Good luck!
Thank you for your website. This has very helpful information. I am wondering if a student is a US medical grad and failed step 1 on first attempt do MOST of the less competitive specialties still grant interviews or is it only a few? Do you know anything about chances at programs in high demand regions of the country such as California? Do these programs offer interviews to people who failed step 1 on first try in the primary care specialties and psychiatry? Thank you for your information.
To Eve:
Many of the less competitive specialties are more interested in your work ethic and specialty interest rather than your board scores. The important thing is to pass Step I on your re-take and have a strong third-year. With a strong third year, you can get good evals from your attendings/chief residents which will carry some weight with residency program directors. Also, take Step II early and pass. You don’t want any more failures. You should plan on taking Step II right after third year ends so that your scores will be there for ERAS. Good luck!
My USMLE step 1 score is 206 which I guess equals an 85%. I have had an elective in Surgery at MASS GENERAL. How would you rate my chances of success? how can prepare for step 2 and what are my option?
To Sussan:
If you are a US grad and do well at your Mass General rotation (get a LOR), you should be fine at moderate-power university programs and good community programs. Good luck!
Hello,
I failed my step 1 twice, the first time I got a 153/60 and this time a 182/74. I am an IMG, I was hoping to get a surgical residency but now I feel that my chances for residency are career crushing low. I am looking at Internal Medicine or pre-lim surgery, what are my chances of getting into either residency? Thank you for your help.
To Paula:
You may have to set your sights on a prelim medicine, get a position and reenter the match with a record of solid work behind you. With three takes on USMLE Step I, you are going to face an uphill battle getting into residency here in the United States. I would say that if surgery is your goal, prelim surgery is an option but Step I is killing you every time you fail. Apply across the board (prelim surgery and prelim medicine) to see what you can get into. Again, once you have passed Step I and you have some solid work experience, you can see where you are. Right now, your goal is to pass Step I.
I don’t want to kid you into to thinking that you have an easy road ahead because you clearly do not but I do want you to take one step at a time and stop worrying about the next step until you have completed the job at hand. The worst case scenario is that you do a preliminary year. The best case scenario is that you don’t but two failures on Step I generally points to prelim year whether you were a US grad or an IMG. Good luck!
i just found out i failed step 1, i was advised not to take the boards because about two weeks before starting to study i got in a car accident and had a serious concussion. i thought i was better a few months later and did have some problems studying but i kept pushing myself. i really freaked out on the day of the exam and was so nervous. i completely blanked. i know i can take step 1 again but i just feel like a huge failure. i wanted to go into EM but now I think that I lost all chances at it. Should I mention the accident in applying for residencies? Would that make a difference at all? Help
I just wanted to add that on my form 3&4 I did really well, I did well on practice questions and exams and was predicted to get about a 230. something just happened. I guess I really freaked out and it got the best of me. Where do I go from here? I left some messages to some of the Deans but none have gotten back to me yet.
To Syn:
Right now, don’t retake Step I until you are sure that you can pass it. You want your retake to be as high as possible. Take a bit of time, regroup your thoughts and do some serious prep for your retake.
After you have passed Step I, you can look at what is ahead of you. While failing Step I didn’t help you; a very strong Step II (both parts) taken early can be of help in terms of possibly landing an EM residency. You haven’t “lost all chances” of an EM residency but you want to do well in everything from here on out.
Solid third year clerkship grades coupled with a very strong performance on Step II can greatly help your cause. You may also want to do an audition EM rotation at programs where you have a shot. Most program directors would consider your Step I a “freak event”, if you have a strong Step II coupled with excellent third year grades and good LORS.
You may want to speak with your Dean (or a faculty advisor) who knows your work well. Let them address your Step I failure in one of their letters. By all means, put this behind you. It’s done and you can’t change it but you can move forward with strong resolve to shore up your weaknesses and get the pass that you need.
Hello! Thank you very much for this forum, failing step 1 was completely devastating and I would love to hear advice about my situation. I am a US med student, my second score on Step 1 was 202/82. I have recently submitted residency apps to 32 med-peds programs one week ago. I will take Step 2 November, and CS december. I’m hoping for interviews in dec and january. Do u have any advice for me and what do u think my chances are w med-peds?
To Elizabeth:
Certainly failing any step isn’t going to help your chances but USMLE steps are but one part of the process. Make sure that you have good solid letters that emphasize your work ethic. Also make sure that everything in your application is excellent. If you have a faculty mentor, have him/her address anything that might potentially offset the sting of your failure. My guess is that if you submit a well-written ERAS and present yourself well, the effect of Step I will be minimal. Good luck!
hi,
i am an img. graduated from carib med school. failed step1,2 AND CS on first attempts! barely passed step1 on the 2nd attempt 206/85 on ck 2nd attempt. didnt match for 2009 year after i got interview and that too b/c i was doing rotations at that hosp, so it was a courtesy interview. i’ve applied to fp, psych, peds and im programs across the US. i am a us citizen…was wondering…what are my chances of landing a residency spot anywhere in anything? thanku
To SS:
Going offshore + the failures are taking a toll as you well know. You might want to look into making sure that you PS is good and that everything else in your application is excellent. You may also want to get a couple of letters from physicians where you have done an outstanding job in your observerships. A strong work ethic is always welcome in most residency programs.
Your board failures are telling programs that you would have a difficult time with in-service exams and that your fund of knowledge is poor. Anything that you can do to get the opposite across would help you. Right now, try to find one strong attending at one location and impress them with excellent patient care. From there, you can build on that foundation enough to get someone to take a chance on you. Also, apply for some prelim medicine programs and do an outstanding job. This might get you into a categorical slot the next year. Good luck!
hi! i’m an img. my grades in med school were pretty mediocre. i got an 87 on my step1, first attempt, but i knew i could do better. it’s just that i didn’t study much because i was not totally decided on pursuing residency in the US. now i’m thinking of pushing through with matching but scared because my step one score isn’t too good. so i’m contemplating whether to push through with step2. what are my options? is my score good enough? thanks!
To Colorspipemd:
Depends on what you want to do. You are probably OK for primary care (not high powered university programs) but surgery and surgical subspeciaties are likely out of reach for you as are the ROAD specialties and EM. You could match into a prelim surgery position but there would be no guarantee that you would match into a categorical or get into a categorical slot the next year. A score of 87 isn’t the end of the world but IMGs have to meet higher standards that american grads.
Do the best you can on Step II and apply to a large number of programs. Again the surgical specialties, ROAD and EM are going to be a reach for you unless you have a solid contact somewhere that will take you. Good luck.
Hello, I am an IMG, I got a 186/77 on step 1 on my first attempt, I graduated with honors top 10 in my class, I have research experience in the US as a postdoc, I have 6 month of clinical clerkships in the US. I am taking the step 2 next month (I am studing really hard to get a high score) but I would like to know what are my chances of matching in an Internal Medcine program with a low Step 1 Score. Thank You!
To JG:
If you apply to a broad number of programs, you are likely to find more success. Many IM programs will demand a score of greater than 80 for Step I. You should scan the websites of programs in the locales that interest you and then look for the IMG requirements.
Plenty of programs will look at your entire application and see that you have excellent Step II scores and won’t care about your Step I score. Just apply to a broad range and see what happens. Good luck on Step II
Hello, I am an IMG one failed step 1 score. I am going to graduate from my med school first before I retake in order to gain more experience. You mentioned that it is getting tight for IMG’s. What about in Psych?
To CL:
Ease of entry for you will depend on the type of program you are trying to get into (community versus university) and the applicant pool. Certainly, you USMLE non-pass isn’t going to help you but psych is still not considered very competitive and thus its impact might be minimal. Good luck and apply to a broad range of programs.
Hi,I am a IMG and I need visa. My step scores are 92/84/CS pass on second attempt. I have few publications in US journals, 4 months USCE, 8 months research experience and good LOR from US doctors. I am only interested in OB-GYN and have applied to 80 programs. I have not received any call up till now. Do you think I have any chance or my attempt in CS has ruined my career?
To Ann:
Definitely your failure of the CS is not going to help you in OB-Gyn. You have applied to a large number of program and you can’t undo your failure. You should try to get a VISA as soon as you can as fewer and fewer programs are sponsering applicants. There is no shortage of folks for OB-Gyn and thus not having a VISA is going to hurt you too. Also, don’t fail any other Board exams. OB-Gyn is going to be very difficult with needing a sponser unless you have an inside track. Good luck.