Why students fail USMLE (any of the steps)…
False sense of security
Every year no matter what medical school a student attends, some people are going to fail one or more of the USMLE Steps. (This can apply to COMLEX as well.) I have heard students say that because they attend school X that has a 100% pass rate, they are assured of a pass. Well, that pass rate for School X is characteristic of the class that it applies to. If you are not a member of that class, you have no assurances. Your medical school attended is no assurance of anything other than they have met the standards set by the LCME (Liaison Committee for Medical Education) and that if you have passed your coursework, you will be eligible to sit for your USMLE/COMLEX exams. With that being said, you have to understand and be proactive if you want to pass and score well on licensure exams regardless of school attended. In short, passage and performance of these very important exams is dependent on how well you prepare for these exams.
The big mistakes
Many students purchase tons of review books and start memorizing questions, outlines and isolated facts as soon as they have been accepted into medical school. You can’t MEMORIZE your way into a pass on licensure exams because these exam require you to master and understand concepts in basic science, clinical science and application of the concepts to patient care. Just memorizing board review books is not sufficient knowledge to do well. Daily and consistent mastery of your coursework with systematic review will enable you to pass and do well on these exams. Many students discount the importance of their coursework with the idea that they will cram in what they need for a course exam and spend the rest of the time memorizing a board review book for the licensure exam. This is the biggest and more common reason that students fail these licensure exams.
Coursework is too detailed for the boards!
While your coursework is very detailed, your mastery of those details (and I mean thorough mastery) is a very significant strategy for doing well on your licensure exams. It’s the details that enrich your understanding of the basic concepts that will be vital to your eventual practice of medicine. Rather than looking for shortcuts or complaining about the rigor of your curriculum, set a strategy for mastery of your materials and get the job done. As a medical student, I complained about the level of detail in many of my basic science courses but was quite happy when Step I came around and I know those details. The more experience and exposure to the details of concepts, the greater your likelihood of being able to rule out incorrect answers and rule in the correct answer. In short, those coursework details are invaluable both for boards and for “pimp” sessions during clinicals.
Get out of the “I will just memorize this” mentality
You have to learn to evaluate and synthesize concepts in both basic science and in clinical medical science. For the rest of your career, you will largely be teaching yourself the things that you need to keep a mastery of for your practice. In short, keeping up with medical literature means that you master how to read what you need and how to incorporate what you need into your practice. Where do your learn these tasks? You learn these tasks in mastery of your coursework and in preparation for you licensure boards. Just taking a review course and memorizing everything in a review book will set you up for an unpleasant surprise when you open your score report because you must have a solid knowledge base in order to review for a board exam.
Every licensure exam will post a list of key topics to be mastered for the exam. These are never secret and are why books such as First Aid for Step I are so crucial for preparation for USMLE. First Aid contains all of the topics but none of the details. It’s up to you to provide the details and provide the thorough grounding and mastery that you need. This can’t be done in a month-long review course unless you have a solid knowledge base to begin with. The solid mastery that you need can’t be done by memorizing the answers to questions on a website either. While practice questions are good, they are not useful memorization and can give you a false sense of security in the long run. I can’t tell you how many times student Y had told me that they were scoring 70% on Q-Bank but they turn up with a failing score on Step I. Kaplan’s Q-Bank is great but it’s an adjunct to solid study and mastery of basic and clinical science materials (coursework).
Giving Step I more power than it deserves
In today’s world of residency application, residency directors know how much time you as a student have to master the knowledge needed for the USMLE/COMLEX steps. While there will be people who want to take a “year off” to study for Step I in order to insure a high score, this is not a sound practice. Residency directors do not want to see students taking “time off” from medical school unless you are pursuing a higher degree such as MPH or a Ph.D. Utilize the time that you are given wisely and efficiently and you will be able to review completely and comprehensively for this exam within that alloted study time.
Residency directors also realize that IMGs also often have years off to study for the USMLE Steps and take that into consideration when evaluating scores from these individuals. This is why IMGs are usually required to post higher scores on Step I than their AMG counterparts in order to be competitive for a residency program. Another caveat for IMGs is do not attempt any of the USMLE Steps if your language is not up to the standards of that exam. You can’t blame lack of language understanding as a reason for failure of Step I. Residency slots are more competitive (more AMGs now) and failure of any steps can be very problematic for an IMG. In short, if you are an IMG reading this, prepare well and be prepared to pass any of the USMLE Steps with at least a two digit score of 85 (even for medicine programs) on one try. Does this mean your are doomed if you are and IMG and you fail? No, but you have greatly decreased your chances of match in the USA and may have shut yourself out of many residency programs (other than prelim slots) because of the sheer numbers of US grads and the lack of categorical slots.
- Your first stop is the USMLE website. On that site, you will find the subject lists for what’s covered on the exam and the characteristics of that exam.
- Your next step is to thoroughly master your coursework with regular and systematic study (if you haven’t done this in the past, start now).
- Obtain the most recent copy of First Aid for USMLE (whatever step) and read it from cover to cover so that you know what tools are available for the particular exam you are taking.
- Look into a commercial prep course only if you are certain that your knowledge base is poor or that you know you need plenty of feedback and practice with USMLE-type questions (most US grads don’t need this).
- Don’t tell yourself that you can’t get into residency if you don’t get a two-digit score of 99. Chances are, you are not going to get that score even if you follow the exact study schedule of someone who did.
- You have to figure out what works best for you, in terms of mastery and review so that you can prepare your best.
- If the worst happens and you fail, look at my post “Failing USMLE and how to get beyond it” for strategies for passing on a retry.
Remember, USMLE is not the MCAT. You don’t get “do-overs” for this exam unless you fail. If you fail, you have significantly made yourself less competitive but you are not out of the residency game. You will need to make sure you don’t fail any other steps and you need to accentuate other things (excellent coursework for one thing) in your residency application. Plenty of US grads who have failed Step I but gone on to have a strong third year have managed to match into very strong university-based residency programs. In short pick up and keep moving forward.
Also keep in mind that wishing and hoping for a pass/high score isn’t going to make it so. Plot a strategy and get busy doing what you need to get the job done. Don’t discount the value of consistent strong coursework performance but realize that you have to have mastery of coursework before you can “review” for boards. Board review is not the same as study for your medical school courses. Good luck!