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.
Passing USMLE
- 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!
Hi there,
I need some feedback about what decision to make, I would like to contact an American Doctor with experience who can provide me with an honest point of view regarding my USMLE pathway situation.
Firts of all, I am an IMG from Latinamerica, I have two bachelor’s degree (Pharmacy and MD), in addition, I have 2 years work experience as a Clinician and 9 years work experience as a Pharmacist, I have Medical courses such as ATLS, BLS, electrocardiography basic and advance, Airway managament basic and advance, Microsurgery course, Human Anatomic Pieces conservation course, some modest experience research at the undergraduate level, English Academic Studies at the University level from Australia, one semester of a Master Degree in the health field from Australia as well, I decided to come to USA to pursue my dream and goal to achieve my Medical Residency in USA, however, during my Step 1 preparation course my mother was diagnosed with Cancer, as a result, I had to travel back to my home country for Family support, I spent there 6 months figthing against my Mom’s disease and under these circumstances, I continued my Step 1 studies at the same time, I remember studying next to my Mom’s clinical bed for this difficult exam, unfortunately my mom lost her battle against her Cancer and she died, it was so devastating for me, I felt so sad, I mean it was my Mother, I loved her so much, I could not study for the Step 1 exam for 2 months, I mean I abandoned my preparation, but anyways after thinking thoroughly all the effort I had done to take this exam, I decided to take it, I passed with a low score 207 first attempt despite the fact I did not study 2 months before the exam, well , I continued my USMLE pathway, preparing Step 2 CS, practicing with academic partners, writing patient notes and so on, I took my exam in Philadelphia and I got my results last wednesday, I passed CIS and SPE components, but I failed the ICE component as a consequence, I failed the exam, I don’t understand what happened if I considered that I wrote good patient notes and I gathered the Medical and Clinical information properly, now I am so confused and I see my Dream of being a specialist in USA becoming very hard to accomplish, I dod not konw what to do, I know I have the option to retake the Step 2 CS exam, but I do not know if it is worth it, my chosen specialtists were Neurology, Pathology, IM, General Surgery or Neurosurgery. However, I think, I have any chances to match to any of theses specialtists even if I pass Step 2 CS at my second attempt and I pass Step 2 CK and Step 3 with at least 230 score, I really need advices and opinions to make a good decision in orde to avoid regrets in the future.
Thank you for reading my message
Jose
To Jose:
As an IMG, trying to enter any residency in the United States with any failures on USMLE will be very problematic. The number of slots for IMGs were less compared to the high number of applicants. Since programs have to either offer all PGY-1 slots outside of the Match or none, most programs have elected to participate in the Match. This means that there are fewer positions for IMGs (most US medical schools increased the size of their classes but the number of residency positions didn’t increase) and this means that IMGs can’t rely on the Scramble to pick up open positions (SOAP, not Scramble anymore). If you are aware that you, as an IMG, will have to meet higher standards, in terms of USMLE Step scores with no failures for many residency programs + having some significant experience (observerships and the like) in this country, you can see that it’s going to be a battle for you to enter a residency program in the United States. If you have some connections in a particular program and know that they will be willing to overlook your non-pass, then definitely get all of your USMLE Steps passed with the highest scores possible. Good luck.
I m an average student of final year .. I feel like I need to study all d basic science subjects from scratch for usmle step 1.also I m an IMG.. is dere any chance dat i can pass dis exam??
You have to master the subject matter of Step 1. Either you have the material mastered or you do not. Many IMGs master the material thus it can be done. The main question that you have to answer for yourself because you know what you know and do not know is what you need to do to get the job done If you as an IMGS want to enter a residency program here in the US, you need more than just a pass but a very strong score. If you approach Step 1 just looking for a pass, you may achieve the pass but not a strong enough score to enter a residency especially since IMGs are held to a higher standard. You need a “slam-dunk”.
Thank you for your advice. You have helped a lot. Good luck with everything.
Thank you for replying back. You are truly an inspiration! The reason why I was a bit nervous and wanted to go back to some of my previous coursework is because I want to become a physician as passionate as you. You seem to have had a great grasp on your basic sciences and I find this so important in becoming a great doctor. I’m currently going through First Aid and Kaplan which i find very helpful. Do you think clinical rotations would help prepare a student that only just passed during medical school to become a great physician? I really want to master everything so that I can provide the best services to patients in the future and not make silly yet dangerous mistakes.
To 7billiontravellors:
There is quite a bit of redundancy in the study of medicine. If you didn’t feel that mastered your basic science materials, review them but don’t try to go through every book that you had in an attempt to relean everything as it isn’t necessary and eats up your valuable time. Much of your basic science will be utilized on your clinical rotations as you go through them. If you find that you are forgetting something, a review book is a great recall method. The people who are the most dangerous are the ones who feel that they don’t need to check things once in a while. For the rest of your career, you will be participating in continuing education work which will keep reviewing things that you need to know. Do keep in mind that as you become experienced in a specialty, your knowledge base gets broader in that specialty and tends to narrow in other specialties. This is fine and in no way indicates an inferior physician.
First of all, I just wanted to thank you for creating this blog. I have been going over your posts for the past few hours now and have found them very helpful! I have a question I was hoping you can please help me with. Can you please tell me what books you found useful to study from during your course work in school? For example, Robbins for pathology. The reason why I’m asking is this is because i’m currently preparing for my step 1 exam but I feel like I need to rebuild my foundation as I was not the greatest student during medical school. I appreciate any tips on how to do this. I look forward to hearing from you.
Thanks!!
To 7billiontravellors:
Going back through textbooks as preparation for USMLE might not be very efficient. Yes, Robbins for path is a good book but it’s far too dense for lisensure board exam review. I spent an entire year with Robbins for my path class thus I hope you get my point. Find some good review books that give a combination of questions and complete explanations of questions. Only use your texts for looking up things that you don’t understand (can do this at the medschool library) but I would not spend loads of time and money on purchasing dense textbooks (great for classroom work) for USMLE study. As I have said in my posts, if you passed your courses-regardless of grades, you already have a foundation for USMLE. You can use good review books (check out First Aid for review book assessments), a through review and you should be fine. This is not the time for overkill or for getting overwhelmed in the revies process but it is the time for making sure that you practice plenty of questions and shore up any gaps in knowledge that might linger.
Thank you for this post. I am starting med school at the end of july. When do you think a med student should even start looking at review books.
To Emelia:
You can “look” at a review book any time that you wish but don’t waste valuable coursework study time trying to master something in a review book. You should master your coursework and then use a review book once you have something to review. You can’t review what you haven’t learned in the first place. It’s definitely worth the money to pick up First Aid for Step I a month or so into your first year so that you know what’s out there. FA gives a list of the topics covered on Step I which can aid your organization of your coursework but don’t sacrifice coursework study time because you believe you will be better served by doing board exam study.