Medicine From The Trenches

Experiences from undergradute, graduate school, medical school, residency and beyond.

Getting Through The Semesters (or what if I Fail Something?)

“The Thrill of Victory or the Agony of Defeat”

The Drama of Human Competition as the opening lines of ABCs “Wide World of Sports” promised. By now, many students have had their first blocks of exams in medical school. Some people have done very well and some people have “breathed a sigh of relief” that they passed and some people have not passed one or or more of their exams. To fail an exam at this stage can be a huge personal blow but your actions after discovering that you have not passed (I am going to avoid the word “failure” here) are critical to figuring out what you need to do to get “above the yellow line”. Sure you NEED to do a bit or mourning in terms of the loss of those wonderful feelings that infused during orientation week but don’t let the mourning phase go on longer than a couple of minutes. Replace mourning with a very objective strategical look at what might have gone wrong and how you are going to fix the situation.

There is something in medical school that will throw every person. It may be that first round of exams, that USMLE score or a patient contact that just did go well. The important thing is that out of every experience, good or bad, you learn something about yourself and what you are capable of achieving. It is out of experience that you will learn to treat your future patients so let your experience become your teacher and move forward from here. Not passing an exam just doesn’t feel good and can play with your “head” in terms of how your look at your future. My point here is that nothing except that round of exams is over at this point. You mourn a bit and then you push forward because (and I am not wrong on this), the material for the next round of exams is already upon you.

As soon as you know that anything has not gone well for you academically, ask for help. Your first action should be reviewing the test and trying to figure out where you went wrong. Do you need to rely on more detail? Did you move too fast and not answer the question that was asked? Did you neglect to read every answer choice with a more correct answer further down? Did you not fully understand the material? Were you distracted by something outside of school such as a relationship or illness and not put in enough time studying? In short, try to figure out what went wrong and take steps to make sure that you don’t repeat your mistakes.

What if I fail a whole course, like Biochemistry?

The consequences of failing an entire course in medical school are largely school-dependent. Some schools will want you to retake only the material that you did not pass while others will have you go through an entire summer remediation course. In any event, look at your remediation/retesting as an opportunity to hone this material well. You definitely want a strong knowledge base for your upcoming classes and you will have made some steps toward review in terms of preparation for USMLE. In this light, having to retake or remediate is not totally the worst situation that you can find yourself going through.

Plunge into your review with total concentration on the subject at hand. If you have one course or one area of subject matter, this is easier than if you have multiple subjects to remediate. Your only resolve in this situation is to not miss this golden opportunity to thoroughly master this material. You are not a “lesser person” because you need a second review and keep in mind, that you are reviewing at this point. In most cases, you have learned the material on the first shot but this review gives you insight into the material that you likely previously missed.

I am always more concerned about those students who “barely” passed than the students who failed and are re-mediating. In most cases, the student who re-mediates does not carry a knowledge gap forward while the student who barely passed likely has gaps in their knowledge base. It is those who barely pass that will need the most intensive review and preparation for board examinations.  I always encourage students who scored below an 80% to study for and take any optional shelf subject exams if offered by their school. These shelf exams can pinpoint knowledge gaps that can be filled in before taking Step I.

Class Attendance – Is this time well spent for me?

In some medical schools, class attendance is not mandatory. If this is the case, and you ran out of study time, try figuring out if there is one day a week that you can stay home and study the material using note service/lecture tapes or vids/textbook and syllabus reading. Many students do not attend class and find that home (or away from school study) works best for them. This may work for you but be careful if you have too many distractions at home or find that not attending class puts you behind. (Getting behind in medical school is deadly.)

If your work is not detailed enough, figure out which classes do not require the detail and which ones DO require more detailed study. In short, give each course what it demands. Many schools have integrated courses that definitely demand loads of detailed work coupled with “professional-type” courses like Practice of Medicine that are more performance-based. Try to look at your coursework from this perspective and see if you can give your integrated course a bit more time and your performance course a bit less time.

Another problem is that in many first year courses, the load of information can seem overwhelming. Resist the urge to dwell on what seems overwhelming and nibble away a chunk at a time. I always remember that scene in the movie “Shawshank Redemption” where the protagonist chips away at the prison wall over the course of 17 years with a small rock hammer. Eventually, he gets through the wall and escapes. Extreme but I think you get my drift in terms of divide your work into manageable chunks and stay on course. Keep moving forward because you can only affect what is happening now and use that to impact the future. Weekends are your friend because you can breathe a bit, relax a bit and catch up if you have fallen a bit behind your class. In the middle of the week, go to where the class is and use the weekend to “catch up”.

Wasting time and less efficient practices

I discourage students from recopying notes as a means of study. When you have volumes of material and information, you can become more of an excellent clerk in terms of producing a beautiful set of notes that you have not mastered. Organizing your material is good (can be done with a highlighter or in the margins of your notebook) but total recopying of every word may be too time consuming and not as beneficial as when you were an undergraduate student with less volume. You may need to review the material and then constantly question yourself or recite the material back to yourself rather than a complete recopy. If you can recopy your work in an efficient manner while learning and your grades are good, then recopying is working for you and don’t change your strategy.

Another problem that can interfere with some freshman medical students is feeling that they “need” to study for boards. You don’t need to take time away from your coursework mastery to do board study at this point in your career. If you absolutely feel that you NEED to do some board study, then do it during the summer between your first and second year but the best preparation for boards is to thoroughly master your coursework and then study for boards at the end of your second year. You cannot “review” what you have not “learned” in the first place. Don’t take valuable coursework study time to do board study. Board review books are most useful because they summarize material but most medical school courses require the details and not summaries. Beware of the “I am going to use a review book to summarize” method of study because it might work against you in terms of you not getting enough of the details to pass your course. The other extreme is to attempt to memorize the textbook which is most likely too much detail. In short, strike a happy medium that will work for you.

Don’t be afraid (or ashamed) to consult your instructor or your dean if you are struggling. Not to reach out for help (especially because of the amount of money that you are paying for your school tuition) is not wise. It really looks great to a residency program director to see comments from your dean or professor that state that you were able to overcome a deficiency and excel. These types of comments indicate excellent problem-solving skills which are highly prized in a physician.

Finally, tune out the boasting of your classmates who say that they “didn’t study” and “aced” their exams. They are lying period. You have to do what you NEED to do for yourself. Congratulate them for being so “brilliant” and don’t waste a second of your precious time worrying that you are somehow deficient because you studied like a demon and didn’t do so well. There is nothing wrong with you that correcting your study strategy will not solve. Just don’t add “questioning your worth” to your list of things to overcome. It isn’t necessary and it won’t get the job done.

Striking a Balance

Finally, one key aspect of medical school, residency and the eventual practice of medicine is that you will have to constantly “strike a balance” between study, personal life and professional obligations. The first semester of medical school will definitely test your resolve to keep working away at your studies until you get them mastered but this should not be at the cost of your personal integrity or sanity. Try to find ways of incorporating some stress relief (physical exercise) and socialization (away from your classmates) into your life. Nothing, including the practice of medicine is one-dimensional and there needs to be balance.

For example, if you are studying in the library and know that you won’t make it to the gym, try to walk up at least 8 floors of steps on the days that you don’t get to the gym. Take 10 minutes and take a brisk walk around the corridors to get your brain relaxed before you keep “grinding” away at your study materials. Study and pace at the same time while reciting the material to yourself in your own words. Try making some study-drill tapes and drill yourself while you are on the elliptical trainer/treadmill in the gym. Finally, picture that professor’s head when you are doing your bicep curls or on the fly machine and pound things out. You will be more relaxed, less stressed and more efficient in your studies. In addition, you can enjoy eating without worrying about gaining weight.

Statistics (and odds) state that if you were accepted to medical school, you will get through the four years successfully. Some people make the adjustment to the rigors of medical school academics faster than others but trust yourself enough to know that you will get the job done. There is very little difference in intellect between the person who graduates first in their medical school class and last in their medical school class. Residency program directors know this which is why the person who graduates last in their class is still called “Doctor”. Run your own race and get what you need.

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23 November, 2008 - Posted by | academics, difficulty in medical school, medical school coursework, study skills, Uncategorized | , ,

16 Comments »

  1. 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

    • See reply under the “Failing USMLE Step I andhow to get beyond it” since this is a duplicate post to one there.

      Comment by drnjbmd | 8 July, 2014 | Reply

    • To WW,
      First of all, your situation is very precarious and fraught with problems that if not handled properly, can derail your career completely. You have some very pressing legal matters to deal with before you start looking into residency application. It is going to be very difficult for you to do the MATCH to see where you land with your present situation and it’s probably premature to try to apply for residency before you seek sound legal counsel to make sure that you are on the correct path in dealing with your situation. If you know what accommodations you needed for your documented learning disability and can show success when those accommodations are met, then you have a fighting chance with residency. You also need to have an honest and accurate answer as to your “irregular” behavior on USMLE unless you can have this removed from your USMLE transcript-appeal should be filed. When you apply for unrestricted license you can have documents filed as to how the “irregular behavior” came about and why it’s not characteristic of you when your learning disability testing accommodations are met. From your performance in medical school, it’s not the clinical skills performance but standardized test-taking (shelf exams, USMLE etc) that causes a problem for you. Your best chance of success is to have all of your accommodations and standardized test-taking documented by an educational specialist with this document accompanying your ERAS application for residency when that time comes.

      Next, you need to focus on residency programs in the states that will license you. You already know which states those are thus you need to put that information good use. Again, look at non-competitive specialties and residency programs in non-university settings in those noncompetitive specialties. While I don’t know the details of the “irregularities” that ended up on your USMLE transcript, could it be safe to say that they involved your learning disability? If that is indeed the case, then you need to do everything that you can to document that this was the case and that you were not aware or your behavior was grossly misinterpreted during the USMLE CS session in question. The good thing is that you are going to graduate- if you were dishonest, this would not be the case as medical school graduation can be withheld or even invalidated if there is proof that said student committed fraud or dishonest acts surrounding educational matters.

      As for disclosure, if you know that “irregular behavior” is on your USMLE transcript, then your school would have received that transcript as medical schools receive transcripts before you receive the transcript. It would be prudent for you to seek out your medical school administration as well as an educational specialist and a legal specialist who is well-versed in educational matters who should accompany you when you meet with your medical school administration. You are going to NEED the positive input of your medical school administration in the residency application process, thus your behavior in terms of disclosing this matter is very important. Take legal representation with you in every meeting to protect your rights should you have to pursue legal options in the future to make sure that you get your diploma in August 2014.

      Finally, the last option would be to enter another health-care profession where you can qualify for relief of your outstanding loans. Possible health care professions might be Physician Assistant (can get loans repaid if you work with under-served populations) or something in nursing with the same option (work with under-served populations). Changing to another profession should be your last resort, not going to be an easy option, and after you have exhausted every means of working or obtaining licensure as a physician.

      Yes, you have an uphill battle ahead of you but you need to find a good legal advocate (check out a law school near you because educational law students/professors can be your best advocates) before you go forward. You need to look at every step that got you into this situation, document those steps honestly for your advocates and let your advocates help you in dealing with your medical school administration. You can’t do this alone because you have to know your rights every step of the way at this point. Again, the fact that you are slated for graduation is the most positive thing in your post above. A good legal advocate can build upon that and help you get some of these things turned around. It won’t be easy and likely won’t be cheap but you have a case that is of some legal study interest which is why I recommend looking at finding your advocate at a law school. Good luck.

      Comment by drnjbmd | 8 July, 2014 | Reply

      • Dr. drnjbmd

        Thanks for the prompt response, and I’m just following up on your suggestions. I strongly agree with everything you have stated above and I will just implement your plan accordingly, however i have couple questions.

        The usmle office has told me that they did not disclose any info of IB to my school and on my passing CS report only the accommodation annotation is visible, because the offense did not occur in testing center, it was on internet blog where I reacted to a posting soliciting the forum to provide cases and they were able to identify me through that posting. I discussed the issue of irregular behavior(IB) with our school Ombudsman. He suggested once the degree is conferred it cannot be invalidated because the offense did not take place in school setting, however disclosing the info before the degree conferral has potential to alert the system and in worst case scenario can lead to automatic dismissal based on my current status of being in probation for failing step 3 times. He gave me two options: 1. to not disclose before degree conferral only to disclose after i have gotten my degree. 2. disclose and take the responsibility of the offense with all consequences that might bring, in order to show strong character and ethics.

        I’m torn between these 2 options. I suggested I will be disclosing the IB info before the degree conferral and I will make sure that I bring a legal counselor with me to protect my rights. The Ombudsman rejected that idea as the university does not allow a legal consul to get involved in matters involving students and the school. If I have to do it before the degree conferral I will have to do on my own. I will strongly appreciate it you can another time our your schedule to think through this and let me know your thoughts.

        thanks, WW

        Comment by WW | 10 July, 2014

      • To WW:
        Please, please obtain good legal representation BEFORE you implement either of the two options. Both options may bring implications in your future career that may (and will likely ) follow you throughout your career. Do NOT rely only on the university’s opinion as to how to handle this situation. The school “ombudsman” looks out for the school’s interests and you need to make sure that someone is dedicated to looking out for your interests. If for no other reason, have a second opinion on matters of this great importance.

        Again, the USMLE’s non-disclosure is favorable at this point. You may be able to have many other favorable options available to you that will allow you to put this incident behind you and allow you to get on with the next steps in your career. In any event, please, please get good legal counsel that is dedicated to you alone (not someone who is paid by the university). I am not satisfied or surprised that the ombudsman stated that “the university does not allow a legal counsel to get involved with matters involving students and the school”. My thoughts are that this ombudsman has consulted with the school’s legal department before they made the two suggestions. In short, you are a student and you need to know all of your rights. Your situation is precarious and complex. As such, I implore you to have the most accurate and complete information surrounding your situation so that you can make the best choices.

        By your postings, you appear to be a very thoughtful person who has be affected by some very complex circumstances much of which involve things that you didn’t know would cause a problem in the first place. As an educator and student advocate, I hope that you can get this behind you so that you can go on to a great career in medicine as a physician. As someone who is involved in student affairs, I would definitely defer to a legal advocate to make sure you, because you are the student, are treated fairly and correctly.

        Comment by drnjbmd | 10 July, 2014

  2. Hi, I am an IMG preparing for my USMlE Step 1 .. I failed in 3 subjects in my final year .. though I cleared them subsequently at my second attempt. Will ny Medical School scores affect my chances of obtaining an IM residency in the U.S. (especially the university-affliated community based programs)

    Comment by hari | 18 February, 2011 | Reply

    • To Hari:
      Yes, your grades in your medical school subjects will be examined and considered in terms of residency selection. The effect of those grades will largely depend on what other things are in your application such as USMLE scores (one take on any step) and clinical performance evals from any observerships done in this country. Also be aware that many (if not most) US residencies have minimum scores (two-digit) for IMGs on any of the USMLE steps and thus, you need to be sure that you exceed them. Good luck!

      Comment by drnjbmd | 19 February, 2011 | Reply

  3. Hi, I am IMG, graduated 2008 and i am going to apply for 2012 match in internal medicine. I am a green card holder, i got 91 in step 1, 95 in step 2 and passed step cs in second attempt. what is the chance of getting into internal medicine program ? how many programs should i apply to get good interview calls ? should i apply for university programs too??

    Comment by krishna kafle | 8 December, 2010 | Reply

    • To KK:
      With that repeat on the CS, you should definitely increase the number of programs that you apply to. Internal Medicine programs have minimum score requirements for IMGs which means that you need to be sure that you meet those first and second, you need to apply to as many programs as you can afford. Certainly, the university-affiliated community programs are going to be a good shot for you along with the community programs. You need to be sure that your comminication skills are above average especially when you interview. With that repeat on CS, communication skills will come into question. Finally, if you can afford it and you meet the miminum pre-recs, do apply to some university programs. The university programs are going to be long-shot but different programs look for different things in applicants. If you don’t apply, your chances would be zero. If you do and don’t make it but get into a solid program anyway, you haven’t lost anything.

      IM, especially the university programs, are competitive for US students. Gone are the day when top programs are a “chip shot” for anyone but you have a shot at some university-affiliated community programs and some of the community programs provided you do a good job in researching the place that you plan on applying to. Good luck!

      Comment by drnjbmd | 9 December, 2010 | Reply

  4. i got 202 at step 2 ck i know it’s not too much but I’m an IMG too do i still have achance to get any residency in usa?

    Comment by mohamed | 25 December, 2009 | Reply

    • To Mohamed:
      It’s difficult to say what your chances of residency in the US would be. You need to look at the websites of some of the requirements for the residency programs that interest you. Most residency programs will put their requirements for IMGs on their websites. I also do not need to tell you that some residency programs do not accept IMGs and thus, you need to not waste your time with these. Good luck!

      Comment by drnjbmd | 26 December, 2009 | Reply

  5. Hello doc,

    Thankyou for this article for I can relate in every bit of it. I’m now in 2nd yr and while I was in 1styr while I’m not one of the best in class I could say that it was still a smooth sailing for me UNTIL 2ndyr where I am failing my subjects 1 by 1, I admit that I am having personal issues and failing my subjects just highlights these issues and here I am again questioning if I am right on choosing to pursue medicine. Also I feel that I am getting depressed by the day and seems to have a hard time focusing specially now that I have failed 2 consecutive exams in this subject where I really studied. Moreso it’s really weird that whenever I fail, most of the class passes and when I pass, most of the class fails. But for me it feels so embarassing whenever I fail bec it’s with a subject that posts our names instead of our id numbers. I really get so embarassed and felt as if I’m a walking failure in class. I know I’m not super intelligent and my friends say to use it as a motivating factor but what’s happening to me is I get more demotivated, and more uninspired to do better.

    But I do agree on you when you said that you mourn a bit and push forward and I’m trying my best to be positive in spite all this.

    Comment by Sam | 21 August, 2009 | Reply

  6. Thanks doc. I am hoping for the best but I am even more motivated. I guess it is a blessing in disguise. Failing feels like hell but I will have the opportunity to study for my boards. Thanks for your encouraging words. I will keep reading your posts for self confidence!

    Comment by John | 7 March, 2009 | Reply

  7. I recently took a pharmacology final and failed it. I am now facing a summer reassessment. The thing that worries me is that if I fail this summer I will have to repeat the year which would be a disaster! I was feeling really down and as though I am not smart enough to be a doctor. Reading this helped a lot. I think my study habits need to change and hopefully everything works out in the summer.

    Comment by John | 26 February, 2009 | Reply

    • To John:
      More people than you would believe end up having to remediate during the summer session. Look upon this as an opportunity to have something throughly mastered (makes Board review that much easier). Many people end up repeating a year too and it’s not a complete disaster as long as you get your work done and keep positive. It’s easy to beat yourself but what is done is past.

      Be ready to get your summer work completed and be confident that you will know that material that much better for Boards. What’s not to like about a great Board score? It will open plenty of doors so that your hiccup during the regular year will be hardly noticed. Good luck!

      Comment by drnjbmd | 26 February, 2009 | Reply

  8. I’m surprised there are no comments here; this was a useful read.

    Comment by Ayla | 19 January, 2009 | Reply


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