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What Happens if I Fail Step 1 (Now That It’s Pass/Fail)?

  • by Dr. Brian Radvansky
  • Sep 22, 2022

Dr. Tzvi Doron, Dr. Daniel Good, and Lauryn Falcone, MD, PhD also contributed to this post.

A failed Step 1 score can be completely devastating. You spent two years learning as much medical knowledgeas possible and lots of valuable time and money preparing for this one big exam. Not surprisingly, many students who fail Step 1 feel overwhelmed and fearful of the future.

However, a failed Step 1 doesn’t mean you are a failure or that you will fail again. According to the 2021 USMLE pass rates, U.S. MDs who retook Step 1 had a 66% pass rate and U.S. DOs who retook the exam had a 75% pass rate. With a dedicated plan and absolute focus, you can get a passing score. Many have done it before—you are not alone.

Whether you’ve arrived at this article before taking Step 1 or after receiving a failing score, here is our comprehensive resource for next steps after failing Step 1.

How do I make sure I don’t fail Step 1?

Naturally, the best thing you can do is pass Step 1 the first time around. If you’re looking to ward off failure before even taking the exam, a simple way to set yourself up for success is not rushing to take Step 1 too early. While it can be enticing to “get it out of the way,” not caring about your score (“I just gotta pass this!”), more time should equate to more studying, more knowledge, and a passing score. The number one factor we’ve seen contribute to a repeat Step 1 failure is students rushing to take the next attempt without giving themselves the proper amount of time to prepare.

When Step 1 was still a scored exam, students pushed the limits of their abilities to master as much material and score as highly as possible. Now that the exam is pass/fail, however, you might be tempted to cash it in once you’re sure you have what it takes to sneak by with a passing score.

But Step 1 is about more than just passing. I can still hear the voices of my classmates, who, after preparing for a scored Step 1, were thrilled about how smart they felt. Studying as hard as possible has the benefit of laying the foundation for what’s to come: third-year clinical rotations. Giving it your all during Step 1 studying (even now that it’s pass/fail) will have you well poised to excel on rotations, and pass shelf exams. The exam train never stops moving forward. The knowledge base you build for Step 1 will continue to be called upon throughout medical school, and throughout life. Remember, after these shelf exams come Step 2, Step 3, and real-life practice! This necessitates firming up all that knowledge you’ve built during the first two years of medical school. Step 1 studying does just that.

If I fail Step 1, will it affect my ability to match into residency?

According to a 2021 survey by the National Resident Matching Program (NRMP), residency program directors ranked the Education and Academic Performance Characteristics that were of greatest importance in selecting applicants to interview:

  1. 1. Failed USMLE attempts
  2. 2. Failed COMLEX attempts
  3. 3. Med school accreditation status
  4. 4. Clerkship grades in preferred specialty
  5. 5. Medical Student Performance Evaluation (MSPE)
  6. 6. Grades in required clerkships
  7. 7. Grade consistency
  8. 8. USMLE Step 2 CK score
  9. 9. COMLEX Level 2 CE score
  10. 10. Awards/honors, clerkship in preferred specialty
  11. 11. Medical school reputation
  12. 12. Passing COMLEX Level 2 PE
  13. 13. Class ranking

 

So, yes — a failed attempt at the USMLE or COMLEX is indeed at the top of the list of the top factors that program directors consider. However, pull back and look at the larger picture of these top ranking factors: There are many other areas that go into the decision making process, many of which are within your control.

What are the next steps after failing Step 1?

1. Contact your school

If you do fail Step 1, first and foremost, you need to contact your medical school. Do not avoid this and do not delay. It can be embarrassing to call your academic advisor to tell them you just failed Step 1, but it is imperative. While each school has its own policy, most schools will immediately reach out to you to assist you in the next steps and offer you support.

Your school isn’t out to get you, and they’re not looking for a reason to throw you out. It’s always good to have someone in your corner, and your advisor can be that someone. The truth is, even if you have had some academic struggles in the past, the fact that your school has stuck with you through the first two academic years in med school is a good sign that they are going to continue to stick with you through this.

This may be the first time you are dealing with a failing Step 1 score, but I guarantee your medical school has helped other students through this same situation in the past. Not only is your school a resource to help you plan and execute your next attempt, but there will undoubtedly be logistics to work out regarding delaying clinical rotations and authorizing a second attempt. Your school will need to get these things rolling quickly.

Also, believe it or not, you will feel better. It is never fun to go through something difficult by yourself. You will likely have a more positive outlook on the situation, knowing you have support. Your school is not there to wag a finger at you, rather they are going to help you through this.

2. Analyze your performance to figure out what went wrong

Complete a self-analysis

Think about the possible reasons for your failing score. Did you just “go for it” after not studying enough? Or were you fully prepared, but test anxiety overtook you in the test center? Or did you get bogged down by the minutiae and miss the big-picture concepts?

Try asking yourself the following questions:

  1. Did I really give the test 110% effort? Or did I study too much without time to breathe, rest, and retain information?
  2. Did I confront my weaknesses head-on?
  3. Was I using only the most important resources and nothing extra?
  4. Did I make effective and honest use of assessment tools? Was I adapting to the results?
  5. Was I willing to ask for help when I was lost? Did I ask the right person?
  6. Was I leveraging the power of USMLE flashcards?
  7. Were my timeline and study plan appropriate? Did I choose my test date wisely?

 

Once you understand what may have caused your past performance, you will know the changes you need to make next time.

Not sure how to assess your own performance and test-taking skills? Take advantage of our free download, A Hero’s Guide to Defeating the USMLE, which has action items and exercises to help you with this essential process. It’ll pay dividends beyond Step 1 through the rest of your life as a learner.

Review your official score report

In the scored Step 1 era, it was a simple matter of seeing how far you were from a passing score, and figuring out how much effort and overhauling the process would take. For instance, if passing required a 192, and you scored a 188, you were merely a few questions away. You don’t need to blow things up and attack the exam from a totally different angle. A mere strengthening of your knowledge base, with just a small amount of attention paid to study habits, will likely be what it takes to get you into passing territory. If you scored 164 but needed a 192, then it’s time to do a hard reset, and reapproach the entire process.

But what do you receive now, in this pass/fail era? A cryptic set of lines to show you “how far away” you were from passing. Take a look at this sample score report of a failed Step 1 result:

 

fail step 1

Image from USMLE

The black dotted line is a passing score, and there you are on the left side of it. So you now need to study…about an inch…harder?

This graphic is difficult to use, other than the obvious thought that being really close to the black line will require less work than being really far from it. Two other factors must be combined with this report, however: a) your confidence level, and far more important, b) your NBME performance(s).

Hopefully, your confidence is congruent with your performance. When you left the test, did you just know that you failed? Or did you leave proud of yourself, only to be furiously surprised when you discovered you failed? You will want to study until you get to a place where you feel confident about taking the test.

But if we can’t measure it, it becomes hard to change. That’s where NBME tests come into play. Taking an NBME test will generate a score report with so much more useful content that you can actually act upon.

The entire report is too large and in-depth to include here and can be accessed on the NBME website. The graphic from the first page says it all:

In this single picture, you are told your probability of passing Step 1, the percentage of content you “have attained mastery” of, and exactly how far away you are from passing (or failing). The 9-page score report that follows even hones things down by subject so that you know where your efforts should be focused.

3. Ask for help

Seek out people who have done well on Step 1, find out how they did it, and ask them for advice. Your medical school can likely help identify and contact upperclassmen who may have tips for you, especially since schools are intimately aware of their students’ academic performance. There may even be some upperclassmen who have worked with other students who failed Step 1 in the past.

Remember, there is no one-size-fits-all approach to being successful on Step 1, but there are general trends among successful students. As you ask people about what helped them find success, identify these trends, and then compare them to your first approach to studying for Step 1. Stick with the strategies that seem to work for other students, and cut out things successful students did not do.

If you were intimidated by the thousands of pages of material you needed to master, a professional dedicated to your success can help you plan out a schedule so that you will know exactly what you should be studying each day. If test anxiety is standing between you and your passing score, a medical (or testing) professional can help you assemble a toolbox to deal with the negative emotions that creep in and foil your efforts. Schedule a free phone consultation with our senior advisors and get personalized, expert guidance to help you ensure your success.

4. Solidify your study approach

Give yourself due time to prepare

After learning that you failed, you probably will benefit from an initial study-free period just to clear your mind and formulate your new plan of attack. Then, you’ll need to make sure you have ample study time to prepare: a combination of enough hours per day and enough days before your test day. The further you were from passing, the more time (and larger overhaul) you will need for studying. Missed it by a hair? Repeat the study period you followed last time, and make some changes to your approach. A few standard deviations away from passing? Slot yourself with multiple months of studying while reworking your entire approach. 

Evaluate your resources

Another important factor is how long it’s already been since your last attempt. If you failed the test more than a year ago, start completely fresh. You will need to update your resources: buy the latest copies of the books you will use to study, and sign up for a full year of your chosen question bank. You might experience some inertia when you first fire up your studying. Starting is always hard, but a body in motion will stay in motion; gather momentum and keep moving forward.

If you are coming off a very recent failing score, your resources are likely up to date. Still, you might want to switch gears for freshness. Consider changing question banks, reference books, and/or video series in order to breathe new life into the material. In this case, change is good.

If you do decide to change up your resources, make sure you avoid one of the most common mistakes among students who fail Step 1: resource overload. While you may feel pressured to find a resource for each topic that may show up on the exam, this is not the case. Your big-ticket items for Step 1 are physiology, pathology, microbiology, pharmacology, and biostatistics. You can get excellent coverage of these topics by sticking with UWorld, Pathoma, BRS Physiology, and First Aid.

Focus on high-yield topics

Another common mistake when preparing for Step 1 is focusing on low-yield topics. For example, you might see a single UWorld explanation that mentions the different anatomic locations of erythropoiesis during fetal life, and become anxious because you are not familiar with that topic. Then, you flip to the page in First Aid containing that information, and spend the next hour writing and re-writing the graph on fetal erythropoiesis, until you feel like you have it down.

Well, the truth is, you probably will never see a question on that topic on your Step 1 exam. Even if you do, the depth of knowledge needed to answer that question will be cursory at best. Instead of diving into these topics for long periods of time, you could have been learning something else that comes up over and over again in the question bank (e.g. hemochromatosis, cardiac tamponade, sickle cell disease, emphysema, etc.).

Let the frequency at which you see questions on a given topic be your guide as to how high-yield it is. If you have incorrectly answered six questions on type 1 hypersensitivities, it would be worth your time to spend an hour on that topic.

5. Make a bulletproof study schedule

If you are unable to get professional help from a tutor, it will be up to you to take your resources and create a study schedule (then stick to it). In reality, making your own study schedule is not as hard as it seems, and it will pay huge dividends in the future.

In the old days, creating a study schedule was a huge pain requiring hours of work breaking up the resources you want to study, and mapping them out on a calendar or spreadsheet. Then the moment you fall behind or need to make a change, you have to spend hours moving your assignments around. Instead, let Cram Fighter do the work for you and create a detailed, personalized plan in minutes. A great study schedule is your map to get you where you want to go.

6. Take any and all Self-Assessments you can find

As stated earlier, NBME exams are your key to success. And along the way, you will need to determine if your new approach to studying is creating positive changes. The best way to monitor your performance is by using Self-Assessment exams along the way—and NBME Self-Assessments are your greatest ally here. Take them frequently (once every 2-3 weeks) and take them seriously. You should give these tests the same effort and dedication you will give to the real Step 1. Nothing else will better prepare you for what it feels like to sit and answer NBME/USMLE questions for hours and hours at a time.

Your question bank might also include a long self-assessment or two as part of the package. Take them all! The more questions you answer during your study period, the better your chance of success will be.

If you are coming up short on your assessments, use the reports to see if a particular subject or type of question is giving you a hard time, or if it’s the test environment in general. 

Summing it all up

The entire Step 1 process is intimidating to face on your own, and it becomes even more intimidating after failing the exam. Utilize all available resources, as your career hinges on being able to pass this test. Don’t repeat exactly what you tried to do last time—you already know it doesn’t work! Make a major change in your approach, and get someone on your team to help you through the prep process. Work with a Step 1 tutor, whether from your medical school or any tutoring company. Enlisting the assistance of your medical school Dean’s office is useful as well. Your dream and career are certainly worth the investment of time and money! 

Further Reading

Photo by David Kennedy on Unsplash