What Happens if I Fail Step 1?

Megan L. Fix, MD


January 05, 2011


I failed my Step 1 board exam. I don't know anyone else who failed, and I just feel like quitting. What should I do?

Response from Megan L. Fix, MD
Associate Residency Director, Emergency Medicine, University of Utah, Salt Lake City

You are not alone! For every 100 US and Canadian medical students, about 5 or 6 will fail Step 1 of the US Medical Licensing Examination (USMLE). Most of these students go on to become physicians, so do not fear. Remember, the boards are "steps" toward becoming a physician, not ultimate deciding factors.

According to the USMLE Website,[1] the fail rate for Step 1 and Step 2 is around 5%. In 2007 and 2008, about 17,000 US and 17,500 Canadian first-time takers sat for the exam. The pass rates were, respectively, 95% and 94%. The ultimate pass rate, however, is higher given that most students who failed Step 1 on the first try will retake the exam, and about 65% of those will pass. The Step 2 Clinical Knowledge pass rate was similar in 2008 at 94%. Students who fail may retake the exam up to 4 times in a 12-month period for Step 1 and Step 2 Clinical Knowledge, but you do have to reapply and pay the fee again.

If you fail Step 1, the first thing to do is to contact your dean's office to make a plan. They will work with you to rearrange your clerkships, etc. Second, try to determine what caused you to fail on your first attempt, and then use a different method of test preparation. Third, make a study schedule and stick with it. There are many resources to assist you with exam preparation. Whether you decide to purchase a board review book, take a course, or use a question bank is up to you. Seek out a trusted classmate or counselor and discuss your options with that person. The most common resources include the Kaplan series of test questions and materials, National Board of Medical Examiners practice exams, review books, and multiday review courses. Read this article on how to prepare for Step 1. Whatever you do, make sure that you take time off to focus on studying.

As with other highly stressful aspects of medical education, the emotional toll of board failure can be overwhelming. Here is what one student said about her failure of Step 1:

The biggest task in deciding what to do was dealing with the emotional side of it. I was humiliated and certainly not used to failing. In an environment filled with such bright people, it is easy to beat yourself up for not measuring up. Failing caused me to seriously doubt my future in medicine, both because I didn't think I'd ever be able to match, and second because I wasn't sure if all the stress and anxiety was worth it. I immediately decided to tell my friends and family what had happened, as I rely on them for a tremendous amount of support. I was scared to tell my fellow med students but found out others were in my position, and we used each other for motivation and support. The other med students were all extremely supportive as well, which was a pleasant surprise! I was afraid they would look at me differently and think me incompetent, but I was never made to feel this way at all.

As she points out, acknowledging your emotions, being honest, and calling on support from friends, family, and colleagues are paramount. Here is another student's recall of this experience:

The keys were using my dean's office and the resources they knew that I otherwise might not have found. It was huge for me to make sure that I was always communicating with the dean's office and my peers. The study group...was a great help to me. We all had different learning needs and styles, but we were able to help each other, and study together. Having people to answer to kept me motivated and focused when I would get discouraged. My review course was hugely helpful.

The first student above provided this list of tactics that helped her not only pass the boards, but crush them:

  • Cry, scream, yell...give yourself the opportunity to cope with the news.

  • Come clean with the dean's office and your friends/family...the sooner the better!

  • Make a plan, and stick to it! This may mean significant cost, time, and energy, but do it anyway. This is important.

  • Assess your progress with board practice exams and look for scores that are trending up.

  • Keep checking in with the dean's office.

  • Take the test only when you are ready! Failing twice is not a good idea.

  • Think about what happened and why, and be prepared to explain. This will come up fairly frequently.

  • Don't let people tell you/infer that your career goals are doomed because you failed. Your options may be fewer, but don't make assumptions.

  • Work hard third year and get good evaluations.

  • Meet with an advisor in your field and make a plan about Step 2, application strategy, and matching.

  • Learn from your mistakes and make a plan (with daily goals) for Step 2. Ask residents early on how they prepared for guidance.

  • Take Step 2 early, if possible, and post a good score before applications are reviewed.

Special thanks to our 2 student contributors, Michelle and Jessica, for their candid thoughts and honesty.