Residency chances with failed Step 1

[thetimegoeson]

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I am at a mid to low-tier USMD school.
I failed Step 1 on my first try. This was shocking since all my practice test scores (NBMEs, CBSEs) were in the 7~80s. Fortunately, I was able to pass on my 2nd try.
I was initially shooting for a competitive specialty (Derm, Plastics, Ortho). I have done amazing research for the past 2 years and I now have four 1st author pubs and numerous 2nd, 3rd author pubs in well-respected journals within the field.

I met with the school after failing Step 1, where I was told that, no matter how well I do from now on, the doors are closed for almost every specialty except for Primary Care. The only exception would be if I have a 280+ Step 2 score, and honor all my rotations that some specialties such as Radiology might consider me but even still it would be highly unlikely.
I was also told that even if I do well on rotations and have a solid Step 2 score, I probably wouldn't match into good academic programs within the Primary Care specialties.
I appreciate the school telling me the reality but it also makes me wonder if I am just destined to end up in a community program at a Primary care specialty no matter how well I do from now on.
I was hoping to hear advice from SDN about this!

 

[Rapsidy]

I sent you a DM. Quick reply here, no you are not limited to primary care only. Do you have to work harder than others now? Likely, but many doors are still open to you.

Derm, plastics, and ortho are probably off the table though.

 

[KendallJennerSniperLady69]

I am at a mid to low-tier USMD school.
I failed Step 1 on my first try. This was shocking since all my practice test scores (NBMEs, CBSEs) were in the 7~80s. Fortunately, I was able to pass on my 2nd try.
I was initially shooting for a competitive specialty (Derm, Plastics, Ortho). I have done amazing research for the past 2 years and I now have four 1st author pubs and numerous 2nd, 3rd author pubs in well-respected journals within the field.

I met with the school after failing Step 1, where I was told that, no matter how well I do from now on, the doors are closed for almost every specialty except for Primary Care. The only exception would be if I have a 280+ Step 2 score, and honor all my rotations that some specialties such as Radiology might consider me but even still it would be highly unlikely.
I was also told that even if I do well on rotations and have a solid Step 2 score, I probably wouldn't match into good academic programs within the Primary Care specialties.
I appreciate the school telling me the reality but it also makes me wonder if I am just destined to end up in a community program at a Primary care specialty no matter how well I do from now on.
I was hoping to hear advice from SDN about this!

I think some paths in family medicine/IM can offer you the same sort of lifestyle/similar practice to derm depending on what you're interested in.

I could be wrong, but I think things like neuro, path, which both have great lifestyle and compensation are still open to you.

Agree that the ultracompetitive things like derm/ophtho/plastics etc. are all off the table. I personally think radiology is pretty much off the table too given how much they are known to emphasize grades/scores.

 

[LunaOri]

Your best chance for any competitive specialty may be at your home program (you will still have to do well on Step2). I would suggest meeting with the program director in the specialty in which you have published, and see if there is any hope. If not, honoring your clinicals and doing well in Step 2 will give you the best chance of matching at a decent program in a less-competitive specialty.

 

[Med Ed]

I was also told that even if I do well on rotations and have a solid Step 2 score, I probably wouldn't match into good academic programs within the Primary Care specialties.

No, that's dumb. A solid application with one blemish is still a solid application.

My general advice for people in your situation is to target academic IM programs in less desirable parts of the country (like the upper midwest) and then slingshot into the subspecialty of your choice. By that point your Step 1 stumble will be a distant memory, and you can proceed to a long, productive, and lucrative career.

 

[ceo_of_stonks]

I'm a USMD failed step 1 back in April. Retook in 6 weeks, passed, and almost done with my first rotation. My school also told me I would be lucky to get a new FM program. I was devastated. However reddit has a ton of success stories, if you want to look for more there. Neurosurg, ophtho etc probably DOA, but you still can do many wonderful specialities

 

[Starr_key]

Someone at my school failed STEP1 and matched ortho. Not sure what their profile looked like, but def. did not have the connections and people didn't think they'd match. Didn't take a RY either.

 

[eyeeye_captain]

Someone at my school failed STEP1 and matched ortho. Not sure what their profile looked like, but def. did not have the connections and people didn't think they'd match. Didn't take a RY either.

I don’t know the year they did, but in the most recent data from 23-24 (link here), there were zero Step 1 failures for matches in derm, ophtho, ortho, ENT, integrated thoracic, urology, and integrated vascular.

Rads had 1. There were 3 integrated plastics matches with a fail though.

Most very competitive specialties are likely a problem. Anesthesiology was 15/1970 positions, psych 68/1906, so better.

Still plenty of good opportunities - it’s not a family medicine in rural North Dakota thing.

 

[Euxox]

No, that's dumb. A solid application with one blemish is still a solid application.

My general advice for people in your situation is to target academic IM programs in less desirable parts of the country (like the upper midwest) and then slingshot into the subspecialty of your choice. By that point your Step 1 stumble will be a distant memory, and you can proceed to a long, productive, and lucrative career.

Step 1 is not a distant memory for IM subspecialty applications. GI and cards programs are filtering out applications based on Step 1 scores this cycle, even though a substantial block of this year's fellowship applicants took Step 1 pass/fail. Score filters will eventually stop being viable as they get more and more applicants who took Step 1 as pass/fail, but I suspect after that they will screen out people with multiple attempts.

The less competitive fellowships (ID, geriatrics, palliative, nephrology) are still attainable. FM and its subspecialties are still attainable. Psych and PM&R are tougher but not totally out of the question.

There were 3 integrated plastics matches with a fail

Plastics is a weird match. It seems like one of those knowing the right people specialties.

 

[Med Ed]

Step 1 will absolutely rear its head again in IM subspecialty applications. GI and cards programs are filtering out applications based on minimum Step 1 scores this cycle, even though a substantial block of this year's fellowship applicants took Step 1 pass/fail.

Well of course. Competitive subspecialties are competitive, and programs can choose to dredge up whatever they want to help the selection process.

I think we can all agree that there are no guarantees in life. But my point is that it is possible, through a combination of intelligent planning, hard work, and some luck, to crawl up and away from an isolated Step 1 failure.

 

[ceo_of_stonks]

Step 1 is not a distant memory for IM subspecialty applications. GI and cards programs are filtering out applications based on Step 1 scores this cycle, even though a substantial block of this year's fellowship applicants took Step 1 pass/fail. Score filters will eventually stop being viable as they get more and more applicants who took Step 1 as pass/fail, but I suspect after that they will screen out people with multiple attempts.

The less competitive fellowships (ID, geriatrics, palliative, nephrology) are still attainable. FM and its subspecialties are still attainable. Psych and PM&R are tougher but not totally out of the question.



Plastics is a weird match. It seems like one of those knowing the right people specialties.

just a reminder, 1 in 10 USMD fail their first attempt (90% pass rate in 2023 and 89% pass rate in 2024 respectively). Lower for USDO and IMGs

 

[Starr_key]

I don’t know the year they did, but in the most recent data from 23-24 (link here), there were zero Step 1 failures for matches in derm, ophtho, ortho, ENT, integrated thoracic, urology, and integrated vascular.

Rads had 1. There were 3 integrated plastics matches with a fail though.

Most very competitive specialties are likely a problem. Anesthesiology was 15/1970 positions, psych 68/1906, so better.

Still plenty of good opportunities - it’s not a family medicine in rural North Dakota thing.

It was this year, 2025.

 

[125896]

I am at a mid to low-tier USMD school.
I failed Step 1 on my first try. This was shocking since all my practice test scores (NBMEs, CBSEs) were in the 7~80s. Fortunately, I was able to pass on my 2nd try.
I was initially shooting for a competitive specialty (Derm, Plastics, Ortho). I have done amazing research for the past 2 years and I now have four 1st author pubs and numerous 2nd, 3rd author pubs in well-respected journals within the field.

I met with the school after failing Step 1, where I was told that, no matter how well I do from now on, the doors are closed for almost every specialty except for Primary Care. The only exception would be if I have a 280+ Step 2 score, and honor all my rotations that some specialties such as Radiology might consider me but even still it would be highly unlikely.
I was also told that even if I do well on rotations and have a solid Step 2 score, I probably wouldn't match into good academic programs within the Primary Care specialties.
I appreciate the school telling me the reality but it also makes me wonder if I am just destined to end up in a community program at a Primary care specialty no matter how well I do from now on.
I was hoping to hear advice from SDN about this!

Yes you’re probably not matching neurosurgery at U Va but there are many primary care spots at university programs that will take you. For example

I am at a mid to low-tier USMD school.
I failed Step 1 on my first try. This was shocking since all my practice test scores (NBMEs, CBSEs) were in the 7~80s. Fortunately, I was able to pass on my 2nd try.
I was initially shooting for a competitive specialty (Derm, Plastics, Ortho). I have done amazing research for the past 2 years and I now have four 1st author pubs and numerous 2nd, 3rd author pubs in well-respected journals within the field.

I met with the school after failing Step 1, where I was told that, no matter how well I do from now on, the doors are closed for almost every specialty except for Primary Care. The only exception would be if I have a 280+ Step 2 score, and honor all my rotations that some specialties such as Radiology might consider me but even still it would be highly unlikely.
I was also told that even if I do well on rotations and have a solid Step 2 score, I probably wouldn't match into good academic programs within the Primary Care specialties.
I appreciate the school telling me the reality but it also makes me wonder if I am just destined to end up in a community program at a Primary care specialty no matter how well I do from now on.
I was hoping to hear advice from SDN about this!

i wouldn’t worry too much granted ultra competitive are probably not but a Quick Look at primary care at university programs shows you would be well received since some were even taking Caribbean grads

 

[Obnoxious Dad]

My general advice for people in your situation is to target academic IM programs in less desirable parts of the country (like the upper midwest) and then slingshot into the subspecialty of your choice.

It may come as a surprise to you, but there are lots of physicians who love practicing in the upper Midwest. In fact, Wisconsin is the very best place to practice medicine in the US. If you look at the BLS physicians' salary data, you will see that physicians in Wisconsin get paid much better than their counterparts in the Northeast. The medical malpractice laws in Wisconsin are extremely physician friendly. You won't find ambulance chasers lurking outside every clinic. The cost of living is moderate. Commute times in the Milwaukee metro area are the shortest of any major metro area in the country.

The state and local tax burden is below the national median.

Tax Burden by State in 2025

Tax Burden by State in 2025

wallethub.com

Then there's great state-owned higher education all over the Midwest. If you have ever lived in Minneapolis, Madison, Ann Arbor, East Lansing, Champaign, Iowa City, Bloomington, West Lafayette or Columbus you might notice that a significant percentage of the young adults in those towns have traveled from the East Coast to take advantage of the professional and graduate schools on the state-owned campuses of the traditional Big 10. Why is that happening? In addition, Ohio residents can take advantage of state resident tuition at the beautiful campuses at Miami of Ohio and Ohio University.

The upper Midwest is highly desirable to informed people.

 

[Med Ed]

It may come as a surprise to you, but there are lots of physicians who love practicing in the upper Midwest.

I am well aware. The region is the best kept secret in the lower 48.