the state of step 1

[ceo_of_stonks]

As many of you are aware, step 1 pass rates are going down. To pull in some official numbers from USMLE (link: Performance Data | USMLE), first time pass rates for step 1:

US MD: 2023- 90%. 2024-89%.

US DO: 2023- 86%. 2024-86%.

For the past 2 years, 1 in every 10 MD students failed, the group that traditionally does the best.

Yes, 90% is a high amount. However, pass rates used to sit in the 98%-96% percent.

I just wonder what this means for the future of medicine. Getting into medical school is already rigorous. If we are weeding out 10% of that group after the first two years, what will this mean for the physician shortage? Potentially nothing, and we’ll fix the residency shortage for medical students. Or, we are weeding out the ones not smart enough for medical school anyways. I see this sentiment on here all the time- everyone who fails is stupid, lazy, didn’t try, etc.

However, I would like to provide another perspective.

I recently found out that I failed. Sure, I always could have tried more. But I really did try, starting with using anki, bootcamp, boards and beyond from the beginning of medical school. I wasn’t a bad student, but definitely middle of the pack. Going into dedicated, my school gives us six weeks. My school also likes to see at least one 65% on a form. Our academic advisor likes to see 2 65%, either forms, the 120s or both. I did that- I got a 66% on form 31 and a 72% on the old 120. Therefore, I was told I was ready and to sit so I could move onto clinicals on time.

Before anyone comes for these policies, my school is a state MD school (had to make a new account because someone could find out my school with my old one). Definitely not Harvard, but matches pretty well every year and is respectable enough. Additionally, I have talked to friends at other in-state schools and many of them have 6 weeks, 65% on a form, or both. My school is even considering giving the next class one less week of dedicated too.

After I got my fail, looking online I see the sentiment online to get at least two 70%. Sure, I see the worth in that, but at the time I listened to my school. Also, my 66% said a 96% chance of passing within a week. What else was I expected to do? We medical students come into medical school and trust that our school policies will get us a pass. I mean, the schools graduate MDs every year, and what do I know, so I trusted them.

I know many people at my school who got one 65% on a form, took it and passed. I also know a handful that got a 65% on a form and failed the real deal. I also know someone at my school who never got a 65%, ignored the school's advice, took it and passed.

I fully accept my fail and I don’t want this to come off as a sob story. I just wish medicine allowed us to be human. If someone’s life is full of success, what are they going to do the first time they face a failure in clinic? I’ve also been told my chances at residency are pretty low unless I want to do FM in rural Montana. I think in this rocky time for medicine + shortages, weeding out 10% of all US MD is insane. I’m all for having high standards since our profession does have other human lives in our hands. However, leaving 2,500+ US MD students without a future every year is genuinely insane to me. But the boomers will probably say I’m just a lazy gen Z.

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[Goro]

I belive what we're seeing is the lingering effects of the COVID-19 pandemic AND boards going P/F. Some students may be taking Boards less seriously "Because all I need to do is pass".

100% online learning seems to have damaged an entire generation of learners.

You're allowed to be human, but you still have to display minimal competency.

Primary Care residencies will still take you even with a Step 1 failure, and you still get to be a doctor.

TLDR, Step 1 failure =/= failing to match.

Your Step 1 failure does NOT define you as a person, nor is it a measure of you as a human being.

The vast majority or retakers pass, and become doctors

 

[ceo_of_stonks]

I belive what we're seeing is the lingering effects of the COVID-19 pandemic.

100% online learning seems to have damaged an entire generation of learners.

You're allowed to be human, but you still have to display minimal competency.

Primary Care residencies will still take you even with a Step 1 failure, and you still get to be a doctor.

like I said, I agree with having high standards. Passing step 1 is a reasonable requirement. It's insane though that with increasing fail rates, a fail is still career suicide and you can kiss your dreams of an IM fellowship goodbye with only hopes of FM in rural Alaska

 

[Goro]

like I said, I agree with having high standards. Passing step 1 is a reasonable requirement. It's insane though that with increasing fail rates, a fail is still career suicide and you can kiss your dreams of an IM fellowship goodbye with only hopes of FM in rural Alaska

My understanding from our wise SDN clinicians is that docs in rural areas make beaucoup bucks.

Now stop feeling sorry for yourself. It's unbecoming.

 

[ceo_of_stonks]

My understanding from our wise SDN clinicians is that docs in rural areas make beaucoup bucks.

Now stop feeling sorry for yourself. It's unbecoming.

my point is, if every residency program screens out step 1 fails 10% of US MD won't match.

 

[Hollow Knight]

The curve has shifted far enough to the right that a good chunk of current attendings would have failed the current exams we take. I do think these exams are getting a little silly and clinically irrelevant.

But it is what it is. We gotta jump through the hoops.

If I was the tzar I’d go back to the days of easier board exams and higher duty hours so we’d be better clinically but nobody cares what I think.

 

[PeteytheFish]

my point is, if every residency program screens out step 1 fails 10% of US MD won't match.

This smacks of panicked med student who is in the anger stage of their grief.

Take a breath. Go talk to your academic advisor. You're making the assumption that your career is now dead in the water, but it's not. You need to go and pass this exam and then figure out how to do well in your clinicals and Step 2, but the overwhelming likelihood is that if you can do that, you'll match just fine. Are you going to match into neurosurgery? Probably not, but almost no one does anyway. You're not likely to be damned to "FM in rural Montana" (though honestly, stop being so elitist and recognize that those are often rigorous and highly respected residencies that people bound for rural medicine seek out).

Several people from my class failed step 1, and with the exception of the guy who actually failed out of school entirely, every one of them matched competitively.

Calm down. Regroup. Retake the test. It's going to be just fine.

 

[DO2015CA]

like I said, I agree with having high standards. Passing step 1 is a reasonable requirement. It's insane though that with increasing fail rates, a fail is still career suicide and you can kiss your dreams of an IM fellowship goodbye with only hopes of FM in rural Alaska

2 points. There isn’t a physician shortage it’s a maldistribution and the subspecialties are even less of an issue… unless you’re a pediatric subspecialist. The major understaffing are the primary care specialties that you can still match into just fine with a step 1 failure.

 

[ceo_of_stonks]

This smacks of panicked med student who is in the anger stage of their grief.

Take a breath. Go talk to your academic advisor. You're making the assumption that your career is now dead in the water, but it's not. You need to go and pass this exam and then figure out how to do well in your clinicals and Step 2, but the overwhelming likelihood is that if you can do that, you'll match just fine. Are you going to match into neurosurgery? Probably not, but almost no one does anyway. You're not likely to be damned to "FM in rural Montana" (though honestly, stop being so elitist and recognize that those are often rigorous and highly respected residencies that people bound for rural medicine seek out).

Several people from my class failed step 1, and with the exception of the guy who actually failed out of school entirely, every one of them matched competitively.

Calm down. Regroup. Retake the test. It's going to be just fine.

I came in not wanting neurosurg/ortho/plastics/etc anyways. I really do respect FM, I promise, and I'm not from Montana nor have any interest moving there lol so thats why I used it as an example. I saw advice on here to give up everything besides maybe a new rural FM program because step 1 fail is career suicide. My school is no help- our dean of student affairs told me to drop out. He apparently tells everyone who failed (backed up by someone else I know).

 

[ceo_of_stonks]

The curve has shifted far enough to the right that a good chunk of current attendings would have failed the current exams we take. I do think these exams are getting a little silly and clinically irrelevant.

But it is what it is. We gotta jump through the hoops.

If I was the tzar I’d go back to the days of easier board exams and higher duty hours so we’d be better clinically but nobody cares what I think.

I appreciate this. I debated putting this in the original post but was afraid everyone would jump down my throat. Talking to people in med school (not just mine) alot of us feel like the real deal was nothing like the forms nor UWorld. My school's policy is a 65% on a CSBE which gives you a 95% chance of passing. Including myself, I know of 4 people in my class that got a 65%+ and didn't pass. Maybe we're all just unlucky.

Overall, this post is to provide perspective from a current med student. The farther people get from med school, the less they understand the exact forces were under, hence labeling the entirety of med students now as lazy. (not that this comment did that at all, just wanted to reinforce my point because I feel like this thread has lost my original plot)

 

[PeteytheFish]

I came in not wanting neurosurg/ortho/plastics/etc anyways. I really do respect FM, I promise, and I'm not from Montana nor have any interest moving there lol so thats why I used it as an example. I saw advice on here to give up everything besides maybe a new rural FM program because step 1 fail is career suicide. My school is no help- our dean of student affairs told me to drop out. He apparently tells everyone who failed (backed up by someone else I know).

Ugh, I'm sorry you're getting bad advice from your dean. Do not drop out! A Step 1 fail really and truly is not the end of the world. It sucks, and it will limit some of your choices, but seriously, don't panic.

Realize also that SDN is a hotbed of catastrophizing and misguided armchair experting. Chances are that half of the advice you're getting on here is from neurotic undergrads who think they know what's going on because they're premeds but who have no real med school or advising experience.

Right now, all of your energy needs to be put into getting yourself ready to nail your retake. It sounds like you were meeting all of the metrics to pass, so was there something that prevented you from performing on the day? Nerves? Exhaustion? I don't have the experience of having failed, but it did take me longer than my dedicated period to get up to passing. One thing that helped me immensely was the Anki deck covering the Rapid Review at the back of First Aid. I'm sure you can find it on Reddit. Another thing that I realized is that I can't kick my brain into gear in the morning without a workout, so I now go to the gym before any big test. Ask your classmates what helped them. Talk to the learning specialists at your school.

Don't take it again until you're sure you will pass. One fail isn't a big deal, but two fails would be a problem.

Once you're through, your goal is to absolutely kill it on your clinical rotations. Don't feel like you have to High Honor every rotation, but be a nice person, help your residents, study hard for your shelf exams, and do the absolute best you can. Start studying for Step 2 early (it's a MUCH better test) and take it when you're scoring high on practice exams.

Above all, absolutely do not believe that a Step 1 failure is the end of your medical career. It's simply not that big of a deal unless you just roll over and give up.

For what it's worth, I had a classmate who had to remediate every single block of didactics and then failed Step 1. This person not only went on to match, but matched at a genuinely competitive program (yes, in FM, but that had been their goal from the beginning). If they can do it, so can you.

Also, Montana is awesome.

 

[DO2015CA]

I came in not wanting neurosurg/ortho/plastics/etc anyways. I really do respect FM, I promise, and I'm not from Montana nor have any interest moving there lol so thats why I used it as an example. I saw advice on here to give up everything besides maybe a new rural FM program because step 1 fail is career suicide. My school is no help- our dean of student affairs told me to drop out. He apparently tells everyone who failed (backed up by someone else I know).

Don’t do that. That isn’t helpful. You can still do some stuff if you rebound well. Lean hard into your home programs for specialties as well. You won’t be stuck in rural FM

 

[Dral]

So if your class has 120 people in it a year, they tell 12 people on average to drop out? I find that a bit hard to believe.

Anyway, things are far from over. Figure out how to knock Step 2 out of the park.

 

[DO2015CA]

I appreciate this. I debated putting this in the original post but was afraid everyone would jump down my throat. Talking to people in med school (not just mine) alot of us feel like the real deal was nothing like the forms nor UWorld. My school's policy is a 65% on a CSBE which gives you a 95% chance of passing. Including myself, I know of 4 people in my class that got a 65%+ and didn't pass. Maybe we're all just unlucky.

Overall, this post is to provide perspective from a current med student. The farther people get from med school, the less they understand the exact forces were under, hence labeling the entirety of med students now as lazy. (not that this comment did that at all, just wanted to reinforce my point because I feel like this thread has lost my original plot)

This is maybe true for those 15-20+ years out. Plenty of us less than 10 years removed are still close enough. The game hasn’t changed that much. FA hasn’t grown that much from my copy hehe

 

[Goro]

my point is, if every residency program screens out step 1 fails 10% of US MD won't match.

And I'm trying to tell you that there are more residency programs than there are medical school graduates, so even people with step one failures can match.

Now, they're not going to match into their preferred specialty, but if the choices not doing that or not being a doctor, which one would you take?

 

[ceo_of_stonks]

Ugh, I'm sorry you're getting bad advice from your dean. Do not drop out! A Step 1 fail really and truly is not the end of the world. It sucks, and it will limit some of your choices, but seriously, don't panic.

Realize also that SDN is a hotbed of catastrophizing and misguided armchair experting. Chances are that half of the advice you're getting on here is from neurotic undergrads who think they know what's going on because they're premeds but who have no real med school or advising experience.

Right now, all of your energy needs to be put into getting yourself ready to nail your retake. It sounds like you were meeting all of the metrics to pass, so was there something that prevented you from performing on the day? Nerves? Exhaustion? I don't have the experience of having failed, but it did take me longer than my dedicated period to get up to passing. One thing that helped me immensely was the Anki deck covering the Rapid Review at the back of First Aid. I'm sure you can find it on Reddit. Another thing that I realized is that I can't kick my brain into gear in the morning without a workout, so I now go to the gym before any big test. Ask your classmates what helped them. Talk to the learning specialists at your school.

Don't take it again until you're sure you will pass. One fail isn't a big deal, but two fails would be a problem.

Once you're through, your goal is to absolutely kill it on your clinical rotations. Don't feel like you have to High Honor every rotation, but be a nice person, help your residents, study hard for your shelf exams, and do the absolute best you can. Start studying for Step 2 early (it's a MUCH better test) and take it when you're scoring high on practice exams.

Above all, absolutely do not believe that a Step 1 failure is the end of your medical career. It's simply not that big of a deal unless you just roll over and give up.

For what it's worth, I had a classmate who had to remediate every single block of didactics and then failed Step 1. This person not only went on to match, but matched at a genuinely competitive program (yes, in FM, but that had been their goal from the beginning). If they can do it, so can you.

Also, Montana is awesome.

thank you for all this. You definitely clocked me with the anger stage of grief. I will definitely come back and reread this until I'm out of this weird headspace I'm in

 

[ceo_of_stonks]

So if your class has 120 people in it a year, they tell 12 people on average to drop out? I find that a bit hard to believe.

Anyway, things are far from over. Figure out how to knock Step 2 out of the park.

this dean of student affairs (or something like that) is a PhD. Idk if that contributes, but he's obsessed with my school's stats, so maybe he sees me as a bad stat lol. My friends told me it was a dumb idea to go to him. Anyways, the dean of the entire COM is an MD, and there's two other MDs that are high up in admin leadership (idk their official titles though) so I'll probably talk to at least one of those three in the coming weeks

 

[ceo_of_stonks]

This is maybe true for those 15-20+ years out. Plenty of us less than 10 years removed are still close enough. The game hasn’t changed that much. FA hasn’t grown that much from my copy hehe

thats true! alot of the posts I saw were from many years ago and I've been getting better advice on this thread than I expected

 

[DO2015CA]

thank you for all this. You definitely clocked me with the anger stage of grief. I will definitely come back and reread this until I'm out of this weird headspace I'm in

Ya that’s ok to grieve. Doors have closed. But you’ll still succeed as long as you respond in the right way. And as USMD you won’t be stuck in rural FM

 

[Dral]

this dean of student affairs (or something like that) is a PhD. Idk if that contributes, but he's obsessed with my school's stats, so maybe he sees me as a bad stat lol. My friends told me it was a dumb idea to go to him. Anyways, the dean of the entire COM is an MD, and there's two other MDs that are high up in admin leadership (idk their official titles though) so I'll probably talk to at least one of those three in the coming weeks

Unfortunately that happens sometimes. I've heard of undergrad institutions advising against applying to med school because the student's stats were on the low side (when they could probably still get in somewhere).

Anyway, yes as DO2015CA noted, it's ok and healthy to grieve. I'll say that I can't know for sure how much your school could do things differently to help people pass, and I'm sure you're looking for places to designate reasons (nicer way of saying 'place blame') of why you didn't pass. However, these things happen. You made it in to medical school. It's not because you aren't intelligent.

I had a setback in the process. I wanted to think it wasn't me at the time, but it was. It's easier to own it since it's in the distant past. Do your best to work past all that and just put your head down and work on passing 1, rocking 2, and doing well on your clinical rotations.

 

[ceo_of_stonks]

Unfortunately that happens sometimes. I've heard of undergrad institutions advising against applying to med school because the student's stats were on the low side (when they could probably still get in somewhere).

Anyway, yes as DO2015CA noted, it's ok and healthy to grieve. I'll say that I can't know for sure how much your school could do things differently to help people pass, and I'm sure you're looking for places to designate reasons (nicer way of saying 'place blame') of why you didn't pass. However, these things happen. You made it in to medical school. It's not because you aren't intelligent.

I had a setback in the process. I wanted to think it wasn't me at the time, but it was. It's easier to own it since it's in the distant past. Do your best to work past all that and just put your head down and work on passing 1, rocking 2, and doing well on your clinical rotations.

maybe I'm being delusional, but I'm trying to own it. Obviously I could always be doing more. I just said the 65% form thing because on reddit people said I should have gotten a 70%+ before sitting. However at the time I just listened to my school's guidelines. I just didn't want this thread to become "why did you take? you should have gotten a 70/80/90%+ on a form before sitting"

 

[operaman]

Agreeing with the others, your career isn’t over and you can still have options. In the end what will matter is the context, whether this is a lone red flag or whether it collects a few friends over the next two years. Fail rates have been up ever since going p/f and covid probably didn’t help either. When the emphasis changed from getting the highest score possible because it defined your career to just pass, a lot more people get hurt accidentally. It will likely adjust over time - the passing scores and scales slowly shifted as prep tools improved and as people studied more insanely. They will eventually equalize a bit but it will take a number of years.

One thought to add as you prep to retake- something I’ve noticed when prep scores don’t match actual results is that often those forms weren’t taken under strict test like conditions. Might be worth asking your school if they have some place you could take a simulated timed exam with timed breaks when the time comes. I remember during my prep I could bang out a block of new uworld questions with plenty of time to spare, but every block on the real deal felt like a photo finish. The pressure and environment of the actual exam definitely impacts performance, so do your best to simulate that as you gear up to retake.

 

[ceo_of_stonks]

Agreeing with the others, your career isn’t over and you can still have options. In the end what will matter is the context, whether this is a lone red flag or whether it collects a few friends over the next two years. Fail rates have been up ever since going p/f and covid probably didn’t help either. When the emphasis changed from getting the highest score possible because it defined your career to just pass, a lot more people get hurt accidentally. It will likely adjust over time - the passing scores and scales slowly shifted as prep tools improved and as people studied more insanely. They will eventually equalize a bit but it will take a number of years.

One thought to add as you prep to retake- something I’ve noticed when prep scores don’t match actual results is that often those forms weren’t taken under strict test like conditions. Might be worth asking your school if they have some place you could take a simulated timed exam with timed breaks when the time comes. I remember during my prep I could bang out a block of new uworld questions with plenty of time to spare, but every block on the real deal felt like a photo finish. The pressure and environment of the actual exam definitely impacts performance, so do your best to simulate that as you gear up to retake.

thanks, this is helpful! I definitely panicked during my take and changed a bunch of flagged at the end. Taking it at my school's testing center would definitely help if they offer it, I'll ask!

 

[Dral]

Fail rates have been up ever since going p/f and covid probably didn’t help either. When the emphasis changed from getting the highest score possible because it defined your career to just pass, a lot more people get hurt accidentally. It will likely adjust over time - the passing scores and scales slowly shifted as prep tools improved and as people studied more insanely. They will eventually equalize a bit but it will take a number of years.

Agree. The folks going through right now are the ones dealing with this recalibration. Back when I took it (not SUPER long time ago), averages for a school were in the upper teens for Step 1 I believe, and a score like 228 or 232 was a respectable good score. Things in the 240s and up were in the 'pretty damn good' to excellent range. I'm not sure of the averages when they stopped scoring, but I think it was up in the 230s (or maybe even higher?).

One good thing about Covid though: They stopped CS.

 

[PeteytheFish]

thanks, this is helpful! I definitely panicked during my take and changed a bunch of flagged at the end. Taking it at my school's testing center would definitely help if they offer it, I'll ask!

Prometric will also let you take the free120 there if you want to take a low-stakes practice run at their facility. Not as a diagnostic, since you've already taken it, but just as a means of getting into the testing facility to feel it out again.

Definitely go talk to your learning specialists and talk about strategy. Sounds a lot like you just need some tools to calm the nerves and make good decisions.

Another thing to keep in mind is that you will definitely feel like you're failing on round two, so figure out some ways to give yourself some encouraging self-talk so you don't freak out.

You've got this!

 

[Doctoscope]

I think another aspect is students (at least on the DO side) just VASTLY underestimate the exam because "it's just P/F." When it was scored, "just passing" was the bare minimum and people grinded to get that 240/250+, so naturally 99% of people passed. But now that goal has shifted down to "just passing," and there has been a proportional reduction in effort coming from students (anectotally).

There are plenty of students in my class who are now delaying their exams or even considering cancelling it altogether 1 week into dedicated because just how behind they are, and/or they got absolutely shafted on an NBME after blowing off studying until Spring break of M2. It also doesn't help our curriculum is doodoo and does a huge disservice for students; if you have a good board-relevant curriculum, then studying for school does kill 2 birds with 1 stone.

For future M1s: you don't have to grind for Step 1 as if it was scored, but I'd seriously recommend starting AnKing lightly when medical school starts, and ramp yourself up slowly. You don't have to watch 3rd parties if you don't want to or do 100s of new cards a day as an M1, but even doing 25-30 new high yield cards a day and stuff related to lecture will do wonders for your long-term retention and dedicated. This is what I did, and the first NBME I took gave me a 99% chance of passing, so it was definitely worth the effort.

 

[ceo_of_stonks]

I think another aspect is students (at least on the DO side) just VASTLY underestimate the exam because "it's just P/F." When it was scored, "just passing" was the bare minimum and people grinded to get that 240/250+, so naturally 99% of people passed. But now that goal has shifted down to "just passing," and there has been a proportional reduction in effort coming from students (anectotally).

There are plenty of students in my class who are now delaying their exams or even considering cancelling it altogether 1 week into dedicated because just how behind they are, and/or they got absolutely shafted on an NBME after blowing off studying until Spring break of M2. It also doesn't help our curriculum is doodoo and does a huge disservice for students; if you have a good board-relevant curriculum, then studying for school does kill 2 birds with 1 stone.

For future M1s: you don't have to grind for Step 1 as if it was scored, but I'd seriously recommend starting AnKing lightly when medical school starts, and ramp yourself up slowly. You don't have to watch 3rd parties if you don't want to or do 100s of new cards a day as an M1, but even doing 25-30 new high yield cards a day and stuff related to lecture will do wonders for your long-term retention and dedicated. This is what I did, and the first NBME I took gave me a 99% chance of passing, so it was definitely worth the effort.

here's what is so fun- I started anking first week of med school. M1s, obviously don't burn yourself out, and definitely do this, but just because you do this don't mean you're 100% in the clear

 

[Ho0v-man]

my point is, if every residency program screens out step 1 fails 10% of US MD won't match.

The point is, not even close to every residency program screens out step 1 failures. There’s enough spots for every USMD and then some.

 

[Ho0v-man]

I think another aspect is students (at least on the DO side) just VASTLY underestimate the exam because "it's just P/F." When it was scored, "just passing" was the bare minimum and people grinded to get that 240/250+, so naturally 99% of people passed. But now that goal has shifted down to "just passing," and there has been a proportional reduction in effort coming from students (anectotally).

There are plenty of students in my class who are now delaying their exams or even considering cancelling it altogether 1 week into dedicated because just how behind they are, and/or they got absolutely shafted on an NBME after blowing off studying until Spring break of M2. It also doesn't help our curriculum is doodoo and does a huge disservice for students; if you have a good board-relevant curriculum, then studying for school does kill 2 birds with 1 stone.

For future M1s: you don't have to grind for Step 1 as if it was scored, but I'd seriously recommend starting AnKing lightly when medical school starts, and ramp yourself up slowly. You don't have to watch 3rd parties if you don't want to or do 100s of new cards a day as an M1, but even doing 25-30 new high yield cards a day and stuff related to lecture will do wonders for your long-term retention and dedicated. This is what I did, and the first NBME I took gave me a 99% chance of passing, so it was definitely worth the effort.

This is exactly the issue. I was one of the last groups to take step 1 scored. Do you think we cared about passing? No. We were trying to murder step 1.