The stakes are high when medical students take the US Medical Licensing Exam (USMLE) Step 1, which tests their knowledge of basic science gleaned after 2 years of medical school. This is especially true if a student aims to be "matched" to a competitive residency program, such as surgery or dermatology, after his or her fourth year of medical school. Although students who fail Step 1 can make another five tries to pass, many residency programs will not accept a student who failed to pass this critical exam the first time. Of equally pressing concern, in most US medical schools, students must pass this exam before they can enter the third year of medical school and/or graduate. Around 4% of students in American MD programs have failed the USMLE Step 1 exam in recent years. However, these students need not feel stigma (or shame) because they can still graduate from medical school if they work hard and subsequently pass Step 1 and make up for any shortcomings, says one expert . The message to medical students who fail the USMLE Step 1 exam is, "continue to pursue one's dream and study diligently," Leon McDougle, MD, MPH, professor of family medicine and associate dean for diversity and inclusion at the Ohio State University College of Medicine in Columbus, told Medscape. "This test is important, but if failed on the first attempt, work with your faculty and education specialist to increase your likelihood to pass on the second attempt," and then focus on excelling in clinical work and on USMLE Step 2, he advises. "Be encouraged. Keep moving forward. The journey continues." Scores Needed to "Match" The current minimum passing score of the USMLE Step 1 exam, which is scored out of 300, is 194. In 2017, 96% of the 21,353 medical students from MD programs in Canada and the United States who took Step 1 for the first time passed. "Failing" USMLE Step 1 actually means failing to get a sufficiently high score to be matched to a residency program of your choice, said Rishi Desai, MD, MPH, an instructor in pediatric infectious disease at Stanford University, in Palo Alto, California, and chief medical officer at Osmosis, a web- and mobile-based learning platform to help medical students pass USMLE Step1. In 2016, students in an MD degree program in the United States or Canada who took the Step 1 exam for the first time had a mean USMLE Step 1 score of 228 (with a standard deviation of 18). Students who were matched into dermatology, neurosurgery, plastic surgery, orthopedic surgery, otolaryngology, and radiation oncology residency positions that year had a mean USMLE Step 1 score of 250. Those who were matched into residency positions in pediatrics or family practice had mean scores of 230 and 220, respectively. Thus, "if you want to go into orthopedic surgery or neurosurgery [residency positions], and you get a 210, technically you may not have failed [Step 1], but you didn't get a high enough score to get to where you wanted to go," Desai told Medscape. "Most of us think of it along the lines of, 'I want to get a 250 or 260,' so really... failure would be not getting a 250." On the other hand, "if you wanted to go into something like pediatrics or family practice, maybe a lower score would have allowed you in." According to the National Resident Matching Program (NRMP), of the 18,818 seniors in their fourth year of an MD program who took part in this year's Residency Match (with results announced in March), 17,740 seniors (94.3%) were matched to first-year postgraduate residency positions. All US state licensure boards for physicians require that medical school graduates have at least 1 year of residency training, Mona M. Signer, MPH, NRMP President and CEO, told Medscape via email. Medical students who wish to become cardiologists or nephrologists, for example, have to do a residency in internal medicine before they do a fellowship in their specialty, she noted. The "NRMP's Program Director Survey shows that many program directors are reluctant to rank applicants who fail USMLE examinations," Signer pointed out. Moreover, although students can re-enter the match as often as they wish, the more time that has elapsed since medical school graduation, the less likely the applicant is to match to a position. Signer believes that, "although the popularity and competitiveness of specialties ebbs and flows, the surgical specialties will remain competitive" in the coming years. Stigma From a Poor Score? "There is a big build-up, especially if you're taking [USMLE] Step 1, because it's so important," Kolin M. Meehan, a medical student at West Virginia University School of Medicine, in Morgantown, told Medscape. "When it comes to applying to the Match, there is certainly some stigma felt if you were to fail or even do poorly," added Meehan, who writes for the Differential blog at Medscape and is currently finishing a fellowship in pathology at Brigham and Women's Hospital in Boston, Massachusetts, between year 2 and 3 of medical school. "It's not as though people are ostracized for failing or for scoring low," he noted, "but it certainly can shape your career of medicine." Medical students who fail USMLE Step 1, said McDougle, "should focus on...learning as much as they can to be the best provider of health that they can upon completion of their medical school education and also becoming a self-directed learner because the learning never ends." "It's good to understand that Step 1 is a very important test in your medical training," Meehan echoed, "but it's important to keep perspective: You're in school to learn how to take care of other people. Any stress that you may feel about any individual test should be put in the context of your overall goal to become a physician and care for patients," he said. What Happens After a Failing Score? Most students who fail USMLE Step 1 eventually graduate, according to a national study of more than 129,000 medical students who took the USLME Step 1 exam for the first time in 1993 to 2000. More than 7800 students (6%) failed on their first try, but 90% of these students ultimately graduated from medical school. Another study of medical students in the classes of 1997 to 2002 in six Midwestern medical schools found that the 50 students (2.5%) who failed USLME Step 1 on their first attempt were more likely to be minorities, from lower-income families, or older when they graduated from university. Compared with students who had initially passed, a higher proportion of those who initially failed became primary care physicians (53% vs 41%). According to Signer, some applicants who fail to be matched to a residency position, "apply to and rank specialties for which they are not competitive based on their academic performance." Instead, students should see what program directors are looking for in the residencies that they plan to apply for. "Students should review NRMP publications such as the Program Director Survey, which describes the characteristics by specialty that are important to program directors, and Charting Outcomes in the Match, which describes the characteristics of applicants who matched to their preferred specialty." Source
