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5 Critical Lessons I Learned From Failing USMLE Step 1
What is the best way to learn how NOT to fail STEP?
I promise you, it isn't necessarily from someone who scored incredibly well on the exam.
Instead, consider listening to someone who actually failed a medical school board exam.
How about someone who failed TWICE—but then passed?
Failure forced me to completely reconsider how I studied, how I approached standardized exams, and what external factors were affecting my ability to learn.
So follow me through my journey and the lessons I learned that ultimately changed how I approached future board exams.
***Check out my NEW Medical School Hidden Curriculum Workbook, which includes pages for studying for Step 1, reviewing practice exams, and dealing with STEP failure.***
****If you would like to meet with me to discuss your unique situation or develop a STEP study schedule, you can sign up for personalized coaching and tutoring here.****
Lesson #1: Practice Multiple UWorld Questions in a Row
Do multiple UWorld questions at a time without constantly stopping or getting up.
Practice sitting and working continuously for approximately an hour, followed by a 5–10 minute break—or longer if you receive testing accommodations.
You aren't only training your medical knowledge.
You are also training your brain and body to tolerate the structure of the actual examination.
Lesson #2: Start Doing Full 40-Question Timed Blocks Early
Begin completing 40-question blocks using the actual amount of time you will have on test day.
For students without extended testing time, this traditionally means approximately 60 minutes for a 40-question block.
Start practicing this EARLY.
Your body and brain need time to become comfortable:
Sitting for extended periods
Maintaining concentration
Making decisions under time pressure
Moving past difficult questions
Managing anxiety
And continuing even when you feel mentally tired
Don't wait until the last week of dedicated studying to start practicing under test-like conditions.
Lesson #3: Make UWorld and First Aid Your Core Resources
There are MANY Step 1 resources available.
You do not need all of them.
My two most important resources were:
UWorld
First Aid for the USMLE Step 1
THEN use secondary resources when you need additional explanations or practice.
Resources I used included:
Learning Across Subjects:
Boards & Beyond, Osmosis, AMBOSS, OnlineMedEd
Pathology: Pathoma
Histology: Histology Guide
Memorizing With Pictures: Sketchy Medical, Pixorize, Picmonic
Anatomy: University of Michigan Anatomy Resources
Cardiology: University of Michigan Heart Sounds
Quizzing Yourself: Anki
Dermatology: DermNet
Psychiatry: NowYouKnow-Psych
Neurology: NowYouKnow-Neuro
The biggest lesson I learned was that MORE resources do not necessarily equal BETTER preparation.
You need a small number of high-quality resources that you actually use consistently.
Lesson #4: Do NOT Take the Exam Until Your Practice Scores Show You Are Ready
This is probably one of the most important lessons I learned.
DO NOT take the exam simply because your scheduled test date has arrived.
Your practice examinations should demonstrate that you are consistently ready to pass.
Ideally, I wanted multiple practice examinations showing a very high predicted probability of passing and a comfortable margin above the passing threshold.
You need some buffer for:
Test-day anxiety
Poor sleep
Unexpected difficult questions
Physical symptoms
Fatigue
Environmental stress
And everything else you cannot completely control on test day.
My personal advice from failing twice:
IF YOU ARE NOT CONSISTENTLY PASSING MULTIPLE PRACTICE EXAMS, SERIOUSLY CONSIDER EXTENDING YOUR TEST DATE.
From my own experience and conversations with many other medical students who failed Step 1, extending your exam date can be far easier to recover from than failing the examination.
Lesson #5: If You Fail, You WILL Be OK
Failure feels catastrophic when it happens.
I know.
I've been there twice.
But failing Step 1 does NOT automatically mean that your career in medicine is over.
There may be academic consequences.
There may be difficult conversations.
You may need additional study time.
You may need to meet with your medical school's academic leadership.
You may need to change your study strategy entirely.
But you can still move forward.
See more below in the Failure section.
Read my related blog posts and videos:
Emotionally Processing Failure: How One's Identity Is Impacted by Failure
Surviving the Taboos of Medical School
Specifically: "#3 Failing Quizzes, Exams, Courses, & STEP"
My Step 1 Dedicated Study Period
Beginning during the first month of my M2 year, I attempted to incorporate UWorld questions into my studying.
However, trying to study unrelated Step 1 material while simultaneously keeping up with the medical school curriculum caused me to fall behind.
I therefore changed strategies and began doing questions that corresponded with whatever material we were currently learning in class.
At my medical school, we were given First Aid during the spring of M2 and approximately two months—or eight weeks—of "dedicated" Step 1 study time.
My school also had specialized tutoring services and additional NBME practice examination vouchers.
BUT YOU HAD TO ASK FOR THEM.
This became another important lesson:
Don't assume that the resources you know about are the ONLY resources your school has.
ASK.
Losing Part of My Dedicated Period Before It Even Started
February was our "Complex Cases" block.
I thought I needed to dramatically increase my UWorld studying, so I began spending more time reviewing older Step material and not enough time learning the new curriculum.
I subsequently failed the summative examination.
That meant I had to spend approximately two weeks of my Step 1 dedicated period preparing to retake the medical school exam.
Thankfully, I passed the summative examination on the second attempt.
But I was now starting Step 1 dedicated with only about six weeks before my M3 year was scheduled to begin.
My First Study Strategy: Re-Learn Everything
My first few practice examinations during dedicated revealed that I did not have a strong enough foundation in many subjects.
So I created a list of topics from least comfortable to most comfortable.
Then I started with the areas I knew the least.
Each day, I focused on:
Reading, Watching review videos, Completing questions, Reviewing explanations
And learning one major subject at a time
Using First Aid as My Main Review Book
The number one reading resource recommended to me was First Aid.
I could generally read and process approximately 10 pages per hour.
I also kept other review books available, including: Crush Step 1, Rapid Review
Other high-yield review resources
For video review, I used different resources depending on the topic: OnlineMedEd, Osmosis, Boards & Beyond, Sketchy, Pixorize
I experimented with questions from Osmosis, Boards & Beyond, and AMBOSS.
However, I felt that UWorld questions were the most useful for my preparation, so I eventually made those my priority.
Starting With UWorld in Tutor Mode
Initially, I completed UWorld questions by individual subject in Tutor Mode.
At first, I could only complete approximately 40 questions per day because thoroughly reviewing them took around four hours.
I then spent another four to six hours reading and watching videos.
As my knowledge improved, I became faster.
Eventually, I could complete and review approximately 20 Tutor Mode questions in an hour because I was answering more correctly and needed less remediation.
When I was consistently getting approximately 50–60% correct within a subject, I felt more comfortable moving on.
Why This Strategy Didn't Work Well Enough for Me
There were several major downsides.
By focusing on one subject at a time, I wasn't practicing the way the real examination actually presented material.
The actual examination is mixed.
You might see:
Cardiology
Then microbiology
Then renal physiology
Then psychiatry
Then biostatistics
Your brain has to rapidly switch between subjects.
My subject-by-subject approach did not adequately train that skill.
Re-Learning Everything Took Too Long
Each major topic contained hundreds of UWorld questions.
When I was only completing around 40 questions per day, one subject could take nearly an entire week.
I also developed anxiety around needing to "finish" every question within one subject before allowing myself to move on.
That made my studying incredibly slow.
Passive Studying Was Taking Away From Question Time
Reading books, watching videos, and listening to podcasts can be helpful.
But they are not the same as answering questions.
Eventually, I realized that an hour spent watching another review video might have instead been spent completing 10 UWorld questions.
Those questions could teach me the same material while ALSO allowing me to practice:
Question interpretation
Clinical reasoning
Timing
Eliminating answer choices
And identifying what concepts the exam actually emphasizes
That was a major shift in how I approached studying.
My Practice Scores Barely Improved
I tried to take approximately one practice exam every week.
Unfortunately, my scores barely improved.
Looking back, there were likely two major reasons:
I still had gaps in my knowledge.
AND
I had not spent enough time practicing mixed, timed questions.
Eventually, I changed strategies again.
Transitioning to Mixed Questions
My next step was: 40 mixed questions in Tutor Mode.
Originally, reviewing 40 questions could take me approximately four hours.
Over time, I decreased that to approximately two hours.
Then I progressed to:
40 mixed questions in TIMED mode.
I would complete the block in approximately one hour and then spend several hours reviewing every question.
THIS was much closer to the actual examination.
Unfortunately, I made this change relatively late in my dedicated period.
My testing deadline arrived.
I took Step 1.
And I failed by ONE point.
My Experience Failing Step 1
At most U.S. medical schools, students traditionally take Step 1 during medical school before progressing through later stages of their clinical education.
Every medical school is different regarding:
Timing
Requirements
Study resources
Extensions
Remediation
Leave of Absence policies
And consequences after a failed attempt
At my medical school, there was an opportunity to request additional study time.
One option was using the first month of M3 as an elective.
If additional time was still required beyond that, students could potentially need a Leave of Absence.
I was not the only person in my class who needed additional time.
What Happens if You Fail Step 1?
First: YOU WILL BE OK.
A failing examination score means that you did not meet the passing standard on that particular attempt.
It does not mean:
You are stupid.
You don't belong in medicine.
You can never become a physician.
You are incapable of passing.
Or your entire career is over.
Depending on your school, you may be allowed to prepare and retake Step 1.
Each institution has its own academic policies regarding repeat attempts and when students must meet with an academic board.
Make sure you know YOUR school's current policy.
Failure Is Not the End of Your Medical Career
When I failed, one of my greatest fears was: Will I ever match into residency?
Historical AAMC data showed that many students who failed Step 1 on an initial attempt still ultimately entered residency training.
That doesn't mean a failure has no consequences.
It can affect your application.
Certain programs may view it negatively.
Some specialties may be more difficult.
But failure does NOT automatically eliminate your future in medicine.
I eventually passed.
I continued medical school.
I applied to residency.
I matched.
And I became a physician.
Accommodations & Accessibility
While preparing to take Step 1 again, I learned that I was eligible to request disability accommodations.
This dramatically changed how I understood my own testing needs.
I ultimately received additional break time.
Check out my blog post:
Requesting Disability Accommodations in Medical School & Step 1
Also check out Docs With Disabilities resources on requesting accommodations for NBME/USMLE examinations.
Don't Be Afraid to Ask About Accommodations
Testing accommodations may be available for students with qualifying disabilities or health conditions that create functional limitations during standardized testing.
The application process typically requires documentation and an explanation of how your condition affects your ability to take the exam under standard conditions.
Your request may include a personal statement describing:
Your condition
Your functional limitations
Your previous academic experiences
Previous standardized testing difficulties
And why specific accommodations are necessary
Check out my Guide to Applying for Testing Accommodations for more information.
My Second Step 1 Study Strategy: Practice Questions
When I began studying for Step 1 again, I knew I could NOT simply repeat the same study strategy and expect a different result.
This time: QUESTIONS became the center of my studying.
Every day, I worked toward completing two 40-question mixed blocks back-to-back.
That meant:
80 mixed questions
Timed
With a short 5–10 minute break between blocks
Then I reviewed the questions afterward.
Building Up My Testing Endurance
Eventually, I experimented with completing three 40-question mixed blocks.
That meant: 80-120 mixed questions
Back-to-back
With brief breaks between blocks
Then reviewing everything afterward.
Realistically, doing 120 questions AND thoroughly reviewing them every day was exhausting and unsustainable.
So I didn't do that every day.
The days I felt most successful were usually when I completed:
80 timed mixed questions in the morning
Then spent the remainder of the day thoroughly reviewing them.
That gave me substantial testing practice without completely exhausting myself.
And my scores started improving.
Practice the Way You Will Be Tested
This became one of my biggest lessons.
If the examination requires you to:
Sit for long periods
Answer mixed questions
Work under time pressure
Move between unrelated subjects
Take structured breaks
And maintain concentration for hours
Then your studying should eventually practice those SAME skills.
You cannot prepare for a marathon solely by reading about running.
At some point, you have to run.
My Second Step 1 Failure
By my second attempt, Step 1 had transitioned to Pass/Fail.
I failed again.
And once again, I was extremely close to the passing threshold.
At the same time, I was dealing with much more than simply studying.
I continued working approximately 30–40 hours per week across multiple jobs to afford:
Rent, Healthcare, Food, and other living expenses
After failing a second time, I had to appear before my medical school's academic board and request permission to take Step 1 a third time.
If You Fail Twice: YOU ARE NOT ALONE
Failing Step 1 twice felt devastating.
But I want anyone who finds this post after experiencing something similar to know:
YOU ARE NOT ALONE.
You can overcome this.
You can pass.
You can match.
You can graduate and become a physician.
I did.
What Changed Before My Third Attempt?
It was not simply that I suddenly became smarter.
Several important things changed.
I learned how to manage my anxiety more effectively.
I addressed major external life stressors.
I received disability accommodations, including additional break time.
I was no longer trying to simultaneously work a full-time or substantial part-time schedule while preparing for the examination.
And I had fundamentally changed how I studied.
Social Determinants of Learning
This is an important place to discuss the Social Determinants of Learning.
Academic performance does not occur in a vacuum.
Students still need: Food, Housing, Healthcare, Sleep, Safety, Emotional support, Financial stability
And an environment where they can actually learn.
The Social Determinants of Learning framework includes six major categories:
Physical health, Psychosocial health,Physical environment, Social environment, Economic stability, Self-motivation
When students experience significant challenges within these areas, academic performance can suffer—including performance on standardized examinations like STEP.
The Social Determinants Affecting My Step 1 Studying
We are all human.
Life does not stop because we are studying for a board examination.
During my own preparation, I was dealing with:
Financial insecurity
Difficulty paying for food
Difficulty paying for healthcare
Difficulty paying rent
Working 20–40 hours per week while studying
Health conditions worsened by stress
Emotional challenges
Relationship stress
Watching my husband and classmates progress through M3 while I remained behind
And mentors who did not always understand why I couldn't simply "study 100% of the time"
Those circumstances mattered.
Sometimes the Problem Isn't Your Study Schedule
This is something I wish more medical students understood.
Sometimes the answer is: More UWorld.
Sometimes the answer is: A better schedule.
But sometimes you cannot optimize your studying until you address what is happening OUTSIDE of studying.
Are you sleeping?
Do you have food?
Is your housing stable?
Can you afford your healthcare?
Is your mental health being treated?
Are you working excessive hours simply to survive?
Do you have a quiet place to study?
Are you experiencing significant family or relationship stress?
Do you need accommodations?
These aren't excuses.
They are factors that affect learning.
Knowing When to Take Time Away
Sometimes addressing these barriers requires taking a single day away from studying.
Sometimes it requires several days.
For me, it ultimately required taking a Leave of Absence between my second and third years of medical school.
Taking an LOA created its own challenges.
I lost access to student loan funding.
I needed to work.
I faced significant financial insecurity.
I had healthcare expenses.
And emotionally, I had to watch my husband and classmates continue progressing through medical school without me.
But I also needed that time.
What Social Determinants Are Affecting YOUR Learning?
Before simply telling yourself:
"I need to study harder"
Ask yourself: What is actually interfering with my ability to learn?
Consider:
Physical health
Mental health
Sleep
Housing
Food security
Finances
Employment
Relationships
Family responsibilities
Study environment
Disability
Accessibility
Academic resources
Mentorship
Testing anxiety
Sometimes identifying the barrier is the first step toward changing your academic performance.
You can analyze your own Social Determinants of Learning in my Medical School Hidden Curriculum Workbook.
Studying for Step 2 After My Step 1 Experience
When it came time to study for Step 2, I approached the exam VERY differently.
I had already spent my clinical clerkships consistently using UWorld.
My end-of-clerkship examinations were NBME shelf exams, so I also had significantly more experience answering NBME-style clinical questions.
I studied for approximately six weeks during June and July.
My strategy centered around the lessons I had learned from Step 1:
UWorld
Practice questions
Mixed questions
Timed practice
NBME practice examinations
And building testing endurance
I Practiced as if I Didn't Have Accommodations
Even though I ultimately received testing accommodations, I frequently practiced under more restrictive timing conditions.
Why?
I wanted the actual examination to feel MORE manageable than my practice sessions rather than harder.
I took two NBME practice examinations.
I passed both.
This time, the objective evidence told me:
I was ready.
Passing Step 2 on My First Attempt
I took Step 2 during my M4 year before applying to residency.
For Step 2, I had accommodations that included additional break time and extended testing time.
I received my passing score the following month.
My score was: 229.
After failing Step 1 twice, seeing that passing Step 2 score meant much more to me than simply another number.
It represented everything I had learned about:
Studying
Failure
Health
Accessibility
Resilience
Test-taking
And myself.
The Biggest Lesson: Failure Forced Me to Learn How I Learn
Failing Step 1 twice was one of the most painful experiences of my medical education.
I would NEVER recommend failing an exam as a learning strategy.
But failure forced me to examine things I had never previously understood.
I learned: How I study best
How important practice questions are
How to build testing endurance
How anxiety affects my performance
How my health affects learning
How external stressors affect academics
When to ask for help
When to request accommodations
When to postpone an exam
And when to stop studying and address the rest of my life
These lessons changed how I approached every major examination afterward.
If You Failed Step 1
First: You are allowed to be devastated.
You are allowed to cry.
You are allowed to be angry.
You are allowed to be scared.
But after you have processed those emotions, start investigating WHY it happened.
Don't simply repeat your exact study plan.
Ask: Was my knowledge foundation weak?
Did I do enough practice questions?
Did I practice timed?
Did I practice mixed blocks?
Did I build testing endurance?
Were my practice scores actually showing that I was ready?
Was anxiety interfering?
Was my physical or mental health affecting me?
Were financial or social stressors interfering with studying?
Do I need accommodations?
Do I need additional time?
What needs to CHANGE before the next attempt?
Failure provides data.
Use it.
You Can Still Become a Doctor
I failed Step 1 twice.
I took a Leave of Absence.
I had to appear before my medical school's academic board.
I needed testing accommodations.
I struggled financially.
I worked while studying.
And there were moments when I genuinely questioned whether I would ever become a physician.
But I kept going.
I passed Step 1.
I passed Step 2 on my first attempt.
I completed medical school.
I matched into residency.
And I became a doctor.
Your path may look different from the path you originally imagined.
That does not mean the journey is over.
More on my medical school journey on my Podcast:
"Life as a Patient-Doctor"
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If you would like to meet with me to discuss your unique situation or develop a STEP study schedule, you can sign up for personalized coaching, advising, and tutoring here.
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