WHY GOOD STUDENTS FAIL STEP 1 – Six common causes

by / Monday, 12 September 2011 / Published in USMLE Advice

Let’s face it, we all know someone or several people who have failed the Step 1, many of them multiple times.  Perhaps you are one of those unfortunate people… the first thing to realize is that this test in no way, shape, or form, a predictor of your ability to become an excellent physician.  With that said, let’s explore six of the very common causes why people seem to fail the USMLE Step 1 exam.


Reason #1 – Lack of adequate preparation

Everyone is looking for the secret to success on the Step 1 – which book is best, which Step 1 review course is best, etc, etc.  But the one thing nobody wants to hear is that it takes an intense desire and tons of hard, dedicated work in order to do very well.

Before you set out to prepare for the Step 1 exam, be sure you are mentally fresh and ready to dedicate several weeks (or months) to non-stop studying and preparation.  If you find that you are having trouble concentrating or finding motivation, take a few days off and regroup – you will only be wasting your time if you aren’t 100% committed.

Reason #2 – Failure to fully grasp Physiology/Pathophysiology

Whether a student chooses to believe it or not, understanding physiology is the single most important ‘must know’ discipline in medicine.  Physiology is everywhere – it is in biochem, it is in OB/GYN, it is in Surgery, it is in Psych, it’s everywhere!

Here is another reason why you should dedicate a TON of time to physio – if you damage normal physiology what do you get? – you get pathology.  Thus, understand what is normal will help you big time when it comes to learning pathology, and as you may know, the Step 1 exam is loaded with pathology – not just questions like ‘what is the pathology’, but questions like ‘what is the underlying pathophysiology in the disease’.

Dedicate a great deal of time to learning, mastering, and understanding how to implement physiology throughout medicine and you will surely be successful.


Reason #3 – Failure to know the essentials of Pharmacology

What are the essentials that you absolutely must know when it comes to pharm?  They are:

1 – Mechanism of action – you will get tons of questions asking you to explain the MOA of a drug (this looks like physiology to me).  This will ultimately also allow you to explain the findings (both positive and negative) that come from using a particular drug.

2 – Common side effects – you need to know all of the common side effects your patients will likely encounter (remember – the Step 1, Step 2, and Step 3 are testing you on the common stuff you’re going to see in a clinical or hospital setting)

3 – Unique side effects – if a drug produces a very unique and telling side effect, you should know what they are.

4 – How to manage an overdose – luckily, if you understand how acids and bases (biochem) are used to handle drugs, you don’t even have to memorize what the next best step should be.

5 – Prototypes – each class of drug has a prototype, you are usually going to be asked about those over all of the other derivatives out there.  Don’t worry about Trade names, they are only testing you on generic names when it comes to Pharm.


Reason #4 – Failure to set a goal and create a study plan

I always tell my students that if you fail to plan then you plan to fail.  It is extremely important that first of all you decide what you want to achieve – and whether it is just to pass the exam or to achieve a 250, you need to write it down and create a study plan that will allow you to achieve your goal.

It seems like an unimportant reason for failure, but ask anyone who is highly successful (in any aspect of life), and they will tell you that they didn’t just wake up one day in their position, they had a goal, set a plan, and worked insanely hard to make it a reality.


Reason #5 – Using a ‘review’ book before knowing the underlying physiology

Here’s the deal – review books like my Step 1 BIBLE and Step 2 CK BIBLES, the First Aid, the Step 1 and Step 2 Secrets, they are all loaded with the highest yield information that you are likely to see on the USMLE exams.  There is a reason however why one student uses them and achieves a high score and another uses the exact same source and fails – that reason is that you should turn to a review book to remind you of what is high yield, you first have to be able to look at a high yield fact and elaborate on it, being able to explain in depth and detail more than just the superficial information you see in these study guides.

Once you have a good grasp on all of the basic sciences, then you can pick up a study guide and get the most out of it.


Reason #6 – Not doing enough (or any) questions

I’ve yet to come across a single successful student who hasn’t completed a question bank while preparing for the Step 1.  There is a lot of misinformation however as to what works best when it comes to doing questions.  There is absolutely no need to buy 3 question banks and do them all over and over!  The best strategy for success is to choose one and do it twice.

The first time through the question bank go slow and learn as much as you can.  Don’t worry about your percentages because the goal is to learn from your mistakes now, not to learn after you write the Step 1.  The second time through your question bank, instead of answering the questions in the classic fashion, go through each question and explain to yourself exactly what is going on and why the answer is what it is.  There is no point in answering the questions from memory, this proves nothing – go through and reinforce the information by talking about it aloud.   This will solidify information and ensure you know everything that the Step 1 is likely to throw your way.  Read how to properly do questions in my How to pass the USMLE Step 1 article.


So you see, just because you’ve failed once doesn’t mean you won’t be a great doctor, it only means you’ve made a mistake in the way you approached the exam the first time.  Re-evaluate your approach, motivate yourself, and get back to the grind.

Best of luck!


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