Getting Through the Semesters (or what if I fail something).

“The Thrill of Victory or the Agony of Defeat”

The Drama of Human Competition as the opening lines of ABCs “Wide World of Sports” promised. By now, many students have had their first blocks of exams in medical school. Some people have done very well and some people have “breathed a sigh of relief” that they passed and some people have not passed one or or more of their exams. To fail an exam at this stage can be a huge personal blow but your actions after discovering that you have not passed (I am going to avoid the word “failure” here) are critical to figuring out what you need to do to get “above the yellow line”. Sure you NEED to do a bit or mourning in terms of the loss of those wonderful feelings that infused during orientation week but don’t let the mourning phase go on longer than a couple of minutes. Replace mourning with a very objective strategical look at what might have gone wrong and how you are going to fix the situation.

There is something in medical school that will throw every person. It may be that first round of exams, that USMLE score or a patient contact that just did go well. The important thing is that out of every experience, good or bad, you learn something about yourself and what you are capable of achieving. It is out of experience that you will learn to treat your future patients so let your experience become your teacher and move forward from here. Not passing an exam just doesn’t feel good and can play with your “head” in terms of how your look at your future. My point here is that nothing except that round of exams is over at this point. You mourn a bit and then you push forward because (and I am not wrong on this), the material for the next round of exams is already upon you.

As soon as you know that anything has not gone well for you academically, ask for help. Your first action should be reviewing the test and trying to figure out where you went wrong. Do you need to rely on more detail? Did you move too fast and not answer the question that was asked? Did you neglect to read every answer choice with a more correct answer further down? Did you not fully understand the material? Were you distracted by something outside of school such as a relationship or illness and not put in enough time studying? In short, try to figure out what went wrong and take steps to make sure that you don’t repeat your mistakes.

What if I fail a whole course, like Biochemistry?

The consequences of failing an entire course in medical school are largely school-dependent. Some schools will want you to retake only the material that you did not pass while others will have you go through an entire summer remediation course. In any event, look at your remediation/retesting as an opportunity to hone this material well. You definitely want a strong knowledge base for your upcoming classes and you will have made some steps toward review in terms of preparation for USMLE. In this light, having to retake or remediate is not totally the worst situation that you can find yourself going through.

Plunge into your review with total concentration on the subject at hand. If you have one course or one area of subject matter, this is easier than if you have multiple subjects to remediate. Your only resolve in this situation is to not miss this golden opportunity to thoroughly master this material. You are not a “lesser person” because you need a second review and keep in mind, that you are reviewing at this point. In most cases, you have learned the material on the first shot but this review gives you insight into the material that you likely previously missed.

I am always more concerned about those students who “barely” passed than the students who failed and are re-mediating. In most cases, the student who re-mediates does not carry a knowledge gap forward while the student who barely passed likely has gaps in their knowledge base. It is those who barely pass that will need the most intensive review and preparation for board examinations.  I always encourage students who scored below an 80% to study for and take any optional shelf subject exams if offered by their school. These shelf exams can pinpoint knowledge gaps that can be filled in before taking Step I.

Class Attendance – Is this time well spent for me? 

In some medical schools, class attendance is not mandatory. If this is the case, and you ran out of study time, try figuring out if there is one day a week that you can stay home and study the material using note service/lecture tapes or vids/textbook and syllabus reading. Many students do not attend class and find that home (or away from school study) works best for them. This may work for you but be careful if you have too many distractions at home or find that not attending class puts you behind. (Getting behind in medical school is deadly.)

If your work is not detailed enough, figure out which classes do not require the detail and which ones DO require more detailed study. In short, give each course what it demands. Many schools have integrated courses that definitely demand loads of detailed work coupled with “professional-type” courses like Practice of Medicine that are more performance-based. Try to look at your coursework from this perspective and see if you can give your integrated course a bit more time and your performance course a bit less time.

Another problem is that in many first year courses, the load of information can seem overwhelming. Resist the urge to dwell on what seems overwhelming and nibble away a chunk at a time. I always remember that scene in the movie “Shawshank Redemption” where the protagonist chips away at the prison wall over the course of 17 years with a small rock hammer. Eventually, he gets through the wall and escapes. Extreme but I think you get my drift in terms of divide your work into manageable chunks and stay on course. Keep moving forward because you can only affect what is happening now and use that to impact the future. Weekends are your friend because you can breathe a bit, relax a bit and catch up if you have fallen a bit behind your class. In the middle of the week, go to where the class is and use the weekend to “catch up”.

Wasting time and less efficient practices

I discourage students from recopying notes as a means of study. When you have volumes of material and information, you can become more of an excellent clerk in terms of producing a beautiful set of notes that you have not mastered. Organizing your material is good (can be done with a highlighter or in the margins of your notebook) but total recopying of every word may be too time consuming and not as beneficial as when you were an undergraduate student with less volume. You may need to review the material and then constantly question yourself or recite the material back to yourself rather than a complete recopy. If you can recopy your work in an efficient manner while learning and your grades are good, then recopying is working for you and don’t change your strategy.

Another problem that can interfere with some freshman medical students is feeling that they “need” to study for boards. You don’t need to take time away from your coursework mastery to do board study at this point in your career. If you absolutely feel that you NEED to do some board study, then do it during the summer between your first and second year but the best preparation for boards is to thoroughly master your coursework and then study for boards at the end of your second year. You cannot “review” what you have not “learned” in the first place. Don’t take valuable coursework study time to do board study. Board review books are most useful because they summarize material but most medical school courses require the details and not summaries. Beware of the “I am going to use a review book to summarize” method of study because it might work against you in terms of you not getting enough of the details to pass your course. The other extreme is to attempt to memorize the textbook which is most likely too much detail. In short, strike a happy medium that will work for you.

Don’t be afraid (or ashamed) to consult your instructor or your dean if you are struggling. Not to reach out for help (especially because of the amount of money that you are paying for your school tuition) is not wise. It really looks great to a residency program director to see comments from your dean or professor that state that you were able to overcome a deficiency and excel. These types of comments indicate excellent problem-solving skills which are highly prized in a physician.

Finally, tune out the boasting of your classmates who say that they “didn’t study” and “aced” their exams. They are lying period. You have to do what you NEED to do for yourself. Congratulate them for being so “brilliant” and don’t waste a second of your precious time worrying that you are somehow deficient because you studied like a demon and didn’t do so well. There is nothing wrong with you that correcting your study strategy will not solve. Just don’t add “questioning your worth” to your list of things to overcome. It isn’t necessary and it won’t get the job done.

Striking a Balance

Finally, one key aspect of medical school, residency and the eventual practice of medicine is that you will have to constantly “strike a balance” between study, personal life and professional obligations. The first semester of medical school will definitely test your resolve to keep working away at your studies until you get them mastered but this should not be at the cost of your personal integrity or sanity. Try to find ways of incorporating some stress relief (physical exercise) and socialization (away from your classmates) into your life. Nothing, including the practice of medicine is one-dimensional and there needs to be balance.

For example, if you are studying in the library and know that you won’t make it to the gym, try to walk up at least 8 floors of steps on the days that you don’t get to the gym. Take 10 minutes and take a brisk walk around the corridors to get your brain relaxed before you keep “grinding” away at your study materials. Study and pace at the same time while reciting the material to yourself in your own words. Try making some study-drill tapes and drill yourself while you are on the elliptical trainer/treadmill in the gym. Finally, picture that professor’s head when you are doing your bicep curls or on the fly machine and pound things out. You will be more relaxed, less stressed and more efficient in your studies. In addition, you can enjoy eating without worrying about gaining weight.

Statistics (and odds) state that if you were accepted to medical school, you will get through the four years successfully. Some people make the adjustment to the rigors of medical school academics faster than others but trust yourself enough to know that you will get the job done. There is very little difference in intellect between the person who graduates first in their medical school class and last in their medical school class. Residency program directors know this which is why the person who graduates last in their class is still called “Doctor”. Run your own race and get what you need.

Failing USMLE Step I and how to get beyond it.

For many second year medical students, the prospect of taking USMLE Step 1 is looming “large” on the horizon. You have completed three semesters of pre-clinical science and the first step toward licensure as a physician rapidly approaches. Along with the exam and its preparation comes the thought of what will happen if you fail this exam. Statistics show that somewhere around 1/4th of people who take this exam, will not pass on the first try. While failing this exam happens, it’s better to consider that 3/4ths of the people who take this exam will pass.

So what happens if I fail?

If you fail, you generally have the option of re-taking the exam. Most medical schools in this country will have you do some remedial work and will have you sit for the exam a second time will little consequences other than damage to your ego. If you fail Step I once, you can still practice medicine and you can still graduate from medical school. You have likely knocked yourself out of the moderately competitive to competitive specialties but you can still have a very satisfying career in the less competitive specialties.

The first thing that you have to do, if you open your test score report and find that you have not passed, is immediately figure out where you were deficient. The USMLE score report comes with a breakdown of where you lost points. You should immediately start your review in your weakest subjects/items. The next thing that you want to do is speak with your Dean of Education so that you can get an idea of the time frame that you have to submit a passing score. Some schools want a passing score on Step I before you can begin third year clinical rotations and some will allow you to complete a rotation that you have started.

Don’t make the grave mistake of attempting to do clinicals and study for Step I. If you failed this exam once, you need to put your entire attention into a thorough and adequate preparation for this exam. You can’t afford two failing scores here and thus, drop/delay your clinical rotations until you have passed Step I. It’s not going to be easy or quick it terms of preparing for a retake so don’t try to rush this process. As bad as one failing score looks, two failing scores can really kill your chances for a solid residency match.

Get the idea out of your head that you “are not good at standardized tests” or “that your career in medicine” is over. You just cannot afford this type of thinking. Your whole attitude needs to be focused on the task at hand, which is, passing Step I. If you cannot focus for a couple of days, then take that time to relax but depending on your school’s schedule, you likely need to get back into the study mode fairly quickly. Take some time to come to terms with your non-passing score but don’t let a non-pass set you into a “tail-spin” that prevents you from doing your best on a second attempt.

The other mistake that many medical students will make is believing that because they were able to do well in their medical school coursework, they are a “cinch” to pass Step I. This is not always the case as since I have been involved in academic medicine, it’s not always the students with the weaker academic records that fail but those who have a “false sense of security” because of their academic record. Make no mistake, Step I takes some preparation and review no matter how you scored in your coursework.

Another thing that you likely need to do is enlist the assistance of your Dean of Academic Affairs. There is no medical school in this country that has never had a student fail Step I. Your Dean of Academic Affairs can offer some assistance in getting your study methods on track. There may be great resources available at your school that you will be able to access since you have a failure on Step I. Be sure to find every resource (many likely free) that is available to you.

Another mistake that many students make is looking at the pass rates of a previous class and thinking that there is no way that you can fail. If the Class of 2008 has a 100% pass rate and you are the only member of the Class of 2009 that fails, that 2008 pass rate hasn’t helped you much. Passing or failing Step I is a personal matter and not class (or school) dependent. Either you have prepared well and performed well or you have not. These are individual characteristics and not school characteristics.

What kind of residency can I get with a failure on Step I?

If you pass on the second try, score some solid performances in your clinical rotations and perform well on Step II, you have a shot at a very good residency. No, you are likely not going to match into Derm, Ortho, Rads and Ophtho but you have a shot at solid programs in just about everything else if you post a good performance in things after your failure. Sure, it’s not the best situation that you have failed this very important exam but your career is not over. There is still a substantial amount of “medical school” in front of you that will provide an ample opportunity to show that a non-pass on Step I (on your first attempt) was an aberration rather than a characteristic of how you perform. Some options may not be there for you but more options exist than you would believe. You simply have to get this behind you and move on with what you have left.

Getting and keeping your head together

Again, your first priority is to do whatever you need to do to pass this exam. You cannot afford to wallow in blame but need to gather your reserves and get busy. Sure, it seems like everyone you know passed without difficulty but you didn’t pass and you have to pass this exam. The thing “is what it is”. The reality is that while this hurts; it’s not fatal. You can take this opportunity to learn what kind of reserve you have and how to thrive in adversity. These are characteristics that any residency program director would be happy to have in an incoming resident. Get your thinking together; enlist the help of your Deans and get this exam behind you.  Performance on one license exam does not define your entire medical career unless you allow this performance to define your and your career. Sure, it’s important but in terms of percentages, most people pass comfortably on the next try and move on to good clinical rotations and residency spots.

Final Thoughts

If you find that you failed Step I, get your resolve together to:

• Get in contact with your academic Dean and Dean of Students.
• Find out what options are there for you to allow you to focus on getting ready for your retake.
• Put that non-pass into perspective and behind you; what have you learned “not” to do?
• Get the idea that your “medical career is over” and that you can’t match into a good residency program out of your head.
• Prepare efficiently and properly so that you do not find yourself failing your re-take (or any other licence step ) exam.

This is not about you as a person, physician or anything else. You simply didn’t pass Step I and you resolve to prepare and pass on the retake.

Playing the Waiting Game and Keeping Your Sanity

Timing

You scrambled around and made sure that every one of your writers of your letters of recommendation did their respective jobs. You started your Personal Statement early and left plenty of time for editing and corrections. You started to fill out your AMCAS application as soon as it was available and you made sure that there were no mistakes. Finally, on the first day that you could, you pushed the submit button and the “waiting game” started. You had heard that in every circumstance, early application is the best strategy for success in getting into medical school. So now, you find that it’s early summer, school is out, and you are in for the wait.

Starting the Wait

Your next hurdle is to receive word that your AMCAS is verified. This can take six weeks or more if there were no mistakes or lost transcripts and can often take much longer if things are not moving efficiently. This step has to happen and it can cause worry if things are delayed. I can tell you that, in terms of medical schools, early summer is a non-time in terms of admissions. Most of our time is spent on getting the current class underway and gearing up for the start of receipt of new applications. For us, that early lag of time between when you can submit your application and verification is vacation time, organization time and just plain much-needed down time for us in terms of application review. It is also the time when we try to put the finishing touches on the class that is set for the new year.

The best strategy for you at this period is to make a folder for each school that you have applied to. In this folder, you will place copies of your personal statement, copies of any completed secondary applications one they have been received and completed and copies of any correspondence that you receive from that school. You can also put an envelop on the front of the folder with a copy of your itinerary once you have made travel plans for your interview. In any event, start making the folders and securing a safe place for them.

The next thing to do is make and Excel spreadsheet. On that sheet, you should make a book for each school that you have applied to. You will eventually log every date and every receipt of correspondence that you will receive. You columns should go something like date received, date sent, and date of school’s receipt. (Needless to say, anything that you send to a school should be sent by certified mail with receipt notification). Repository services such as Interfolio will also post dates of when they send your materials and when they were received. You definitely want to make sure that you keep your application materials and correspondence with each school very organized and safe.

Plan B

Plan B is what you will do if you are not accepted. In the business of medical school acceptance, nothing is a certainly except you won’t get accepted to a school if you don’t apply there. Acceptance, even if you have submitted an application with a 4.0 uGPA and 45 MCAT is not assured for anyone. It is wise to have a carefully though out and planned Plan B. From experience -mine and others- the more elaborate and complete your Plan B, the less chance you will have to use it. Start planning and working on you Plan B.

Financial Aid Forms

Right after you have submitted your AMCAS, you should begin and complete your FAFSA forms. You will need to obtain a financial aid transcript from every school that you have attended whether or not you received financial aid.  If you are not applying for scholarship or financial aid for medical school, you can skip this step.

When you complete your FAFSA, have the results sent to every school that you have applied to. This will save you time in the long run. If you are not accepted, having your financial aid information sent is not going to make a difference one way or the other. If you are accepted late, having your financial aid information already in place can save plenty of headache when school starts.

Senior Year

If you are an undergraduate, you want to plan a strong senior year. I know that “senioritis” sets in and you are tempted to want to coast because you are done with MCAT and done with the majority of your courses but don’t do this. Take some seminar courses and expand your knowledge base or take some research courses and pick up some valuable skills. My senior year of university was spent writing and presenting my honors thesis work. This was actually great experience for me and propelled me into the world of research scholarship. Use that senior year to shore up any possible deficiencies that you might have and to finish strong.

This is also a prime time to begin a solid exercise program. My biggest regret in medical school was that I didn’t stay in good physical condition. If I had kept up with my conditioning, I would have been an even more efficient student and a student with far less stress. Take this time to start and hone a solid aerobic exercise system that you can complete in 30 minutes to 1 hour each day. It can be as simple as taking three 10-minute brisk walks or climbing a couple of floors of stairs until you work up to 14 floors daily (only up direction counts). Even today, I make sure that I do at least 14 floors up every day. I can find steps pretty easily and do a couple of floors between cases or when I need a break from my desk.

Early Fall

By this time, you should be keeping your senior coursework strong and completing all secondary applications within one week of receiving them. Another thing that you need to do is go to a professional photographer and have some professional head shots taken of you in your interview attire. You will need these for many secondary applications and you will need them later for things like USMLE application. Don’t use a cheap “Passport photo” service. These cheap services will take photos that make you look like you have been in prison. Use a professional photographer and groom yourself as if you were going for interview. That secondary application should look polished and professional. Once you have chosen a good photo from the proofs, have several passport-sized sheets made and keep these in a safe place.

Again, as soon as you complete and post a secondary, make a copy and place this in the folder for that school. It’s a good idea to make a copy of everything that pertains to each school including things from their website (names of deans of admissions, names of admission coordinators) along with dates of any phone conversations. Also place copies of any e-mails that you have received for each school.

Interview Time

Most schools spend July and August reviewing applications and interviewing Early Decision applicants. You can expect to receive notification that you are complete but not much more information from your schools. Early Decision applicants have to be notified by September 1 so their applications are processed first. After the first couple of weeks of September, some of the earliest regular applicants may be notified of acceptance by some schools. If you receive a notification of invitation to interview at this time, this is great but don’t read anything into not receiving an invitation to interview. At this point, it is way early and you should be either working on Plan B or working diligently on your coursework. In short, don’t start obsessing about timing.

Many schools will not even begin interview session until late October and early November. Again, if you applied in early June, it will have been a long time. Don’t get crazy and don’t begin to call schools. If you have received a “complete” notice, then you wait. Find something else to do. If you have an interview notification, then work on your travel plans and logistics. Elsewhere on this blog, you will find posts about traveling to interview.

If you haven’t heard from any school by the end of October, consider applying to more schools. If you were in the very early applicants, you may need to broaden the number of schools that you have applied to. A major mistake that many applicants make is overestimating their competitiveness for medical school. If you are not securely above the averages for matriculants (uGPA 3.65 and MCAT 31) then you likely need to add more schools. If you are above those averages, you can hold but you probably should have head from schools by now. If not, make sure that your application materials have arrived.

Holiday Time

You applied early and haven’t received any interview notifications. Yes, it’s easy to fall into the trap of being depressed  but this is the time to plunge into the holidays and not get insane. Yes, I know that it’s only your future here but you cannot do anything more at this point. I will repeat in all caps for emphasis, YOU CANNOT DO ANYTHING MORE AT THIS POINT. If your application is complete then you have to wait. It’s a good time to plan your trip home for the holidays and take a breather from coursework.

January and February

These are very heavy interview months. You may find that the interview invitations will roll in at this time. Again, there is still plenty of time to receive an interview and receive an acceptance. This is also a time when many of the early interviewers will begin to receive acceptances. If you have done a couple of interviews but received no acceptance, don’t panic here either. Again, work on and finalize your Plan B.

If you are a dedicated reader of The Student Doctor Network, don’t obsess over the fact that others have been accepted but you are still waiting. Timing is out of your control and dependent on things like the number of applications received by the schools that you have applied to and the competitiveness of those applications. The only thing that you can do at this point is WAIT (dread).

March and April

By the beginning of April, some folks will find themselves on wait lists and without an acceptance. This is not entirely a bad situation though you may want to make a decision as to whether you will begin to collect the things you need for reapplication. If you need to do things like re-take the MCAT, you need to have gotten started on your study and planning for the test. You can’t wait too late and you can’t do a re-take without some significant review and preparation. The worst thing that you can do is post an MCAT retake with a mediocre score.

If you are on a wait list, remember that there is a huge wait list movement on and after May 15th. May 15th is the date when people cannot hold multiple acceptances. I always advise folks to release acceptances as soon as they have either been accepted by their first choice or when they have made the decision as to where they want to attend. I released my acceptances by the third week of February because I had made my decision. I am sure that five people were grateful that I did that because they were able to get in that year.

May and later

In general, after May 15th, you are not likely going to gain acceptance. There are exceptions, especially the schools with rolling admissions but by this time, you should either have an acceptance or gathered your materials for reapplication. You can look at my previous post on when to give up on application to medical school but if you don’t have an acceptance by now, you likely need to take an objective look at your competitiveness and do some application upgrading.

If you need more coursework, this is a good time to get registered for post bacc work. If you are planning to enter a SMP (Special Masters Program), then you need to get busy fast. These SMP programs have deadlines too. In short, these may become your new Plan B and you need to get to work. If you are on a waitlist at this point, it will not hurt you to go ahead and plan on reapplying. Sure, you will lose the money of submitting your application but if you are not accepted off of a wait list, you will be happy that you reapplied early.

If you reapply, change everything that you can change about your application. Do not apply to the same schools with the same application materials. We do compare old and new applications. If you were unsuccessful and submit the same unsuccessful application materials, you are most likely not going to be successful next year either. The average matriculant uGPA and MCAT scores have always gone up. Also, unless a school tells you that you need more extracurricular activity, you likely don’t need to add more here either.

Finally

You may want to look into the following:

• Getting the services of a professional pre-med counselor. For nontraditional applicants who have been unsuccessful, this is money that will be well spent.
• Taking more undergraduate coursework to raise your uGPA. If you are significantly below 3.5, you likely need a year or two of more coursework.
• If you have an MCAT score below 28, you need a re-take period if you are applying to allopathic medical schools.
• Making sure that you have applied to a wide range of schools. If you only applied to schools in the Northeast, you may want to go out of that region. You need a minimum of 10 schools if your are a strong applicant and 15 to 20 if you are less than competitive.
• Don’t thumb your nose at osteopathic medical schools. If you are under the averages for allopathic but your uGPA is above 3.2 and MCAT above 27 but less than 30, you stand a good shot at osteopathic medicine. If you get into osteopathic medical school, you can have the same career as attending allopathic medical school. If you want to be a physician, they are definitely the way to go.