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.

Why I chose Surgery (Part 1 and Part 2)

Part I (an earlier post)

I can vividly remember starting my third year of medical school. My school chose our third-year schedules for us and I remember some of the angst of my fellow classmates when our schedules were posted during the summer between our second and third years. I was in the midst of a wonderful Pathology fellowship that I had received for scoring very high in my Pathology course. I was assigned to various Medical Examiners offices and to the Pathology Departments of a couple of very large teaching hospitals. I had been spending the summer doing everything from crime scene investigation to transfusion medicine to bone marrow transplant. It had been a great summer. I was very strongly considering Pathology and Transfusion Medicine as my specialty.

I stopped by my Dean of Academic Affairs office and was told to wait for my USMLE Step I scores. The school had received them before I had received them. I took a deep breath because I really hadn’t prepared myself for facing the prospect that I might have failed that test. I sat in a chair outside the Dean’s inner office and ran a couple of scenarios as to what I would do if I had failed. I would quickly sign up for a retest and I would only miss one rotation at the start of third year. Since I was doing Pathology, I could study in between cases and get my preceptors to help me with covering the material.

The Dean came out and handed me a sheet of paper. I had to just sit there in disbelief. Not only had I passed, I had done extremely well. I was on my way. It was hard to hold back the tears of joy because I had studied about two and a half weeks for Step I. My fellowship had the requirement that I take Step I by the second week in May and my last exam from second year was on April 28th. I would be starting third year and I would be starting third year on Pediatrics with one of my best friends as my rotation partner. Life was good… I found out later that two people from my class did not pass USMLE Step I. It was very sad because one girl ran down the hall screaming and sobbing when she received her score. That put loads of people on edge.

I started third year on Pediatrics. It was a good rotation and I received Honors. I really enjoyed taking care of patients and I was very popular with the residents because I could place IVs and draw blood. I had also spent loads of time with an excellent pediatric pathologist so I knew my congenital defects inside and out. I could interpret cath reports and I was quite comfortable in the Pediatric Intensive Care Unit. I had been a Pediatric-Perinatal Respiratory Therapist before starting medical school so the interns found me quite useful.

My second rotation was Psychiatry. This was one of my best required clerkships. I knew that I wasn’t going into Psychiatry (you know these things early) so I was free to enjoy the rotation and pick up anything that I could. My preceptor was an excellent Consultation-Liaison Psychiatrist who exposed us to everything from the wards for the criminally insane to hard-core substance abusers to schizophrenics and other stuff. I earned another Honors grade and got some excellent experience. I learned above all that I was not crazy, my friends are not crazy because I spent loads of “quality time” around people who were genuine crazy.

My third rotation was Family Medicine. I had a great preceptor who even delivered babies. This rotatations was entirely office based but I learned to do prenatal exams and care for entire families. I also learned how and when to refer which is great stuff to know. My preceptor was extremely brainy and “pimped” me on just about everything. Turns out this was a good test for USMLE Step II because we either discussed or I had to report on most everything in Family Medicine that was on the shelf exam or on USMLE Step II. I received Honors for this rotation but decided that I really did not enjoy being out of the hospital too often. I also did not enjoy the slow pace of the office.

Holiday break came and I was happy to be done with shelf exams and rotations for five weeks. I knew that Surgery was coming up and my friends had warned me to be ready for two months of pure hell. The rotation is designed so that you spend your first month on General Surgery on one of two services: Trauma or General Surgery. I drew Trauma out of the hat and I received the condolences of my classmates. I figured, “you can do anything that you want with me but you can’t stop that clock.” No matter how bad, in four weeks, it would be over.

I was hooked on Surgery from my first case. It was a total colectomy with four females operating. My chief resident was female, the junior resident was female, the attending was female and I was female. We talked about shoes and Chanel suits during the case. I tied tons of knots and helped the junior resident close the incision. It was heaven. I found out that I loved Trauma and I couldn’t wait to be on call every third day. I had the time of my life and I loved everything about surgery.

My next month was spent on ENT and then on Cardio-thoracic and Vascular Surgery. I scrubbed every case that was assigned to me and many cases that were assigned to some of my colleagues. I became hooked on Vascular Surgery during that rotation. I loved the detective atmosphere on Vascular and loved taking care of the patients. My chief resident on Vascular taught me some great pearls about making sure that even with an amputation, fashioning a well-constructed stump can make the difference between ambulating and not ambulating for the patient. It was great stuff.

After Surgery, I rotated through OB-Gyn. I hated everything about this specialty. This rotation became my only High Pass during third year. I just couldn’t get into delivering babies and I wasn’t thrilled with tubal ligations. I wasn’t thrilled with spending too much time in the clinics and offices. The one bright spot was the Gyn surgeries which I excelled at. I learned the surgical anatomy like a sponge but I knew that this was not going to be the specialty for me.

I finished up on Medicine and Neurology. This would be my final sixteen weeks of third year. I was fortunate to have medicine last because this made study for USMLE Step II a snap. I totally enjoyed Medicine and Neurology but my heart was back in surgery. All of my Pathology experience really paid off because I aced these rotations and moved onto fourth year.

My faculty adviser was chairman of surgery and helped pave the way for my entry into this specialty. I was also co-president of the Surgical Society during my fourth year which also helped. My USMLE scores were good so this helped too. I had some awesome interviews and I landed at a great residency program. My experiences began there and they keep on.

As I continue to write, I will be posting more of my experiences.

Part 2 Why I chose Surgery.

As I moved through medical school, I knew that any specialty that I would enter had to have the following aspects:

• Ability to have long-term relationships with patients
• Ability to see every type of patient under a variety of circumstances
• Practice in office, clinic, hospital, intensive care, operating room and emergency department.
• Ability to handle a wide variety of clinical conditions
• Ability to deal with both acute and chronic conditions
• Ability to perform many procedures

The only specialty that met all of those requirements for me was Surgery. I also loved the aspect that I had to utilize my knowledge of both medicine and physiology to the surgical patient both preoperative and postoperatively. This was very appealing for me. I also utilize pathology and biochemistry to a great degree especially in my teaching of surgery and surgery practice. Again, this made surgery a very attractive specialty.

I definitely started out in residency with a strong interest in vascular surgery. Not only were the vascular surgical patients among the sickest in the hospital on any given day, I also loved seeing the immediate aspects of my work. Once you increase blood flow to an extremity that had previously been lacking blood flow, you see the immediate effects both good and bad. I also liked becoming very familiar with wound care and the healing of chronic wounds.

I had heard about the “surgical personality” and that some surgeons were very difficult to deal with but that never became a factor in my choice of specialty. I don’t care if the devil himself is teaching me if the teaching is good. Fortunately for me, that was rarely the case and my knowledge base expanded exponentially with every year of training. Good teaching is good teaching and good faculty allow you to grow and learn from both them and your mistakes in a constructive manner. I also found that I could profit from the mistakes of others at time too.

The other factor that did not deter me from surgery was the horror stories that I had heard about the residency experience. Yes, sometimes I had to work long hours but those long hours yielded some of the best teaching of my life. Yes, I did miss parties and social events but that happens with any aspect of medicine and comes with the territory. Physicians often work long hours taking care of patients who are sick. If you don’t like to take care of sick patients, medicine/surgery is not the career for you.

Finally, I have a very good life. I do something that is very interesting and I give my patients 100% at all times. I have encountered some physicians who were psychotic, neurotic, dishonest, unprofessional, racist, sexist, anti-Semitic and just down right stupid. The interesting thing is that I am none of those things and my life is good.  Good will goes out from me to my patients and it come back to me in droves. Yes, I work very hard and under extreme conditions at times but I have been blessed with an even temper and a love of my fellow humans.

If you choose a specialty, choose for what you know that you will enjoy doing in most aspects for the rest of your life. If not, you have many years of misery ahead of you. Conditions of practice will change and your income is largely based, not in how hard you work, but on what third-party payers are willing to pay for your services. If you can’t deal with this aspect of your chosen profession, get out as soon as you can.

If you choose a specialty because the rest of your classmates were in awe of you, you are likely going to be very unhappy in that specialty. Specialty choice is personal and your classmates will not be entering residency or practice with you. You, and not your classmates, will be the person at 0400h who is admitting that patient with the chronic condition, thousands of medications and multiple needs. You have to love that aspect of medicine/surgery as much as you love the other aspects of medicine/surgery.

Finally, you have to be a ethical and honest person. Showing up at the church door every Sunday does not make you a moral person if you know that deep inside yourself, you couldn’t be honest with yourself, your patients or your colleagues. You may not ”like” everyone that you work with or work on but you have to have respect for them and give them your best. In short, you can’t be having a “bad day” unless you are on vacation. If you are prone to allowing external influences to influence you internally, you are going to have a difficult time medicine/surgery.

Especially with surgery, you will find yourself multi-tasking, juggling six or seven balls at once, shifting up and shifting back on a daily basis. That’s the nature of the work and the challenge of the work. If you can’t do this, surgery is going to be tough for you on a regular basis.  In short, I have never had a day that was strictly “routine” unless I was just teaching for the entire day.

Finally, take some time and get to know yourself and your career needs because after all, this is YOUR career. Your parents, your significant other, your classmates or anyone outside of yourself, can’t make this decision for you. You have to know your competitiveness for certain specialties (forget derm if you struggled with every aspect of medical school including boards) and you have to have a good idea of how competitive you are for programs within that specialty.

Also, remember that while residency is when you will hone your skills, it is a short period out of the length of time that you will actually practice those skills. Again, I heard that surgical internship was the worst time on earth but I actually enjoyed my experiences during internship. I heard that surgical residency was the worse time on earth but it wasn’t. No residency program is going to be perfect but unless you encounter dishonest or illegal activity, you can live with residency. The clock is always ticking and time passes (quickly in most cases).

Residency requires hard work and hard study. In my case, during my first two years of residency, I studied far more than at any point in medical school in addition to getting my work done. At times, I was “bone tired” but I made myself read and study (minimally for 30 minutes daily). No, I didn’t get to the gym as often as I would have liked and I didn’t hang out late at night (outside the hospital) but I did live pretty well and my significant other saw as much of me as he could stand anyway.

It’s Saturday afternoon on call…

Well, it a S-L-O-W call day even though it’s a Saturday. Please note that I spell that word and don’t write it or (gulp) say it. As soon as I say or write that word, all he– will break loose and the trauma bay will fill up. I do love a good trauma but I am sitting here after a nice lunch of Pho (Vietnamese beef noodle soup) and there’ s a little food coma about to set in. I mused with turning on the TV to see if I could catch an Orioles’ game but I just don’t want to wrap my head around anything. It would be cool to just nap for 20 minutes and then check a couple of patients.

My junior residents are not busy so I don’t feel obligated to micromanage them. All of my senior residents have signed out to me and our services are Q-U-I-E-T (another word I don’t say write). My attending on call, has just checked in to say that he’s going to afternoon lunch with his wife and would like to let me know that he is on Mobile. I love it when they do that. It saves me the trouble of paging and waiting for a call back. I can go right to the source.

So far, I have rounded on my service and discharged just about everyone who could go. I elected to keep one gentleman over the weekend because no one is home to be with him and he is a 75-year-old recovering from a sigmoid resection. His daughter will arrive on Sunday night and he can go home Monday morning. Besides, a couple of extra days of watching especially since I am not happy with his food intake will be good for his recovery. My attending agreed with my assessment.

I am also contemplating doing a stairwell walk to get some exercise. When I start to feel the afternoon slump, I walk up the 10-stories from basement to top floor and back to my digs on the fifth floor. Then I look for a fresh cup of coffee or grab a diet Pepsi. There are fountain soft drinks on every floor at the nursing station that feature, colas, iced tea, lemonade and water. The coffee has to come from the coffee bar that is in the cafeteria. Since Saturday lunches are usually not too great, I had my fiance bring in some Pho so that I wasn’t drowning in grease this afternoon. The bad thing is that I can be pretty hungry around 5pm so I need a good protein dinner.

I am also thinking about the logistics of getting to the White Coat Ceremony that my medical school will be having for the incoming medical students. There is usually a nationally recognized speaker and then the name of each incoming student is called. A member of the physician graduates will then cloak the incoming student. We all take the Hippocratic Oath again just to remind us of what being a physician is all about. It’s a great day and loads of fun to see the newest class and catch up with some of my classmates and professors. It’s always a good time. This year, I am going to be buff so I really want to go. The bad news is that I will be making the schedule so I have to be totally fair with time off, if I leave town.

I spent an hour this morning preparing one of my pathology review lectures. I am amazed at the depth of information that I can burn out in a PowerPoint in about 60 minutes. My teaching experience has really helped me in putting together presentations. I am hoping to have all of my lectures done just in case something comes up and I am not able to teach n the days that I have been scheduled. Sometimes a case can run later or a complication will develop and thus, I have my work ready to go.

One of my junior residents just beeped me to ask about making a patient NPO (nothing by mouth). Since this patient is low-risk for surgery today, I opted for “sips and chips” meaning sips of clear liquids (no carbonation and limited to 30 ccs per hour) plus ice chips. If we do end up operating emergently, we can do so after “sips and chips”. One of my attendings allows hard candy with “sips and chips” but I leave this up to the patient. If there is any hint of nausea or vomiting, back to NPO and I will increase the IV rate.

Well, that’s a glimpse of my world at present. I have to get back to studying for my board exams. I have a strict reading schedule that I am adhering to complete with check offs. I may yet do the stairs and take a nice hot shower before the evening rush. On a Saturday night, I can expect some trauma work.