• Michael Dworkin, MD

How to bounce back after a disappointing Step 1 score

Updated: Aug 13

If your USMLE Step 1 came back lower than you had hoped, do not despair. Here's what you can do.



Accept your score, but don't lose hope!


USMLE Step 1 score is the most important factor in determining whether or not you're offered an interview at a residency program. However, the next 5 most important factors for residency admission, specifically, for getting an interview, are all things you can prepare for, so it's important to stay motivated! If you are feeling really discouraged, check out our post on how to stay motivated during medical school; maintaining a growth mindset will be key to bouncing back!



You can still improve several key aspects of your residency application.


Of the remaining 5 factors, one is your personal statement (see here for how to write an outstanding residency personal statement).


The remaining 4 factors are as follows.


(1) Letter of recommendation in your specialty of interest (dependent on clinical performance)

(2) Medical student performance evaluation (a summary of residents' and attendings' written evaluations of your clinical performance)

(3) Grades in your clinical clerkships (dependent on clinical performance and NBME shelf exams)

(4) Most importantly, USMLE Step 2 CK score.



What to focus on?


Based on the above information, it is important to focus on how maximize clinical performance, shelf exam scores, and your USMLE Step 2 CK score.


Read our post on how to optimize clinical performance during clerkships in med school.


The remainder of this article is dedicated to helping you understand how to improve your performance on the Shelf exams and the USMLE Step 2 CK.



Self reflect: what did you do wrong in your preparation for your USMLE Step 1?


A disappointing Step 1 score is a red flag. It should signal to you that you should think carefully about how best to improve you approach to preparing for the Shelf and USMLE Step 2 CK exams.


Some common reasons for a disappointing USMLE Step 1 performance are following.



1. Failure to complete UWorld or only completing several practice tests.


As a USMLE tutor, I have had several students seek my help after failing Step 1 without completing UWorld or after only completing 1-2 practice tests. Research shows that the number of practice questions completed is the strongest determinant of your USMLE score. Make sure to complete your Step 2 CK UWorld questions early in your clerkship, to do all the practice NBME shelf exams before your Shelf, to repeat UWorld 2x (including your incorrects) while preparing for CK, and to complete all the NBME CK practice exams and UWorld Step 2 CK self assessments.



2. Failure to take practice exams seriously.


Make sure that you strictly simulate real testing conditions. Don't give yourself extra time. Don't say "It was just a stupid mistake" or "I knew that". Identify and learn from every mistake you make.



3. Failure to study from the right resources.


A corollary #1, see our blog article on the list of resources to use for clerkships and Step 2 CK prep. We have also written articles for each of the major clinical clerkships.



4. Failure to properly retain information.


Anki has been shown to improve USMLE scores. For clerkships and Step 2 CK, we recommend spaced-repetition via use of premade Anki decks such as our comprehensive MedSchoolGurus Clerkship Decks or MedSchoolGurus USMLE Step 2 CK deck. Premade decks should be supplemented by adding pictures and your own notes to the back of cards, and making your own cards as needed. If you make your own cards, make sure that they are testing a single fact critical to understanding a key-testable concept that arose in a question you got wrong.



4. Poor time-management


Read our article on how to manage your time during med school. Key points for clinical year: do a little bit every day. Don't cram or fixate on nitty-gritty details. Make sure you get all of your UWorld questions done 1-2 weeks before the shelf exam so you can give yourself enough time to go the practice shelf exams.



5. Poorly developed test-taking strategies


Performance on NBME style exams is 50% knowledge and 50% test-taking strategy.


Do you run out of time during exams? If so, make sure to do your UWorld blocks on timed mode and to read our post on how to pace yourself during practice exams. During your second pass through UWorld for Step 2 CK, make sure to do your questions on timed random mode.


Try to develop a systematic approach to each question. Read. Every. Word. Especially in the first sentence. As you read, pause deliberately after each sentence to allow yourself to synthesize what you have just read. If you know how to think like an NBME exam writer, you'll understand that all questions are reverse engineered with an important testable-concept in mind, so ask yourself: "What key testable concept that I have been taught about is the examiner trying to get at here?". It is important to understand that 90% of the time, you will already have been taught about the key testable concept. Therefore, don't overthink nitty-gritty details or spend too much time focusing on something you don't understand. Thinking about something that you do not understand will not get you anywhere. This process will help you learn to distinguish between essential and non-essential information. Formulate a differential diagnosis or hypothesis after reading the question stem and before looking at the answer choices. Think through the set of important testable concepts you have previously been tested on and ask yourself "Which answer is most consistent with a key concept I've already been tested on? Which answer choice is most consistent with my differential diagnosis or hypothesis?". Use process of elimination, since each incorrect option is incorrect along a single dimension of information. For example, if the case is a 50 year-old female with sudden onset dyspnea two days after an orthopedic surgery, the answer choice of COPD exacerbation is incorrect along the dimension of timing, as COPD exacerbation occurs over days, not suddenly. '



It is often difficult for students to self-identify exactly why they are getting questions wrong. For example, it is common for my students to initially think they got a question wrong because they did not know a nitty-gritty detail. After review of the question together, it often becomes apparent that their difficulty was more cognitive - for example, they focused on a detail they did not know, got stuck, and then guessed, as opposed to following the above technique. Metacognition is key to improving your test-taking strategy: think about how you thought about a question you got wrong, and try to identify why and how your thinking went wrong. For example, the "why" in this case is a distracting piece of information. The "how" is thinking about that distracting piece of information instead of the key task at hand. Metacognition and this process of self-identifying your own cognitive pitfalls is not easy to do on your own. This is why USMLE or shelf tutoring can be so valuable to some students.



Final Thoughts


Carpe-diam! Now is your time to take control and bounce back from a disappointing Step 1 score. One of our outstanding shelf exam and USMLE tutors can help you identify where your preparation went wrong for USMLE Step 1, how to crush your clerkships, and how to develop the test-taking skills necessary for success on your shelf exams and USMLE Step 2 CK. To set up a free 15 minute consultation or for more information about our tutoring services, contact us via medschoolgurus.com/contact.