How Many Times Can You Take the USMLE Step 1? Preparing for the Worst Case Scenario

The USMLE Step exams are no joke. There are plenty of students who have struggled to pass their exam on the first, second, or even third try. If you find yourself in a position where you are asking, “How many times can I take USMLE Step 1?”, know that you are not alone. Plenty of other students have asked the same question, and at Elite Medical Prep, we are here to help in any way we can. This blog post will help outline planning for USMLE Step 1 studying when you have had a previous Step 1 failure.

I just received my score report of a “fail”, what are my next steps?

Every Wednesday morning students open their emails with a pit in their stomach, anxious to see the results of their Step 1 test that they took just a few weeks ago. What happens if you are one of the ones who opens your score report and sees a “FAIL” reported?

1. Take a Breath and Be Kind to Yourself

First all, take a deep breath, it’s going to be okay. And allow yourself to be sad. This sucks. You worked hard studying, you spent plenty of money on the exam, you have been anxiously awaiting your score, and now you realize you have to tackle it all again. Allow yourself to cry/be upset/be angry. Process as best you can. Talk it out with friends or maybe go for a run (I personally always find exercise to be a great solution to my stress!). Know that it is expected to be sad and disappointed.

2. Make a Plan!

Second, once you have grieved your test results, it’s time to make a game plan! Figure out what you did that worked well and figure out what didn’t work for you. If you have the opportunity, chat with your friends and ask for their insights. Try your best to come up with a plan to ensure that your next attempt will be successful. Try using our 10-week study schedule as a starting point. If you feel you may want a more individualized study plan, at Elite Medical Prep, we always take our students through an in depth evaluation of their study experiences, testing environment, and schedule for studying. Reach out to us, and we’ll work with you to develop a customized game plan tailored to your needs and goals.

3. Don’t Give Up

Third, don’t give up! Sometimes I feel that my students who are struggling the most have made a decision (either consciously or unconsciously) that they are not capable of passing the exam. And it is simply not true. You ARE capable! But, if you give up now, you are certain you will not succeed. As you navigate this process, keep your chin up! Maximize your study time, stay focused, and do the best you can. As a gentle reminder, I always push my students to aim for quality studying over quantity studying!

If you find yourself in the position of a Step 1 fail, make sure that you allow yourself to be sad, come up with a plan to succeed next time, and don’t give up. You’ve got this!

How many times can you take USMLE Step 1?

If you recently received the news of a failure on your exam, you may be asking yourself: how many times can I take USMLE Step 1? The answer has changed recently. As of July 1, 2021, the USMLE updated its policy, reducing the lifetime maximum attempts from 6 to 4. This change was implemented due to the committee’s goal to support medical licensing in the United States. They  based their decision on data indicating that students who take the exam more than 4 times rarely succeed.

Additionally, you may only take the exam up to three times within a 12-month period. This means that you cannot cram all four attempts into one year (nor would we recommend that). Your fourth attempt must be at least twelve months after your first attempt and at least six months after your most recent attempt on the exam.

For example, if you took the exam in January of 2024, July of 2024, and December of 2024, you would need to wait until June of 2025 to retake the exam. You can find answers to commonly asked questions about retakes here.

This waiting period may actually work in your favor.  If you’re facing a fourth attempt, it’s likely a sign that you need to take a step back, reassess your approach, and refine your test-taking strategies and skills.

USMLE vs. State Rules on How Many Times You Can Take USMLE Step 1

Ultimately, USMLE has their own rules regarding retaking Step exams. That being said, USMLE rules aren’t the only ones to consider when retaking Step exams. State-by-state rules also apply, and they can vary significantly. For example, Delaware permits 6 attempts to pass each USMLE exam. In Georgia, you have 3 attempts to pass each USMLE Step exam. Illinois limits you to 5 attempts total for all 3 exams.

This can get confusing, especially when USMLE and state requirements seem to conflict.  However, ultimately USMLE regulations come first, as they will not allow you to physically test again. The state requirements are used for licensure in that state. There are some stories of students in certain states appealing to obtain a fifth opportunity, but there are no guarantees. You can read more about state requirements here.

What is the seven-year rule?

Around 25 states have a rule that you must pass all three USMLE exams within seven years of passing the first exam. This is most likely pertinent for IMGs who may be attempting USMLE Step 1, 2, and 3 prior to residency. If you are encroaching on the seven-year limit, make sure that you are able to complete all exams, regardless of your application status to residency. Additionally, you must pass Step 3 within four years of your first attempt for Step 3. This helps ensure that those who are board-certified are able to complete their attempts in a timely manner (and prior to their training).

Below is a list of states that enforce the 7-year rule:

• Alabama
• Alaska
• Arizona
• Colorado
• Delaware
• Washington, DC
• Georgia
• Illinois
• Indiana
• Maine
• Massachusetts
• Michigan
• Mississippi
• Missouri
• Montana
• Nevada
• New Jersey
• New Mexico
• North Dakota
• Oregon
• Puerto Rico
• South Dakota
• Texas
• Utah
• Vermont
• Washington
• Wyoming

Some states not listed may have a 10-year timeline or other variations, while others impose no time limit at all. You can learn more about specific state requirements here.

Can I retake USMLE exams after 7 years?

After 7 years, you can retake the exams, but you have to restart from the beginning. Here’s an example: if you passed Steps 1 and 2 in 2015, but want to retake Step 3, you’ll need to restart the entire process. This means taking Step 1, Step 2, and then Step 3 again. However, your cumulative attempts still contribute towards the lifetime maximum of 4. So if you’ve already reached the 4-attempt maximum, you won’t be eligible to retake the exams after 7 years. 

What’s the difference between a one-time fail on USMLE Step 1 versus multiple fails?

A one-time fail on Step 1, will unfortunately decrease your chances of matching to your top program, but it is certainly not the end of the world. At the end of the day, passing is passing. Step 1 is difficult, and achieving that “PASS” should be at the top of your priority list. That said, there is a big difference between students who failed Step 1 once and students who failed twice or even three times. We recognize (and hope that residency programs would also recognize) that a one-time fail on Step could be a “fluke.” Perhaps you were having a bad day or maybe you happened to receive a test form that didn’t test your knowledge set. Maybe the testing environment was distracting the day you tested.

Failing USMLE Step 1 multiple times can raise serious concerns for residency programs. While it’s not impossible to recover from, multiple failed attempts can be a significant red flag. It may suggest that your knowledge was truly deficient, you didn’t prepare adequately, or you struggled under stress. This can significantly hurt your chances of matching into a top competitive specialty or your dream program. Unfortunately, it highlights that something went wrong, and you struggled to identify and correct the issues the first time around.

The bottom line is, the goal is to pass on your first attempt. If you end up with a fail, this is not the end of the world, but it is a kink in your plans. Do your best (and ensure you are completely ready) for the second attempt so that you do not find yourself worried about a third or a fourth and final attempt. Multiple fails on Step 1 could harm your chances of matching. Don’t risk it!

So, I have a fail (or two) on my score report. Does this mean all hope is lost?

Absolutely not! With a Step 1 pass rate of 90%, there are plenty of students out there who did not succeed on their first attempt. With over 30,000 students testing each year, that means over 3,000 students fail USMLE Step 1 each year. You are most certainly not alone.

Even if you have multiple fails, 65% of repeat testers are passing Step 1. Again, this means that you are not alone! Others have been in your situation and have struggled to pass Step 1.

There is hope! You can help bolster your application in other ways to ensure success. Make sure to invest in other areas to help present yourself as a qualified applicant. Perhaps you should become involved in research. Maybe you are able to really study hard for Step 2 and illustrate a much higher Step 2 score on your first time testing. Try your best to get the best letters of recommendation possible, and reach out to faculty early. If you plan on completing a sub-internship, make sure to bring your very best while on service.

All this to say, while a Step 1 fail is certainly not ideal, it also doesn’t mean that it is the end of the world. Plenty of other students have found themselves in the same situation. Do all you can to make sure you pass the next time you take the test, and try to bolster your application in other ways. Read our blog about navigating red flags in your residency application to learn more!

How can I recover from a USMLE Step 1 fail?

As we have discussed, a Step 1 fail is not the end of the world. Regardless, we want to make sure that you appropriately recover from a Step 1 fail. If you have a learning advisor at your school, we recommend meeting with them to help discuss your next steps. You may need to adjust your course schedule or plan to graduate a few months later. As you adjust your schedule, you need to plan a date for a Step 1 retake. Give yourself enough time to ensure that you will be in a “safe” passing zone. We recommend a “safe” passing zone to mean that you are consistently in the high 60%s to low 70%s on NBME Self-Assessments. This likely means that you need 6-12 weeks to study for the exam again.

Second, make a study plan. Start with our 10-week study schedule and customize from there. List what topics you plan to cover and when you plan to take NBME Self-Assessments. The NBME Self-Assessments are key to making sure that you are prepared to take the exam. Even if you have taken the self-assessments previously, take them again! That said, if you are retaking a self-assessment, you should have a higher goal score. We recommend a goal of 76% (two standard deviations above the passing zone) if you are retaking the NBME self-assessments. You will likely remember more than you realize and this may skew your score.

Finally, do not take the test again if you are not ready! The self-assessments are the best marker for your readiness for test day. If you are not yet in the safe passing zone, move your test date!!! Even if it costs money to move the date, this will ultimately save you money in the long run as you will not be paying to retake your step exam. When you are retaking USMLE Step 1, do not “risk it”, make sure that you are fully prepared to pass the exam.

Any other advice?

If you find yourself in the situation of a failing Step 1 score, we want you to know that you are not alone! Exams are tough, anything can happen on test day, and we understand that it is difficult to judge someone based on their performance from one day in their life. I remember on my Step 1 exam, I had a proctor who kept opening the door to let students in the room, and at the same time he would yell back to his colleagues who were outside the room and continue their conversation. This was SO frustrating. He kept distracting me, and this made for a much more difficult testing environment. I was thankful that I had a “safe passing score”, but nonetheless it made a stressful day all the more stressful.

If you had uncontrollable circumstances on your test day, anything could happen that might contribute to a lower Step 1 score. Don’t be too hard on yourself. Becoming a physician is a true privilege and honor, but it is not an easy road. There are many great physicians who have experienced failing a board exam. Step 1 is the first of many board exams on this exciting pathway. You may have hit a speed bump, but this is not the end of the road.

Keep your head up, know that you have options, and do your best to move forward with a continued commitment to becoming a compassionate and kind physician.

If you feel that you want a guide alongside you in this journey, reach out to us at Elite Medical Prep to schedule your consultation today.