Askdoc's USMLE Newsletter

Why Failure is Not an Option For the IMG

Why Failure is Not an Option for the IMG

Hey there,

Mike here. This is the eight issue of our newsletter and I hope you are learning a lot. And I hope you are beginning to realize that as an IMG, you can't hope to do well in the USMLE by just opening a book and start reading. That unless you research what the USMLE is all about, you can't really hope to know how to prep properly for this exam.

In short, this is a letter about hope. Hope that you don't fail the USMLE Steps. Hope that you do well or even ace it. Hope that you will learn and follow what I have done so you can do the first two.

In a previous issue, we talked about how it is important to know what makes the USMLE hard so you know how to prepare for them. And the only way you can do that is to do proper research about the USMLE right from the start.

However, the USMLE is not the only thing we need to research way before we start prepping for the exam and today we will discover another important thing we need to research even before prepping. So you can take the necessary steps to make the exam "easier".

Today, we will talk about "Why Failure is Not an Option For the IMG".

There are two big reasons why failure is not an option for the IMG.

First, for the IMG, failing even once, means your chances for getting a residency position falls to almost zero.

Second, there is no reasonable and valid excuse for any IMG (including old IMGs) to fail the USMLE Step 1.

For the IMG, Failing or Low Scores Means No Residency

When I first started preparing for the USMLE Step 1, I not only spent time researching about the USMLE, I also spent a lot of time researching about the process of getting into a medical residency program in the US.

That is how I avoided one of the most common mistake IMGs and old IMGs make in their quest for a US medical residency. Passing and only passing the USMLE.

Even while I was poring over exam experiences of those taking the USMLE, I was also going through the experience and posts of people going through the NRMP or what we call the "Match" and what I found out wasn't pretty.

If you just relied on the ECFMG or USMLE website, it seems you can fail and retake the USMLE as many times as you want until you passed. Once you passed the score is permanent and you are not allowed to retake it.

If you dig deeper, you will find that the USMLE recommends you take the USMLE no more than 7 times because some states put a limit of 7 or you can't get licensed. But if you take the time to look at the Federation of State Medical Board website (, some states will allow you to be licensed even if you took more than 7 tries to pass Step 1 subject to some additional requirements which differ by state.

So officially, you can take the USMLE multiple times and be eligible for licensing once you are done. These are what the US State and Federal Government requires for you to be licensed to practice medicine. And for all intents and purposes applies to all graduates of US medical schools.

However, for most IMGs and especially old IMGs, the reality on the ground is very different. Once an IMG fail the USMLE even once, the chance of getting into a residency position is almost none. There are of course exceptions and I will discuss how some of this exceptions were able to overcome the problem of having failed Step 1 before in a future lecture seminar on the match and how to get into a US medical residency.

Even, just passing the exam will guarantee you won't get any interviews. These are not requirements imposed by the US Federal Government or Individual States. These are standards imposed by individual residency programs in teaching hospitals across the US.

In 2006, the minimum score to get at least one interview is 82 (202) and that's not a guarantee. The minimum number of interviews an IMG needs to match is 5. On average, to get five interviews you need about a score of 88 (218) and that is for fresh grad IMGs. That was way back in 2006. The scores needed are way much higher now.

It's even worse if you want to get into a surgical residency.

I remember a post in a forum that went like this:

Poster 1: Hey guys, I got a 90 in my Step 1. My dream of getting into a surgical residency is over.

As everyone were condoling him, another poster wrote.

Poster 2: I don't know what all the fuss is about. I know someone who matched in a surgical residency with an 82.

Poster 3: Ah. He is an IMG. He needs a minimum of 92 to get interviews. Higher if he wants at least a 50-50 chance getting into a surgical residency program.

Poster 2: Oh…

Yeah guys, it's that bad.

So if you are an IMG, the best person to ask about USMLE and residency are fellow IMGs, not AMGs. They live in a completely different world from us IMGs.

In my case, I'm an old IMG, so the score I need to get are even higher than most people. You could imagine how disconcerting that could be. And that maybe one of the most important reasons why I wind up acing the USMLE. I felt I had no choice. It's that or bust.

Now, you may be wondering if things were that bad, why did I bother to proceed with my USMLE Steps. In order to answer that, we need to look at the annual residency matching statistics.

Every year, there are roughly 25,000++ residency positions open in the whole US. There are around 17,000 US graduates each year and they match 100%. So that leaves about 7000 positions open for IMGs and Fifth Pathway Graduates. That is a lot of positions. So you know that at least 8000++ IMGs do get into a residency position each year.

However, every year, about 20,000 IMGs will take the USMLE exam and roughly 13,000 of them will pass the Steps. And all of them will be applying for residency positions. From this alone, you will realize that at least 4000 IMGs who passed Step 1 will not be able to match into a position.

It gets worse. Add about 4000 IMGs who passed the USMLE but failed to match the previous years and you realize that about 9000 IMGs will not match each year. And all of them passed the Steps.

However, if you monitor the NRMP match statistics, only roughly 5000 IMGs match each year. The reason is, the balance are usually pre-match positions that are offered to IMGs before the match. Therefore, a large number of IMG positions are given out in pre-match offers.

The key to getting pre-match offers is high scores. Especially 99s. And the reason is rather practical. If you want to know more about pre-match, why residency program offers positions outside the match and what is the best way to increase your chances of being offered such positions. I will discuss it in more detail on a future seminar workshop on the match and how to get into a US medical residency.

In reality, there are a lot of positions open for IMGs. The problem is there are just too many people applying for them. So if you are a fresh grad IMG and able to get good scores without failing, you should have a pretty good job at matching.

Now, if you are wondering why it's so hard for IMGs to get residency interviews compared to AMGs, I will explain it in more detail in a future seminar workshop on matching and getting into a US medical residency.

Why Program Directors Won't Even Interview IMGs who Failed Step 1?

Don't you think it's unfair that as an IMG, once you failed the USMLE even once, your US medical career is essentially over. I mean there are exceptions, but for most people, the chances of getting into residency is close to zero. This is also true if you got a low score.

That was how I felt when I first learned about this truism. Why do AMGs get a pass. I mean they can fail multiple times or get a low score and they will still be able to get into a residency program. It's unfair!!! It's discrimination.

However, as I learned more about the whole process of taking the USMLE, I realized that it's not really that unfair at all. And the main reason why is that no IMG has a reasonable excuse for failing this exam, while AMGs have.

First, IMGs can schedule the exam when they want it. If they are not ready, they can skip or postpone it. So long as you did not sit for it, it is not counted as a failure. Meanwhile, American medical students are required to pass Step 1 before they can continue into third year, so they need to take it by a specified date.

Second, with the NBME assessment tests, there are now reliable indicators of what score you will most probably get if you sit for the exam. It can tell you whether you will pass or fail Step 1 even before you actually take it.

It seems obvious that if I decided to sit for the steps even though I know I am going to fail, then program directors will probably think I am a really stupid Doctor, right? And if I did not even bother to do a proper self-assessment test before taking the exam, then I am incompetent or too lazy to research on how to pass this test. Now if I failed because I used the "downloaded " NBME forms instead of the online ones, then I show lack of ethics. (See "NBME Self-Assessment Tests and USMLE Review".)

Obviously, all of the above traits is undesirable not only for a physician, but also for residency applicants to their medical residency programs. No wonder program directors won't even consider interviewing IMGs who have failed this exam or scored low. So watch out.

I did not make this mistake. And I hope you won't either.

Hope to see you all again next issue.


P.S. Next issue, we talk about "How to Create a Schedule" A study plan is more than a schedule, but the schedule is the centerpiece of your study plan. It outlines when you need to do what and therefore an important aspect of your study plan.

Better Prep.

Easier Exam.

Higher Scores.

How to Master the USMLE Step 1 Book

Better Prep.

Easier Exam.

Higher Scores.

How to Master the USMLE Step 1 Seminar

Score HIgher. Read the Book.

An in-depth written guide on how to prep better and score higher for the USMLE Step 1. Read the book. Better Prep. Easier Exam. Higher Scores,

Score Higher. Listen to the Lecture

A 48-module lecture seminar on how to prep better and score higher for the USMLE Step 1. Listen to the Lecture. Better Prep. Easier Exam. Higher Scores.