Wednesday, August 14, 2013

How can I overcome a low USMLE Step I score?


Nemanja (not his real name) writes: I am a fourth year medical student at a US school. I am planning on applying to general surgery in the next month. I have a few concerns and questions about my application and competitiveness. 

I did very well years 1 and 2, all but one honors. I got a 209 on USMLE Step 1 and a 243 on step 2. The caveat about my step 1 score is as follows. I had a family tragedy 1-2 months prior to taking step 1. In retrospect I probably should have deferred and not taken it but hindsight is 20/20.

After that poor step 1 score, I did well on my clinical rotations. I received a high pass in surgery and honors in 4 other clinical rotations with no grade less than a high pass. I expect to receive strong letters of recommendation from my program director and clinical faculty. I am interested in applying to programs in the northeast portion of the US.

How can I let a program director know about my situation (e.g., in my personal statement, in my dean's letter). Some of the people at my institution have led me to believe that this is an important part of my story and something that may provide an explanation for a below average step 1 score. I am afraid that I will be filtered out due to my step 1 score from many university based programs. What do you think is my best approach to this situation? 

Your question is a good one. I am sorry about your family tragedy. 

I suggest you explain it in your personal statement and ask the dean to mention it in his letter too. You need to emphasize the fact that your Step II score is very good. Strong letters of recommendation will help.

If you search PubMed for "USMLE Step I," you can find a fair amount of information about the weight program directors put on it. One paper says it is the single most important factor used by PDs to screen applicants. Another says that a Step I score of < 200 is associated with a higher risk of failing part I of the general surgery board exam.

Here is a link to a PDF from the NRMP about match outcomes. If you go to page 84, you will find some interesting data about the 2011 general surgery match.

I have some screen shots for you. 

Here's a table listing some summary statistics.


This is a graph indicating that a USMLE Step I score of 209 gives you about a 75% chance of matching in surgery.


But here is a chart showing that a Step II score of 243 gives you a very good chance of matching. No graph was provided.

The message is very clear. Get the PDs to look at your Step II score

You may want to apply to some community hospital-based programs to be safe. I think you will match in a categorical position.

Good luck. Please let me know how things turn out.

36 comments:

  1. Thanks for the thorough lit search and response. My follow up question would be this. You mentioned that I need to show PD's my improvement on step 2, how do I go about making sure they know about this? Do you suggest I reach out to PD's and tell them, or have my PD reach out to fellow PD's? Should I write about my step 1 score in my personal statement? I have heard that some programs will filter applicants based on step 1 and will never even see my application. In your experience, did you ever wind up with a good resident by way of someone reaching out to you and vouching for them?

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    1. I said to write about it in your personal statement explaining why the score was low. I see no harm in you and/or your PD contacting other PDs independent of the ERAS application system. If a PD was going to reject you just because of your Step I score and rejects you anyway despite you and your PD trying to mitigate the circumstances, you have not really lost anything.

      I believe that many programs do filter by USMLE Step I scores.

      Yes, I have had some good residents who I might have overlooked if not for someone vouching for them.

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    2. Hey Nemanja, did you end up matching?

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    3. That's a very good question. I hope he matched and will let us know.

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  2. The thing that strikes me here is something I used to be guilty of during the med school years; namely, letting the ratio of my worry about my academic performance to the actual seriousness of the situation get inappropriately high.

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    1. Todd, that's a good point. I was trying to tell Nemanja not to worry too much and that he would have a good chance to match. You said it better than I.

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    2. So true Todd! These days, medical students absolutely obsess about USMLE Step 1 score. It's crazy. I don't know if it's always been like that. Maybe Skeptical Scalpel can shed light on this.

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    3. I think there has always been a sense of urgency about the USMLE, especially Part I. It's getting worse now because competition for residency positions seems more intense, and many more applicants are going unmatched.

      A recent post on @KevinMD discussed the issue of whether schools should teach to the USMLE. Here's the link http://www.kevinmd.com/blog/2014/05/medical-schools-start-teaching-usmle-step-1.html.

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  3. Thanks for this post! I am in a very similar situation and was wondering if you could offer me some of your wisdom. I go to a top-30 research university located in a major city in the Northeast, did very well years 1 and 2, but also had to deal with a family tragedy 3 weeks before my USMLE Step 1 exam (I essentially lost a whole week out of 3 I had planned to use as my comprehensive review period). I didn't end up moving my test date given the proximity (and financial cost of doing so) to the exam, and the fact that my 3rd year was set to begin promptly after my exam. In retrospect I also regret not opting to postpone my exam, but as Nemandi also said, "hindsight is 20/20..." Unfortunately, I ended up getting a 199 on Step 1. Looking at the 'histogram' on the score report, not having the time to re-review pharmacology essentially decimated my score (luck of the draw, my exam ended up being very pharmacology heavy).

    I just finished up my 3rd year and did well, attaining Honors in 4 rotations (including surgery) and High Pass in the 4 remaining rotations. I worked closely with faculty on my surgery rotation and have strong letters of recommendation lined up. I am currently studying for Step 2 and am confident I can greatly improve. However, my Step 1 score is making me lose sleep at night. I understand 199 looks very bad... and that PDs commonly use 200 as their cutoff.

    Do I have any chance of having my application looked at? How often do PDs use hard cutoffs? Do I have a chance of matching? I am not looking to go to a tier-1 academic program, but would love to go to a tier-2, tier-3 academic program or a strong community program with an academic focus. I also have no geographical limitations on where I would like to go. Thanks in advance.

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    1. I'll give it to you straight. The cutoff for many programs is about 215 to 220. You are right to be worried about the 199.

      The post above contains most of my advice. I must admit that after rereading it, I realized that just about everyone with a low USMLE Part 1 score has an excuse. What you are going to have to do is not only kill Part 2, but ask your surgical chairman to make some personal calls to PDs of programs you are interested in. A personal endorsement by phone is a lot more influential than a letter. What good is a letter if a PD won't look at an application with a USMLE below 215?

      I assume the chairman of a top 30 research university must be well-known. That would help.

      You should also consider applying to a few community programs that have historically matched with mostly US IMGs. There are several. It may be that your school's reputation will get your application past the USMLE Part 1 barrier.

      Good luck. If you remember, let me know how things turn out,

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    2. Thanks for the advice, it's pretty much what I figured. I have a steep slope ahead of me I guess, I appreciate you being honest. What are your thoughts on another professional degree and research? My institution has a strong MD/MPH program that students can join between their 3rd and 4th years. My thought was getting an MPH for some research acumen and also getting involved in research projects simultaneously to strengthen my application. I have floated the idea by some of my peers and mentors and haven't really gotten any concrete advice. Just curious what your 2 cents are on that.

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    3. Normally I'm not wild about research and advanced degrees. In your situation, an MPH might be worth doing. To me, research isn't worth much unless it produces published studies, preferably in an area that is clinically relevant. Your low USMLE Part 1 score is going to hold you back from academic residencies so papers on cytokines may not be enticing to community hospital PDs. However, clinical research is difficult to produce in large quantities in many community programs. A resident with good research skills would have interested me a lot.

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  4. Hi
    I am Usman Akmal from Pakistan. For you to be easy i be an IMG in u.s.
    After reading the forum, i dont want to put up any excuse.
    My current status is i am a resident of general surgery here in pakistan. And will be joining orthopedics by end of june next year. Thats good for me because thats confirmed .
    I did my step 1 in september 2013 with score of 204 with mean of 227 and Standard devation of 22 and minimum passing score of 75.
    There is no percentile mentioned.

    My score is low. I know that. So i left the intrest in usmle back tgen in 2013.
    But now when my program suoervisor for orthopedics interviewed me , who is an american board in orthopedics nd worked in u.s for 20 years, and now in pakistan. He asked me to complete my steps atleast step 2 cs and ck before joining him.
    He told me i can get into post fellowship program and my fcps degree of orthopedics will have its worth in u.s provided i also do MRCS.
    I am not in a postion to come to u.s nd do unpaid research job. I already have a residency job here.
    BUT I WANT A FOREIGN QUALIFICATION. A QUALIFICATION OF HIGHEST STANDARDS.
    I have started my usmle step 2 prep. After 13 months of break

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  5. And so i want to ask that , can i get into post fellowship program with doing steps ,fcps, and extra jam of mrcs too....

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    1. I am not sure about the situation in orthopedics at this time. I know nothing about the competitiveness of orthopedic fellowships.

      I wish I could give you some advice, but I cannot.

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  6. Well if ask our competency...hmmm ok
    I have applied for Atls course..which was due on 21 st of this month but postponed. And after going through atls course mannual , what i concluded that we a doing diaster mangement type of mangement in our tertiary care hospital. Becaue of too much lack of infrastructure .
    Our fcps degree is acknowledge in u.k to practice there.
    But point is what about entry in post fellowship programs?

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    1. I have no knowledge of the situation regarding IMGs and orthopedic fellowships. I suggest you contact some of the programs and ask them what their policies are. Sorry I can' be more helpful. Good luck.

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  7. Hi,
    I am IMG not US citizen but green card holder , my step 1 score is 219 !! and i wonder if i should continue to do step 2 because the mean of matching is 227 score of step 1 !! will my step 2 score rescue me or am done !! and what is my chances if i get high step 2 score because as mentioned above the programs directors will filter the application according to step 1 scores !!? Any ADVICE please !!

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    1. My post above is only an opinion. There are stories of people overcoming the odds and matching. 219 is not that bad. I see no harm in trying to do better on Step 2. You will need to take Step 2 eventually no matter what specialty you end up in. I think a really good Step 2 score would get you noticed.

      USMLE is not the only criterion that program directors use. You should try to get some interviews at surgery programs. If you don't get many, be sure you have a back up plan.

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  8. Hey there! Thanks for the blog.

    My question: I scored 234 on Step 1, and I know it's above the mean. That said, I've consistently seen that now, for some reason, programs want way more than that. I get that looking into forums to predict how match season is going, is not very effective, but I do notice the trend of only being granted and interview if your scores are above 240 and for other programs, above 250. I think realistically, with my 234 I'll be filtered out by many many programs. Considering also that I'm a 2010 USIMG. I do have potential to score way above that, but I cut myself short on a few subjects that I didn't even look at because I wanted to rush to apply this season- bad move. Anyway, have you also noticed this on some programs only inviting those 240+ for interviews?

    Thanks.

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    1. I really don't know what program directors are doing with USMLE scores this year. It is early in the process. If I were you you, I would be more concerned with the fact that you graduated from med school so long ago. I hope you have a good explanation of what you have been doing for the last 4+ years. If it was not something clinical, you probably will get very few interviews regardless of your USMLE scores.

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  9. I m an img .Scored 206 on step1.what best can I do now. Is it worth a try. Or should I lose it all n say bye to usmle

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    1. I don't think a 206 on Step 1 is fatal. I doubt you would get a surgical residency position, but some other specialties might be interested.

      I don't see how you can say goodbye to USMLE. If you don't take the other parts of it, you won't be able to get a license.

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    2. Hi, Last year I was exactly in the same situation. I sscored 206 in step 1, then took step 2 cs- passed 1st attempt, Step 2 ck- 235. I am IMG, I dont have USCE. Now preparing for step 3 which I will be taking before applying. My speciality of choice is IM but will be applying for Family Medicine as well. What do you think about my chances of getting matched? Thanks in advance.

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  10. Hi I m an IMG...I jus got my devastating step 1 score 209 :( I dnt knw wat to do...do I stand a chance for internal medicine or paediatrics... Will b givin my ck soon...I hav no electives...will b doin observer ships soon...plz help me I m in desperate need of an honest advice..thank you

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  11. To the two anonymous commenters from May 20:

    I am not sure what the parameters are for IM, family medicine or peds. A lot depends on your school's reputation, your clinical experience and maybe other factors too.

    I don't think a USMLE Step 1 of 206 or 209 is fatal. I hope some other readers will comment.

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  12. Hello. I am an IMG, scored a 234 on the Step 1. Since I began my program (Ireland) I have been working hard to make myself competitive for a residency in the United States or Canada. I am hoping to do family medicine myself. I have several thoughts and theories about matching in the United States, but I do believe it is possible to obtain a residency (IM/FM/PEDS) with a 200+. What I believe any and every IMG should emphasize is obtaining letters of reference from an American or Canadian elective (my understanding is that American and Canadian letters of reference are roughly treated as equivalent). These electives are not as difficult to obtain as some may think. Some schools such as McGill University in Canada and UNC in North Carolina welcome international students for electives. If you work hard (or very hard as was my experience) a GOOD letter should be achievable. Do the elective in what you want to specialize in. Don't be scared of a few rejections. Be prepared to pay a decent amount of cash to do these electives and to apply to them. Consider doing a couple of electives, two letters are better than one. Some schools will only take you if you're considered a final year student (consider doing the elective immediately following your next to final year). Some schools will let you do a next to final year rotation, but these are less common (McGill is an option for this). Hope this helps.

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  13. I think I got a 216. Took step 2 and got a 246. Got my Step 2 scores back right after I started getting interview invites and rejections, and I emailed the rejected programs my Step 2 score and landed a few more interviews. Matched to my #1 in anesthesiology. Addressed it in my personal statement and interview.

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  14. Hello, I am a US IMG. Been applying to residency programs for 7 years with interviews but no match. I also have an MPH from a US grad school. I got 190 in Step 1, 210 in Step 2 and 191 in Step 3. I've been conducting clinical research for the past few years with a few publications. Is there any hope of matching into any specialty? Should I go back to medical school since my year of graduation is now 10 years? Or should I go the Public Health route? Please advise. Thank you.

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  15. I can't tell you what to do. I can tell you that if you have not been involved in clinical medicine for a few years, your chances of finding a residency position are very slim indeed. How can you go back to med school? Where would you go?

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  16. Hi,
    This post is for a friend who just got his step 2 result and is quite upset. He had 250 in step 1 and 227 in step 2. He is currently working at a post doc position and really wants to pursue general surgery. Is there any hope for him!? and what can he do now to strengthen his application.
    I would be really grateful for your advice.

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    1. I don't think a score of 227 on Step 2 necessarily precludes obtaining a surgical residency. Of course, there are other factors such as what school your friend attended, how long ago he graduated, what he is doing now, and others.

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  17. Hello

    I am an IMG going to start rotations this december in the US and I'm canadian. I just wanted to ask an experienced person about my chances of matching. My step 1 score is a 218. And I'm really worried as to whether I will be able to match into any specialty at all. I don't know what to do and this is relly stressing me out a lot. What can I do to increase my chances of matching?

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    1. I'm not that familiar with specialties other than general surgery, but I think a step one score of 218 for a Canadian graduate would very likely get you into internal medicine or family medicine and possibly some other nonsurgical specialties.

      A few months ago I wrote a post about this. Here's the link: http://skepticalscalpel.blogspot.com/2016/07/what-are-residency-prospects-for.html

      In that post are links to some data from the matching program that should help you find the information you are looking for. I also show some figures from NRMP publications specifically describing the prospects for matching in surgery for various categories of applicant including Canadian.

      If you read that material and still have questions, feel free to email me at SkepticalScalpel at Hotmail dot com.

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  18. Hi I am a US IMG and I got a 212 on step 1 and a 252 on step 2 ck, pass step 2 cs on first attempt. With these scores do you think there is a chance of matching in gen surg for 2018 match? i have no publications, but I am desperately searching for the opportunity to do a case report on something surgery related. Any advice? I am in fourth year right now and have 3 surgery electives letters from all.

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  19. I think you have a chance of matching.

    The 252 on Step 2 can't hurt, but I believe some program directors screen applications using only Step 1 scores.

    I have blogged about this more recently. Here are links to two posts on the subject: http://skepticalscalpel.blogspot.com/2016/07/what-are-residency-prospects-for.html and http://skepticalscalpel.blogspot.com/2016/04/faqs-from-imgs-about-applying-for.html

    Factors other than your USMLE scores--such as what medical school you attend and whether you did any US clinical rotations--will affect your chances too.

    I hope this helps. Good luck.

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