I think if you truly know you worked hard and never gave up when you were tired, then board scores and class rank will follow. It's my feeling that even though competitive residencies will look for high marks, recommendations noting hard and diligent work from important physicians hold as much or more weight in certian circumstances. Case in point, you could be the brightest in your school, but if you don't seem like a team player or a person who could "fit in" at a residency program, you suddenly become less desirable.