How to respond to failed Step 3 attempt at interview (PDs please weigh in)

[totful]

Hello,
I am an old IMG (YOG 2003) who recently (summer 2013) completed my MPH at a top 10 school of public health, and my thesis has recently (October 2013) been accepted for publication in JAHA. I passed my steps 1, 2 and CS in one sitting (June, July and August test dates in 2012) while in the middle of a rigorous MPH program but failed my 1st step 3 (187) in January 2013. I retook the test after 2months of observership in August, 2013 and passed with a score of 198.

I already know that my YOG is a red flag but a friend helped me to get an interview in an community IM program. He told me though, that I must be impressive at the interview to be considered for a competitive ranking position in the program.

My concern is born from the logic I was hoping to use in arguing that I am a strong candidate despite my year of graduation. I intend to state that I have strong organizational skills, being able to navigate a rigorous MPH program in 2years, coming from a developing country and to write my exams in 3 consecutive months leading to my ECFMG certification. I am thinking this should somewhat demonstrate that I am still educable and intelligent for an IM residency. But not sure how to respond to my failed step 3 attempt, and it may weaken my case.

I'll be grateful for your kind suggestions.

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[IMPD]

When can you retake Step 3? The only acceptable answer for a failed Step on interview day (for me), is "I'm retaking it on xx/xx".

I don't really care who got sick, or who died or that Mercury was in retrograde. I just want you to pass the freaking test before I turn my rank list in.

 

[totful]

Thanks IMPD,
I have retaken the step 3 test and scored 198 (passed). Should that cover for the initial failed attempt to get a good ranking? I'm just a little worried I didn't score above 200.

Thanks for your reply.

 

[IMPD]

Thanks IMPD,
I have retaken the step 3 test and scored 198 (passed). Should that cover for the initial failed attempt to get a good ranking? I'm just a little worried I didn't score above 200.

Thanks for your reply.

Without knowing anything about your application.....

You are a marginal candidate who is getting an interview, which is frankly, kind of miraculous. I assume you know that.

So, you're not being chosen for the usual qualities and that is good in this instance. Many posters here will endorse a don't-ask-don't-tell policy. Which is fine.

OTOH, you should have a good answer if asked. The truth is fine - "I was ill-prepared, I'm a bad test taker" whatever it is. The followup statement from you should also be "I have a study plan starting tomorrow with the MKSAP and I'm confident I'll stick to it"

 

[Knicks]

I don't really care who got sick, or who died or that Mercury was in retrograde.

Well, screw you and whoever thinks like that.

You truly disgust me.

 

[Buzz Me]

What were you doing in the 10 years between 2003 - 2013, besides getting your master's?

 

[totful]

What were you doing in the 10 years between 2003 - 2013, besides getting your master's?

I practiced as a primary care physician in under served communities. I was lead medical officer for two years prior to coming to the United States, and helped to improve the utilization of preventive care services by conducting health promotion campaigns and health education seminars, in addition to my clinical duties. My only break from clinical practice has been the two years of my Masters program, and now, working as a research coordinator in a Community based participatory research (CBPR) affiliated with the medical school of a public university.

 

[Winged Scapula]

Well, screw you and whoever thinks like that.

You truly disgust me.

You're missing the point.

The reason for failure is not all that important; what is is the applicant's plan for rectifying the situation.

 

[Syncity]

IMPD, how important do you feel taking Step 3 is prior to rank list submission?

 

[IMPD]

IMPD, how important do you feel taking Step 3 is prior to rank list submission?

I assume you're talking as an IMG, since this wouldn't apply to AMGs.

Because we only offer J1 visas, it is my understanding that Step 3 is NOT needed.

Is it possible that a program might move you up (or down) in ranking based on Step 3? Anything is possible, but we don't. Our rank list will be ~250 applicants. I don't review every applicant's updated ERAS to look at the 4th letter or Step 3 scores in January. I'm just too tired by then. I assume that there are programs where these details are sweated out up until the very last minute.

We definitely DO review new Step 2 scores and make sure that everyone is good to go with those. Every year there are 1 or 2 applicants, who, for reasons I do not understand, fail to take Step 2 in a timely manner. Or, they take it, fail and don't release their score. Either way, they come off the list.

 

[Syncity]

Interesting - so to give an insight into the process - your rank list comprises around 250 applicants out of how many? And for how many positions? I know this won't give an insight into how every program works, but would be useful to know.

 

[SouthernSurgeon]

Well, screw you and whoever thinks like that.

You truly disgust me.

You're missing the point.

My program is small. We still review 800 applications or so a year. Of those, probably 790 of them manage to pass all of their exams on the first try. I can guarantee you that those 790 people weren't all having bright and sunshiny days when they took their exams. Life happens, and successful people find a way to deal.

If a personal event causes you so much disruption that you can't pass step I, II, or III - what happens when a personal stressor arises during residency? Is that person going to fall apart, have their work suffer, take an unexpected leave of absence?

These aren't fun questions. They aren't warm and cuddly questions. But they are questions that a responsible program director has to ask when they evaluate an applicant.

 

[IMPD]

Interesting - so to give an insight into the process - your rank list comprises around 250 applicants out of how many? And for how many positions? I know this won't give an insight into how every program works, but would be useful to know.

ha! Trade secrets.

Seriously, the usual range of interviews/spots is anywhere from 6:1 to 10:1. The range depends on many many factors that are idiosyncratic. The number of interviews per spot at our program has changed (in both directions) over the past two years. As a PD I do measure some of my success by "how far" I go down my rank list, my faculty doesn't give a **** about that kind of inside baseball.

My main give-away advice in this matter is similar. Rank your programs from top-to-bottom. 10 years from now, you'll still know your rank list, but no one else will remotely care.

** About 10-15% of applicants are judged "unrankable" by our group on interview day. This ranges from folks who seem to be serial-killers in the making to simply "bad fit". My goal over the last year was to get this % down, but it stubbornly persists. The paper record is a good approximation of a candidate, but only good. Not great.

 

[gutonc]

If a personal event causes you so much disruption that you can't pass step I, II, or III - what happens when a personal stressor arises during residency? Is that person going to fall apart, have their work suffer, take an unexpected leave of absence?

^This. I've seen it time and time again, in med school, residency, fellowship and now beyond. One of my good friends had one of her (as it turns out, semi-regular) psychosocial crises around the time of Step 1 and, while she didn't fail it...kind of bombed it, especially compared to her grades. She improved Step 2 by almost 50 points and wound up being AOA at a Top 20 school. But, in residency, whenever she had another personal/family problem, she'd be gone for a week or 4. She wound up finishing residency 9 months late and (with the help of a good therapist) decided not to pursue further training as she had planned.

This is all just good business practice on the part of any PD.

 

[gutonc]

Interesting - so to give an insight into the process - your rank list comprises around 250 applicants out of how many? And for how many positions? I know this won't give an insight into how every program works, but would be useful to know.

My residency program (which I'm doing a few interviews for this year) has 35 spots. They got over 1000 apps and are planning to interview between 350 - 450. No idea how long the rank list will be but they don't tend to go very far down their list.

 

[dolhan16]

To the PDs in this thread. What percentage of applications are actually not even looked at? And what decides whether or not they are looked at (time of application, is there a filter, etc).

Also, the reality is that the "2nd attempt" applicants have something that filters them out quickly. But it really is a shame that one bad day on a test can be the nail in the coffin after nearly a decade of work.

 

[totful]

* About 10-15% of applicants are judged "unrankable" by our group on interview day. This ranges from folks who seem to be serial-killers in the making to simply "bad fit". My goal over the last year was to get this % down, but it stubbornly persists. The paper record is a good approximation of a candidate, but only good. Not great.


^This. I've seen it time and time again, in med school, residency, fellowship and now beyond. One of my good friends had one of her (as it turns out, semi-regular) psychosocial crises around the time of Step 1 and, while she didn't fail it...kind of bombed it, especially compared to her grades. She improved Step 2 by almost 50 points and wound up being AOA at a Top 20 school. But, in residency, whenever she had another personal/family problem, she'd be gone for a week or 4. She wound up finishing residency 9 months late and (with the help of a good therapist) decided not to pursue further training as she had planned.

This is all just good business practice on the part of any PD.


I'm curious to know about the flip side to this.... What qualities/characteristics does a PD look out for, in a candidate that appears "marginal at best" on paper (10 years past graduation, average step scores 218,210) but confident that he is better than his paper application suggests. Is there any chance this candidate can be a "good fit" for a competitive program in the eyes of the PD? Or is it entirely up to chance?

 

[gutonc]

To the PDs in this thread. What percentage of applications are actually not even looked at? And what decides whether or not they are looked at (time of application, is there a filter, etc).

There are tons of ways to do this and it will vary from program to program, and even over time at one program since it's easy to make it an iterative process. This has been discussed many times here (look for posts by myself and aPD among others) but the short answer is that, if it exists as discrete data in ERAS and isn't "protected class" data (age, race, gender, etc), you can filter or sort apps by it. If one were so inclined, they could only choose to look at apps from applicants with the middle initial 'W'. But the bolded question above is often unanswerable since, if a PD chooses to filter out an app (by, for instance "Any Step failure") they won't even know it exists. The good ones will go through and send rejections to those folks and will then get that data but they may not bother. Also, this will vary widely by program type since in something like Rad Onc or Derm or Integrated Plastics, applicants will apply to nearly every program in the country making the denominator unreasonably large and not really representative.

As a rough example though, the year that I did first pass screening of fellowship apps for a mid-tier program in a relatively competitive specialty, over half the apps got no more than a cursory glance if at all. We auto-screened Step failures, any Step <200, IMGs and anybody needing a visa...and still had over 150 apps for 3 spots, 6x the number of people we ultimately interviewed.

Also, the reality is that the "2nd attempt" applicants have something that filters them out quickly. But it really is a shame that one bad day on a test can be the nail in the coffin after nearly a decade of work.

The only time that a failed Step is truly a nail in the coffin is when it's the last nail for an otherwise borderline candidate, or when it comes from someone with completely unrealistic expectations. A failed Step is going to make a competitive program (in virtually any specialty) much more difficult to obtain. But there are plenty of less competitive programs and less competitive specialties. So a failed Step may mean you're not going to get to be a dermatologist, but that, in and of itself, won't mean you won't get to be a doctor.

 

[gutonc]

I'm curious to know about the flip side to this.... What qualities/characteristics does a PD look out for, in a candidate that appears "marginal at best" on paper (10 years past graduation, average step scores 218,210) but confident that he is better than his paper application suggests. Is there any chance this candidate can be a "good fit" for a competitive program in the eyes of the PD? Or is it entirely up to chance?

Every applicant is convinced that they're "better" than their file suggests they are. Some are right.

But you describe 1 bright red flag (YOG), and two yellow flags (IMG status and Steps...since passing and median continue to go up and scores are no loner scaled, a 218, viewed in today's climate is pretty bad I'm afraid...even though it's within 5 points of my own score from 15 years ago). The likelihood of getting a "competitive" spot with those numbers are very low, virtually zero if you also need a visa. Your research/pubs will help, but probably not as much as you're hoping they will.

Finally, you're applying for a job as a physician. Something you've had no experience with for 10 years. That is probably the biggest red flag of all.

 

[dolhan16]

Thanks for the responses. I know what you mean, it is only another red flag (or yellow as you said) that pushes programs to reject the already average candidate.

I am biased because I failed Step 2 CK once. Despite doing better the 2nd time, it wasnt phenomenal. Right now I am stressing over not even getting FM interviews (3 total, all family). It is frustrating that I havent even received interviews from rural community based programs, let alone large competitive programs. This leads me to believe there are more factors at play in my application than just the red flags of being an IMG and failing step 2 once.

 

[Raryn]

The only time that a failed Step is truly a nail in the coffin is when it's the last nail for an otherwise borderline candidate, or when it comes from someone with completely unrealistic expectations. A failed Step is going to make a competitive program (in virtually any specialty) much more difficult to obtain. But there are plenty of less competitive programs and less competitive specialties. So a failed Step may mean you're not going to get to be a dermatologist, but that, in and of itself, won't mean you won't get to be a doctor.

I once asked the PC for my own, markedly mid-tier IM program (low enough down the totem pole that our program is a good mix of DO, carib, foreign grads, and US MDs) what their standards are for filtering applications. She basically said the only two things that they filtered by were year of graduation (I don't recall the cutoff) and any step failures. The reasoning was that they have so many applicants who don't have any step failures and met the minimum qualifications to pass on 1/2/CS right off the bat, they feel that looking at people with step failures to round out the list is unnecessary. That said, maybe they make exceptions for people who rotate at our program, I have no idea. (I don't even know what the requirements are to rotate at our program as a student).

Then again, I do know several people in my medical school who matched successfully with step failures, including a couple of my good friends. But if it closes the door on my program, I'm willing to bet it closes the door on a not insignificant number of others.

 

[dolhan16]

I once asked the PC for my own, markedly mid-tier IM program (low enough down the totem pole that our program is a good mix of DO, carib, foreign grads, and US MDs) what their standards are for filtering applications. She basically said the only two things that they filtered by were year of graduation (I don't recall the cutoff) and any step failures. The reasoning was that they have so many applicants who don't have any step failures and met the minimum qualifications to pass on 1/2/CS right off the bat, they feel that looking at people with step failures to round out the list is unnecessary. That said, maybe they make exceptions for people who rotate at our program, I have no idea. (I don't even know what the requirements are to rotate at our program as a student).

Then again, I do know several people in my medical school who matched successfully with step failures, including a couple of my good friends. But if it closes the door on my program, I'm willing to bet it closes the door on a not insignificant number of others.

No doubt. I'd be willing to bet its the number 1 or 2 filter. That said, its not stopping me from contacting friends who will vouch for me personally and professionally and from contacting some PDs directly. Its an uphill climb and it is worth fighting for.

 

[NotAProgDirector]

I expect almost every program uses filters to some extent. "Higher quality" (loosely defined) programs probably filter applications at the bottom -- the obvious choices being YOG, step scores, visa status, and IMG/USMG/DO. The latter may not be a "filter", but rather groupings -- look at all of the AMG's, then all the DO's, then all the IMG's for example. "Lower quality" programs might filter off the top -- figuring that top performers are unlikely to come. Everyone is going to do it differently.

One thing I can't filter upon is a past step failure. The database only has your last step score in it (I think). So, I can filter out everyone who has currently failed a step, but if you failed in the past and now have passed, I only "see" your passing score in the filter. Of course, I see all of the scores on your report.

Like applicants, programs rank most of the people they interview. There's no extra cost. The only reason not to rank someone is that you'd rather have an open spot in SOAP then get that person.

I do find it interesting that everyone** has an explanation for why they failed a Step -- some life stressor usually. It would be nice to see someone write "I just wasn't prepared, studied more, and then did better".

** Not quite. There was this applicant a few years ago who had failed both Step 1 and Step 2 at least 15 times. Each. Plus at least 5-10 attempts at CS. Over a period of 2 decades. I've never seen anything like it, their USMLE transcript stretched over two pages. This person had no explanation at all. We added up the USMLE fees, it was amazing.

 

[totful]

Every applicant is convinced that they're "better" than their file suggests they are. Some are right.

But you describe 1 bright red flag (YOG), and two yellow flags (IMG status and Steps...since passing and median continue to go up and scores are no loner scaled, a 218, viewed in today's climate is pretty bad I'm afraid...even though it's within 5 points of my own score from 15 years ago). The likelihood of getting a "competitive" spot with those numbers are very low, virtually zero if you also need a visa. Your research/pubs will help, but probably not as much as you're hoping they will.

Finally, you're applying for a job as a physician. Something you've had no experience with for 10 years. That is probably the biggest red flag of all.

Thanks for the insight gutonic. I have been out of clinical practice for 2years though, when I came for my MPH (Epidemiology) in the U.S and have been involved in clinical research during this period. While I understand my scores are not impressive, I did take the USMLE tests in 3 consecutive months (June, July, August of 2012), while actively involved in research and being a full time student. I wonder how many students/residents can multi-task and have the mental stamina/ organizational skills to navigate through all these like I did.
Will a GPA of 3.8/4.0 , 2nd best in research poster presentation in my school's public health program, and publication of my MPH thesis not "unflag" something for me?

But I am realistic....

 

[gutonc]

Thanks for the insight gutonic. I have been out of clinical practice for 2years though, when I came for my MPH (Epidemiology) in the U.S and have been involved in clinical research during this period. While I understand my scores are not impressive, I did take the USMLE tests in 3 consecutive months (June, July, August of 2012), while actively involved in research and being a full time student. I wonder how many students/residents can multi-task and have the mental stamina/ organizational skills to navigate through all these like I did.
Will a GPA of 3.8/4.0 , 2nd best in research poster presentation in my school's public health program, and publication of my MPH thesis not "unflag" something for me?

But I am realistic....

Do you have any USCE? Because, quite honestly, that's the only clinical experience anyone is going to care about.

And the MPH, while nice, is not that big of a deal to most programs.

I'm not trying to pile on here but you need to realize what you're up against. There are plenty of fresh US MD grads, with MPHs and 240+ on the steps out there. That's who you're dealing with as "competition".

But the most important measure of all this is, how many interview offers do you have? Nothing else really matters that much.

 

[totful]

Do you have any USCE? Because, quite honestly, that's the only clinical experience anyone is going to care about.

And the MPH, while nice, is not that big of a deal to most programs.

I'm not trying to pile on here but you need to realize what you're up against. There are plenty of fresh US MD grads, with MPHs and 240+ on the steps out there. That's who you're dealing with as "competition".

But the most important measure of all this is, how many interview offers do you have? Nothing else really matters that much.

Thanks gutonic. I do get that... much better now, honestly.
I have just 2 interviews (1 i.m and 1 peds ) and at this point I wonder aloud how to stand out in those interviews in spite of my credentials (yog, need visa, etc).
Wish me luck (that is, if it does exist at this stage).