Bad Step 1, Bad Clinical Grades

[ThirdFifthFourth]

Hi Everyone,

Sorry if this isn’t the right forum. I'll try to keep this as short/relevant as possible.

MS3 at a “top” med school, <200 STEP 1, Clinical Grades: HP/P/P/P

Late-diagnosed, "excellent"* medical reason for poor Step 1/preclinical prep, now adequately treated but limiting some long term career options--nothing super intense like surgery. Now finding it difficult to get good grades in 3rd year, due in large part to poor fund of knowledge--two grades were explicitly limited by score cutoffs--however, two others were equally due to other typical 3rd year performance issues.

Some leadership positions and volunteering. Long term exposure/interest/experience with EM. Psych is a newer but equally fond interest that I'm actively pursuing. My research will be in a field applicable to many specialties and I am trying to find a way to bridge it with my specialty interests, specifically.

It's unlikely that my clinical grades during these core rotations will change their trend, although I am certainly working on getting better shelf scores and improving my clinical performance.

The rest of my current plan is to take an extra year to do research, extra clinical electives, and informal/unofficial remediation. I'm trying to decide which end of that year should be saved for studying/step 2 (probably 1.5 mo at beginning?)

Question: What are chances for getting into EM and Psych programs? Ideally somewhere West Coast, Mountain West, or TN/GA/TX? Any other general advice would be genuinely appreciated.


*I don't like to make excuses, but this one, once detailed, is clearly legitimate. Not that that fixes my knowledge deficits. Sorry I'm not being more specific, I'm trying to keep my post a little anonymized, although I think it is still immediately recognizable to people who know me. Although it limits my career options as mentioned earlier, I do not think it would affect my ability to do Psych/EM work, now that it's adequately treated.

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[TheRiddler]

I think psych is def within reach, even without an extra year. Take step 2 early and rock it.

 

[organdonor]

An extra year would probably just be another red flag. Take step 2 early so that when they see your low step 1 they can see a good step 2 as well.

If you have an idea of programs you like an away rotation could show them you can perform above your numbers.

Psych is not very competitive. There are programs that would jump at the chance to get an American MD grad even with sub 200 (but passing) scores.

 

[J ROD]

Psychiatry is within reach fairly easily. Just make sure to do HP or more on Psy, FM, and IM if possible. Try and do a little better on Step 2. EM probably not gonna happen. EM is very competitive now IMO and it is only getting more competitive. I myself am interested in those 2 as well and plan to do EM Psychiatry if I can get a spot.

We all cant be superstars. Just do your best and get through it. I would not waste an extra yr. This process is hard and long enough as it is. Just be glad you passed Step 1!

 

[Snoopy2006]

Sit down with your home psych PD/chair and get some important advice. A year off can be a red flag instead of strengthening your application, especially if you emerge without publication. I'd advise against it. If I were you, I'd look for several important people - deans, psych PD, etc. - to recommend a year off (based on my individual application) before I began to consider it.

Your medical reason may be discussed in your ERAS application, and programs may be willing to overlook your Step 1 based on your US-grad status and the reputation of your medical school. Programs will look at the whole picture - but if your Step 1, clinical grades, and Step 2 are all poor, even a strong medical reason won't be enough. Everyone has obstacles, some far more serious than others. What programs will want to see is that you overcome those obstacles. Adversity without signs of overcoming adversity will (fair or not) be looked at as an excuse or crutch.

So your best bet is to invest a ton of energy into studying for Step 2. Take a few weeks vacation if you can, and spend a ton of time with UWorld from now until you take Step 2. If you can break 220 on Step 2, psych programs will place more legitimacy in your medical reason and be willing to invite you for an interview.

Another helpful move would be to identify a reasonable psychiatry program you're interested in (not one at a super competitive place) and do an away rotation there early on in your fourth year. If you have strong interpersonal skills and are a hard worker, the program will get to know you and will be more willing to overlook sub-par scores.

 

[JoshSt]

Agree with everyone's sentiments about avoiding an extra year. Rock step 2. Squeeze in a super quick publication before ERAS if possible, but focus on Step 2. Talk to psychiatry faculty for research opportunities and emphasize your timeline. Would advise against any labwork unless they say it would be super quick, go for clinical research.

I don't think EM is out of reach with a good Step 2 and noncompetitive programs.

Would advise picking one field to focus on quickly and rock on to a good Step 2 and some <<QUICK>> clinical research.

Best of luck.

 

[ThirdFifthFourth]

Thanks for the advice so far. The extra year was recommended by my academic adviser here, she was of the opinion that some relevant/interesting research and 3-6 months of extra, good elective grades would strengthen my application by proving that I could get good clinical grades, doing some interesting research, and to be frank, spending more time solidifying my knowledge base vs. trying to rush step 2, 4th year electives, and required research project. Is the worry seeming as if I was officially doing remediation/a LOA/"required" 5 years to graduate? Would publications "prove" that the research I was doing was legitimate? (There should be 1 group pub and potentially 1 1st author pub from the currently planned experience.)

 

[link2swim06]

Psychiatry is within reach fairly easily. Just make sure to do HP or more on Psy, FM, and IM if possible. Try and do a little better on Step 2. EM probably not gonna happen. EM is very competitive now IMO and it is only getting more competitive. I myself am interested in those 2 as well and plan to do EM Psychiatry if I can get a spot.

We all cant be superstars. Just do your best and get through it. I would not waste an extra yr. This process is hard and long enough as it is. Just be glad you passed Step 1!

I don't agree with this advice.

I had the same range step 1 as the op and only slightly higher grades. I worked my ass off on step 2 (had a huge improvement) and did well on my EM rotations.

I have had 21 interview invites this season. According to the old charting outcomes if you can get 10 interviews you have a high chance of matching.

OP if you really want to do EM you need to blow step 2 out of the water, honor or high pass your EM rotations and apply VERY broad (which means the northeast and midwest; most of the west is too difficult for your scores imo).

 

[Snoopy2006]

Is the worry seeming as if I was officially doing remediation/a LOA/"required" 5 years to graduate?

Yes. The general consensus is to avoid gaps or extra years in your education like the plague. Again, a good amount of pubs (2-3) in that year off will make it more palatable. But if your low clinical grades are due to a "low fund of knowledge" (in your words), what makes you think your clinical grades in a 5th year will be that much better? If you take cake electives, it'll show (not to mention most electives don't have shelf exams). Your best bet would be to do rotations in your desired field (especially away rotations) and knock them out of the park, but there's no need to take an extra year to do that.

I think it really depends on your Step 2. If you knock it out of the park, I doubt you'll need an extra year to match. If you don't, then you can re-visit the idea. Another option is to apply and only do the extra year of research if you fail to match. Again, I always feel that PDs offer the best perspective (or at least an academic clinician who sits on the residency committee and reviews many applications), so if you have a home program, use those resources. Academic advisors are not all created equal. I couldn't schedule a meeting with my initial one, and my replacement didn't know the difference between a transitional year and a preliminary year. I'm not saying your advisor's advice is bad - they have far more knowledge of your situation than we do - but it's best to get several opinions.

 

[J ROD]

Like I said probably. There are always exceptions. I know those with 240+ Step 1s that did not match too. EM is not all numbers but the average Step 1 is rising fast. Hard to really know since we don't have Charting the Outcomes anymore. But, I have been told to hit 230+ if you really want a strong chance along with all the other things like normal.

 

[evilbooyaa]

You're definitely competitive for matching in psych as long as you don't want to live in only CA and/or NE. Willing to be in the south or midwest in psych? I'm pretty sure you're a lock to match if you're a MD student who passed everything on the first attempt.

A year off for EM or psych research isn't the best idea. EM doesn't really care for the most part, and doing research to improve your chances of matching into psych just sounds kind of odd.

If you really want to do EM, give it a shot like link2swim said.

All this being said, doing the absolute best you can on Step 2 is important.... but taking a year off just for step 2 probably isn't a good idea.

 

[ThirdFifthFourth]

Thanks for the advice so far, everyone.

Just to clarify with regard to this post (Sorry, off topic, can you multiquote on this forum?)

" Yes. The general consensus is to avoid gaps or extra years in your education like the plague. Again, a good amount of pubs (2-3) in that year off will make it more palatable. But if your low clinical grades are due to a "low fund of knowledge" (in your words), what makes you think your clinical grades in a 5th year will be that much better? If you take cake electives, it'll show (not to mention most electives don't have shelf exams). Your best bet would be to do rotations in your desired field (especially away rotations) and knock them out of the park, but there's no need to take an extra year to do that. "

According to my advisor (read: dean's letter writer), she thinks that a few extra months of clinical electives--EM, Psych CL, likely Anes/PMNR, probably IM and/or Surg--would help if I got better clinical grades (better than P). Why do we think my grades would be better? No shelf exams is a positive, as they are the most common limiting factor. Time between 3rd year and those electives to study/take Step 2 would hopefully improve on current knowledge deficits, whether they would have impacted elective grades or not.

As for the research, it is a project that I have really been wanting to have some time to work on, regardless.

 

[JoshSt]

Thanks for the advice so far, everyone.

Just to clarify with regard to this post (Sorry, off topic, can you multiquote on this forum?)

" Yes. The general consensus is to avoid gaps or extra years in your education like the plague. Again, a good amount of pubs (2-3) in that year off will make it more palatable. But if your low clinical grades are due to a "low fund of knowledge" (in your words), what makes you think your clinical grades in a 5th year will be that much better? If you take cake electives, it'll show (not to mention most electives don't have shelf exams). Your best bet would be to do rotations in your desired field (especially away rotations) and knock them out of the park, but there's no need to take an extra year to do that. "

According to my advisor (read: dean's letter writer), she thinks that a few extra months of clinical electives--EM, Psych CL, likely Anes/PMNR, probably IM and/or Surg--would help if I got better clinical grades (better than P). Why do we think my grades would be better? No shelf exams is a positive, as they are the most common limiting factor. Time between 3rd year and those electives to study/take Step 2 would hopefully improve on current knowledge deficits, whether they would have impacted elective grades or not.

As for the research, it is a project that I have really been wanting to have some time to work on, regardless.

Is advisor an MD residency director? Even if so, I disagree with that advice. If I'm looking at your application, how am I supposed to interpret all those elective without shelf scores? It would raise more questions than impress people, IMO.

If you would be really really fulfilled by doing this research project, you can do it. However, it would delay starting your professional career by a year. I would urge you to find some kind of case report or project where the work is done and the manuscript needs to be drafted that you could get submitted before ERAS deadlines. It may not be EM or psych but many programs are impressed by any type of research. Again, if you would find fulfillment by doing your planned project, do it during MS4 knowing that it will not be in before ERAS.

I don't think an extra year would help you do that much better on Step 2. I would take 4 to 6 weeks and just study very hard for it.

You can apply for both EM and psych. A headache but you can target EM if you like it more than psych and use psych as a backup.

I would be interested if residency directors, attendings or those who took a year off for research and/or step X studying commented on this thread. I stand by my opinion but am a fellow medical student and don't have their perspectives.