Disappointed in Step 1 score

[camtheram1815]

Got my score back - upper 230's. Undershot my practice scores significantly (250+ on UWSA2 1 week out, 76% average on UWORLD). I would be satisfied with this except I've been building an application for neurosurgery the last 2 years (pubs, networking, etc..). I have connections in the field that will help me but it freaks me out to put my eggs all in one basket with such a mediocre score for the field.

Anyone have advice/can offer support?

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[kinjin24]

You’re fine

 

[THEBACKANDFORTH]

chill

 

[7331poas]

You’re fine

a 230 applying neurosugery is "fine"?

 

[mrbreakfast]

a 230 applying neurosugery is "fine"?

In a vacuum, upper 230s puts OP at close to an 80% chance of matching. Pretty decent odds.

 

[GoSpursGo]

Got my score back - upper 230's. Undershot my practice scores significantly (250+ on UWSA2 1 week out, 76% average on UWORLD). I would be satisfied with this except I've been building an application for neurosurgery the last 2 years (pubs, networking, etc..). I have connections in the field that will help me but it freaks me out to put my eggs all in one basket with such a mediocre score for the field.

Anyone have advice/can offer support?

Clearly it's not ideal, but as mentioned above you still have better than even odds of matching (~75% based on my read of Charting Outcomes). If you're as well-connected as you think, you're probably in the top 75% of applicants with that kind of score.

My general advice to people who have their heart set on a competitive specialty but who have a below-average score is that you should put all your eggs in the basket for the field you really want; trying to build a back-up application for GS or something else will only take time away that you could be further strengthening your app for your real goal, and if you really only have one shot for your competitive specialty then take your best shot. Hopefully--and probably--you'll match.

Not matching sucks, but it really isn't the end of the world. You would have no difficulty SOAPing into a GS-prelim, after which you would have a strong application for regular GS. Alternatively if you school is supportive, you can extend graduation and try again for neurosurg while also applying to GS as a backup.

The good news is you're going to be able to match somewhere. Hopefully it will be in your specialty of choice and on your original timeline, but if it's not then you have good backups available to you.

 

[kinjin24]

a 230 applying neurosugery is "fine"?

Yes. And OP said upper 230 to be exact. He or She will match

 

[AnatomyGrey12]

a 230 applying neurosugery is "fine"?

Yes.

 

[OrthoTraumaMD]

Listen. Worst case you don’t match and do another specialty. Life is so vast, and we are so puny and incompetent, our lives so easily snuffed out and forgotten, that as I get older, I realize that these worries aren’t worth much. Just do your best. You can’t change your score. Maximize your connections and then go for what you want. You can’t lose— because in the end, you’ll still be a doctor and be more well off and successful than most people on this planet.

 

[sovereign0]

The average Step 1 for neurosurgery was a 245 I believe, and before that a 249. High 230's will be fine. You aren't going to match at a top program but a high step 1 alone wouldn't have won you that anyway. You'll match. Also, neurosurgery is a particularly incestuous and prestige-driven field and coming from a top med school will blur the lines a lot, if that applies to you.

 

[jhamaican]

I think you had a good run with this medicine thing.

At least you can drop out now before year 3 and 4 so as to not accumulate more debt.

I would never want someone operating on me that scored in the 230s.

Incompetent at best, a hazard to human life at worst.

 

[7331poas]

Yes.

Perhaps you know something our faculty dont. We have two students here who are taking gap years in order to build research because they score 234. This is at the advice of the chair.

 

[Lawpy]

I think you had a good run with this medicine thing.

At least you can drop out now before year 3 and 4 so as to not accumulate more debt.

I would never want someone operating on me that scored in the 230s.

Incompetent at best, a hazard to human life at worst.

I hope this is sarcasm

 

[jhamaican]

I hope this is sarcasm

How do you get the rocket scientist title next to your name?

That badge is sweet and I would like one

 

[jhamaican]

Perhaps you know something our faculty dont. We have two students here who are taking gap years in order to build research because they score 234. This is at the advice of the chair.

More like the chair saw a potential opening to get free research mules

 

[sovereign0]

Perhaps you know something our faculty dont. We have two students here who are taking gap years in order to build research because they score 234. This is at the advice of the chair.

Unless Step 1 was not the sole deficiency in their applications, a research year is an unnecessarily conservative and potentially misguided suggestion, especailly since a research year likely will not open any doors that a low step closed in the absence of a prestigious grant or fellowship. Also, chairs are typically pretty far removed from the residency application process unless they were formerly PD, and is going to make a decision that is in the best interest of the department and it's reputation. The program director is a much better resource.

 

[Frogger27]

I

Got my score back - upper 230's. Undershot my practice scores significantly (250+ on UWSA2 1 week out, 76% average on UWORLD). I would be satisfied with this except I've been building an application for neurosurgery the last 2 years (pubs, networking, etc..). I have connections in the field that will help me but it freaks me out to put my eggs all in one basket with such a mediocre score for the field.

Anyone have advice/can offer support?

Can't offer advice but I feel you OP. High 230s after 250+ on UWSA2 and aiming for surgical sub. **** happens. Time to move forward, we'll be ight

 

[NickNaylor]

Join the club. I had a very similar experience with my step 1 scores and ultimately scored almost a full standard deviation below my practice exam scores. I was quite disappointed, thought the world was ending, etc. etc. Now, I finished my year as chief resident a couple of weeks ago and I had a very productive residency experience that I really enjoyed. I'm writing this from Japan on a trip with my wife, exploring the Japanese countryside, and incredibly excited to start at an academic position that fits exactly what I want in a job in about 3 weeks. I can't wait to get my career launched and am excited for what the future holds.

This disappointment seems so great because at this stage in your training, step 1 seems like the most important thing you have ever done or will do. In reality, it's only one milestone in your training, and its importance will quickly fade. It's easy for me to say that, but just know that this is not the end all be all. You will still be able to do something that you love, you will still have a great life, and you will still have a fulfilling career. Step 1 is done so there's nothing to be done about it. Time to focus on continuing to work toward your goal, which, based on what others have said, seems entirely feasible.

 

[AnatomyGrey12]

Perhaps you know something our faculty dont. We have two students here who are taking gap years in order to build research because they score 234. This is at the advice of the chair.

I mean if all you have is a 234 on your app then yeah sure, but OP already has pubs and says they've been networking in the field. A high 230s in that scenario is likely going to be in a fairly decent position.

 

[7331poas]

Unless Step 1 was not the sole deficiency in their applications, a research year is an unnecessarily conservative and potentially misguided suggestion, especailly since a research year likely will not open any doors that a low step closed in the absence of a prestigious grant or fellowship. Also, chairs are typically pretty far removed from the residency application process unless they were formerly PD, and is going to make a decision that is in the best interest of the department and it's reputation. The program director is a much better resource.

They were a former PD.

 

[libertyyne]

Neursurgery mean was around 245. with IQR between 240 and 255. This means literally 1/4th of all neursurgery applicants matched with a score below 240. from charting outcomes.

Roughly an 80% match rate in 230-239 bracket for US seniors. in 2018
Looking long term 2014-2018 data indicates the match rate for that bracket to be around 73% .

The odds are not terrible. Your home program is going to be your best bet. Suck up to them like there is no tomorrow, mesh well with the residents , and generally dont be a tool and you have a good shot of matching.

The question is , is a 72-80% historical match rate an acceptable risk for you to end up in something like IM or gen surg? That is a question only you can answer. I do know that neursurgery does not like dual applicants so you would have trust the process and put all your eggs in that basket if you would want to continue.

 

[aafisahar]

Join the club. I had a very similar experience with my step 1 scores and ultimately scored almost a full standard deviation below my practice exam scores. I was quite disappointed, thought the world was ending, etc. etc. Now, I finished my year as chief resident a couple of weeks ago and I had a very productive residency experience that I really enjoyed. I'm writing this from Japan on a trip with my wife, exploring the Japanese countryside, and incredibly excited to start at an academic position that fits exactly what I want in a job in about 3 weeks. I can't wait to get my career launched and am excited for what the future holds.

This disappointment seems so great because at this stage in your training, step 1 seems like the most important thing you have ever done or will do. In reality, it's only one milestone in your training, and its importance will quickly fade. It's easy for me to say that, but just know that this is not the end all be all. You will still be able to do something that you love, you will still have a great life, and you will still have a fulfilling career. Step 1 is done so there's nothing to be done about it. Time to focus on continuing to work toward your goal, which, based on what others have said, seems entirely feasible.

disingenuous, you went into psychiatry and went to a top 10-20 school, depending on the rankings for that year.

OP's circumstances may be similar or not (eg 230 from Hopkins or Harvard is probably overkill for NSG vs 230 from bottom tier is going to be a tough sell at many programs). But posting your experiences doesn't really do any justice to the vast majority of students who didn't score what they wanted.

 

[sargon2123]

disingenuous, you went into psychiatry and went to a top 10-20 school, depending on the rankings for that year.

OP's circumstances may be similar or not (eg 230 from Hopkins or Harvard is probably overkill for NSG vs 230 from bottom tier is going to be a tough sell at many programs). But posting your experiences doesn't really do any justice to the vast majority of students who didn't score what they wanted.

This. This forum has a lot of people who went to top schools trying to give advice. At this point, I’m just gonna laugh when I see them give advice after step 1 goes p/f.

 

[sargon2123]

I also think OP should be mentally and emotionally prepared for a backup specialty. Let’s face it, he’s got rotations coming up, and they’ll determine a lot of his class rank. Idk if the nsurg unmatch rate is that high, but I’m sure plenty of people trying to match nsurg at least thought about backups throughout med school.

OP does have networking and connections though, and research. With that I also don’t think he should count himself out just yet given his 80% odds from his step score

 

[Cranjis McBasketball]

Neursurgery mean was around 245. with IQR between 240 and 255. This means literally 1/4th of all neursurgery applicants matched with a score below 240. from charting outcomes.
View attachment 271856
View attachment 271854
Roughly an 80% match rate in 230-239 bracket for US seniors. in 2018
Looking long term 2014-2018 data indicates the match rate for that bracket to be around 73% .
View attachment 271855
The odds are not terrible. Your home program is going to be your best bet. Suck up to them like there is no tomorrow, mesh well with the residents , and generally dont be a tool and you have a good shot of matching.

The question is , is a 72-80% historical match rate an acceptable risk for you to end up in something like IM or gen surg? That is a question only you can answer. I do know that neursurgery does not like dual applicants so you would have trust the process and put all your eggs in that basket if you would want to continue.

Get out of here with your data and graphs. We want anecdotal evidence..

 

[libertyyne]

I also think OP should be mentally and emotionally prepared for a backup specialty. Let’s face it, he’s got rotations coming up, and they’ll determine a lot of his class rank. Idk if the nsurg unmatch rate is that high, but I’m sure plenty of people trying to match nsurg at least thought about backups throughout med school.

OP does have networking and connections though, and research. With that I also don’t think he should count himself out just yet given his 80% odds from his step score

This is absolutely not true. Neurosurgery is a long and brutal journey. The programs select for people who cannot imagine doing anything else. Let alone dual applying.

 

[AnatomyGrey12]

This is absolutely not true. Neurosurgery is a long and brutal journey. The programs select for people who cannot imagine doing anything else. Let alone dual applying.

They are quite literally the only doctors I've ever met where I truly believed that their job was their calling in life.

 

[NickNaylor]

disingenuous, you went into psychiatry and went to a top 10-20 school, depending on the rankings for that year.

OP's circumstances may be similar or not (eg 230 from Hopkins or Harvard is probably overkill for NSG vs 230 from bottom tier is going to be a tough sell at many programs). But posting your experiences doesn't really do any justice to the vast majority of students who didn't score what they wanted.

The point is that there is a lack of perspective from the OP. And that’s not the OP’s fault - it’s a consequence of being at that stage in training.

If “the vast majority of students who didn’t score what they wanted” is actually true, and if most people don’t find themselves moping about their step 1 score a year later, doesn’t that prove my point?

 

[7331poas]

Get out of here with your data and graphs. We want anecdotal evidence..

Stats != Truth

You don't know the people behind the information and any particular biases. Some people might have decided not to pursue a match because they didn't think they were competitive, this increasing the match rate.

 

[The Knife & Gun Club]

Unless Step 1 was not the sole deficiency in their applications, a research year is an unnecessarily conservative and potentially misguided suggestion, especailly since a research year likely will not open any doors that a low step closed in the absence of a prestigious grant or fellowship. Also, chairs are typically pretty far removed from the residency application process unless they were formerly PD, and is going to make a decision that is in the best interest of the department and it's reputation. The program director is a much better resource.

Interesting. Our school advises all students with less than 245 to take a gap year if they’re applying for ortho, plastics, ENT, or optho. Our Derm department won’t support ANY application for a student that didn’t do a gap year, period.

I always thought this seemed overly conservative, good too see some people agree

 

[GoSpursGo]

Interesting. Our school advises all students with less than 245 to take a gap year if they’re applying for ortho, plastics, ENT, or optho. Our Derm department won’t support ANY application for a student that didn’t do a gap year, period.

I always thought this seemed overly conservative, good too see some people agree

I mean, it just depends how much time you need to do the research that is requisite in applying for these specialties. The median number of abstracts/presentations/publications for each of the specialties you mention is 10+. A lot of applicants find that a gap year is the best way to rack up that kind of productivity without sacrificing the grades that they also need for a successful application.

If someone like the OP already has the requisite research experience, then the gap year may not be helpful/necessary.

 

[sargon2123]

For these competitive specialties, it’s as if residency is now lengthened by a year. At wha point do you say “enough is enough?” Just curious about what you all think.

 

[The Knife & Gun Club]

For these competitive specialties, it’s as if residency is now lengthened by a year. At wha point do you say “enough is enough?” Just curious about what you all think.

Personally I think we’re already at that point. The competitive specialities are already so astronomically competitive that it doesn’t seem logical or sustainable.

The advent of step 1 for students plus automatic filters for PDs has created an admission system that is meritocratic but relatively ineffective at identifying who will actually be a good resident

 

[sargon2123]

Yeah, there are just too many big "if’s” with these fields now, as you’ve listed in your post. I’d argue that these hurdles for these fields and step 1 maybe going pass fail should dissuade people from any gap years before med school. Now there’s no telling if you’ll need a research year later in med school or something else to distinguish yourself. Sure, they run the risk of being "immature", but just tell the younguns to travel the world or something.

 

[sargon2123]

As of now, I will finish fellowship at 35-36 and hopefully pay off my $300K in principle student loan (probably $350K+ with interest) by 42-45 (while having 2-3 kids). Delaying that will add $20K in interest, interfere with me having kids before 40, and wouldn't even guarantee that I match.

I guess this is a surgical field?

 

[sovereign0]

I guess this is a surgical field?

Not necessarily, a lot of internal medicine sub-specializations can take 6-7 years or more. 3 years IM, 3 years fellowship, additional time for things like interventional cards (+1)/electrophysiology (+2?)/sleep medicine (+1?) etc. Combined with people typically graduating medical school at 26-27 (not taking into account non-trads or gap years), it's not uncommon for people to finish training at 35-40.

 

[kb1900]

Not necessarily, a lot of internal medicine sub-specializations can take 6-7 years or more. 3 years IM, 3 years fellowship, additional time for things like interventional cards (+1)/electrophysiology (+2?)/sleep medicine (+1?) etc. Combined with people typically graduating medical school at 26-27 (not taking into account non-trads or gap years), it's not uncommon for people to finish training at 35-40.

Too many bright people don’t enter medicine due to the high opportunity cost already.

While these super competitive fields are able to increase their defacto requirements of research years etc., they are also effectively reducing any interest of many bright medical students that don’t want to sacrifice more than they have already

Long training > 5 years and requiring a research year or phd or multi-year fellowship? A large % of medical students wont even consider the field (looking at you NSGY). Hence why psych and EM continue to gain popularity

 

[7331poas]

Too many bright people don’t enter medicine due to the high opportunity cost already.

While these super competitive fields are able to increase their defacto requirements of research years etc., they are also effectively reducing any interest of many bright medical students that don’t want to sacrifice more than they have already

Long training > 5 years and requiring a research year or phd or multi-year fellowship? A large % of medical students wont even consider the field (looking at you NSGY). Hence why psych and EM continue to gain popularity

and yet nsg remains very competitive. I agree with the proposal actually. just let us buy in

 

[libertyyne]

Stats != Truth

You don't know the people behind the information and any particular biases. Some people might have decided not to pursue a match because they didn't think they were competitive, this increasing the match rate.

if you are not pursuing a match in a specific specialty . You by definition are making the statement of not being interested in the particular specialty enough to take a gamble on matching into it. I have given you real world evidence of 1/4th of Neurosurgery matches coming from <240. At least step score wise it is possible to gain a neurosurgery seat with a step score below 240 with rates as high as 70-80% of success.

Too many bright people don’t enter medicine due to the high opportunity cost already.

While these super competitive fields are able to increase their defacto requirements of research years etc., they are also effectively reducing any interest of many bright medical students that don’t want to sacrifice more than they have already

Long training > 5 years and requiring a research year or phd or multi-year fellowship? A large % of medical students wont even consider the field (looking at you NSGY). Hence why psych and EM continue to gain popularity

The market will bear what it can bear. These fields have not gotten any less competitive with the defacto requirements of research years or long training time, and added on fellowship requirements.

I personally know a few people who didnt initially match neursurgery, did a few years in another field and when an opportunity opened up jumped in to do 7 years of training from the start. The people who want this, cant imagine doing anything else.


I think an aspect to consider is that there is a huge opportunity cost lost if a trainee drops out for the program. It stresses small programs like neursurgery where there are a handful of residents each year. where call has to be absorbed by the rest of the team. To prevent attrition at all costs these programs go through a fairly rigourous vetting process, because they can, and people will still apply.

My personal take is that at the end of the day I do not care about money all that much, and even training for extended amount of time with a group of similar minded and driven people is an extension of learning a craft, a craft that not many people possess and is just a continuation of practice afterwards.

to do anything interesting procedurally in medicine, or surgery is going to take 6-8 years of post grad training.

 

[libertyyne]

I mean, it just depends how much time you need to do the research that is requisite in applying for these specialties. The median number of abstracts/presentations/publications for each of the specialties you mention is 10+. A lot of applicants find that a gap year is the best way to rack up that kind of productivity without sacrificing the grades that they also need for a successful application.

If someone like the OP already has the requisite research experience, then the gap year may not be helpful/necessary.

Atleast in my limited experience in talking to people that have matched into these fields. It seems like a lot of trash research is hurled at the wall in a fury like a monkey throwing poop. Small retrospective chart reviews, case reports are a bulk of the 10+ submissions or double counting of poster and publication ,and these are not too difficult to generate in a year if you are interested early enough in m3.

 

[kb1900]

if you are not pursuing a match in a specific specialty . You by definition are making the statement of not being interested in the particular specialty enough to take a gamble on matching into it. I have given you real world evidence of 1/4th of Neurosurgery matches coming from <240. At least step score wise it is possible to gain a neurosurgery seat with a step score below 240 with rates as high as 70-80% of success.

The market will bear what it can bear. These fields have not gotten any less competitive with the defacto requirements of research years or long training time, and added on fellowship requirements.

I personally know a few people who didnt initially match neursurgery, did a few years in another field and when an opportunity opened up jumped in to do 7 years of training from the start. The people who want this, cant imagine doing anything else.


I think an aspect to consider is that there is a huge opportunity cost lost if a trainee drops out for the program. It stresses small programs like neursurgery where there are a handful of residents each year. where call has to be absorbed by the rest of the team. To prevent attrition at all costs these programs go through a fairly rigourous vetting process, because they can, and people will still apply.

My personal take is that at the end of the day I do not care about money all that much, and even training for extended amount of time with a group of similar minded and driven people is an extension of learning a craft, a craft that not many people possess and is just a continuation of practice afterwards.

to do anything interesting procedurally in medicine, or surgery is going to take 6-8 years of post grad training.

I don’t really disagree with anything your saying but don’t buy the notion that a candidate spending extra years to “demonstrate their commitment” before residency even begins is a evidence-backed judgement for reducing likelihood of dropout. It’s as inflationary as the increase in number of apps applicants send out despite no change in relative competitiveness. Similarly analogous to most research experiences, it’s largely fluff. Yet...surgical and subsurgical residencies continually prove to have the highest attrition rates despite being Uber competitive. Sure the market can bear it - med students as a whole are incredibly privileged with regards to both baseline SES status and future SES status - but is it effective in actually reducing attrition or improving resident output/performance?

 

[libertyyne]

I don’t really disagree with anything your saying but don’t buy the notion that a candidate spending extra years to “demonstrate their commitment” before residency even begins is a evidence-backed judgement for reducing likelihood of dropout. It’s as inflationary as the increase in number of apps applicants send out despite no change in relative competitiveness. Similarly analogous to most research experiences, it’s largely fluff. Yet...surgical and subsurgical residencies continually prove to have the highest attrition rates despite being Uber competitive. Sure the market can bear it - med students as a whole are incredibly privileged with regards to both baseline SES status and future SES status - but is it effective in actually reducing attrition or improving resident output/performance?

i agree that it is not evidence backed, but it makes sense. What is a more dedicated way of showing commitment to a field than delaying graduation, debt repayment, income, and a full year of your life.

Frankly, the quality of research being published in these research years is not going to get into NEJM. But it is just a stupid arms race to see if the candidate does have experience to publish.

I think the question that it is interesting that these fields still have attrition, I wonder if the attrition rates have gone up or down after becoming more competitive. I do think that a factor of difficulty of the residency itself is something that contributes to attrition, not to mention program characteristics. Relatively non competitive fields like gen surg and obgyn have attrition rates equal or exceeding Neursurgery.

Analysis of national trends in neurosurgical resident attrition - PubMed

A majority of residents in the attrition group pursued training in different medical specialties, most commonly neurology, radiology, and anesthesiology. Factors associated with an increased rate of attrition were older age at the beginning of residency, female sex, and junior resident (PGY-1 to...

www.ncbi.nlm.nih.gov

Why Residents Quit: National Rates of and Reasons for Attrition Among Emergency Medicine Physicians in Training - The Western Journal of Emergency Medicine

Lu, MD, MSCI, MBE, et al. We investigated national rates of EM resident attrition and examined the reasons and factors associated with their attrition.

westjem.com

It seems like Neursurgery attrition of ~5% over 7 years(if you exclude horizontal transfer to other programs) vmay be lower than most other specialties like bolded this data is per year attrition.

Specialty​	Overall % (95% CI)​
Anesthesiology​	1.2 (1.0–1.4)​
Emergency medicine​	0.8 (0.7–0.9)​
Family medicine​	1.8 (1.5–2.1)​
Internal medicine​	0.9 (0.8–1.0)​
Neurology​	1.5 (1.2–1.8)​
OBGYN​	1.5 (1.2–1.8)​
Pathology​	1.9 (1.6–2.2)​
Pediatrics​	1.0 (0.8–1.2)​
Psychiatry​	6.0 (5.7–6.3)​
Radiology​	0.9 (0.8–1.0)​
Surgery-general​	2.7 (2.4–3.0)​

.

The market that I was referring to was the supply of positions to these fields and the demand amongst applicants. It truely only deters people if less qualified applicants end up applying to these competitive specialties. Just by looking at the stats though Neurosurgery, Ortho, derm, have not experienced such a decline in the objective quality measures.