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Where I believe you are going wrong is that it's all relevant. It's just some of it is more or less relevant to your specific field. As a dermatologist, it's important to have a solid foundation of knowledge of a broad range of systems that aren't directly related with the skin (i.e. your specialty) this is because it is your responsibility to know how things are interacting in the background, and how your treatment plan will effect those things (making it worse or better). More over, when you take Step 1 you still don't really know what you want to be. You may have an idea, but you still haven't gone through rotations so you don't know what you will truly be interested in. Meaning at this point, everything is even more relevant. At the end of the day, residencies see every single system as important and relevant and expect students to take the following approach. Scoring high on my Step 1 gives me the flexibility and increased likelihood that I match into my desired specialty. Step 1 tests everything, therefore, everything is relevant in order to score high.Actually it doesn't contradict anything and experience indicates very little in this case, plus it takes very little time and thought to see that this process is very analogous to every depersonalized standardized test system such as those run by non-profit$ such as collegeboard. I know that people do best when theyre actually exposed and allowed to work and then tested on relevant material (ex: going through a residency and then being tested on the material you learned which was directly relevant.). Tests such as the step1 and mcat are quick ways of evaluating people in large numbers, but are really artificial glass ceilings. There's nothing say that someone who doesn't get a score in "x" range isn't a good candidate for a given speciality and i'll tell you the same thing a few years from now.
If you put a large number of those people who dont qualify for a given range for a few points in the residencies they wanted they'd still end up doing damn fine in the speciality they wanted. It's an artificial dichotomy.
Also, realize that the amount of material in Step 1 is also similar to the amount of new material you will be exposed to during residency and will be expected to master. There was an AMA for a derm resident a bit ago, and I remember him saying how starting his intern year was like starting medical school all over again because he had the same or more things to remember and learn about then when he did in MS1 and MS2, so the Step 1 also judges your ability to learn a lot of material over a short period of time, which I am sure I do not need to explain why this would be desirable.
Finally, I am sure there are people who don't make specialties because of their scores, and would have been good/great doctors in that specialty. Unfortunately there is no way to know exactly which people those are. When dealing in such a large group of people, you must weigh the needs of the many, over the needs of the few, and rely on statistical indicators of success. Like any statistical tool, will there be error, yes over a large amount of people, it's inherent. But this does not make the system flawed. Conceding that the system is flawed indicates that you there currently exists a better way to approach the issue, and unfortunately, there isn't. Also realize that for this reason, it is beneficial to continuously select those who are good test takers because your final exam (your board certification) will be a standardized exam, and will be one you will have to repeatedly pass every 10 years of your career.
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