Pre-clerkship period length, Step 2 timing, and specialty choice in the Step 1 P/F era

[skeptastic]

So, I've seen this topic brought up on SDN within a thread, but can't seem to find a thread with many comments that has this topic as its primary subject matter. What I'm referring to is the fact that Step 1 has gone P/F, and was historically a metric used by students to assess their likelihood of being deemed fit for specific specialties. For example, if someone got a score of 215 on Step 1, they'd be unlikely to pursue an ortho residency, and proceed to tailor their residency app toward less competitive specialties. On the other hand, if someone got a 250 and had an interest in dermatology, they could feel confident that, although matching would still be tough, pursing derm wasn't a ridiculous notion.

So, Step 1 is now P/F, and yet most schools have preclinical periods lasting long enough that their students won't get Step 2 scores back until a few months prior to the residency app cycle. What I'm wondering is, how are students expected to make informed decisions regarding their competitiveness for certain specialties and pursue projects and activities to build a CV for that specialty, when they won't necessarily know their Step 2 score until the very last minute? Of course, schools with 12-month preclinical periods set their students up well to take Step 2 early enough to adjust expectations and goals as necessary, but even 18-month preclinical schools seem to leave little time or room for error if one gets an unwelcome Step 2 score and has to pivot to prepare for a different specialty. In addition, someone who was worried about how competitive a speciality of interest was but then gets a great score back late in the game would find it difficult to show a consistent pattern of interest in that speciality through activities on their CV.

I'm an accepted MS0, so super green about these matters, but am curious as to how students can choose a specialty with confidence when they no longer have that early Step 1 score to inform and guide them as to which specialties are wise to pursue and which may be a bit lofty. Does anyone have any thoughts or advice about this? My guess is that a school with a 12-month preclinical period is one's best bet for being equipped as early as possible with a score that can guide and help them make an informed specialty choice without the risk of sudden doom at a later stage of medical school, just before the residency app period.

Thanks for any input you all have to contribute.

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[deleted1126476]

Seems like the easy answer would just be a research year or taking extra time, which sucks. I'm also just a M0 but I've asked this question to a few mentors and most don't have a solid answer. The schools with 12 month preclinicals do seem to make an appealing case though, especially considering most of them already have a 'research year' or 'flex year/time' since you have that shortened preclinical.

 

[skeptastic]

Seems like the easy answer would just be a research year or taking extra time, which sucks. I'm also just a M0 but I've asked this question to a few mentors and most don't have a solid answer. The schools with 12 month preclinicals do seem to make an appealing case though, especially considering most of them already have a 'research year' or 'flex year/time' since you have that shortened preclinical.

I think you're right, and it is unfortunate. Medical school costs more than ever (naturally), the number of graduates continues to outpace the number of residency seats, and now one with a competitive app might have to strongly consider a research year, simply because of timing. Not saying this is the only reality, but I think what you're saying rings true, and will be the case for many. It might just be a time period in which a changing of the guard happens, and more students start considering less competitive specialties out the gate.

Thanks for chiming in!

 

[imidazzle92]

1-year preclinical seems pretty intense. No summer break and limited time for research/EC's.
Step 2 CK is one metric but you could also drop the ball during rotations, subI's, receive mediocre LOR's, have interviews go poorly. Even in some residencies, the attrition rate is notable.

Just focus on doing well in whichever curriculum you have. If you're worried about having a mediocre Step 2 CK for certain specialties, prepare well in advance.

I personally prefer a traditional pre-clinical (2 years). Gives you enough time to get research papers submitted/accepted before ERAS. If you're doing the bulk of your research during 3rd year, you're probably not going to have as much output by ERAS.

 

[Billiam95]

So, Step 1 is now P/F, and yet most schools have preclinical periods lasting long enough that their students won't get Step 2 scores back until a few months prior to the residency app cycle. What I'm wondering is, how are students expected to make informed decisions regarding their competitiveness for certain specialties and pursue projects and activities to build a CV for that specialty, when they won't necessarily know their Step 2 score until the very last minute?

I think my class will be finding out the hard way, unfortunately. See a lot of people shooting for some of the competitive surgical subs, especially optho for some reason, in excess of the class ahead of us at my school. I feel relatively fortunate to be interested in a specialty with better match rates.

 

[DarkBluMage]

I think the best answer is to focus on what’s in front of you which is doing well in preclinical. You’re looking far ahead, which isn’t necessarily a bad thing, but given the climate it’s best to pursue what you’re interested in and make sure your knowledge foundation is solid so that you’re able to do well come step 1/2 time. You can dabble in research that interests you and try to tailor your app once you start clerkships and see where you actually want to land in regards to a specialty. Position yourself to make strong connections in that field and find a mentor that is able to advocate for you and get your foot in the door for important people (aways, research, etc.). Part of matching involves your network and relationships you build. Step 1 going P/F certainly presents its own challenge but you’re not shut out completely as before if you don’t score high. You can be strategic and find other ways to match in your field that aren’t solely dependent on step scores. Also keep in mind that if your interest ends up being a non-competitive specialty then you stress yourself from day one about the future for no reason. My view as an M2 is to focus on what’s in front of me and prepare myself and app for my specialty interest. I’ll cross the step/board scores bridge when I get to it.

 

[Med Ed]

I'm an accepted MS0, so super green about these matters, but am curious as to how students can choose a specialty with confidence when they no longer have that early Step 1 score to inform and guide them as to which specialties are wise to pursue and which may be a bit lofty.

A few of thoughts.

Step 2 is basically a composite of the shelf exams. It doesn't come out of left field.

Step 2 scores don't occur in a vacuum. By the time you take Step 2, you'll have three years of exam performance data under your belt. There will also be even more Step 2 practice tests available to gauge your preparedness.

The students who match into uber-competitive fields are "total packages." In my experience it is exceedingly rare to have one of these superstars crush every thing in medical school and then tank Step 2. I'm sure it happens, but it's not something to plan your life around.

A far more common situation is the student who crawls through pre-clinical, pulls it together during third year, and gets a decent Step 2 score. Those students go into the match more competitive now than they would have in the past, and I think that's a positive development.

If you're applying to an uber-competitive field you should have a contingency plan regardless of your Step 2 score.

 

[Esmolol]

Step 2 scores don't occur in a vacuum. By the time you take Step 2, you'll have three years of exam performance data under your belt. There will also be even more Step 2 practice tests available to gauge your preparedness.

Yes and no. At some schools you really have only one year of true NBME exams experience (shelves). Pre-clinical exams can be either in-house or hand-picked NBME questions. The P/F Step 1 is very binary. You won't know how you truly did if you passed.

If you're applying to an uber-competitive field you should have a contingency plan regardless of your Step 2 score.

Some specialties will be more competitive because a lot of students who passed Step 1 and don't know their true performance will think they are competitive for a lot of specialties that could have been out of reach knowing true Step 1 performance.

 

[Kardio]

Realistically, you’ll have one extra year of wasted effort for your primary specialty of choice and some stress doing a hard pivot if you hadn’t developed a contingency plan before taking Step 2. Also - as has been stated - there are many prognostic indicators along the way (Scored Step 1 practice exams, shelf exams, etc).

 

[PathNeuroIMorFM]

You'll have a pretty good clue if you're going to do well on Step 2 by the end of clinicals. If you are consistently failing your shelves, then you probably wont hit 270. If you're consistently in the 80th percentile, you'll probably do great. You can also opt to take additional time to study for Step 2 via a vacation or research block in your 4th year.

I think it's important for everyone, at every step of the game, to have a backup specialty in mind and to keep exploring the various fields of medicine. If you want to match Optho on day one of school, then start out doing research on that. If you change your mind and move to IM, EM, derm, plastics, then that research will still count for something assuming you have been productive.

The AAMC consistently shows us that 75% of students change their mind about what specialty they want to apply to between M0 and their actual application. Shoot for the moon with applying to ortho or whatever, if you miss, you can still be among the stars of a good residency studying a topic you still find enjoyable, like gen surg or PMR.

 

[cj_cregg]

I think you're right, and it is unfortunate. Medical school costs more than ever (naturally), the number of graduates continues to outpace the number of residency seats, and now one with a competitive app might have to strongly consider a research year, simply because of timing. Not saying this is the only reality, but I think what you're saying rings true, and will be the case for many. It might just be a time period in which a changing of the guard happens, and more students start considering less competitive specialties out the gate.

Thanks for chiming in!

I don't have any good advice about the question you asked lol, other than to say that every single applicant is going through the same thing and I think programs will expect and accommodate this until things settle into a new equilibrium.

But it's not quite so bad as all this - the number of graduates does NOT outpace the number of residency seats even if you count applicants from non-US schools. This is a really common misconception. See page 15 in the 2022 NRMP report. There were 18,486 US MD seniors and 6,666 US DO seniors who applied to the match last year = 25,152 US senior applicants for 36,277 total PGY1 spots. Even if you add in US IMGs (3,099) and non-US IMGs (4,571), you still only get 32,822 applicants. Now add in 1,242 US MD/DO grads (859 MD, 383 DO, presumably reapplicants or people switching specialties), and whatever the 11 "other" people are, and you're still only at 34,075 applicants for those 36,277 PGY1 slots, and we are left with 2,022 unfilled PGY1 spots from last year.

 

[skeptastic]

I think it's important for everyone, at every step of the game, to have a backup specialty in mind and to keep exploring the various fields of medicine. If you want to match Optho on day one of school, then start out doing research on that. If you change your mind and move to IM, EM, derm, plastics, then that research will still count for something assuming you have been productive.

The AAMC consistently shows us that 75% of students change their mind about what specialty they want to apply to between M0 and their actual application. Shoot for the moon with applying to ortho or whatever, if you miss, you can still be among the stars of a good residency studying a topic you still find enjoyable, like gen surg or PMR.

I guess what throws me off is having read on SDN that folks who don't match into less competitive specialties like anesthesiology, despite having good Step scores, tend to have CVs that clearly point to previous interest in another specialty, which shows a pivot instead of a commitment to the new specialty. I definitely understand that folks should not be putting all eggs in one basket, and am also aware of the data about 75% of students changing their mind (I mentioned this in pretty much every interview when asked what speciality I'm interested in). My concern is that, for example, a ton of ortho-related activities followed by an anesthesiology app signals a pivot and thus less dedication to anesthesiology. Is this not an issue?

 

[PathNeuroIMorFM]

I guess what throws me off is having read on SDN that folks who don't match into less competitive specialties like anesthesiology, despite having good Step scores, tend to have CVs that clearly point to previous interest in another specialty, which shows a pivot instead of a commitment to the new specialty. I definitely understand that folks should not be putting all eggs in one basket, and am also aware of the data about 75% of students changing their mind (I mentioned this in pretty much every interview when asked what speciality I'm interested in). My concern is that, for example, a ton of ortho-related activities followed by an anesthesiology app signals a pivot and thus less dedication to anesthesiology. Is this not an issue?

PDs understand that people change their minds.

I would take precautions to let them know you've changed your mind and be prepared to answer about that on interviews, but as long as your LORs are from anesthesia, your PS shows genuine interest in it, you perform well on you anasthesia rotation/do electives and aways in anesthesia, I think you're more than secure.

 

[skeptastic]

I think my class will be finding out the hard way, unfortunately. See a lot of people shooting for some of the competitive surgical subs, especially optho for some reason, in excess of the class ahead of us at my school. I feel relatively fortunate to be interested in a specialty with better match rates.

Yeah, someone said this below and had a good point: the competitiveness of certain fields may increase now that folks won't have the early Step 1 score to gauge where they're at. It works both ways, I suppose. Some will gain confidence and others will feel less sure about going all-out without a board exam score in the early stages.

 

[skeptastic]

I think the best answer is to focus on what’s in front of you which is doing well in preclinical. You’re looking far ahead, which isn’t necessarily a bad thing, but given the climate it’s best to pursue what you’re interested in and make sure your knowledge foundation is solid so that you’re able to do well come step 1/2 time. You can dabble in research that interests you and try to tailor your app once you start clerkships and see where you actually want to land in regards to a specialty. Position yourself to make strong connections in that field and find a mentor that is able to advocate for you and get your foot in the door for important people (aways, research, etc.). Part of matching involves your network and relationships you build. Step 1 going P/F certainly presents its own challenge but you’re not shut out completely as before if you don’t score high. You can be strategic and find other ways to match in your field that aren’t solely dependent on step scores. Also keep in mind that if your interest ends up being a non-competitive specialty then you stress yourself from day one about the future for no reason. My view as an M2 is to focus on what’s in front of me and prepare myself and app for my specialty interest. I’ll cross the step/board scores bridge when I get to it.

Indeed. I already stated this in response to another post, but I think may main concern is tailoring an app toward a competitive specialty and then having to pivot, which will be glaring on a residency app and potentially point to lack of commitment to the specialty one pivoted toward.

 

[skeptastic]

A few of thoughts.

Step 2 is basically a composite of the shelf exams. It doesn't come out of left field.

Step 2 scores don't occur in a vacuum. By the time you take Step 2, you'll have three years of exam performance data under your belt. There will also be even more Step 2 practice tests available to gauge your preparedness.

The students who match into uber-competitive fields are "total packages." In my experience it is exceedingly rare to have one of these superstars crush every thing in medical school and then tank Step 2. I'm sure it happens, but it's not something to plan your life around.

A far more common situation is the student who crawls through pre-clinical, pulls it together during third year, and gets a decent Step 2 score. Those students go into the match more competitive now than they would have in the past, and I think that's a positive development.

If you're applying to an uber-competitive field you should have a contingency plan regardless of your Step 2 score.

These are excellent point, and probably the thoughts I've had so far which have given me the most peace of mind. I do like that the best correlation to a good Step 2 score is a good Step 1 score, but we won't get those scores. I honestly think that keeping Step 1 P/F but still providing the score would be the best of both worlds, but I may be missing something. Those who simply want to pass and move on with life can do so, and seeing their score won't matter because they've passed. Those who fail can see how far off they were and shore things up for the repeat. Those with high scores can be equipped with early info that might give confidence to continue down a path toward a competitive specialty. Those with low (but passing) scores can decide whether they feel they have what it takes to right the ship and kill Step 2, which would still allow them to go competitive with confidence.

 

[skeptastic]

I don't have any good advice about the question you asked lol, other than to say that every single applicant is going through the same thing and I think programs will expect and accommodate this until thins settle into a new equilibrium.

But it's not quite so bad as all this - the number of graduates does NOT outpace the number of residency seats even if you count applicants from non-US schools. This is a really common misconception. See page 15 in the 2022 NRMP report. There were 18,486 US MD seniors and 6,666 US DO seniors who applied to the match last year = 25,152 US senior applicants for 36,277 total PGY1 spots. Even if you add in US IMGs (3,099) and non-US IMGs (4,571), you still only get 32,822 applicants. Now add in 1,242 US MD/DO grads (859 MD, 383 DO, presumably reapplicants or people switching specialties), and whatever the 11 "other" people are, and you're still only at 34,075 applicants for those 36,277 PGY1 slots, and we are left with 2,022 unfilled PGY1 spots from last year.

Great data. I'm definitely off about seats outpacing applicants. I guess the real issue is seats for competitive specialties vs applicants for competitive specialties, which is a matter of luxury and not necessity. If you want something competitive, you gotta be willing to play the game and play it incredibly hard.

 

[Med Ed]

Yes and no. At some schools you really have only one year of true NBME exams experience (shelves).

The shelf exams are the NBME clinical subject exams that are administered through the clerkship year. So one year of them is standard.

Pre-clinical exams can be either in-house or hand-picked NBME questions. The P/F Step 1 is very binary. You won't know how you truly did if you passed.

Some specialties will be more competitive because a lot of students who passed Step 1 and don't know their true performance will think they are competitive for a lot of specialties that could have been out of reach knowing true Step 1 performance.

This may be relevant if you happen to attend a school whose pre-clinical exams have no correlation with Step 1 performance. I think such schools are few and far between.

Either way, an interested student can access a plethora of self-assessments from the NBME itself or other vendors.

 

[Med Ed]

I honestly think that keeping Step 1 P/F but still providing the score would be the best of both worlds, but I may be missing something. Those who simply want to pass and move on with life can do so, and seeing their score won't matter because they've passed. Those who fail can see how far off they were and shore things up for the repeat.

Generating numeric scores will create incentive for programs to try and obtain them at some point in the process. This would obviously undermine the whole rationale for making the exam P/F.

Here is what the NBME says about those who get a fail: "Examinees who fail Step 1 will receive information about how far they were from passing, as well as content-based feedback to guide the study plan for their next attempt."

 

[skeptastic]

Generating numeric scores will create incentive for programs to try and obtain them at some point in the process. This would obviously undermine the whole rationale for making the exam P/F.

Very true and unfortunate. would be great for the student, if the programs would have integrity and simply look at the P/F data offered to them.

Here is what the NBME says about those who get a fail: "Examinees who fail Step 1 will receive information about how far they were from passing, as well as content-based feedback to guide the study plan for their next attempt."

That's definitely a positive.

 

[Redpancreas]

So, I've seen this topic brought up on SDN within a thread, but can't seem to find a thread with many comments that has this topic as its primary subject matter. What I'm referring to is the fact that Step 1 has gone P/F, and was historically a metric used by students to assess their likelihood of being deemed fit for specific specialties. For example, if someone got a score of 215 on Step 1, they'd be unlikely to pursue an ortho residency, and proceed to tailor their residency app toward less competitive specialties. On the other hand, if someone got a 250 and had an interest in dermatology, they could feel confident that, although matching would still be tough, pursing derm wasn't a ridiculous notion.

So, Step 1 is now P/F, and yet most schools have preclinical periods lasting long enough that their students won't get Step 2 scores back until a few months prior to the residency app cycle. What I'm wondering is, how are students expected to make informed decisions regarding their competitiveness for certain specialties and pursue projects and activities to build a CV for that specialty, when they won't necessarily know their Step 2 score until the very last minute? Of course, schools with 12-month preclinical periods set their students up well to take Step 2 early enough to adjust expectations and goals as necessary, but even 18-month preclinical schools seem to leave little time or room for error if one gets an unwelcome Step 2 score and has to pivot to prepare for a different specialty. In addition, someone who was worried about how competitive a speciality of interest was but then gets a great score back late in the game would find it difficult to show a consistent pattern of interest in that speciality through activities on their CV.

I'm an accepted MS0, so super green about these matters, but am curious as to how students can choose a specialty with confidence when they no longer have that early Step 1 score to inform and guide them as to which specialties are wise to pursue and which may be a bit lofty. Does anyone have any thoughts or advice about this? My guess is that a school with a 12-month preclinical period is one's best bet for being equipped as early as possible with a score that can guide and help them make an informed specialty choice without the risk of sudden doom at a later stage of medical school, just before the residency app period.

Thanks for any input you all have to contribute.

It took me a while to figure out what you were asking because you basically restated what everyone on SDN has known for a while now.

1.) Yes, no longer having Step 1 can prolong one's differentiation into a "competitive" vs. "less competitive" applicant until directly before the application season when Step 2 scores are usually reported.
2.) In terms of how to counter #1:
A) Like you've probably been told, improve your CV in other areas like research in the time traditionally allotted for Step 1 dedicated time.
B.) Personally, I would caution against a solely pass approach to Step 1. There's a lot of material and it gets tested both directly/indirectly on Step 2 CK to the extent that some people would say the best way to prep for CK is to prep for Step 1 well.