School is starting class ranking this year - what do I need to know?

[Mre1123]

Hi folks,

My class recently found out that this year will be the first year that our class ranking is going to be reported to schools during residency applications via our Dean's Letter. So far, the only information we have received about this is:

1. Our quintile rank will be reported, not our individual class ranking
2. We will only be given a chance to find out our quintile at 2 time points: after Step 1/before beginning 3rd year (rank from years 1-2), and during the fall of our 4th year (rank from years 1-3)
3. There has been no decision on whether or not to rank the pre-clinical and clinical years separately.

Our school has decided to host a "town hall" with some of the admin and the class to discuss this new system. While they said they are open to discussion, it doesn't sound like anything is up for change at this point.
At this point, I'd like to ask all of you: Is there anything that we should be asking this administration about this new quintile ranking system that we may not have thought of? and should I do anything differently, now knowing that my quintile is going to be reported? and finally, are there any credible/reliable sources that say that class ranking/reporting is harmful or helpful to students during residency applications? Thank you!

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[operaman]

Overall this is probably a good thing. With step 1 going pf, top students need more ways to show prospective residency programs their abilities. Ironically, step 1 was not originally used for comparing applicants but grew into this as more schools went p/f and stopped reporting class rank.

A number of schools already do this. If you Google it, there’s a great paper in a radiology journal looking at deans letters and coded language for class rank. There was even a supplementary document that listed every school and what their practices were. You could look and see what your school was already reporting.

But overall I think this is a solid move that will help the students it needs to help.

 

[Mre1123]

Overall this is probably a good thing. With step 1 going pf, top students need more ways to show prospective residency programs their abilities. Ironically, step 1 was not originally used for comparing applicants but grew into this as more schools went p/f and stopped reporting class rank.

A number of schools already do this. If you Google it, there’s a great paper in a radiology journal looking at deans letters and coded language for class rank. There was even a supplementary document that listed every school and what their practices were. You could look and see what your school was already reporting.

But overall I think this is a solid move that will help the students it needs to help.

Thanks for the reply! I found the article you mentioned, it was definitely an interesting read. Going off of what you said, I just have a follow up question. You say "top students need more ways to show...their abilities." Would you say that a class ranking system like this is advantageous to the students at the top of the class but detrimental to those at the bottom? Or does it really not matter, since you would still be able to determine a student's "rank" using other data, such as LORs and Step 1/2 scores. I'm just curious how this will impact the performance of some individuals at the lower end of the class, especially without the graded Step 1.
Also, if you have any thoughts about it, how do you feel about students not being able to access their quintile ranking until after 2nd and 3rd year? Thanks again!

 

[Lawpy]

Class rank looks redundant if the school also has AOA, but i guess class rank can make the AOA process more objective

 

[operaman]

Thanks for the reply! I found the article you mentioned, it was definitely an interesting read. Going off of what you said, I just have a follow up question. You say "top students need more ways to show...their abilities." Would you say that a class ranking system like this is advantageous to the students at the top of the class but detrimental to those at the bottom? Or does it really not matter, since you would still be able to determine a student's "rank" using other data, such as LORs and Step 1/2 scores. I'm just curious how this will impact the performance of some individuals at the lower end of the class, especially without the graded Step 1.
Also, if you have any thoughts about it, how do you feel about students not being able to access their quintile ranking until after 2nd and 3rd year? Thanks again!

I don’t see much downside for the bottom group honestly. It’s not like they were going to fool anyone into thinking they were higher up anyhow. These folks aren’t really going to successfully competing for top fields/programs.

Where I think it really helps is those middle and upper middle tiers. The top students already have AOA to demonstrate their standing, but top students and those just below the cutoff will benefit from showing they are performing well compared to their peers.

Limited access to quintiles is a good thing lest people get more obsessive than they already are. Presumably the school already lets students know how they performed compared to the class overall after each exam so anyone who wants more detail can keep track themselves. I think a reasonable request at the town hall would be to allow one more viewing after after the first year.

 

[PhillyMed777]

Class rank looks redundant if the school also has AOA, but i guess class rank can make the AOA process more objective

AOA has changed over the years at some schools —
A couple years after I graduated it heavily incorporated your “wokeness” into it. Plenty of top students by grades and other similar metrics who deserved AOA were not selected

 

[nicks9000]

Overall this is probably a good thing. With step 1 going pf, top students need more ways to show prospective residency programs their abilities. Ironically, step 1 was not originally used for comparing applicants but grew into this as more schools went p/f and stopped reporting class rank.

A number of schools already do this. If you Google it, there’s a great paper in a radiology journal looking at deans letters and coded language for class rank. There was even a supplementary document that listed every school and what their practices were. You could look and see what your school was already reporting.

But overall I think this is a solid move that will help the students it needs to help.

But is there proof that preclinical class rank and step 1 score correlate with clinical performance as a resident, which is what I assume residency directors are looking for? I thought the reason classes and step 1 are going P/F is because they don't?

 

[operaman]

I don’t think there is but then again it’s a terribly difficult thing to study. Most resident evals are just as bad as Med student evals so drawing meaningful conclusions are challenging.

I think their ability to predict performance is not important. I want them to help me measure differences between applicants, regardless of whether those differences have a strong evidence base as to their future performance. Give me the best students I can get!

Where it really helps me is to see the overall story arc. I prefer people with cohesive arcs, consistent performance over their entire experience. I don’t like disparate performance with sky high step scores but low class rank or clinical grades. Sporadic performance is highly predictive of major underlying issues.

I don’t think anyone has done rigorous study on this, but my own personal experience is that this is extremely predictive.

 

[IR3A4]

Hi folks,

My class recently found out that this year will be the first year that our class ranking is going to be reported to schools during residency applications via our Dean's Letter. So far, the only information we have received about this is:

1. Our quintile rank will be reported, not our individual class ranking
2. We will only be given a chance to find out our quintile at 2 time points: after Step 1/before beginning 3rd year (rank from years 1-2), and during the fall of our 4th year (rank from years 1-3)
3. There has been no decision on whether or not to rank the pre-clinical and clinical years separately.

Our school has decided to host a "town hall" with some of the admin and the class to discuss this new system. While they said they are open to discussion, it doesn't sound like anything is up for change at this point.
At this point, I'd like to ask all of you: Is there anything that we should be asking this administration about this new quintile ranking system that we may not have thought of? and should I do anything differently, now knowing that my quintile is going to be reported? and finally, are there any credible/reliable sources that say that class ranking/reporting is harmful or helpful to students during residency applications? Thank you!

All I can say is you're lucky. Our school got rid of rank, and now shifted AOA from being 80% based off grades to less than 50% 🙃 - so what is AOA based off? Nobody knows! Probably whoever is best able to write about their ECs or straight fluff/lie.

 

[PhillyMed777]

Our school got rid of rank, and now shifted AOA from being 80% based off grades to less than 50% 🙃 - so what is AOA based off?

yup, see my comment above. it's a shame.

 

[nicks9000]

I want them to help me measure differences between applicants, regardless of whether those differences have a strong evidence base as to their future performance. Give me the best students I can get!

This American fixation on ranking and stratification not only of medical students but also of hospitals, residency programs, and even physicians doesn't even translate to healthcare outcomes (and IMO is at the expense of healthcare outcomes). America performs below the average of developed countries for almost every single healthcare outcome including stroke and heart attack mortality, errors in medication/treatment, rates of post-operative PE/DVT, infant and maternal mortality, hospital admissions for chronic diseases, etc. Even people living in the richest zipcodes in America who have access to the supposedly "best healthcare in the world" have shorter lifespans than the "extremely impoverished" in Europe. The juxtaposition of America's fixation on being "the best"/at the "top" with it having the worst healthcare outcomes across the board among developed countries is just uncanny. What is it exactly that you are chasing if not healthcare outcomes/clinical performance?

Maybe medical students should spend less time chasing preclinical rank and step 1 scores which have been proven with data to not correlate with clinical performance and more time developing skills that will actually help bring healthcare outcomes up to at least the average of developed countries

 

[operaman]

This American fixation on ranking and stratification not only of medical students but also of hospitals, residency programs, and even physicians doesn't even translate to healthcare outcomes (and IMO is at the expense of healthcare outcomes). America performs below the average of developed countries for almost every single healthcare outcome including stroke and heart attack mortality, errors in medication/treatment, rates of post-operative PE/DVT, infant and maternal mortality, hospital admissions for chronic diseases, etc. Even people living in the richest zipcodes in America who have access to the supposedly "best healthcare in the world" have shorter lifespans than the "extremely impoverished" in Europe. The juxtaposition of America's fixation on being "the best"/at the "top" with it having the worst healthcare outcomes across the board among developed countries is just uncanny. What is it exactly that you are chasing if not healthcare outcomes/clinical performance?

Maybe medical students should spend less time chasing preclinical rank and step 1 scores which have been proven with data to not correlate with clinical performance and more time developing skills that will actually help bring healthcare outcomes up to at least the average of developed countries

I'm always amazed when I hear such stats about US healthcare. Whatever those data suggest, the US remains the destination of choice for the world's wealthy elite to receive their care. Our top hospitals see patients from all over the world who fly on their own jets to come here. Even today I was asked to add on a patient who is flying 4000 miles to see me. I'm not sure how we reconcile data from think tanks that suggests we're terrible with the objective reality that those with the means to go anywhere invariably choose to come here.

There's also the issue that many who cite these data have an agenda so they purposely skew what they present. For example, using your own linked data, they present post op DVT by cherry picking a number of countries with lower rates, but omitting those with higher rates like France, Germany, Israel, Finland, Ireland, etc. They could have made the same graph with the same data and showed the US as one of the best, but they made an editorial choice to show us as one of the worst. Further, in your own assessment you suggest a higher MI mortality when your own data says exactly the opposite on the page you linked.

My feeling is that we do provide the best healthcare in the world for those who can afford to access it, and the data linked here suggest just that when you look at more solid outcomes measures (post MI mortality, cancer survival rates, etc). The data get skewed by other societal and public health issues here, but what happens once you cross the threshold of our greatest hospitals is some of the best care in the world. I would argue that our obsession with being and recruiting the best is precisely what gives us a healthcare system that remains the choice of the world's elite.

Despite what many would like to believe, people are not equal and no amount of p/f and unranking will change that immutable fact. Physicians are not interchangeable cogs in a machine and some are genuinely better and smarter than others. Not only do I personally prefer to work alongside and train the very best, but I would advocate in favor of any systematic change that enable the best among us to further distinguish themselves.

 

[collegestud2013]

But is there proof that preclinical class rank and step 1 score correlate with clinical performance as a resident, which is what I assume residency directors are looking for? I thought the reason classes and step 1 are going P/F is because they don't?

Step 1 scores do to some extent one's ability to pass specialty-specific boards during or after residency, with lower scores often raising increased concern about failing. Obviously failing a specialty board down the line is also a big deal as it can limit employment opportunities, and for the residency programs themselves they could go on probation if too many residents fail. For example IM programs are required to have an ABIM pass rate of 80% of higher averaged across 3 years.

The whole reason to move to P/F step 1 was to relieve stress off med students on what's obviously a high stakes exam. But it's probably just going to shift the stress to M3 year and Step 2.

 

[collegestud2013]

Hi folks,

My class recently found out that this year will be the first year that our class ranking is going to be reported to schools during residency applications via our Dean's Letter. So far, the only information we have received about this is:

1. Our quintile rank will be reported, not our individual class ranking
2. We will only be given a chance to find out our quintile at 2 time points: after Step 1/before beginning 3rd year (rank from years 1-2), and during the fall of our 4th year (rank from years 1-3)
3. There has been no decision on whether or not to rank the pre-clinical and clinical years separately.

Our school has decided to host a "town hall" with some of the admin and the class to discuss this new system. While they said they are open to discussion, it doesn't sound like anything is up for change at this point.
At this point, I'd like to ask all of you: Is there anything that we should be asking this administration about this new quintile ranking system that we may not have thought of? and should I do anything differently, now knowing that my quintile is going to be reported? and finally, are there any credible/reliable sources that say that class ranking/reporting is harmful or helpful to students during residency applications? Thank you!

A ranked system can be definitely harmful to most students as it incentivizes students to spend a lot more time studying for small gains in test scores. But all that time could be used for other things that are productive to a strong residency application such as research (which can be time consuming if you want to pull off high quality pubs for a competitive specialty but don't want to take a year off for dedicated research) or maybe just getting a part time job to help pay of med school debt.

Nearly all med students are pretty smart so grades and ranking in med school a more of a reflection of how hard someone is willing to work and how much time they can put into studying. And when studying for exams, there are diminishing returns the more you study. For example, there is usually much more studying work involved to go from a 90% to a 100% than from 60% to 70%. In a graded system, students have the incentive to spend significantly more time for minor gains in grades (but possibly large improvements in class rank since the grade distributions tend to be very narrow among med school classes).

And a ranked class will benefit those at the top but can definitely hurt those at the bottom of the class. This can be the case especially for for someone at the bottom of the class in terms of grades but otherwise has strong Step scores and significant research background (and maybe their grades were lower since they spent more time doing research and not as much studying for classes) applying to more competitive specialties. That's why some schools that rank only recognize those at top 15-25% of the class so they get the benefit on their apps, but everyone else is not ranked (so you could be in the top 26% or at the very bottom) so it doesn't hurt them as much.

 

[Hzreio]

Overall this is probably a good thing. With step 1 going pf, top students need more ways to show prospective residency programs their abilities. Ironically, step 1 was not originally used for comparing applicants but grew into this as more schools went p/f and stopped reporting class rank.

A number of schools already do this. If you Google it, there’s a great paper in a radiology journal looking at deans letters and coded language for class rank. There was even a supplementary document that listed every school and what their practices were. You could look and see what your school was already reporting.

But overall I think this is a solid move that will help the students it needs to help.

Lol this is such sdn mentality. You do realize not everyone can be a top student. Ever think about the gunner like behavior stuff like this will encourage?

I see your point, but there’s a lot of cons associated to ranking as well…

 

[operaman]

Lol this is such sdn mentality. You do realize not everyone can be a top student. Ever think about the gunner like behavior stuff like this will encourage?

I see your point, but there’s a lot of cons associated to ranking as well…

I still fail to see why anyone would think there’s merit to hiding which students aren’t performing as well. Sure, you probably help a few at the bottom survive one more round of cuts in interview season, but you handicap all of the better students.

This is especially so now from mid and lower tier schools with step going p/f. In a world where I don’t know which students in a class are rising to the top, I’m going to look only at students from top schools where even if I get a bottom tier student by accident, they still may be pretty good.

I see minimal issues with gunner like behavior because there’s minimal opportunity for that to have any meaningful impact. Preclinical study is almost entirely solo and exams are MC. Maybe this will increase some gunnery on the wards but since those are largely still graded, probably not much more than we already have.

 

[Anakinmemer]

Overall this is probably a good thing. With step 1 going pf, top students need more ways to show prospective residency programs their abilities. Ironically, step 1 was not originally used for comparing applicants but grew into this as more schools went p/f and stopped reporting class rank.

A number of schools already do this. If you Google it, there’s a great paper in a radiology journal looking at deans letters and coded language for class rank. There was even a supplementary document that listed every school and what their practices were. You could look and see what your school was already reporting.

But overall I think this is a solid move that will help the students it needs to help.

Could you link that paper, I can't seem to find it

 

[deleted1097413]

expect cheating and a toxic environment -- good luck

 

[Ho0v-man]

Sounds like a crazy toxic preclinical experience. It was nice after first semester at my school when half the class got their ego checked by class rank announcements and stopped being jerks.

 

[operaman]

Could you link that paper, I can't seem to find it

I think it's this one. Having trouble with my login at the moment so I'm not completely sure, but I remember it having a supplemental document in table format that listed every school and their current system.

A program director's guide to the Medical Student Performance Evaluation (former dean's letter) with a database - PubMed

The authors recognize that this database is incomplete and that the individual institutions will alter their ranking system from time to time. But this database is offered in an open format so that it can be continuously updated by users.

pubmed.ncbi.nlm.nih.gov

 

[Hzreio]

I still fail to see why anyone would think there’s merit to hiding which students aren’t performing as well. Sure, you probably help a few at the bottom survive one more round of cuts in interview season, but you handicap all of the better students.

This is especially so now from mid and lower tier schools with step going p/f. In a world where I don’t know which students in a class are rising to the top, I’m going to look only at students from top schools where even if I get a bottom tier student by accident, they still may be pretty good.

I see minimal issues with gunner like behavior because there’s minimal opportunity for that to have any meaningful impact. Preclinical study is almost entirely solo and exams are MC. Maybe this will increase some gunnery on the wards but since those are largely still graded, probably not much more than we already have.

“I see minimal issues with gunner like behavior”

Lol congrats I’m sure you did great/are doing great in your preclinicals med school. Ever consider how people who are struggling are feeling?

Ever consider the toxicity and cheating that comes with collaboration?

 

[operaman]

“I see minimal issues with gunner like behavior”

Lol congrats I’m sure you did great/are doing great in your preclinicals med school. Ever consider how people who are struggling are feeling?

Ever consider the toxicity and cheating that comes with collaboration?

I would say the feelings of those who are struggling are not particularly relevant to the issue at hand. The bigger question is how to create the most opportunities for the most students in the new step 1 paradigm. We cant obfuscate the performance of the entire class just because a few at the bottom are going to have their feelings hurt. These are professional adults in a highly competitive professional program, not 19 year old undergrads.

I have full faith in our ability to deal with cheating and toxicity if/when it occurs. Given that most schools already rank at least internally for AOA and whatnot, the true gunners were already gunning anyhow. In reality there just aren’t many ways a gunner can sabotage anyone else these days, especially in the preclinical years.

 

[nicks9000]

I would say the feelings of those who are struggling are not particularly relevant to the issue at hand. The bigger question is how to create the most opportunities for the most students in the new step 1 paradigm. We cant obfuscate the performance of the entire class just because a few at the bottom are going to have their feelings hurt. These are professional adults in a highly competitive professional program, not 19 year old undergrads.

I have full faith in our ability to deal with cheating and toxicity if/when it occurs. Given that most schools already rank at least internally for AOA and whatnot, the true gunners were already gunning anyhow. In reality there just aren’t many ways a gunner can sabotage anyone else these days, especially in the preclinical years.

This conversation on preclinical grades was held 10-20 years ago and medical education has since long decided to move away from preclinical class ranking and now step 1 scoring due to substantial data showing that they DO NOT correlate with clinical performance. Medical education just like medical practice should be evidence-based and current, not stuck on tradition/"the way things have always been done." The goal of medical education is and should be to improve healthcare outcomes, not make residency interviewers' jobs easier.

 

[operaman]

This conversation on preclinical grades was held 10-20 years ago and medical education has since long decided to move away from preclinical class ranking and now step 1 scoring due to substantial data showing that they DO NOT correlate with clinical performance. Medical education just like medical practice should be evidence-based and current, not stuck on tradition/"the way things have always been done." The goal of medical education is and should be to improve healthcare outcomes, not make residency interviewers' jobs easier.

I agree to a point - the end goal should be selecting the best people who will perform well.

I’ve read the literature on various metrics and their correlation with residency performance and they are all handicapped by the terrible data on the resident evaluation side. Just like in Med school, many evaluators simply click down one column without thinking, usually after multiple annoying reminder emails from the PC to get it done. Trying to look for differences in performance from such crappy data is a Sisyphean task.

Absent good data, a reasonable approach is looking for students whose performance in medical school has been significantly better than that of their peers. Ignoring that would imply that all medical students are essentially equal which is laughably false.

 

[Lawpy]

A P/F Step 1 should warrant a reduction of preclinical education to 1 yr, not reestablishing the ranks/metrics that previously existed and were removed because they created too much stress and competition

It's clear boards resources have far surpassed preclinical education quality at nearly all schools. Focus on expanding clinical education and standardize the grading metrics to make it less arbitrary.

 

[altblue]

This conversation on preclinical grades was held 10-20 years ago and medical education has since long decided to move away from preclinical class ranking and now step 1 scoring due to substantial data showing that they DO NOT correlate with clinical performance. Medical education just like medical practice should be evidence-based and current, not stuck on tradition/"the way things have always been done." The goal of medical education is and should be to improve healthcare outcomes, not make residency interviewers' jobs easier.

I'm not necessarily even the biggest fan of these metrics, but the thing to consider is that competitive programs already face a surplus of applicants, so if there's a chance they can cull the herd for the smartest or hardworking applicants on a statistical level with class ranking and Step, they can by all means do so

There are definitely people in the 220s and 230s who got individually shafted by an unlucky Step/life crisis and are more capable than many of those in the 240s and 250s, but in terms of the population level, the latter group is probably slightly more academically inclined and might even be easier to train. Why not choose that metric then if you're whittling things down? Beats the hell out of subjective MSPE comments

I'm not even a star student, so this doesn't come from the standpoint of internalized elitism. My Step 1 is good but unexceptional, and my class rank is pretty meh because poor study habits earlier on, burning out and not giving a **** about PhD minutiae. I accept that this partially reflects my work ethic, so I'm not opposed to class rank in reference to my app

 

[collegestud2013]

I'm not necessarily even the biggest fan of these metrics, but the thing to consider is that competitive programs already face a surplus of applicants, so if there's a chance they can cull the herd for the smartest or hardworking applicants on a statistical level with class ranking and Step, they can by all means do so

There are definitely people in the 220s and 230s who got individually shafted by an unlucky Step/life crisis and are more capable than many of those in the 240s and 250s, but in terms of the population level, the latter group is probably slightly more academically inclined and might even be easier to train. Why not choose that metric then if you're whittling things down? Beats the hell out of subjective MSPE comments

I'm not even a star student, so this doesn't come from the standpoint of internalized elitism. My Step 1 is good but unexceptional, and my class rank is pretty meh because poor study habits earlier on, burning out and not giving a **** about PhD minutiae. I accept that this partially reflects my work ethic, so I'm not opposed to class rank in reference to my app

It may be okay if you never planned on going into a competitive specialty. But it happens all the time that med students are forced to switch to a less competitive specialty partway through med school after finding out lower-than-expected Step 1 score.

As Step 1 (and now Step 2) are obviously super high stakes, students should be to retake them even if they pass as the measurement variation is high (the MCAT was high stakes too but one of the main differences is that you can retake if you score low just because you had a bay day on your test day). The standard error of measurement is 6 points, wo that means if someone retook a different version the exam with the exact same amount of knowledge, there's an approximately 95% chance they will fall within +/- 12 points (2 SEM) of their original score. That's a 24 point difference. So someone who scores a 240 would likely score anywhere between a 228 to a 252 on a retake.

And in terms of class ranking, some med schools try to help those at the top and not hurt those at the bottom by only identifying the top 15-25% of the class while not specifying the rank of anyone else. So those who want to be gunners can do so but rest of the class can pass and not be hurt too much. In a quartile or quintile system, being at the bottom quartile or quintile will significantly hurt when applying to any super-competitive specialty, but just having a residency program know that you were not in the top 15-25% looks a lot better (they'll likely assume you were middle of the class).

 

[altblue]

It may be okay if you never planned on going into a competitive specialty. But it happens all the time that med students are forced to switch to a less competitive specialty partway through med school after finding out lower-than-expected Step 1 score.

As Step 1 (and now Step 2) are obviously super high stakes, students should be to retake them even if they pass as the measurement variation is high (the MCAT was high stakes too but one of the main differences is that you can retake if you score low just because you had a bay day on your test day). The standard error of measurement is 6 points, wo that means if someone retook a different version the exam with the exact same amount of knowledge, there's an approximately 95% chance they will fall within +/- 12 points (2 SEM) of their original score. That's a 24 point difference. So someone who scores a 240 would likely score anywhere between a 228 to a 252 on a retake.

And in terms of class ranking, some med schools try to help those at the top and not hurt those at the bottom by only identifying the top 15-25% of the class while not specifying the rank of anyone else. So those who want to be gunners can do so but rest of the class can pass and not be hurt too much. In a quartile or quintile system, being at the bottom quartile or quintile will significantly hurt when applying to any super-competitive specialty, but just having a residency program know that you were not in the top 15-25% looks a lot better (they'll likely assume you were middle of the class).

I don't disagree with you, really. Hell, there's also the fact that some students work the system to give themselves extra time while others lose time to coping with a personal tragedy. In the months leading up to Step, I had all kinds of things go down that prob cost me 4-12 points

All I mean to say is that residency programs are behaving rationally, to their benefit, by sorting by already provided metrics that in general select for book-smart students. That doesn't mean that those metrics are perfect or even good. That also doesn't mean that some students don't get screwed by score variability or by going to a program with tough competition for internal rankings. It's simply just useful for what it does: help sift through applicants

 

[Angus Avagadro]

I'm not necessarily even the biggest fan of these metrics, but the thing to consider is that competitive programs already face a surplus of applicants, so if there's a chance they can cull the herd for the smartest or hardworking applicants on a statistical level with class ranking and Step, they can by all means do so

There are definitely people in the 220s and 230s who got individually shafted by an unlucky Step/life crisis and are more capable than many of those in the 240s and 250s, but in terms of the population level, the latter group is probably slightly more academically inclined and might even be easier to train. Why not choose that metric then if you're whittling things down? Beats the hell out of subjective MSPE comments

I'm not even a star student, so this doesn't come from the standpoint of internalized elitism. My Step 1 is good but unexceptional, and my class rank is pretty meh because poor study habits earlier on, burning out and not giving a **** about PhD minutiae. I accept that this partially reflects my work ethic, so I'm not opposed to class rank in reference to my app

As a medical student, your honesty and ability to reflect internally is refreshing.
The entitled belief that people should be selected for competitive specialties , even when they are not competitive, is what drives these discussions. Some students get accommodations for more time on exams. That would not inspire me if I'm the patient having a cardiac arrest and the doctor thinks they should get more time to rescue me.. Medicine is not the only game in town. There are other options, DPM, PA, NP, PT, etc.. So if a person decides medicine, then they have decided its only game in town. The choice is to play or not. Understanding the game is critical, along with playing well. Complaining about MSPEs and clinical evals is not the best solution. The best solution is when on clinical, show up early, stay late, make them chase you out of the hospital with a stick. DONT be playing with your phone for whatever reason. Be helpful and polite. Ask thoughtful questions. I have sat on resident selection committees. Everyone in med school is smart enough to master their craft. Finding a hard working team player who gets along with everyone is Gold. I can teach that person. Someone watching the clock or their phone all day who is chronically late and looking to do the minimal can train somewhere else imo. As far as I'm concerned, class rank only helps or hurts those in the top and bottom quartile.