Shouldn't people with higher step scores go into "harder" residencies?

[begoood95]

Bear with me, because I'm a lowly pre-med but I've had this question for a while now...

So before medical school, you'll usually get a concentration of high stats apps at the "top" schools. Harvard, Hopkins, UCSF and so-on get their pick of the top percentiles; these students are usually the highest achieving, both academically and personally. I'm not going to get into whether or not "top 20's" really are better than anything not "Top 20," but let's just assume you get some benefit from going to a highly ranked medical school (which is at least arguable).

Here's where step 1 comes in. With that standardized exam, the highest scorers usually go into the more competitive specialties (Derm, Ophtho, Plastics, etc.), while lower scorers tend to match into IM.

My question is: shouldn't the "higher scorers" (i.e., high achievers in my pre-med example) match into "harder" residencies though not necessarily the "easiest" residencies" (i.e., the lifestyle residencies)? In other words, I feel like all this talent is being spent on "easier" residencies, where they might be better used in more difficult ones.

Of course, there are exceptions to this observations, and obviously you're entitled to pursue whichever path you want, and none of this is meant to place the residencies on some sort of hierarchy of difficulty—but I'm sure we can all agree that some are more "lifestyle" than others. That being said, wouldn't we want to incentivize the brightest and best medical students to match into a more diverse set of residencies?

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[Planes2Doc]

Medicine is one of the most polarizing fields you will ever find. You can love one thing, and absolutely hate the other. The person sitting next to you can be the exact opposite. Even if I had the board scores for it, I would never pick dermatology because I find it boring and do not enjoy clinic. But to each their own. Also, one of the top students from my class was gung-ho about family medicine since he matriculated and matched into family medicine later. You likely won't find people with low board scores and awful grades in the most competitive residencies (unless they have very close connections or bought the hospital a new wing), but you'll find the top people all the way down the chain from radiation oncology to primary care and pathology. I have nothing against any specialties and neither do other people. To each their own.

 

[peridotthecat]

What are you defining as the "hardest" residencies? And how do you propose incentivizing them? Also, note that many of the surgical subs (neurosurgery, for example) are both "hard" and require extremely high step scores

 

[begoood95]

What are you defining as the "hardest" residencies? And how do you propose incentivizing them? Also, note that many of the surgical subs (neurosurgery, for example) are both "hard" and require extremely high step scores

I guess what I'm defining as "hard" are those that do not pay as well as the other residencies (post-graduation) while still holding a high volume of work; I'd also include in my definition as hard as those specialities that are intellectually stimulating.

So by that, something like dermatology would be "easier" than say ped/onc, because it pays more while being less emotionally draining. And I'm not proposing anything—just bringing up the question for discussion.

 

[CommyO]

What are you talking about OP?

People who do exceptional on step generally gravitate toward the more competitive specialties in general, right?

It's not really hard to understand. Another example is people with exceptional UG stats settling for their state MD instead of t20 med school OOS. There are certainly other factors that play into this.

 

[Goro]

Bear with me, because I'm a lowly pre-med but I've had this question for a while now...

So before medical school, you'll usually get a concentration of high stats apps at the "top" schools. Harvard, Hopkins, UCSF and so-on get their pick of the top percentiles; these students are usually the highest achieving, both academically and personally. I'm not going to get into whether or not "top 20's" really are better than anything not "Top 20," but let's just assume you get some benefit from going to a highly ranked medical school (which is at least arguable).

Here's where step 1 comes in. With that standardized exam, the highest scorers usually go into the more competitive specialties (Derm, Ophtho, Plastics, etc.), while lower scorers tend to match into IM.

My question is: shouldn't the "higher scorers" (i.e., high achievers in my pre-med example) match into "harder" residencies though not necessarily the "easiest" residencies" (i.e., the lifestyle residencies)? In other words, I feel like all this talent is being spent on "easier" residencies, where they might be better used in more difficult ones.

Of course, there are exceptions to this observations, and obviously you're entitled to pursue whichever path you want, and none of this is meant to place the residencies on some sort of hierarchy of difficulty—but I'm sure we can all agree that some are more "lifestyle" than others. That being said, wouldn't we want to incentivize the brightest and best medical students to match into a more diverse set of residencies?

Focusing on a single metric is a foolish way to look at Medical Education and Beyond.

 

[Psych_hopeful]

My problem with this statement that you made is that all fields of medicine have their difficulties and challenges, and it's like the statement doesnt acknowledge that.

Internists have to deal with a patient with kidney failure combined with congestive heart failure, in which treating one pathology leads to the other pathology getting worse. Psychiatrists have to deal with bipolar/schizophrenic patients in which 50% of both patient populations will attempt suicide and medications and dosages have to be constantly adjusted with emphasis of finding the correct psychotherapy. Pediatricians have to deal with the occasional cyanotic heart disease of a newborn and not only treating this and ensuring that the child lives a full life, but counseling the parents to cope and also handle the pressure.

So even for the lowly competitive fields, it's good that people who are high performers go into these areas, because many times, the challenges that have to be dealt with are great and require a person that can perform at a high level.

 

[•Syzygy•]

im not sure what you are trying to ask

for your information, most residencys from what i can tell are soul-sucking, and low paying, no matter what you go into.

i saw a guy post on here one time saying that the derm residency is absolutely brutal. nonstop studying on top of work, and studying material you have never seen in medical school. its basically medical school all over again.

derm is a "lifestyle" speciality because post residency is comfortable, not the residency itself. this goes for all specialities from what i have seen

and even then, it makes complete sense that some of the brightest will go for the most competitive residencys because they provide the most comfortable lifestyle when schooling is done.

what you are arguing is a fact of life... there are plenty of people for example who would be amazing doctors but instead work for NASA. and so on and so forth.


EDIT: sorry if i misunderstood you and you actually did mean post residency, but still its just the way things go. the brightest will often go for the highest paying positions. but that isnt always what the brightest do. ive seen people with 260s go to IM. i say let them do what they want. they worked that hard to get where they are

 

[efle]

I think the premise here doesn't hold up in reality. If you have two people, one with a 250 and the other with a 220, there really isn't any reason to expect the former would make for a better or more talented physiatrist / psychiatrist / etc.

Like think about what a day in the life of a private practice derm or ophtho is like. Would swapping them out with people who had 40th percentile step 1s instead of 80th percentile, cause a tangible drop in what they provide their patients? Def not, in my opinion, I don't think a specialty benefits in that way from having a high step average among its practitioners.

The basic idea here could be applied in a big way to academia overall, though. It would obviously be great to have the best and brightest all concentrated into the major academic centers, and not pulled away to private settings where they can make far more $$

 

[NotASerialKiller]

Higher test scores = better doctor right? RIGHT?

 

[bananafish94]

I think that the best doctors are going to be passionate about their work. It doesn't matter how smart you are or how well you did on Step 1 if you hate your job.

 

[Psych_hopeful]

I think that the best doctors are going to be passionate about their work. It doesn't matter how smart you are or how well you did on Step 1 if you hate your job.

Can I like this comment infinity +1 times?

 

[eteshoe]

Also some people are interested in IM subspecialties which means they have to get through IM first. No point in doing dermatology if you see cardiology in your future.

 

[Planes2Doc]

I think that the best doctors are going to be passionate about their work. It doesn't matter how smart you are or how well you did on Step 1 if you hate your job.

And there will still be people who rocked Step 1 and suck at their job.

 

[pyrrion89]

The only way you can incentivize high scorers to match into a more "needed" field is to increase the $$$ per effort/per hour. For FM: Increase the compensation and the docs will follow. It's no coincidence all the cushy specialties pay well.

 

[Mad Jack]

Bear with me, because I'm a lowly pre-med but I've had this question for a while now...

So before medical school, you'll usually get a concentration of high stats apps at the "top" schools. Harvard, Hopkins, UCSF and so-on get their pick of the top percentiles; these students are usually the highest achieving, both academically and personally. I'm not going to get into whether or not "top 20's" really are better than anything not "Top 20," but let's just assume you get some benefit from going to a highly ranked medical school (which is at least arguable).

Here's where step 1 comes in. With that standardized exam, the highest scorers usually go into the more competitive specialties (Derm, Ophtho, Plastics, etc.), while lower scorers tend to match into IM.

My question is: shouldn't the "higher scorers" (i.e., high achievers in my pre-med example) match into "harder" residencies though not necessarily the "easiest" residencies" (i.e., the lifestyle residencies)? In other words, I feel like all this talent is being spent on "easier" residencies, where they might be better used in more difficult ones.

Of course, there are exceptions to this observations, and obviously you're entitled to pursue whichever path you want, and none of this is meant to place the residencies on some sort of hierarchy of difficulty—but I'm sure we can all agree that some are more "lifestyle" than others. That being said, wouldn't we want to incentivize the brightest and best medical students to match into a more diverse set of residencies?

Step scores have literally never been correlated with quality of practice.

 

[LizzyM]

Students with high board scores can do as they please. And in large numbers, they prefer the cushy specialties.

Also, keep in mind that someone who wants one of those cushy residencies is going to pour everything into Step 1 prep whereas someone who knows that they can get the residency they want if they do reasonably well will not knock themselves out doing Step 1 prep.

 

[Med Ed]

I guess what I'm defining as "hard" are those that do not pay as well as the other residencies (post-graduation) while still holding a high volume of work; I'd also include in my definition as hard as those specialities that are intellectually stimulating.

So by that, something like dermatology would be "easier" than say ped/onc, because it pays more while being less emotionally draining. And I'm not proposing anything—just bringing up the question for discussion.

You think it isn't hard to be a good family medicine doc?

 

[efle]

You think it isn't hard to be a good family medicine doc?

Wait you think most family medicine docs are not good at their job??

 

[DNM]

OP - I get what you are saying from a theoretical point of view. Realistically, I don't think board score necessarily corresponds with how good of a doctor you are/will be (I wonder if something like research acumen or later pubs would correlate, but I digress). Have worked with plenty of brilliant doctors who don't deliver great patient care because they have low to moderate social intelligence and don't work well with people (especially when many patients evaluate decisions emotionally rather than logically, so optimal medical evidence doesn't always help)

In the end, you can't dictate what people pick for specialty. You're selected on a competitive basis. Step scores are a currency in that process. The fields where people are competing for spots will be the fields that get the highest scoring students. Currently, those are generally the lifestyle fields as you mentioned above (as well as some really sexy/small fields like neurosurg and rad onc)

 

[infectiousdisease101]

Please go watch Good Will Hunting. It will teach you a thing or two.

 

[wholeheartedly]

I'll take a different route and address what you actually seem to be asking.

The basic question you seem to be asking is, wouldn't it be best for medicine if those with the highest intellectual capabilities went into the toughest fields?

First, you're talking about board scores so you're talking about intellectual capability there, but then you talk about competitive or lifestyle specialties which you refer to as being easier.

The problem is these are "easier" with respect to work hours, call schedules, and so on mostly after residency. So here easier or harder has to do with work hours and work ethic, which is quite different than board scores and intellectual capabilty. Something can be intellectually challenging, but less physically demanding or time consuming and vice versa. You can find threads on here discussing/debating which specialties are most intellectually demanding, so I won't get into it here, but some of the suggested ones are very different from the competitive lifestyle specialties you propose.

Based on your examples, there wouldn't seem to be much benefit to what you suggest as far as easier vs harder goes.

Now, if we rephrase a bit and ask "wouldn't it be best if those with the highest intellectual capabilities went into the most intellectually challenging fields? " I'd still say no.

Each field has a range of problems from routine to highly complex, so having bright problem-solving types in every field would seem to be better overall, more diverse specialties as you suggest. Ideally, you'd probably want those folks to be in academia doing work to move their respective fields forward and training the future generations of docs.

Lastly, I agree with the above comments that board scores are a small part of being a good doc and also that people tend to excel in things that they enjoy.

So maybe things are pretty ok the way they are?

 

[Chromium Surfer]

I'll take a different route and address what you actually seem to be asking.

The basic question you seem to be asking is, wouldn't it be best for medicine if those with the highest intellectual capabilities went into the toughest fields?

First, you're talking about board scores so you're talking about intellectual capability there, but then you talk about competitive or lifestyle specialties which you refer to as being easier.

The problem is these are "easier" with respect to work hours, call schedules, and so on mostly after residency. So here easier or harder has to do with work hours and work ethic, which is quite different than board scores and intellectual capabilty. Something can be intellectually challenging, but less physically demanding or time consuming and vice versa. You can find threads on here discussing/debating which specialties are most intellectually demanding, so I won't get into it here, but some of the suggested ones are very different from the competitive lifestyle specialties you propose.

Based on your examples, there wouldn't seem to be much benefit to what you suggest as far as easier vs harder goes.

Now, if we rephrase a bit and ask "wouldn't it be best if those with the highest intellectual capabilities went into the most intellectually challenging fields? " I'd still say no.

Each field has a range of problems from routine to highly complex, so having bright problem-solving types in every field would seem to be better overall, more diverse specialties as you suggest. Ideally, you'd probably want those folks to be in academia doing work to move their respective fields forward and training the future generations of docs.

Lastly, I agree with the above comments that board scores are a small part of being a good doc and also that people tend to excel in things that they enjoy.

So maybe things are pretty ok the way they are?

+1 also I think you were the one who most understood what he was saying haha. A lot of people assumed quite negatively in my opinion lol.

 

[begoood95]

Thank you for all the replies!🙂 Some things:

@wholeheartedly was the first person to actually answer my question. I don't blame others for misunderstanding though—it was the nature of my question, I had to oversimplify (assuming high board scores = high intellectual capability). But I think @LizzyM made a good comment, that "someone who wants one of those cushy residencies is going to pour everything into Step 1 prep whereas someone who knows that they can get the residency they want if they do reasonably well will not knock themselves out doing Step 1 prep."

So, really, the process seems self selective. Because matching into "cushy" residencies is a priori more competitive than others, then those people who want to match there will try much harder than, say, someone who wants to match IM. Makes sense.

@Goro you're right, "Focusing on a single metric is a foolish way to look at Medical Education and Beyond," but I had to mention at least one metric. I guess we could add others in order to better measure high intellectual capability (# of pubs, and etc). Didn't mean for it to come off as though step 1 is the end all be all of intelligence in medicine!

@Med Ed who said being a fam doc was easy? Not me, so you're getting the idea from someone else. All I said that, comparatively, on the basis of lifestyle, work hours, etc., dermatology is probably "easier" than EM.

Though @Mad Jack is right: step scores don't have much to do with quality of practice. What I was suggesting, perhaps incorrectly (which is why we have this discussion) was what @wholeheartedly said.

 

[Peach Newport]

There have been many doctors who have made this same point. OP is not being ridiculous.

That being said, the answer is "Because this is America!"

 

[cactusman]

You think it isn't hard to be a good family medicine doc?

It seems like OP is actually saying the opposite - family medicine (although I think maybe they're mostly thinking of IM subspecialties) is more emotionally draining and harder, and since these people have been successful academically so far, shouldn't they be interested in entering a field with long hours and high stress?

The obvious answer is that many high-achievers are motivated by the thought that they can put in a lot of work and reap the lifestyle rewards later. Not every high achiever is an intellectual masochist.

 

[DokterMom]

I guess what I'm defining as "hard" are those that do not pay as well as the other residencies (post-graduation) while still holding a high volume of work; I'd also include in my definition as hard as those specialities that are intellectually stimulating.

So by that, something like dermatology would be "easier" than say ped/onc, because it pays more while being less emotionally draining. And I'm not proposing anything—just bringing up the question for discussion.

You're wondering why the top graduates of top schools wouldn't choose the lower-paying specialties? Really?

 

[begoood95]

It seems like OP is actually saying the opposite - family medicine (although I think maybe they're mostly thinking of IM subspecialties) is more emotionally draining and harder, and since these people have been successful academically so far, shouldn't they be interested in entering a field with long hours and high stress?

The obvious answer is that many high-achievers are motivated by the thought that they can put in a lot of work and reap the lifestyle rewards later. Not every high achiever is an intellectual masochist.

Yeah, this is a big underlying assumption.

We place all this emphasis on altruism and so-on, but when push comes to shove, many of us end up taking that "cushy" route—which isn't a bad thing at all, but you'd think that many of these high-achievers (whose pre-med application probably screams "altruism/serve those less fortunate than oneself/etc") go into something more... intellectually stimulating?

Maybe they are gunners and whatnot, but then, towards the end after obtaining that 250+ with X # of pubs and volunteering and so on, we feel burned out and become allured to the cushy lifestyle. Again, there's nothing wrong with that from an individualistic perspective, just an interesting discussion.

From a more collective perspective though, we can start normative arguments: should it be like this? Should people who obviously excel and could contribute to medicine's body of knowledge go towards these cushy options? Or should they be at (or would they better serve the public at) academic centers designing and running trials, being at the forefront of policy, and so on? I think the obvious answer to this would be that, yes, they should be at these academic centers. However, as we are a nation with individualistic and self-serving perspectives, it's hard to admit that and even harder to put that into play.

It seems like things are fine though, and I'm not too worried about this. The topic is just interesting to me, pitting the self vs. the collective, and autonomy vs. servitude against one another.

 

[begoood95]

You're wondering why the top graduates of top schools wouldn't choose the lower-paying specialties? Really?

No—again I totally understand it, and this in fact might happen to me. I'm always wondering which route I'll take: gunner for life or up until I have the chance to match a cushy job? Time will tell I guess. In this post, I'm really just asking for opinions on whether or not this is how things ought to be.

 

[Mad Jack]

Yeah, this is a big underlying assumption.

We place all this emphasis on altruism and so-on, but when push comes to shove, many of us end up taking that "cushy" route—which isn't a bad thing at all, but you'd think that many of these high-achievers (whose pre-med application probably screams "altruism/serve those less fortunate than oneself/etc") go into something more... intellectually stimulating?

Maybe they are gunners and whatnot, but then, towards the end after obtaining that 250+ with X # of pubs and volunteering and so on, we feel burned out and become allured to the cushy lifestyle. Again, there's nothing wrong with that from an individualistic perspective, just an interesting discussion.

From a more collective perspective though, we can start normative arguments: should it be like this? Should people who obviously excel and could contribute to medicine's body of knowledge go towards these cushy options? Or should they be at (or would they better serve the public at) academic centers designing and running trials, being at the forefront of policy, and so on? I think the obvious answer to this would be that, yes, they should be at these academic centers. However, as we are a nation with individualistic and self-serving perspectives, it's hard to admit that and even harder to put that into play.

It seems like things are fine though, and I'm not too worried about this. The topic is just interesting to me, pitting the self vs. the collective, and autonomy vs. servitude against one another.

Every field is only as intellectually stimulating as you make it. I don't get how you seem to believe that only certain fields are cerebral, as there is plenty of research to be done all over and plenty of stuff to read and apply basically everywhere. I mean, look at family med- you can go into it being a guideline reader or go as in-depth in any given area as you want, since your scope is almost everything. I'd argue it's the most intellectually stimulating specialty, but only if you're willing to make it so.

 

[begoood95]

Every field is only as intellectually stimulating as you make it. I don't get how you seem to believe that only certain fields are cerebral, as there is plenty of research to be done all over and plenty of stuff to read and apply basically everywhere. I mean, look at family med- you can go into it being a guideline reader or go as in-depth in any given area as you want, since your scope is almost everything. I'd argue it's the most intellectually stimulating specialty, but only if you're willing to make it so.

Because I'm not yet in medical school and haven't been exposed to much beyond shadowing and work, unlike you who, I assume, has had a much broader exposure; that's why I ask these questions and why we have these discussions🙂

But I get that, it's what you make of it.

 

[Mad Jack]

Because I'm not yet in medical school and haven't been exposed to much beyond shadowing and work, unlike you who, I assume, has had a much broader exposure; that's why I ask these questions and why we have these discussions🙂

But I get that, it's what you make of it.

Ah, that makes much more sense.

 

[DBC03]

As someone who has been in the work field for close to fifteen years, I can tell you that being in a job you feel dispassionate about can be soul crushing. There are so many options as a physician that what one physician loves doing may be a terrible option for another. Some people find that their work is more important than their pay. Others may find that a manageable schedule and time with their families is important. Some people like the idea of doing shift work and never being on call while others may get energy from working 70+ hours per week. You would be surprised at the number of brilliant people who would do more good in a smaller position as a private physician than perhaps in academia. Not everyone is cut out for that and I believe people should use their gifts in their work. It is difficult to analyze and I know that regardless of intelligence, physicians should go into an aspect of medicine that they are passionate about or they run the risk of burnout, depression, or any other number of negative things. I personally do not want someone in academia (or any other medical niche or specialty) who does not want to be there.

One thing I learned from going to an academically challenging school with people who were all much more brilliant than me was that people had so many varied talents and gifts. And when people use their talents and gifts they add to society. Brilliance does not necessarily correlate with being a productive physician in a more cerebral specialty and, while we can certainly question people's motives, I think it works out surprisingly well.

 

[IgEdoc]

Knowledge (hence, high test scores) doesn't always mean great medical care. I know extremely knowledgeable colleagues but when I read their notes, there is no real thinking or analysis behind their medical decisions. Practicality or logic is missing. Then, there is the other important side and that is "bedside manners" or patient interactions that has nothing to do with one's medical knowledge.

I always said that one important experience that can help anyone aspiring to be a physician is having done "sales". If you can talk and sell any product, you can definitely sell yourself and what you offer your patients.

 

[cossackdoc]

Bear with me, because I'm a lowly pre-med but I've had this question for a while now...

So before medical school, you'll usually get a concentration of high stats apps at the "top" schools. Harvard, Hopkins, UCSF and so-on get their pick of the top percentiles; these students are usually the highest achieving, both academically and personally. I'm not going to get into whether or not "top 20's" really are better than anything not "Top 20," but let's just assume you get some benefit from going to a highly ranked medical school (which is at least arguable).

Here's where step 1 comes in. With that standardized exam, the highest scorers usually go into the more competitive specialties (Derm, Ophtho, Plastics, etc.), while lower scorers tend to match into IM.

My question is: shouldn't the "higher scorers" (i.e., high achievers in my pre-med example) match into "harder" residencies though not necessarily the "easiest" residencies" (i.e., the lifestyle residencies)? In other words, I feel like all this talent is being spent on "easier" residencies, where they might be better used in more difficult ones.

Of course, there are exceptions to this observations, and obviously you're entitled to pursue whichever path you want, and none of this is meant to place the residencies on some sort of hierarchy of difficulty—but I'm sure we can all agree that some are more "lifestyle" than others. That being said, wouldn't we want to incentivize the brightest and best medical students to match into a more diverse set of residencies?

I'm not sure exactly what you're suggesting, but in my experience (and others to whom I've spoken) the constellation of skills/interests of the individual doctor generally determine residency choices, which at once does not necessarily align with step scores or any other quantifiable factors. Further, criterion determinations of "hard" vs "easy" subs are subjective enough to render such distinctions irrelevant.

 

[jm192]

You need to get over the idea of where you go and what you do defines you or defines how smart/good you are.

Figure out what you enjoy doing. Do that. Go to the place that will prepare you well and you'll be happy being.