Step 1 P/F: Decision

[ciestar]

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Correct me if I am wrong, but Step 1 is more on the individual, while i could foresee Step 2 CK being more dependent on the diversity and quality of clinical education you can get, which will vary significantly based on where you go to school and how well that school is connected.

ehh, it can help..
But UWorld/OME is what i used most of the time

 

[dienekes88]

But there's still step 2, right? Overperformers at mid-tier schools still have a chance in 'proving' themselves by doing well on step 2...

If step 1 is p/f, step 2 is close behind.

A critical element of step 1 was that EVERYONE had to take it. Only a subset will be taking step 2, which makes it harder to interpret. Everyone with good CVs or anyone who suspects they might do poorly will elect to take step 2 very late.

I’m not sure why people keep glossing over this piece of info. This test has a better reputation of being more clinically relevant anyways & as long as it’s still graded, I’m not sure why this would change the process that much.

See below.

The only actual problem with this is that people don’t take it until so late in the process that if you score lower than you need, it’s really late to switch specialties.

Agree.

No one is glossing over it. 1. The timing of Step 2 makes this very difficult to pull off. If people thought Step 1 was stressful... 2. It follows a very logical path that Step 2 will ultimately become P/F because the exact same issues that applied to Step 1 apply to Step 2.

This.

In the old days when I took step 2, the results only came back early into the actual interview season, and after most invites went out. Way too late to make an impact on the invitation process. And I took it relatively early. Most people will just not take it except for the subset of people who absolutely need to impress. This will make step 2 harder to interpret.

If step 1 is p/f, step 2 will soon follow.

 

[Cornfed101]

If step 1 is p/f, step 2 will soon follow.

The interim is going to blow. I expect step 2 to follow but before 2024? Probably not. What a great time to enter medical school /s

 

[ace_inhibitor111]

Correct me if I am wrong, but Step 1 is more on the individual, while i could foresee Step 2 CK being more dependent on the diversity and quality of clinical education you can get, which will vary significantly based on where you go to school and how well that school is connected.

Yup, or how early the residents at your clinical site let you out.

 

[NicMouse64]

Yup, or how early the residents at your clinical site let you out.

This is exactly what I'm most worried about. Clinical education is going to suffer because the NBME couldn't foresee these consequences. Students will get mad when they can't leave early and being kept in clinic may actually cause you to be a less successful medical student because you can't study for step 2.

 

[HappEness]

If step 1 is p/f, step 2 is close behind.

A critical element of step 1 was that EVERYONE had to take it. Only a subset will be taking step 2, which makes it harder to interpret. Everyone with good CVs or anyone who suspects they might do poorly will elect to take step 2 very late.

Sorry if this is a dumb question but what is the timeline of step 2? Like when do people typically take it? And how does this compare with the residency application timeline?

 

[longhaul3]

Sorry if this is a dumb question but what is the timeline of step 2? Like when do people typically take it? And how does this compare with the residency application timeline?

Not a dumb question. People usually take it some time after their clerkship year, so anywhere from January-December of the year before graduation. Since ERAS apps are sent to programs in September of the year before graduation, some will take it before applying and some won't. Generally CK doesn't matter much at all, but high Step 1 scorers can better afford to take it later.

 

[Engrailed]

Not a dumb question. People usually take it some time after their clerkship year, so anywhere from January-December of the year before graduation. Since ERAS apps are sent to programs in September of the year before graduation, some will take it before applying and some won't. Generally CK doesn't matter much at all, but high Step 1 scorers can better afford to take it later.

is there a particular advantage to taking the Step 2 exam earlier or later? What prevents people from waiting until the end and having as much expereince as possible before taking the exam to maiximize their score/chances

 

[Matthew9Thirtyfive]

any official update on how class of 2023 is affected?

No way to know until they put out more information. It will depend on when they actually initiate this and how they plan to report (i.e., will anyone applying for residency in 2022 be reported as a P regardless of when they took it, or will you get a score if you take it before the change). I'm inclined to believe they will initiate this at a time where the vast majority of the people taking step 1 after the change will not be applying until the following year. Cause otherwise, all of us in c/o 2023 who take it in 3rd year could be applying to residency with a P while the majority of the applicants have scores. That would be ****ty for us and PDs, I assume.

 

[longhaul3]

is there a particular advantage to taking the Step 2 exam earlier or later? What prevents people from waiting until the end and having as much expereince as possible before taking the exam to maiximize their score/chances

The main decision is whether to take it in time for your score to be included in your ERAS application. If you get your score back before 9/15, it will automatically be sent with your Step 1 score. If it's not back by 9/15, you have the power to release it to programs when you decide to.

CK is like a giant combination of all the shelf exams. Most people are best prepared for it closer to the end of their clerkship year, rather than later on in 4th year when you've forgotten everything that's not relevant to your chosen specialty. If you go into neurosurgery, for instance, you're not doing a bunch of various electives that will help you on Step 2. You're doing all neurosurgery all of 4th year, and there will be about 2 neurosurgery questions on CK.

 

[ciestar]

is there a particular advantage to taking the Step 2 exam earlier or later? What prevents people from waiting until the end and having as much expereince as possible before taking the exam to maiximize their score/chances

one advantage is not having to sit down and study for it while doing sub-i’s, aways, or interviews.

i took CK in May

 

[DokterMom]

is there a particular advantage to taking the Step 2 exam earlier or later? What prevents people from waiting until the end and having as much expereince as possible before taking the exam to maiximize their score/chances

I have to think with Step 1 going P/F that everyone who anticipates a good score or is applying to a competitive residency will now take it early enough to release scores before interview decisions are made.

And that now that 'everyone' will also include DOs

 

[Engrailed]

I have to think with Step 1 going P/F that everyone who anticipates a good score or is applying to a competitive residency will now take it early enough to release scores before interview decisions are made.

And that now that 'everyone' will also include DOs

Ah, that clarifies a lot-and succinctly! thanks @DokterMom

 

[Mad Jack]

Regrettably, it is very tough to compare people across schools... especially in residencies with a small number of spots. What if everyone has good letters and solid grades. Then you're going by school reputation and "x-factor." Oddly enough... the latter is the reason colleges are citing for keeping asians out of top colleges. Without step 1, there's no equalizer. Everything is subjective.

While step 1 may not have been developed to sort students, they have to realize that it's the easiest way to facilitate upward mobility. Otherwise, it's harder for a student from a smaller school to make a splash.

Make those audition rotations count!

 

[SDeduN]

Potential unintended consequences all round. I‘m interested to see what more they have to say on this in the weeks/months ahead. The plan/reasoning, if you will. Hope there is one.

Another random thought that popped into my head, what if they increase the pass threshold for Step 1? So it’s harder to pass, thus easier to fail. Not sure on the “merit” of doing that aside slowing progression (which ironically would probably make them more money with increased retakes) or maybe that would even thin the residency application pool year-to-year. Hmm.

 

[7331poas]

Make those audition rotations count!

audition rotations only matter for single programs. PDs know that a vast majority of the positive LORs coming from these sub-Is are complete BS.

 

[Matthew9Thirtyfive]

one advantage is not having to sit down and study for it while doing sub-i’s, aways, or interviews.

i took CK in May

Maybe I’ll just take CK first and then cram for step 1 after since it’ll just be p/f. Use my dedicated for CK.

 

[Mass Effect]

People's concerns are very valid. This is not just about the format of a test. People are putting themselves through debt and years of rigorous work. They deserve to have an equal chance at a great residency program, even if they don't go to HMS...the stress people are experiencing is valid. If the AAMC can somehow clarify how they plan on ensuring that the match process is not becoming less objective, I'm sure people would stop "projecting."

So if you were still in college and knew Step 1 would be pass/fail and you didn't get into a top med school, you wouldn't have chosen med school at all? Come on, you're not guaranteed a 260 on Step 1. You can study your ass off and still get slammed. Just ask in the Step forums. Everyone thinks they'll get that coveted score and everyone is quick to say they did, but the reality is that most people score average (which is why it's the average). SDN is the only place on Earth where 99% of the population scored over 250. Everyone needs to take a breath and realize that when the metrics change, you change your strategy. Shouting about the unfairness of it is counter-productive.

Step 1 was an “equalizer” for applicants from all ranks of med school.

It was a stupid equalizer. It had little to do with how you'd perform in residency and was never meant to be any kind of equalizer.

 

[Mass Effect]

Correct me if I am wrong, but Step 1 is more on the individual, while i could foresee Step 2 CK being more dependent on the diversity and quality of clinical education you can get, which will vary significantly based on where you go to school and how well that school is connected.

You're wrong. The only difference between Step 1 and Step 2 is that Step 2 is actually relevant because it's all clinical. People still use UWorld, people still take practice exams, people still study hard for it, regardless of quality of clinical education.

A critical element of step 1 was that EVERYONE had to take it. Only a subset will be taking step 2, which makes it harder to interpret. Everyone with good CVs or anyone who suspects they might do poorly will elect to take step 2 very late.

And you don't think that's a problem? I, for one, am glad that the emphasis is on Step 2. It forces everyone to take it before applying.

Schools will likely make Step 2 completion mandatory by July of 4th year.

 

[ace_inhibitor111]

You're wrong. The only difference between Step 1 and Step 2 is that Step 2 is actually relevant because it's all clinical. People still use UWorld, people still take practice exams, people still study hard for it, regardless of quality of clinical education.



And you don't think that's a problem? I, for one, am glad that the emphasis is on Step 2. It forces everyone to take it before applying.

Schools will likely make Step 2 completion mandatory by July of 4th year.

Yup, I’m sure knowing how to treat genitourinary syndrome of menopause is a great use of my time now that I know I’m going into surgery. Step 2 is an absolutely useless test for anyone not going into EM, FM, or IM.

 

[VA Hopeful Dr]

Yup, I’m sure knowing how to treat genitourinary syndrome of menopause is a great use of my time now that I know I’m going into surgery. Step 2 is an absolutely useless test for anyone not going into EM, FM, or IM.

Its crazy, its almost like we expect people to be doctors and not mere technicians

 

[ace_inhibitor111]

Its crazy, its almost like we expect people to be doctors and not mere technicians

Doing something based on guidelines or an algorithm is the definition of being a technician.

 

[ReturnToMed]

when the medicine vs surgery war starts

 

[ciestar]

Its crazy, its almost like we expect people to be doctors and not mere technicians

“Rest per primary team”

 

[Mad Jack]

Yup, I’m sure knowing how to treat genitourinary syndrome of menopause is a great use of my time now that I know I’m going into surgery. Step 2 is an absolutely useless test for anyone not going into EM, FM, or IM.

You'd be surprised how often routine medical stuff comes up elsewhere in medicine. Nothing worse than a surgeon that has forgotten everything about being a doctor and tries to dump patients on IM the second they're closed...

 

[Usmle_Seeker2020]

Probably most of them.


Simply passing Step 1 is honestly not terribly difficult. please stop saying step 1 is not a difficult exam just because you disagree with someone on the pass/fail change. We all studied hard for step 1, even the ones who weren't interested in scoring high. I don't remember studying hard for an easy exam.



Most of Step 1 is not zebras..

 

[Usmle_Seeker2020]

I disagree

and?

I was speaking in the context of wanting a good score.

if you have noticed, suddenly step 1 has become an easy exam to pass in their eyes. Oh they were studying hard for step 1 just because all of them wanted to score really high !!!. But if they just need to pass, oh just another easy exam to pass, never mind. They get to this point of silliness just because they want to prove that their opinion regarding step 1 is right.

 

[Usmle_Seeker2020]

I'm completely surprised by the negative response to this. Do you guys just enjoy punishing yourself or something?

It was (is) a stupid exam that was (is) being completely misappropriated in terms of its function.

Very stupid exam.

 

[ace_inhibitor111]

if you have noticed, suddenly step 1 has become an easy exam to pass in their eyes. Oh they were studying hard for step 1 just because all of them wanted to score really high !!!. But if they just need to pass, oh just another easy exam to pass, never mind. They get to this point of silliness just because they want to prove that their opinion regarding step 1 is right.

If you look at the new practice NBMEs, you can miss almost 80 out of 200 questions and still pass the exam.

 

[Mass Effect]

Yup, I’m sure knowing how to treat genitourinary syndrome of menopause is a great use of my time now that I know I’m going into surgery. Step 2 is an absolutely useless test for anyone not going into EM, FM, or IM.

Says the med student who's in for a rude awakening...

 

[MedicineZ0Z]

Yup, I’m sure knowing how to treat genitourinary syndrome of menopause is a great use of my time now that I know I’m going into surgery. Step 2 is an absolutely useless test for anyone not going into EM, FM, or IM.

Your general argument can be made about anything in education and isn't exclusive to medicine. Also, if you think step 2 knowledge is useless to you, step 1 is 100x more useless for a surgeon.
Also, I strongly disagree that step 2 is useless for other fields. Yes it is MOST useful for FM/IM/EM. But Peds? They also take care of older teens and young adults and hence IM/FM/Obgyn general knowledge and psych become very useful.
Obgyn? General medicine knowledge is very useful for many (most) Ob triages, maternal medicine, etc. Gensurg? Again, medicine knowledge is very useful. Psych? Same thing.

I agree subspecialties don't benefit from general medical knowledge as much, but the majority of fields do.


edit: wait, are you in ms1-2? If ms3, what the hell are you doing on your rotations? your comment is ridiculous for someone who has any clinical exposure.

Very stupid exam.

Most people in medicine are masochists so it makes sense that they're mad over not having to study extreme hours for a test that has 0 purpose beyond establishing baseline knowledge.

 

[dienekes88]

You're wrong. The only difference between Step 1 and Step 2 is that Step 2 is actually relevant because it's all clinical. People still use UWorld, people still take practice exams, people still study hard for it, regardless of quality of clinical education.



And you don't think that's a problem? I, for one, am glad that the emphasis is on Step 2. It forces everyone to take it before applying.

Schools will likely make Step 2 completion mandatory by July of 4th year.

Mandating step 2 before July of 4th year just makes step 2 the new step 1. I think that's fine, because I think standardized tests are important. But. There's nothing that will prevent the NBME from making step 2 p/f for the same reason that step 1 is now p/f.

Many places will not be behind making step 2 mandatory before 4th year, for the simple fact that it doesn't help them. "Top" medical schools have nothing to gain from having their students take step 2 if it's not mandated.

 

[MedicineZ0Z]

What’s with all these calls to authority? I’m currently studying for Step 2 right now and I personally don’t find it useful at all for surgery. You’re forgetting just how similar Step 2 is to Step 1, with the exception of taking it at point in time when I’ve already decided on a specialty and don’t have the patience to study for something that’s for the most part irrelevant.

It's not calls to authority dude. What do you think happens when you admit patients to your service? You just dismiss their dozen medical problems and just operate?

You don't yet understand the scope of your future practice and hence can't determine that step 2 knowledge isn't useful.

 

[Phloston]

Been kinda lurking on this post, but not really seen this mentioned....

But if all goes as predicted (I agree with what the DDS student completing the MD part of this training) is that now, premeds may lean toward choosing a school of prestige and devalue comfort. Why force yourself to be in a place that doesn't feel right for 3/4 years? Well, P/F USMLE might be why.

I would much rather enjoy the medical experience to avoid burnout and decrease stress levels by choosing where I see myself fitting in best. For some, they may already love the environment at a top MD program, which is totally great! But now, it seems like a lot of comfort may be sacrificed for better potential.

I have also seen the benefits, and there's lots to say both ways. However, since we aren't four years ahead, can't quite say what will happen for sure...

Most people don't have the luxury of comfort. This is wishful thinking. Most people just hope to get in anywhere.

 

[Mass Effect]

Mandating step 2 before July of 4th year just makes step 2 the new step 1. I think that's fine, because I think standardized tests are important. But. There's nothing that will prevent the NBME from making step 2 p/f for the same reason that step 1 is now p/f.

Many places will not be behind making step 2 mandatory before 4th year, for the simple fact that it doesn't help them. "Top" medical schools have nothing to gain from having their students take step 2 if it's not mandated.

Then the "top" med school students with a Step 1 pass and no Step 2 score can compete against those who have a 250+ Step 2 score.

 

[Mass Effect]

It's not calls to authority dude. What do you think happens when you admit patients to your service? You just dismiss their dozen medical problems and just operate?

You don't yet understand the scope of your future practice and hence can't determine that step 2 knowledge isn't useful.

Like I said, rude awakening is coming...

 

[Phloston]

You could really argue both ways... Now the international students would basically be shunned from residency and second thing is that you dont have to stress too much on the minutiae that you may never see clinically ever in your life... .

Minutiae focus will transfer over. Maybe no student will care anymore about why foscarnet is effective in ganciclovir-resistant CMV, but they'll all of a sudden care about the the 6th most common indication for MRCP.

 

[Phloston]

Med school was always difficult. It didn't suddenly get difficult with step. Before Step 1 mania, it was class rank, AOA etc. Step 1 mania came about because the 3rd party resources became almost sure-fire ways to well on the exam, in they just explained things better than 90% of faculty. Make no mistake, this it an attempt to re-justify the high costs of medical tuition. Schools knew that their pre-curriculum were slowly becoming outdated, clunky and irrelevant in the modern era, and instead of looking at their flaws, they changed the game to buy them some time.

^This.

 

[MedicineZ0Z]

Minutiae focus will transfer over. Maybe no student will care anymore about why foscarnet is effective in ganciclovir-resistant CMV, but they'll all of a sudden care about the the 6th most common indication for MRCP.

Clinical minutiae is actually useful. Basic sciences minutiae is not. I can use esoteric clinical details at some point, but if you try and justify clinical decision making based off of basic sciences minutiae; you'll be committing malpractice at some point.

 

[dienekes88]

Then the "top" med school students with a Step 1 pass and no Step 2 score can compete against those who have a 250+ Step 2 score.

Indeed. Will make it a little tricky.

Especially since the same argument for step 1 being useless can be applied to step 2.

The Hopkins/WashU kid with 2 first author publications may not want to risk it with taking step 2 early, since it is high risk/low reward. But the state school kid with no pubs may take step 2 (low risk/high reward) and knock it out of the park with a 260. Suddenly. Programs have a difficult decision to make. Then. There are all the students who try to take step 2 early and do middling or poorly.

 

[Phloston]

There is a singular emphasis placed on one's step score that is inescapably tied to feelings of intellectual inadequacy/prowess for a lot of people. If you don't believe that, maybe you just run with a chiller crowd than my school has to offer.

Again I don't think the low-yield PhDs got to tell the NBME what to do on this one. Their test wasn't built for this. What was happening was psychometrically unsound and they'd been saying it for years, falling on deaf ears.

Then explain the myopia to not simultaneously make the 2CK P/F. Clearly people understand the importance of objective scoring to stratify out students. The bottom line is that this isn't 1996 where education is constrained to what you learn behind four walls anymore. The internet has made obsolete being physically present at an institution to get good education. Students can sit in Iceland and do three Qbanks and learn more than attending lectures every day at probably most institutions.

 

[Phloston]

1. Nothing changes except all the pressure gets moved to Step 2. The students that were skipping class and bailing on small group bull**** to study for Step 1 will now just be grinding for Step 2 hammering the Dorian deck and UWorld while on the wards. It truly is burying your head in the sand if you think that won't happen. 100%, despite what the NBME says right now, Step 2 CK will ultimately end up P/F as well. If they thought a bunch of PhDs were complaining hard about having their lectures skipped, just wait until the clinicians are being blown off en masse.
2. Step 2 is taken right before residency applications. You could work your butt off for a specific field only to find out that you aren't competitive for it with exceptionally little time to change course, probably on your first Sub-I.
3. There absolutely has to be a way to discriminate between residency applicants. Step 1 served that function as a standardized measure. If they wanted to move it to P/F they should have developed another standardized system before getting rid of Step 1 scoring. Without standardized measures subjective random crap takes its place like name of school, clinical grades, and research (which the majority of the time is the equivalent to monkey's throwing poop at the wall and seeing what sticks).
4. Anyone from a low tier/unranked MD or DO school gets completely shafted. The ceiling for good DO/low tier MD candidates just came crashing down. People's ability to match mid-tier programs in GS/IM/OB/Etc, is now significantly handicapped. Effectively, the ceiling to match became the very level at which you attend school. No more punching up.
5. The NBME didn't clarify anything at all with regards to its implementation and left a lot up in limbo. They have effectively increased stress to unprecedented levels at dozens of schools and classes by not clarifying what the plan is.
6. Stress will increase at every step of the medical pathway, even bleeding into the pre-med levels now since what school you go to is more important than ever before.

It's honestly very ignorant to think that none of these things will happen. There are PD's in this very thread saying as such themselves.

AnatomyGrey12 nailed it. Good post here.

 

[MedicineZ0Z]

Malpractice would be a hospitalist overstepping their boundaries and thinking they could manage someone’s GPA without consulting rheumatology because of what they learned when studying for Step 2. Guidelines change, critically thinking and diagnosis for the most part stays the same.

1. That isn't malpractice. You can manage anything, especially as a hospitalist/generalist. Look up the definition of malpractice. You're arguing about whether or not you should do something. And yes in the real world we would consult for GPA, because it's the right thing to do and not because managing it is malpractice by definition.

2. What you just said is completely unrelated. What are you going to do with your patient's diabetes? Or their inhalers. Or many other bread and butter medical issues? That's the core argument for why you need medical knowledge.

 

[ace_inhibitor111]

1. That isn't malpractice. You can manage anything, especially as a hospitalist/generalist. Look up the definition of malpractice. You're arguing about whether or not you should do something. And yes in the real world we would consult for GPA, because it's the right thing to do and not because managing it is malpractice by definition.

2. What you just said is completely unrelated. What are you going to do with your patient's diabetes? Or their inhalers. Or many other bread and butter medical issues? That's the core argument for why you need medical knowledge.

I feel there is a disconnect to what you think is tested on Step 1 and Step 2. Step 1 already tests the basics of diabetes and COPD medications. Step 2 only asks questions like what is the target HbA1c and what should be added on for better control. These things aren’t useful for someone not managing these conditions in the appropriate setting (such as primary care).

 

[Phloston]

I'm an M1 in an accelerated curriculum and will be starting my clinicals in spring of next year. I'm interested in surgery and think it would be better if I take step 1 before it becomes pass/fail. I'm not extremely interested in doing tons of extracurriculars or worrying my ass off over evaluations in clinicals. Could I/should I try to take it before it becomes pass/fail? Any advice is appreciated, this is kind of throwing off all my plans on how to approach school.

If you can blow Step 1 out of the park then take it for the numerical score yes. I'm an example of an ongoing strong test-taker who always just did so-so in school. If I were in your shoes I'd be gunning already yes.

 

[Phloston]

You are still going to have a full application including good evals on clinicals, research , and other ecs. even if step 1 was not pass fail . Even in the current climate you dont just waltz into a residency position with just a step score a picture of yourself wearing a surgical mask.

If he can ace the exam it's in his best interest to sit before the switch.

 

[Phloston]

I bet an applicant with a 250 of Step 1 will be judged the same as someone with a Step 1 of Pass and a Step 2 of 260, rendering this apparent advantage moot. Residencies will just extrapolate. It's sort of like the old MCAT vs new MCAT. There was a time when applicants could literally send in scores for both.

This is probably accurate.

 

[Lawpy]

I still maintain that all Steps should've been changed to quartiles. The current change is absolutely absurd

 

[MedicineZ0Z]

I feel there is a disconnect to what you think is tested on Step 1 and Step 2. Step 1 already tests the basics of diabetes and COPD medications. Step 2 only asks questions like what is the target HbA1c and what should be added on for better control. These things aren’t useful for someone not managing these conditions in the appropriate setting (such as primary care).

I've taken both of them and know what's tested on both. Step 1 material doesn't in any way prepare you for managing a patient's medical problems. Step 2 material gives you a foundation of knowledge that you can apply as you accumulate clinical experience.

Again, you also ignore my key question. Do you think as a surgeon, that you will just ignore your patient's ongoing medical issues once they're admitted to your service?

 

[7331poas]

You're wrong. The only difference between Step 1 and Step 2 is that Step 2 is actually relevant because it's all clinical. People still use UWorld, people still take practice exams, people still study hard for it, regardless of quality of clinical education.



And you don't think that's a problem? I, for one, am glad that the emphasis is on Step 2. It forces everyone to take it before applying.

Schools will likely make Step 2 completion mandatory by July of 4th year.

No, the difference between step 1 and step 2 is the writing quality. Step 2 CK was a wayyy worse written exam with vague question stems and questionably correct answer choices.