MD & DO What does the future look like post-Steps 1-3 P/F?

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slowthai

slowthai

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This is a speculation/prediction thread. Serious and unserious answers are welcome.

I for one predict that some specialties will begin to use in-service exams + non-categorical years (like OMFS does) + research years as hard requirements for entry. You've got the trifecta of objectivity, in person evaluation, and research productivity. Say hello to PGY-30+, lol.

Don't know when this could happen. Maybe 20+ years from now. Can't wait to tell med students "I don't think I could match ortho if I was applying today!" lol
 
Going to be interesting when an objective, 100% chance of spending 2-300K bumps up against a subjective, ??% chance of getting to do what you want to do in life, regardless of how hard you work.

Being a member of the class of 2022, I feel lucky being the last class to have their match lists in by the time this change could take place.

1581633703405.png


^ How I feel about it and how I imagine the NBOME feels about making their decision.
 
ktyler789 said:
Going to be interesting when an objective, 100% chance of spending 2-300K bumps up against a subjective, ??% chance of getting to do what you want to do in life, regardless of how hard you work.

Being a member of the class of 2022, I feel lucky being the last class to have their match lists in by the time this change could take place.

View attachment 295571

^ How I feel about it and how I imagine the NBOME feels about making their decision.
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I don't particularly love the p/f decision but I wouldn't say step 1 was a great metric either. It wasn't subjective but it was really crappy, vague and the score was essentially meaningless due to such a wide confidence interval. And there are always people who won't get to do what they want regardless of how hard they work. There are only so many competitive specialty spots to go around and someone is going to be the odd man out if too many people apply.
 
They’ll probably do it like before the Step mania. Grades and ECs. Will likely also make aways mandatory for many specialties
 
Dantrolene FC said:
I bet they probably only 10% of the applications back then, which is much more reasonable to read the entire application without a filter.
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I thought this as well, but according to @efle, there's actually less competition overall (lumping all specialties together) but it's skyrocketed for the surgical subs + derm.
 
slowthai said:
I thought this as well, but according to @efle, there's actually less competition overall (lumping all specialties together) but it's skyrocketed for the surgical subs + derm.
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Yep, the lowest it ever got was 1.25 residency seats per 1 US senior, and currently its 1.5 seats per person. Its just many seats in primary care we dont like to take. But, even in surgical subspecialties the numbers applying per spot aren't much different than 10+ years ago before Step was king. The big change has been the number of applications each person sends; that's been skyrocketing. But eventually everyone still just fills one seat.
 
efle said:
The big change has been the number of applications each person sends; that's been skyrocketing. But eventually everyone still just fills one seat.
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That's still a problem though! How are PDs supposed so sort through the increased number of applications? I agree that Step 1 was not designed to stratify applicants, but now PDs will put increased emphasis on even less useful/objective measures such as clinical rotation grades and school prestige.
 
Anonymous Lurker said:
That's still a problem though! How are PDs supposed so sort through the increased number of applications? I agree that Step 1 was not designed to stratify applicants, but now PDs will put increased emphasis on even less useful/objective measures such as clinical rotation grades and school prestige.
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The solution to the rising number of applications is to make students write secondary applications.

Before people chastise me, I’d hate that process very much.
 
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efle said:
Yep, the lowest it ever got was 1.25 residency seats per 1 US senior, and currently its 1.5 seats per person. Its just many seats in primary care we dont like to take. But, even in surgical subspecialties the numbers applying per spot aren't much different than 10+ years ago before Step was king. The big change has been the number of applications each person sends; that's been skyrocketing. But eventually everyone still just fills one seat.
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That is definitely due to change with the proliferation of schools. But I agree, the unlimited app numbers has been making it crazy. People have thought about instituting an app limit. That could work, but it would theoretically hamstring the low tier MDs, DOs, and IMGs. But to be fair, I think your only real pathway into these fields if you belong to the DO/IMG category is multiple research years at one to two places, which should theoretically only require application numbers in the single digits for each person.

But it would also limit the reach of the mid to low tier applicants, which I think make up the majority of applicants.
 
Dantrolene FC said:
The solution to the rising number of applications is to make students write secondary applications.

Before people chastise me, I’d hate that process very much.
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They tried that crap in ENT. Didn't work out very well, lol. They scrapped it after a year I think. They could start requiring aways to even apply, which would drastically, drastically drop the number of apps. Like there's only so many aways one can do in time for ERAS. Don't think people would be able to do more than 4-6, depending. It would be similar to how the DO side operates, I believe.
 
slowthai said:
They tried that crap in ENT. Didn't work out very well, lol. They scrapped it after a year I think. They could start requiring aways to even apply, which would drastically, drastically drop the number of apps. Like there's only so many aways one can do in time for ERAS. Don't think people would be able to do more than 4-6, depending. It would be similar to how the DO side operates, I believe.
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Actually, it worked TOO well in ENT which is why they scrapped it. They actually had a spot open in SOAP last year for the first time in a while and I think that scared them - they didn't want to scare away competitive applicants. However, if everybody does it (or at least the small competitive fields), then it might actually be a feasible solution.

I also think a hard app limit (say ~15 per applicant?) is overblown in the effect it would have on mid/low tier students. These students are already being screened out without ever being looked at at top programs. Applying to 20 top programs is the exact same as applying to 3 if you get zero applications either way.

The problem right now is kind of akin to the problem many men have with online dating (if you want to read more about that). Because the risk of not matching is associated with such devastating consequences, even very competitive applicants are sending tons of what could be considered "safety" applications. So every program in small competitive specialties, even those that are less likely to match the cream of the crop candidates, are exposed to the best of the best. Although it may not be realistic for them to match these people, they fill every year regardless, so why not take a swing for the fences and use up most of their interview slots on these top applicants while including just enough lower tier applicants to fill safely? The top percentage of applicants snag more than their share of interviews, a problem that is actually exacerbated by not capping applications.

In addition, this degrades programs ability to choose people who actually want to be there when choosing from the middle of the pack applicants. They have to go by really soft or random things to decide who to invite. Whereas with an application cap, it is very clear that everybody who is applying to your program is seriously considering you. I argue that this would actually increase lower tier applicants chances at the programs they would like to be at, within reason. Maybe you don't get to take as many shots at the moon (which might initially feel more detrimental), but you actually end up with MORE say over where you're likely to match.

Edit: curious to hear @efle take on this, I don't actually know if there are numbers supporting a bimodal distribution of interviews/application or not.
 
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FindersFee5 said:
Actually, it worked TOO well in ENT which is why they scrapped it. They actually had a spot open in SOAP last year for the first time in a while and I think that scared them - they didn't want to scare away competitive applicants. However, if everybody does it (or at least the small competitive fields), then it might actually be a feasible solution.

I also think a hard app limit (say ~15 per applicant?) is overblown in the effect it would have on mid/low tier students. These students are already being screened out without ever being looked at at top programs. Applying to 20 top programs is the exact same as applying to 3 if you get zero applications either way.

The problem right now is kind of akin to the problem many men have with online dating (if you want to read more about that). Because the risk of not matching is associated with such devastating consequences, even very competitive applicants are sending tons of what could be considered "safety" applications. So every program in small competitive specialties, even those that are less likely to match the cream of the crop candidates, are exposed to the best of the best. Although it may not be realistic for them to match these people, they fill every year regardless, so why not take a swing for the fences and use up most of their interview slots on these top applicants while including just enough lower tier applicants to fill safely? The top percentage of applicants snag more than their share of interviews, a problem that is actually exacerbated by not capping applications.

In addition, this degrades programs ability to choose people who actually want to be there when choosing from the middle of the pack applicants. They have to go by really soft or random things to decide who to invite. Whereas with an application cap, it is very clear that everybody who is applying to your program is seriously considering you. I argue that this would actually increase lower tier applicants chances at the programs they would like to be at, within reason. Maybe you don't get to take as many shots at the moon (which might initially feel more detrimental), but you actually end up with MORE say over where you're likely to match.
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All great points.

I'm all for a cap as well. I think 15 may be TOO harsh. What sounds right (and not completely unfair) is ~30, with couples matching maybe double that? That would allow people to pick a few different locations and 'tiers', without mindlessly applying nor feeling short-changed. There are 4th years at my school who applied to CA programs just so they could go hang out at the beach (with no intention of ranking anything in CA high). There are also people with good/great stats who applied to 100+ programs in primary care specialties. Something has to be done.

My question is if this were to ever come true, how would programs make sure that they filled? Would programs be allowed to fill on a rolling basis?
 
tulip81 said:
All great points.

I'm all for a cap as well. I think 15 may be TOO harsh. What sounds right (and not completely unfair) is ~30, with couples matching maybe double that? That would allow people to pick a few different locations and 'tiers', without mindlessly applying nor feeling short-changed. There are 4th years at my school who applied to CA programs just so they could go hang out at the beach (with no intention of ranking anything in CA high). There are also people with good/great stats who applied to 100+ programs in primary care specialties. Something has to be done.

My question is if this were to ever come true, how would programs make sure that they filled? Would programs be allowed to fill on a rolling basis?
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I went into the application process with a very negative bias, but after all has been said and done, I have been quite pleased with the process, other than the excessive application fees.

All in all, I got an interview at all the programs I truly wanted interviews at except for 1 program. But if I got an interview at that program, it would probably be ranked #5 on my list, so I didn’t really lose out on much.

The best way to limit the applications is to make it more difficult to apply to a program. Right now you just click a button, and I applied to plenty of programs without ever even reading their website or anything.

For med school, you had to do secondary applications and pay a fee of about $50-100 for each school and I only applied to 6 schools because of that. So I think that system would be the best way to limit applications without setting a hard cap which would make it difficult for people with lesser stats.

And I would be curious to see how many applications the programs actually read. Some programs said they had 1200 applications this year for only 10 slots. But how many of those get filtered out based on USMLE, and IMG vs USMD vs DO status.

I bet the mid-tier and up programs only look at 25% of their applications.
 
In a podcast released on the official USMLE announcement page, making CK P/F was never and will never be in the talks. Not saying it's concrete, but they also admitted they want CK to be the new Step 1 since they feel it's a better predictor of residency performance
 
FutureSurgical said:
In a podcast released on the official USMLE announcement page, making CK P/F was never and will never be in the talks. Not saying it's concrete, but they also admitted they want CK to be the new Step 1 since they feel it's a better predictor of residency performance
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Yeah I listened to it too. It’s just the timing of step 2 sucks. I honestly think and can imagine worst case scenario for DO students where we are mostly relegated to primary care. I mean if this happened we would fill the shortage and shaft IMGs. I believe networking will be key and any prospective DOs should choose programs with sponsored ACGME.
 
Kumorebi said:
Yeah I listened to it too. It’s just the timing of step 2 sucks. I honestly think and can imagine worst case scenario for DO students where we are mostly relegated to primary care. I mean if this happened we would fill the shortage and shaft IMGs. I believe networking will be key and any prospective DOs should choose programs with sponsored ACGME.
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I'm not sure of the timing for CS/CK. When do people usually take that (as opposed to when we should take it when Step 1 becomes P/F?) I've seen sometimes right before interview season, people will take it just to show they have it on ERAS.
 
FutureSurgical said:
I'm not sure of the timing for CS/CK. When do people usually take that (as opposed to when we should take it when Step 1 becomes P/F?) I've seen sometimes right before interview season, people will take it just to show they have it on ERAS.
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Depends on the school’s curriculum. The problem is they require step 1 now as a pre-req to step 2 CK. So even if one wanted to take step 2 CK before step 1, this can’t happen anymore. Imagine waiting for interview season planning to go for ortho residency and suddenly you get your step 2 CK back. 220. You wasted medical school (over statement, ik) pursuing a specialty you are no longer competitive for.
 
FutureSurgical said:
I'm not sure of the timing for CS/CK. When do people usually take that (as opposed to when we should take it when Step 1 becomes P/F?) I've seen sometimes right before interview season, people will take it just to show they have it on ERAS.
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Summer between 3rd and 4th years seems ideal. That’s when I took mine and I had my score back in time for ERAS.
 
Dr. Death said:
If there is money to be made, they'll find a way to allow it.
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libertyyne said:
Why?
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My thought is based on the fact that the ACGME is a governing body that currently conducts zero examinations. If given the option to create a whole new department dedicated to creating/validating standardized tests for EACH speciality OR not doing it, I assume they would prefer not doing it.
 
OnePunchBiopsy said:
My thought is based on the fact that the ACGME is a governing body that currently conducts zero examinations. If given the option to create a whole new department dedicated to creating/validating standardized tests for EACH speciality OR not doing it, I assume they would prefer not doing it.
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Acgme would not be doing it. It would be the individual specialty societies that administer in service exams that would be doing it.
 
Kumorebi said:
Depends on the school’s curriculum. The problem is they require step 1 now as a pre-req to step 2 CK. So even if one wanted to take step 2 CK before step 1, this can’t happen anymore. Imagine waiting for interview season planning to go for ortho residency and suddenly you get your step 2 CK back. 220. You wasted medical school (over statement, ik) pursuing a specialty you are no longer competitive for.
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The only thing I’ve seen on the site was that they require step 1 for CS now. I don’t see anything about it being required for CK.
 
Matthew9Thirtyfive said:
The only thing I’ve seen on the site was that they require step 1 for CS now. I don’t see anything about it being required for CK.
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Yeah, I'm kinda surprised they didn't make step 1 mandatory to be able to take CK. That would be a humongous money maker, especially for next year's class of DOs.
 
slowthai said:
Yeah, I'm kinda surprised they didn't make step 1 mandatory to be able to take CK. That would be a humongous money maker, especially for next year's class of DOs.
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Yeah, I'm actually wondering if it would make more sense to use my dedicated time to really study for and take 2CK so that I can do really well on it, then just cram enough for step 1 to be able to pass it.
 
Matthew9Thirtyfive said:
Yeah, I'm actually wondering if it would make more sense to use my dedicated time to really study for and take 2CK so that I can do really well on it, then just cram enough for step 1 to be able to pass it.
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Exactly what I would do. Let me know how you like Dorian, lol
 
Matthew9Thirtyfive said:
Yeah, I'm actually wondering if it would make more sense to use my dedicated time to really study for and take 2CK so that I can do really well on it, then just cram enough for step 1 to be able to pass it.
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You should only do this if your dedicated time is after your clerkship year. You really want to have had all the didactics, taken all the shelf exams, seen some of the cases, etc. If that's the case for you, I think this is a good move.

As I mentioned before, be careful planning to take Step 1 after that because it's really hard to schedule CS.
 
longhaul3 said:
You should only do this if your dedicated time is after your clerkship year. You really want to have had all the didactics, taken all the shelf exams, seen some of the cases, etc. If that's the case for you, I think this is a good move.

As I mentioned before, be careful planning to take Step 1 after that because it's really hard to schedule CS.
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It is. We take all our steps after a year of clerkship, then we get 3 weeks of leave and 6 weeks of dedicated. I feel like that would be plenty of time to study for 2CK, then hit up step 1.
 
Matthew9Thirtyfive said:
It is. We take all our steps after a year of clerkship, then we get 3 weeks of leave and 6 weeks of dedicated. I feel like that would be plenty of time to study for 2CK, then hit up step 1.
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It absolutely is. CK and step 1 are not the problem with that scenario; it's CS with the updated pass-step-1 requirement. Say your clinical year ends at the end of December, you have your dedicated however many weeks, then you take CK and Step 1 some time in Feb/March of the year before you graduate. You really want at least 9 months to schedule CS in my experience (my own exam, seeing my classmates scramble, and then advising those who came after me). If you have to wait 4 weeks for a Step 1 score, then get your school to sign off on your CS application, and wait for the permit, it could be April or even May, and there may not be any CS dates available until the spring of your graduation year. That's dangerous, and a lot of schools have a rule that you have to take CS by December or whatever in order to avoid this pickle.

I think the answer is to take a couple weeks for yourself at the end of preclinical, pass Step 1, then go on to your clerkship year knowing you can schedule CS for whenever during your 4th year. As a first-year med student I realize this may not be an option for you because Step 1 will still be scored when you finish pre-clinical (if I'm reading my mental calendar correctly), but that's the best option I foresee for future classes when this situation reaches equilibrium.
 
longhaul3 said:
It absolutely is. CK and step 1 are not the problem with that scenario; it's CS with the updated pass-step-1 requirement. Say your clinical year ends at the end of December, you have your dedicated however many weeks, then you take CK and Step 1 some time in Feb/March of the year before you graduate. You really want at least 9 months to schedule CS in my experience (my own exam, seeing my classmates scramble, and then advising those who came after me). If you have to wait 4 weeks for a Step 1 score, then get your school to sign off on your CS application, and wait for the permit, it could be April or even May, and there may not be any CS dates available until the spring of your graduation year. That's dangerous, and a lot of schools have a rule that you have to take CS by December or whatever in order to avoid this pickle.

I think the answer is to take a couple weeks for yourself at the end of preclinical, pass Step 1, then go on to your clerkship year knowing you can schedule CS for whenever during your 4th year. As a first-year med student I realize this may not be an option for you because Step 1 will still be scored when you finish pre-clinical (if I'm reading my mental calendar correctly), but that's the best option I foresee for future classes when this situation reaches equilibrium.
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Yeah, how I try to do it will largely depend on when we get more info. If it will be scored for me regardless, I'll likely just focus on it for my dedicated and then take step 2 whenever. We have to take CK at some point before October and CS no later than November of 4th year. Either way though, I would be taking Step 1 (or CK) in mid-Feb at the latest. If I end up being part of the P/F group, I will probably use my leave to study for step 1, take it at the beginning of January, and then use the actual 6 weeks of dedicated for CK and take it in the beginning of Feb. That way I can get CS scheduled.
 
Set a max cap of applications at 40 with a supplemental essay for every program.
 
Sterling_Archer said:
Why not just cap the amount of applications students can submit?
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This has been discussed for years, but it's unclear if it would survive inevitable legal challenges.

The rationale for creating the Residency Explorer was to encourage self-limiting of applications. I'm not sure if it has been effective, but I'm not optimistic.

Other ideas have been floated. With Step 1's fate now settled I think ERAS will come under increasing pressure to do something constructive.
 
Med Ed said:
This has been discussed for years, but it's unclear if it would survive inevitable legal challenges.

The rationale for creating the Residency Explorer was to encourage self-limiting of applications. I'm not sure if it has been effective, but I'm not optimistic.

Other ideas have been floated. With Step 1's fate now settled I think ERAS will come under increasing pressure to do something constructive.
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It is my understanding they limit the applications to 45 in the SOAP. So I don’t think they would have issues from the legal side of things.
 
Dantrolene FC said:
It is my understanding they limit the applications to 45 in the SOAP. So I don’t think they would have issues from the legal side of things.
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Perhaps, but it's not exactly apples-to-apples. I think you are far more likely to incur legal challenges from a cap on the broader application process compared to a supplemental, time-limited process that follows. The NRMP has already undergone a serious antitrust lawsuit that started in 2002. It won the case in 2004, but the whole incident underscores the fact that the match does restrict free trade. An application cap would put a cherry on top of that argument.

There are, however, softer ways to approach the issue without a hard cap.
 
Med Ed said:
Perhaps, but it's not exactly apples-to-apples. I think you are far more likely to incur legal challenges from a cap on the broader application process compared to a supplemental, time-limited process that follows. The NRMP has already undergone a serious antitrust lawsuit that started in 2002. It won the case in 2004, but the whole incident underscores the fact that the match does restrict free trade. An application cap would put a cherry on top of that argument.

There are, however, softer ways to approach the issue without a hard cap.
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They already put a soft cap on allocations with the increasing application fees, which only serves to hurt poorer students. But then again, a few thousand dollars in fees pales in comparison to the overall process.

My regret this cycle was not applying to more programs. I’m not gonna lie, if there was a flat fee, I would have applied to every single anesthesia, transitional year, and prelim medicine program… because why not?

People like me is the reason the process is so messed up.
 
I have been thinking of an outrageous idea. Flex residency positions, where the number of specialty positions increase or decrease depending on demand. A few years would be insane, but ultimately a sharp increase in dermatologists or orthopeadic surgeons a few years would drive down compensation and result in a more sane market where income potentials would normalize accross specialties and differ by malpractice risk and hours worked, and people would realistically only go into stuff they want to go into which for the most part is probably primary care. ultimately making the supply of physicans more in sync with market demands.
This central planning of residency positions has not been very effective in alleviating shortages of particular specialties, nor has it been really beneficial to communities in terms of access or pricing. Its really a guild system that artificially limits training , controlled by people in the guild, the only real incentive they have is to keep on restricting positions, or increase positions when their specific procedures are at risk of being absorbed by another guild.

One could say the same thing about UGME as well i suppose.

Obviously there are many issues with the idea like quality control, volume of cases etc.
 
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libertyyne said:
I have been thinking of an outrageous idea. Flex residency positions, where the number of specialty positions increase or decrease depending on demand. A few years would be insane, but ultimately a sharp increase in dermatologists or orthopeadic surgeons a few years would drive down compensation and result in a more sane market where income potentials would normalize accross specialties and differ by malpractice risk and hours worked, and people would realistically only go into stuff they want to go into which for the most part is probably primary care. ultimately making the supply of physicans more in sync with market demands.
This central planning of residency positions has not been very effective in alleviating shortages of particular specialties, nor has it been really beneficial to communities in terms of access or pricing. Its really a guild system that artificially limits training , controlled by people in the guild, the only real incentive they have is to keep on restricting positions, or increase positions when their specific procedures are at risk of being absorbed by another guild.

One could say the same thing about UGME as well i suppose.

Obviously there are many issues with the idea like quality control, volume of cases etc.
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I personally agree that they should do it. Enough of this garbage jousting for certain fields because of the money and the lifestyle. I would say that a 230 Step 1 is smart enough to succeed in all specialties. How about getting passionate people in their fields in order to advance humanity instead?

At the end of the day, the passion and heart trump all for 50% of the medical students out there. You don't need a 250+ Step 1 to be a kicka$$ orthopedic surgeon. That's ridiculous.
 
Epilepsy365 said:
I personally agree that they should do it. Enough of this garbage jousting for certain fields because of the money and the lifestyle. I would say that a 230 Step 1 is smart enough to succeed in all specialties. How about getting passionate people in their fields in order to advance humanity instead?

At the end of the day, the passion and heart trump all for 50% of the medical students out there. You don't need a 250+ Step 1 to be a kicka$$ orthopedic surgeon. That's ridiculous.
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The system would also probably have a lot of people switching out in residency into something else as well considering most med students dont even realize what the lifestyle or sacrifices one has to make to be in a surgical field. Feilds like rad onc have had a decrease in applicants because compensation/job prospects have soured. So in theory it should work.
 
libertyyne said:
The system would also probably have a lot of people switching out in residency into something else as well considering most med students dont even realize what the lifestyle or sacrifices one has to make to be in a surgical field. Feilds like rad onc have had a decrease in applicants because compensation/job prospects have soured. So in theory it should work.
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There are two problems with this. The first is greed: the people in charge of deciding how many residents are in a program are the same people who would be losing income down the line. A young ortho program director has no incentive to overtrain the people who would be decreasing his paychecks in 10 - 15 years.

The second is the problem of volume, especially in the surgical fields. In many programs, cases are pretty limited. If you suddenly admitted 3x as many people, you're not going to have enough cases to go around and you're going to train unsafe surgeons. I heard about this happening at a neurosurgery program near me where they increased from 2 to 3 residents a year at the same time as their case volume stagnated. They ended up forcing two of the residents to take a research year to ensure that they would be able to get them enough cases.
 
libertyyne said:
Theoretically it would be exactly the same.
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Not really. You would see tons of students going into more lifestyle friendly specialties such as FM.

I would be curious what the fellowship rates would be too, especially the IM fellowships. I bet less people would want GI as they do today.
 
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