Why does step 1 not step 2 appear to be the gold standard for residency?

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MrChance2

MrChance2

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Step 1 is more basic science, step 2 is more clinical and done after a year of clinical rotations. Most people have both by time of applications. Why does everyone talk about step 1 for score for residency when doctors will most likely never be in a classroom environment long term again or look into a microscope at histology, be able to draw out the Krebs cycle, etc but most of them will ,at the very least during intern year, be doing most of the step 2 stuf.
 
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bashwell said:
I think for some specialties Step 1 does seem to be weighted a bit more (path, rads).

In other nations like the UK, Ireland, Canada, Australia, and New Zealand, I believe the exams are more geared toward the clinical sciences and more OSCE based. No reason the US can't do the same, I suppose, but I'm not sure why we don't. Or at least I'm not sure why we don't put more emphasis on the clinical but instead we put roughly equal emphasis on both the basic sciences and clinical sciences. There are probably good reasons.
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I would think it's cultural. Honestly though, I feel that it is more appropriate to place equal emphasis on both aspects rather than focusing purely on clinical medicine. So much of the basic science is clinically applicable, and I feel that forcing students to think through the MOA of drugs and pathophysiology of disease inevitably makes for a more rounded and conscientious clinician; I also think that those with a stronger foundation in the basic sciences have far greater learning potential when it comes to mastering the clinical material.

With that said, I'm truly envious of the physical exam skills of physician's trained under the British model.
 
... along with many things in medicine... there is no good reason. Why is there a Step 2 practice question asking me if I know what PHRASE to use for a mother who has interuterine fetal demise... that's not intellectually insulting?
 
In EM, Step 2 CK carries a lot of weight. PDs will forgive a low step 1 score with a large increase in Step 2, but the reverse (high step 1 with lower step 2) is a red flag. More and more applicants are getting their CK scores in time for interviews for this very reason.
 
omn said:
... along with many things in medicine... there is no good reason. Why is there a Step 2 practice question asking me if I know what PHRASE to use for a mother who has interuterine fetal demise... that's not intellectually insulting?
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You will never be a good physician with that attitude!

Just kidding. Those questions are especially BS when all 5 options suck and you're essentially answering the question: "Which of these is the LEAST horrible thing to say to the patient?"
 
omn said:
... along with many things in medicine... there is no good reason. Why is there a Step 2 practice question asking me if I know what PHRASE to use for a mother who has interuterine fetal demise... that's not intellectually insulting?
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"Lol, sucks lady. Better luck next time."

or

"We can get started on the repeat attempt now if you're down."

or

"We need to suck it out now otherwise it'll pop out of your stomach like in that movie, Alien!"

Before the rage - I'm kidding. Obviously you pick the one that is most understanding, without judgement, super touchy-feely, etc. etc.

I'd make my examples even worse but I know SDN can only handle so much.
 
I think also because there is a super big emphasis on 3rd year grades to help allieveate that lack of clinical knowledge on step 1
 
for what its worth, doing IM interviews now, step 2 has been mentioned at 3/5 interviews and step 1 at none
 
It's because step 1 has always been used. Most people didn't even take step 2 until after they applied. Now poeple are asking for step 2 scores because they think it's more clinically relevant and they want to ensure that the people they pick will be able to pass exams (including board exams).

I think it's silly to even use step 1 as a measure for quality as a resident. It wasn't designed to do that and it can be gamed as seen by all the schools going to a 1 or 1.5 year preclinical curriculum and having step 1 being taken after a year of clinical experience.

Step 2 is even sillier to use as it's a much easier test. Neither of them do a good job of predicting who will be a successful resident although I do think that people who know more will do better in general.
 
Step 1 is the student's first national standardized test, and we in IM see the score as one indicator of medical knowledge. And we use the score as a baseline for residency applicants.
 
Lots of misconceptions about the two steps. My personal favorite is when someone scores around a 220 on step one and then a 240 on step 2 -- everyone pats them on the back for the increase not realizing those scores reflect identical performance. The scoring scales are completely unrelated for the two exams and basically offset by about 15-20 points based on the NBME publications and norms tables.

As far as use in selection, I think it's changing but obviously comes from a time when most people simply hadn't taken it yet. Some fields are/were early matches which makes it that much less likely applicants would have had time for step 2. As it is, it's not easy to squeeze in along with some sub-Is depending on when your school finishes third year. Personally I didn't take CK until later because by step 1 was really good and the new score could only be hurtful or neutral. I'm sure a number of others did and still do the same.
 
operaman said:
Lots of misconceptions about the two steps. My personal favorite is when someone scores around a 220 on step one and then a 240 on step 2 -- everyone pats them on the back for the increase not realizing those scores reflect identical performance. The scoring scales are completely unrelated for the two exams and basically offset by about 15-20 points based on the NBME publications and norms tables.

As far as use in selection, I think it's changing but obviously comes from a time when most people simply hadn't taken it yet. Some fields are/were early matches which makes it that much less likely applicants would have had time for step 2. As it is, it's not easy to squeeze in along with some sub-Is depending on when your school finishes third year. Personally I didn't take CK until later because by step 1 was really good and the new score could only be hurtful or neutral. I'm sure a number of others did and still do the same.
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It's more like 10 from step 1 to 2 but your points are taken

http://www.usmle.org/pdfs/transcripts/USMLE_Step_Examination_Score_Interpretation_Guidelines.pdf
 
Psai said:
It's more like 10 from step 1 to 2 but your points are taken

http://www.usmle.org/pdfs/transcripts/USMLE_Step_Examination_Score_Interpretation_Guidelines.pdf
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It varies year to year and the range is 9-15. The averages for both are going up, but Step 1 is going up faster, so it's narrowed over time.

https://www.med-ed.virginia.edu/handbook/academics/licensure.cfm is the easiest data source to use because they post the school reports for every year that include the national average.

So comparing the 2014 national average for Step 1 for US and Canadian Students to the 2015 Step 2 average gives you the typical person going from 229->240 (11 points). My year (2010-2011) was 224->237 (13 points).
 
I've heard some PDs remark that they only care about step because it's just a show that someone can buckle down, study hard, and do well on a licensing exam, and much less because it is a show that they have some great baseline knowledge.
 
Raryn said:
It varies year to year and the range is 9-15. The averages for both are going up, but Step 1 is going up faster, so it's narrowed over time.

https://www.med-ed.virginia.edu/handbook/academics/licensure.cfm is the easiest data source to use because they post the school reports for every year that include the national average.

So comparing the 2014 national average for Step 1 for US and Canadian Students to the 2015 Step 2 average gives you the typical person going from 229->240 (11 points). My year (2010-2011) was 224->237 (13 points).
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Oh interesting.

It's strange though because I took the test in 2014 and I know the average was 230 on my score report. Their website says 229. It was 229 this year as well.
 
Psai said:
Oh interesting.

It's strange though because I took the test in 2014 and I know the average was 230 on my score report. Their website says 229. It was 229 this year as well.
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The school reports are issued the following year when all the data is in, so it's possible that what you saw was a preliminary average and it went down a point by the end of 2014.

For example, my score report said

"For recent administrations, the mean and standard deviation for first-time examinees from U.S. and Canadian medical schools are approximately 222 and 24". The final numbers for my year were 224 and 22.
 
If step 2 mattered more than step 1, would we see a lot more students trying to cut away time in the hospital considering a large chunk of material we are responsible for is almost never seen in the hospital?
 
Psai said:
Oh interesting.

It's strange though because I took the test in 2014 and I know the average was 230 on my score report. Their website says 229. It was 229 this year as well.
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On another topic, is the 229 the average of MD U.S. students or literally any medical student from the U.S. to Nauru who decided to take step1 that year? In which case if it's the latter then we should expect the U.S. MD allopathic average score to be significantly higher than 229.
 
Anicetus said:
If step 2 mattered more than step 1, would we see a lot more students trying to cut away time in the hospital considering a large chunk of material we are responsible for is almost never seen in the hospital?
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Step 2 takes relatively little time to prepare, it's very different from step 1
 
Anicetus said:
On another topic, is the 229 the average of MD U.S. students or literally any medical student from the U.S. to Nauru who decided to take step1 that year? In which case if it's the latter then we should expect the U.S. MD allopathic average score to be significantly higher than 229.
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People who go to an MD-granting school in the US and Canada.
 
Psai said:
Step 2 takes relatively little time to prepare, it's very different from step 1
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Why is that? There's MtB and uworld just like step 1 had first aid and uworld.... I still don't understand why people take less time for step 2.
 
Anicetus said:
Why is that? There's MtB and uworld just like step 1 had first aid and uworld.... I still don't understand why people take less time for step 2.
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because you have stuff to do?
 
Raryn said:
It varies year to year and the range is 9-15. The averages for both are going up, but Step 1 is going up faster, so it's narrowed over time.

https://www.med-ed.virginia.edu/handbook/academics/licensure.cfm is the easiest data source to use because they post the school reports for every year that include the national average.

So comparing the 2014 national average for Step 1 for US and Canadian Students to the 2015 Step 2 average gives you the typical person going from 229->240 (11 points). My year (2010-2011) was 224->237 (13 points).
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What the heck happened in 2015?
 
We look at Step 1 for two reasons:
1) It is a standardized test - lets us compare applicants from different schools with an objective measure.
2) It is an indicator or how well you take a test and is predictive of your ability to do well on speciality board exams. At the end of the day, we need our graduates to pass their speciality boards.

We don't use step 2 for the reasons others have mentioned - not everyone has taken it.
 
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ProfMD said:
We look at Step 1 for two reasons:
1) It is a standardized test - lets us compare applicants from different schools with an objective measure.
2) It is an indicator or how well you take a test and is predictive of your ability to do well on speciality board exams. At the end of the day, we need our graduates to pass their speciality boards.

We don't use step 2 for the reasons others have mentioned - or everyone has taken it.
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the not taking it excuse is a cop out IMO. there's plenty of time in 4th year. I see people taking like 2 months off to interview but they don't have time to take step 2 before january? come on. If I was a PD I'd want all the information I can get
 
Urology and Ophthalmology don't care about Step 2 at all.
PD's in the more competitive specialties have told me that they care more about Step 1 than 2.
PD's in Family Medicine seem to care more about Step 2, but it is most important for candidates who barely passed Step 1.
 
PL198 said:
the not taking it excuse is a cop out IMO. there's plenty of time in 4th year. I see people taking like 2 months off to interview but they don't have time to take step 2 before january? come on. If I was a PD I'd want all the information I can get
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From a program's (or at least my) standpoint, step 2 doesn't add much over step 1 unless there is a wide discrepancy in scores, which there typically is not.

I can't force people to take it early, nor would I want to. From an applicant's standpoint it is a strategic decision whether to take it early:
-if you did poorly on step 1 and are confident you can do better on step 2, take it
-if you did well on step 1, don't risk it
-err on the side of not taking it (in my opinion)
 
Anicetus said:
Why is that? There's MtB and uworld just like step 1 had first aid and uworld.... I still don't understand why people take less time for step 2.
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It's not that it's easier. It's more that you've been preparing for it for an entire year by studying for each shelf exam, which is a much more accurate representation of Step 2 than your school exams were for Step 1.


Sent from my iPad using SDN mobile
 
ProfMD said:
We look at Step 1 for two reasons:
1) It is a standardized test - lets us compare applicants from different schools with an objective measure.
2) It is an indicator or how well you take a test and is predictive of your ability to do well on speciality board exams. At the end of the day, we need our graduates to pass their speciality boards.

We don't use step 2 for the reasons others have mentioned - not everyone has taken it.
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If those are the only two reasons then why wouldn't even the most competitive residencies only make their cut offs at 230 and then toss the step 1 score in the trash and look at other aspects of the application? Or does one need a 250+ to prove they will pass an orthopedic board exam and that they are at risk of failing the board for getting a 235?
 
Raryn said:
Because the test is a lot easier.
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I don't think so. I know quite a few people that got burned on it by not taking enough time to study (followed my schools advice). I think they were fairly equal personally (when looking at percentile scores)
 
kenjixshadow said:
Simple answer: not everyone has a step 2 score while everyone has a step 1 score by the time residency applications open.
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This.

Also, I believe that when it comes time to rank students for the match, and most have their Step 2 score...they look at Step 2 more heavily then.
 
Because people who do better on exams are generally smarter and there's only so much time to read apps. Also there's really not much difference between a 229 and a 231.
 
Im my own personal opinion, step 1 was way harder, and as we all know it includes a lot of basic science, less clinically relevant :inpain:🙁
 
Anicetus said:
If those are the only two reasons then why wouldn't even the most competitive residencies only make their cut offs at 230 and then toss the step 1 score in the trash and look at other aspects of the application? Or does one need a 250+ to prove they will pass an orthopedic board exam and that they are at risk of failing the board for getting a 235?
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The step 1 score is only one component of the application. It is also not the most important component. Setting the bar too high risks missing out on otherwise good candidates. However, more competitive fields/programs can afford to set the bar higher and still fill.

People who struggle or score low on the USMLE are more likely to struggle in the speciality boards and this is something programs want to avoid.
 
ProfMD said:
The step 1 score is only one component of the application. It is also not the most important component. Setting the bar too high risks missing out on otherwise good candidates. However, more competitive fields/programs can afford to set the bar higher and still fill.

People who struggle or score low on the USMLE are more likely to struggle in the speciality boards and this is something programs want to avoid.
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I just see the bolded getting thrown around a lot. But I'm asking how low is low enough to start worrying about the applicant's performance on specialty board exams. Is there data that shows a linear relationship? Or is it exponential by the time you get below 230?

I just don't know why even the most competitive residencies would set a score cutoff at 240 instead of say 220 and then have OTHER cut offs ie # of publications or class rank.

Edit: I guess I'm just asking if they actually believe a 235 step 1 would be a risk of failing the board at all or if setting the bar at 240 step 1 score is just the easiest thing to do to narrow down applications, in which case why don't PDs just say that instead of "low step 1 score is a risk".
 
Anicetus said:
I just see the bolded getting thrown around a lot. But I'm asking how low is low enough to start worrying about the applicant's performance on specialty board exams. Is there data that shows a linear relationship? Or is it exponential by the time you get below 230?

I just don't know why even the most competitive residencies would set a score cutoff at 240 instead of say 220 and then have OTHER cut offs ie # of publications or class rank.
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I don't know off the top of my head what the relationship is. I would bet, though, that someone with a 220 is just as likely to pass the boards as someone with a 260. Competitive programs get many more applicants than they have interview spots for and need a quick way to weed through the applications.

Number of publications is much more subjective since you have to consider not only the number but also the quality and the applicant's degree of involvement.

Class rank, to me, is of less value since it is school specific and therefore more difficult to compare applicants from different schools.

Letters of recommendation are very important, but also take more time to evaluate than the USMLE score.

Ultimately, though, a lot of this is to get the applicant in the door where the interview really matters.
 
failedatlife said:
NO it is NOT.
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*shrug*

I was in a different place in my life as a new M4 compared to the period between M2 and M3, but I can say I studied for several weeks less on Step 2... and my score went up 36 points. I know people who studied the same amount and score went up >40 points. Others studied for only a couple weeks and scores stayed flat and went down, it's true, but the effort and knowledge of esoteric material needed to get an above average score on step 2 was a LOT less than step 1.

Obviously, people vary but Step 2 has not only a higher average but a narrower standard deviation, leading to a narrower range of scores and less discrimination between candidates.
 
ProfMD said:
I don't know off the top of my head what the relationship is. I would bet, though, that someone with a 220 is just as likely to pass the boards as someone with a 260. Competitive programs get many more applicants than they have interview spots for and need a quick way to weed through the applications.

Number of publications is much more subjective since you have to consider not only the number but also the quality and the applicant's degree of involvement.

Class rank, to me, is of less value since it is school specific and therefore more difficult to compare applicants from different schools.

Letters of recommendation are very important, but also take more time to evaluate than the USMLE score.

Ultimately, though, a lot of this is to get the applicant in the door where the interview really matters.
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I'm confused, why not just split up the applications amongst a group so all the applications get a quick read. If you sort by Step scores, you are going to get the robots who just studied for Step 1 their whole life and are good test takers whom ultimately can't even hold a conversation in real life because they have been looking at MC questions all the time. If you are interested in publications, we have to list PUBMED ID numbers, you can easily look up the work in 2 seconds and see the depth and involvement on the paper.
 
failedatlife said:
I'm confused, why not just split up the applications amongst a group so all the applications get a quick read. If you sort by Step scores, you are going to get the robots who just studied for Step 1 their whole life and are good test takers whom ultimately can't even hold a conversation in real life because they have been looking at MC questions all the time. If you are interested in publications, we have to list PUBMED ID numbers, you can easily look up the work in 2 seconds and see the depth and involvement on the paper.
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I think it is actually more fair to have one or two people pre-screen - usually the PD and/or chair. That way everyone is treated the same.

And, I think you are underestimating the volume of work you are asking of people who barely have enough time as it is.

I know it sounds harsh, but it is the reality of the system we are in.

And, at least in our program, we do have a step 1 "cutoff," but it is a soft cutoff. People who are borderline get a closer look at the other stuff prior to getting a thumbs up or down on the invite.
 
failedatlife said:
I'm confused, why not just split up the applications amongst a group so all the applications get a quick read. If you sort by Step scores, you are going to get the robots who just studied for Step 1 their whole life and are good test takers whom ultimately can't even hold a conversation in real life because they have been looking at MC questions all the time. If you are interested in publications, we have to list PUBMED ID numbers, you can easily look up the work in 2 seconds and see the depth and involvement on the paper.
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You need to stop hating. Just because you didn't do well on step 1 doesn't mean that the people who do are robots. Not sure where you even got that from
 
failedatlife said:
I know everything....except how to do well on Step 1
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... and apparently the basic medicine you learn in the first two years. You don't know that either or you would have done well on Step 1. Also, time management skills and prioritizing. Maybe if you didn't spend so much time on research you would have done well on Step and we all would not have to hear you incessantly bitch every time somebody says it's important.
 
gyngyn said:
Urology and Ophthalmology don't care about Step 2 at all.
PD's in the more competitive specialties have told me that they care more about Step 1 than 2.
PD's in Family Medicine seem to care more about Step 2, but it is most important for candidates who barely passed Step 1.
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EM also seems to highly value Step 2.
 
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