Why is there hesitance for PDs to require step 2 scores?

[Qwerty122]

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Been talking with some local PDs who say that things like school reputation and nepotism (through aways, letters, and research) will be the main things residencies will focus on now that step 1 is pass/fail. Sure, research productivity, ECs, and class rankings may play a role, but to less of an extent when PDs are doing that initial scan through the applicants, says the PDs. School rep and nepotism might serve as substitutes for the role of step 1, which is to do that initial easy stratification of applicants. But when I asked about step 2 being used instead of step 1, there seems to be uncertainty in being able to rely on that metric, as not all applicants report a step 2 score in their ERAS app.

And so I'm thinking isn't this a bit silly to retain this old rule of an optionally reported step 2 score in the step 1 p/f era? Shouldn't it eventually be made required as that will be a win-win for both the applicant and the PDs? The PDs will have an easy way of quantitatively stratifying applicants based on their standardized academic performance. And applicants have some more certainty about their standings and will have a more level playing field? Like it is just bound to happen right? And if so, if this eventual change of requiring a step 2 score for ERAS has to happen, I'm just not sure why PDs (and many others) are so worried that it'll turn to nepotism?

But that's just my current thoughts on the matter. What do y'all think about this?

 

[Goro]

Given that PDs will now screen people by Step 2, it will be incumbent upon applicants to submit thier scores, otherwise, they'll get crowed out by those who do.

 

[Redpancreas]

It may be used exactly as Step 1. Reasons for what you're hearing:

1.) No one wants to bite the bullet and say hey, we're looking at Step 2 CK now until everyone is forced to do it.
2.) Step 2 CK is close to ERAS as you reported. People can all see this and there is hesitancy hence everyone's waiting to see what the other person does and how this year pans out. It will be interesting to see what happens. On the human side, people will probably recognize the stupidity of someone preparing for something for 3.25 years only to receive a score that disqualifies them, however, the demand for those surgical subspecialty/derm spots will still be there and they will still fill with highly qualified applicants. I anticipate this will trickle down to less competitive residencies. IM given its procedural fellowships as well as Anesthesia will see a spike in interest as back up specialties.

In regards to the lack of a rule, rules often lag behind what actually happens. Make no mistake, everyone will be taking CK before the deadline when Step 1 becomes P/F unless they're willing to settle for any residency. I personally think shifting to CK was a good idea, but this intermediate isn't very stable. It's going to be hell for people applying to competitive fields and don't agree with the way this was implemented but I do hope having Step 2 CK be the deciding exam places more clinical emphasis in medical school education and brings earlier clinical exposure to medical students instead of the antiquated preclerkship/clerkship model.

 

[Redpancreas]

Given that PDs will now screen people by Step 2, it will be incumbent upon applicants to submit thier scores, otherwise, they'll get crowed out by those who do.

Agreed. This is effectively what will happen although no one is going to say that officially.

 

[Qwerty122]

I completely agree with what @Goro and @Redpancreas said, and so then I'm just worried that by the time the Class of 2024 applies, much less stock will be given for step 2 scores simply because of the fact that ERAS might not come out with a definite rule saying that step 2 scores are absolutely required to submit your application. Without this rule, it'll logically make sense for PDs to not put too much weight on step 2 scores, since not every applicant has them and putting too much weight on step 2 scores thus wouldn't be a "holistic" evaluation.

Again, it goes back to the governing bodies. For step 2 CK to have as much value as step 1 I think a new rule from the ERAS folks saying step 2 reporting is mandatory is needed. I just feel 10-20 years down the line, it can't stay like this and something has to change in the status quo. So why not enact that change sooner? I think that's my main gripe about this. Step 1 is announced to be pass/fail but there's no follow up to create a system that can counter the consequences of such a significant change.

 

[NotAProgDirector]

No rule is needed. Some programs may require a S2 score. Some may not.. Perhaps some programs will interview without a S2 score, but require it for ranking. Perhaps some programs won't want it at all. There's no good way to know.

Regardless, it would probably be in your best interest to have a S2 score by the time applications open. That covers all the bases.

 

[Riven_1KV]

Been talking with some local PDs who say that things like school reputation and nepotism (through aways, letters, and research) will be the main things residencies will focus on now that step 1 is pass/fail. Sure, research productivity, ECs, and class rankings may play a role, but to less of an extent when PDs are doing that initial scan through the applicants, says the PDs. School rep and nepotism might serve as substitutes for the role of step 1, which is to do that initial easy stratification of applicants. But when I asked about step 2 being used instead of step 1, there seems to be uncertainty in being able to rely on that metric, as not all applicants report a step 2 score in their ERAS app.

And so I'm thinking isn't this a bit silly to retain this old rule of an optionally reported step 2 score in the step 1 p/f era? Shouldn't it eventually be made required as that will be a win-win for both the applicant and the PDs? The PDs will have an easy way of quantitatively stratifying applicants based on their standardized academic performance. And applicants have some more certainty about their standings and will have a more level playing field? Like it is just bound to happen right? And if so, if this eventual change of requiring a step 2 score for ERAS has to happen, I'm just not sure why PDs (and many others) are so worried that it'll turn to nepotism?

But that's just my current thoughts on the matter. What do y'all think about this?

I don't know if I'm misremembering, but I recall going back through the NRMP PD surveys and noticing a trend of PD's requiring Step 1 scores as Step 1 was increasingly prioritized as a screening metric. I believe PDs are going to prioritize Step 2 scores as a screening metric, and more are going to require Step 2 scores. Even if they don't, see Goro's comment.

I don't know what a rule on requiring a Step 2 scores actually does for anyone. Every other field in existence manages to not turn to nepotism without things like board scores. You could remove board scores from the application process and nepotism would still be there.

My thoughts on pretty much every issue with the residency match are "Application limits 4head".

 

[Goro]

I completely agree with what @Goro and @Redpancreas said, and so then I'm just worried that by the time the Class of 2024 applies, much less stock will be given for step 2 scores simply because of the fact that ERAS might not come out with a definite rule saying that step 2 scores are absolutely required to submit your application. Without this rule, it'll logically make sense for PDs to not put too much weight on step 2 scores, since not every applicant has them and putting too much weight on step 2 scores thus wouldn't be a "holistic" evaluation.

Again, it goes back to the governing bodies. For step 2 CK to have as much value as step 1 I think a new rule from the ERAS folks saying step 2 reporting is mandatory is needed. I just feel 10-20 years down the line, it can't stay like this and something has to change in the status quo. So why not enact that change sooner? I think that's my main gripe about this. Step 1 is announced to be pass/fail but there's no follow up to create a system that can counter the consequences of such a significant change.

Boards were never meant to be a screening tool, only a measure of competency.

The sky isn't falling, so calm down.

 

[Lawpy]

It's completely bizarre for any program to not take into account of a scored Step 2 in a post P/F Step 1 environment.

 

[Phloston]

Been talking with some local PDs who say that things like school reputation and nepotism (through aways, letters, and research) will be the main things residencies will focus on now that step 1 is pass/fail. Sure, research productivity, ECs, and class rankings may play a role, but to less of an extent when PDs are doing that initial scan through the applicants, says the PDs. School rep and nepotism might serve as substitutes for the role of step 1, which is to do that initial easy stratification of applicants. But when I asked about step 2 being used instead of step 1, there seems to be uncertainty in being able to rely on that metric, as not all applicants report a step 2 score in their ERAS app.

And so I'm thinking isn't this a bit silly to retain this old rule of an optionally reported step 2 score in the step 1 p/f era? Shouldn't it eventually be made required as that will be a win-win for both the applicant and the PDs? The PDs will have an easy way of quantitatively stratifying applicants based on their standardized academic performance. And applicants have some more certainty about their standings and will have a more level playing field? Like it is just bound to happen right? And if so, if this eventual change of requiring a step 2 score for ERAS has to happen, I'm just not sure why PDs (and many others) are so worried that it'll turn to nepotism?

But that's just my current thoughts on the matter. What do y'all think about this?

Students generally score higher on 2CK than Step 1. So if a student "aces" Step 1, then that's more or less a predictor of aptitude on 2CK. Once the Step 1 officially goes to P/F, however, I don't think an application without a 2CK score would even be viewed as complete.

 

[Ms. Incognito]

Boards were never meant to be a screening tool, only a measure of competency.

The sky isn't falling, so calm down.

Exactly. Thank you, just...thank you.

 

[AlbinoHawk DO]

This depends on the program. When i interviewed in Arizona they told me they were already considering step 2 only for their neurology and psychiatry programs

 

[Redpancreas]

Exactly. Thank you, just...thank you.

The point Goro makes is an ideal. If anyone feels CK won’t be important, I challenge them to not take Step 2CK before application time. The extent that Step 2CK will fill in for Step 1 will be field dependent.

For Internal Medicine for example, you better believe Step 2CK is the new Step 1. It’s a better test of clinical knowledge, 75% of which is Internal Medicine. IM PDs have been wanting this for years. Add that to the fact that IM is one of the most highly applied to fields with the largest class sizes so there's a need for a standardized test to sift through the masses is imperative and necessity of fit is minimized.

For other fields, I don’t know and would have to speculate what their PDs want to see as it's less clear. I would think pubs/4th years performances in specialty specific electives/rotations/aways can fill the void for surgical subspecialties and given the legwork that needs to be done on the front end, I anticipate some programs may decide to relax the cutoffs for Step 2CK.

 

[Lawpy]

Ugh i hate PDs giving even more weight to pubs. It encourages trash research spamming and benefits predatory journals

 

[Redpancreas]

Students generally score higher on 2CK than Step 1. So if a student "aces" Step 1, then that's more or less a predictor of aptitude on 2CK. Once the Step 1 officially goes to P/F, however, I don't think an application without a 2CK score would even be viewed as complete.

Agree with that for a majority of people. That said, there is a small minority (which I'm a part of) that just sucks at Step 2 CK stuff for whatever reason. I did well on Step 1, did meh on Step 2 CK, and then Step 3's basically a microcosm of both tests where day 1 is representative of Step 1 and day 2 is representative of Step 2. I felt the day 1 questions were way easier (second/third order diagnosis/MOA questions) than day 2 (vague next step questions).

 

[aldol16]

This is exactly the problem that many of us brought up when Step 1 went pass/fail. So many medical students were for the change that it can't be chalked up to pure lack of foresight. Making Step 2 CK required by ERAS date presents a problem because it just replaces Step 1 and therefore negates the rationale from getting rid of Step 1 in the first place. If one score was just going to be replaced by another, I would argue that students have more control over Step 1, as you can choose how much time you want to spend studying in your pre-clinical years. Step 2 CK is best taken after the clinical year and by that time, you're already applying or thinking about applying to residency and due to clerkships, may have less time to prepare.

Hence why people will rely on other metrics during resident selection. These metrics are publications, research, connections, etc. As I've been saying from the start, this is not in the benefit of students who do not go to top-tier schools. The trick behind this whole scheme is that somehow people got medical students to support it even though it was against the interest of most medical students.

 

[Lawpy]

This is exactly the problem that many of us brought up when Step 1 went pass/fail. So many medical students were for the change that it can't be chalked up to pure lack of foresight. Making Step 2 CK required by ERAS date presents a problem because it just replaces Step 1 and therefore negates the rationale from getting rid of Step 1 in the first place. If one score was just going to be replaced by another, I would argue that students have more control over Step 1, as you can choose how much time you want to spend studying in your pre-clinical years. Step 2 CK is best taken after the clinical year and by that time, you're already applying or thinking about applying to residency and due to clerkships, may have less time to prepare.

Hence why people will rely on other metrics during resident selection. These metrics are publications, research, connections, etc. As I've been saying from the start, this is not in the benefit of students who do not go to top-tier schools. The trick behind this whole scheme is that somehow people got medical students to support it even though it was against the interest of most medical students.

Med students are self destructive so listening to them airing their ignorance will only make everyone worse off

 

[Redpancreas]

This is exactly the problem that many of us brought up when Step 1 went pass/fail. So many medical students were for the change that it can't be chalked up to pure lack of foresight. Making Step 2 CK required by ERAS date presents a problem because it just replaces Step 1 and therefore negates the rationale from getting rid of Step 1 in the first place. If one score was just going to be replaced by another, I would argue that students have more control over Step 1, as you can choose how much time you want to spend studying in your pre-clinical years. Step 2 CK is best taken after the clinical year and by that time, you're already applying or thinking about applying to residency and due to clerkships, may have less time to prepare.

Hence why people will rely on other metrics during resident selection. These metrics are publications, research, connections, etc. As I've been saying from the start, this is not in the benefit of students who do not go to top-tier schools. The trick behind this whole scheme is that somehow people got medical students to support it even though it was against the interest of most medical students.

I think/hope the intent was not what you describe (marginalizing non-top students) but to emphasize earlier clinical integration. Lawpy posted some kind of outline of UMichigan’s curriculum and it looks like that’s what they’re doing by putting all basic science into a year.

I think it was a good thing to be done but now it created a shock for the first class that’s going to be dealing with this. I personally think that Step 2CK will very much be used as a screening tool akin to Step 1 for many fields particularly Family Medicine, EM, and IM because the exam is directly testing clinical material directly pertinent to those fields.

Long term I hope (and I’ve outlined this in my own thread) that medical students ought to be taking Step 2 CK at the end of M2. Then they can do electives. Edit I’m just going to post that in the next post since it’s not getting any traffic where it’s at.

 

[Redpancreas]

M1:
A1.) Foundations in Human Biology (2 months/8 weeks):
Covers introductory concepts that recur in human medicine including cellular biology/biochemistry, histology, and physiology. Exams are Friday mornings.

A2.) Foundations in Clinical Medicine: (2 months/8 weeks):
For the first two months, a student is lectured on foundational concepts like the elements of the history and physical exam as well as preventative medicine concepts. Each week, there will be an OSCE on Friday afternoons with escalating level of sophistication. Emphasis will be placed on the art of doctoring as opposed to technical knowledge.

B1) Organ Systems (8 months/36 weeks) :
Each organ system will be covered from anatomy (prosection)/histology and progress to pathophysiology and pharmacology. Everything from Cardiology to Dermatology will be covered.

B2) Advanced Clinical Medicine (8 months/36 weeks)
Students will learn differential diagnosis skills through hybrid lecture/socratic discussions from clinical faculty in addition to interpretation of lab findings, treatment of common disorders (ex. anti-HTN agents). At the end of each organ system, there will be an OSCE (ex. 3 weeks for Cardiology, 1 week Dermatology) where a student will complete an H&P and be graded on his bedside manner, exam skills, data collection in the note, and assessment & plan. Students will also be graded on a separate verbal presentation to a preceptor who has not read their note.

Summer (2 months) : Students will sit for USMLE Step 1. Afterwards, they may use additional time to start work on research projects.

M2:
A1.) Internal Medicine Clerkship (2 months)
Students will pre-round, round on patients, and present them. Their patients will be rounded on and they will be dismissed for lunch.

A2.) Principles of Internal Medicine (2 months)
In the afternoons, students will solidify their clinical reasoning skills targeted at work-ups of common differentials such as chest pain, shortness of breath, anemia, etc. The final grade will be a mixture of a OSCE, NBME Exam, and Clinical Evaluations. Step 2 CK targeted material will be incorporated into the didactics.

B, C, D (8 months): Clerkships and Foundations Courses in General Surgery (3), Family Medicine (1), Neurology (1), Psychiatry (1), Pediatrics (1), and OB/GYN (1). Note that 2 weeks of IM, General Surgery; 1 week of Pediatrics, and Neurology will be ICU medicine.

E) Students will have 2 months to prepare and sit for USMLE Step 2 CK. Results will be provided in 2 weeks.

M3:
Students will rotate through structured electives. There will be required counts on hospital medicine, OR, clinic medicine, ICU, and night float. Formative and summative feedback will be provided to students during this time in the format of Standardized Letters of Evaluations. Competencies such as written documentation, verbal presentation, basic procedural capabilities will all be assessed. Students will obtain letters of recommendation at this stage.

M4:
All students complete a year long internship in either Medicine or Surgery effectively committing themselves to one or the other. Adequate time off will be provided for interview season. During the initial period, students can get an additional early letter that can be used for their residency application. Students will apply directly to advanced positions (PGY-2 IM/GS) or directly to Neurology, PM&R, Dermatology, Plastics, Neurosurgery, or Urology. Students must sit for USMLE Step 3 prior to December 31st of M4 year. If they fail, they will be enrolled in a intensive Step 3 USMLE prep course alongside clerkships to ensure passage prior to start of residency. By graduation, all students should be eligible to apply for a full medical license to work as a general practitioner.



Pros:
1. It saves a year in medical training. I think medical schools need to take more responsibility in the clinical training of their students. They will realize what their students struggle when doing the actual job and will adjust upstream accordingly.
2. It emphasizes clinical medicine as students are learn doctoring skills in M1, do half day clerkships in M2, and are ready to start applying everything in M3+
3. It creates a timeline more in line with the Step 2 CK focus.
4. Students have way more clinical experience before deciding on a field of choice.
5. It gives unmatched students the able to be licensed so they can do clinically relevant jobs while they are in the application cycle loop.

Cons:

1. The presentation of the basic material is obviously faster. I do think there are significant parts of the preclerkship curriculum that can be cut. I think this would be countered by having detailed didactics in M2 from the clinical perspective. For example, pulmonary physiology can be revisited or clarified in didactics while an M2 reports vent settings and gives a plan in their M2 ICU rotiation.

The whole point is to speed up the minutiae everyone learns in medical school, but nevers sees again and slow it down in M2 and focus on what really matters...clinical medicine. More detailed mechanisms if necessary and applied physiology (ventilator medicine, acid&base) can be taught alongside M2 clerkships.

 

[aldol16]

I think/hope the intent was not what you describe (marginalizing non-top students) but to emphasize earlier clinical integration. Lawpy posted some kind of outline of UMichigan’s curriculum and it looks like that’s what they’re doing by putting all basic science into a year.

I think it was a good thing to be done but now it created a shock for the first class that’s going to be dealing with this. I personally think that Step 2CK will very much be used as a screening tool akin to Step 1 for many fields particularly Family Medicine, EM, and IM because the exam is directly testing clinical material directly pertinent to those fields.

Long term I hope (and I’ve outlined this in my own thread) that medical students ought to be taking Step 2 CK at the end of M2. Then they can do electives. Edit I’m just going to post that in the next post since it’s not getting any traffic where it’s at.

I don't think the intent was ever to marginalize students from non-top schools. Regardless of what the intent was, the impact was to marginalize students from non-top schools. We're seeing it now and it's going to get worse.

Step 2 CK might be good as a screening tool for those specific fields (granted IM is the largest one so makes sense that some processes are built around them) but it represents nothing more than a marginal increase over Step 1 for most other fields. It's not a great exam to assess preparation for entering the other specialties. And if the issue with Step 1 was the high-stakes nature where students were going way too hard on outside resources to study for it and focusing too much time on it rather than learning the basic science, you get the same issue with Step 2. Step 2 CK isn't a great measure of clinical performance / knowledge. I saw it as a floor rather than as an ideal. I don't think I had a single rotation where I got by just prepping for what's on CK - most of the time I was looking into things in more depth / detail than that for patient care. So imagine if students now study for the test instead of taking those deeper dives that are really informative and give you the clinical pearls you need from each patient case you encounter. Is that much better than wasting countless hours of pre-clinical time studying for Step 1?

How would students take CK at the end of M2? If all schools switch to a 1-year pre-clinical curriculum? I'd be all for switching to a 1-year pre-clinical curriculum. Unfortunately, only a few schools have that now. Making the switch over now before any of these mechanisms are in place is putting the cart before the horse.

 

[Redpancreas]

I don't think the intent was ever to marginalize students from non-top schools. Regardless of what the intent was, the impact was to marginalize students from non-top schools. We're seeing it now and it's going to get worse.

Step 2 CK might be good as a screening tool for those specific fields (granted IM is the largest one so makes sense that some processes are built around them) but it represents nothing more than a marginal increase over Step 1 for most other fields. It's not a great exam to assess preparation for entering the other specialties. And if the issue with Step 1 was the high-stakes nature where students were going way too hard on outside resources to study for it and focusing too much time on it rather than learning the basic science, you get the same issue with Step 2. Step 2 CK isn't a great measure of clinical performance / knowledge. I saw it as a floor rather than as an ideal. I don't think I had a single rotation where I got by just prepping for what's on CK - most of the time I was looking into things in more depth / detail than that for patient care. So imagine if students now study for the test instead of taking those deeper dives that are really informative and give you the clinical pearls you need from each patient case you encounter. Is that much better than wasting countless hours of pre-clinical time studying for Step 1?

How would students take CK at the end of M2? If all schools switch to a 1-year pre-clinical curriculum? I'd be all for switching to a 1-year pre-clinical curriculum. Unfortunately, only a few schools have that now. Making the switch over now before any of these mechanisms are in place is putting the cart before the horse.

The bolded are absolutely true.

Step 2 CK still has tons of minutiae and stupid stuff despite its "clinical nature". You're not learning what you need for General Surgery by doing UWorld Surgery. You're learning general surgery by reviewing cases before they occur, etc. That said, I do think Step 2 CK has the potential to change and improve to cover the essentials for what medical students can know. Ethics/vaccine incorportation questions that got added recently to emphasize that the answer is never to wait with a vaccine in kids unless there is anaphylaxis to XYZ is one example. I think there are tons of foundational concepts any physician should know and I think the exam should serve that purpose whether it is what Step 2 CK effectively is now or not (I agree with you that it's not).

That still doesn't address the point of the Step 2 CK craze and everyone hyperfocusing on Step 2 CK. For that, I think having Step 2 CK and general clerkships done by the end of M2 is valuable as it will provide opportunities for students to go into M3 and focus on their electives (ex. if Gen Surg, you're going to be doing a few months of trauma and a few months of electives, maybe a rotation in Internal Medicine Consults to learn about surgical clearance, maybe a month or two of ED). They would receive SLOE like evaluations from all these faculty and hopefully this is a more substantial thing to assess applicants.An alternative is for the UME/GME transition team to do a ton of work and create an "XYZ Aptitude Exam" for every field which students would then study for in M3 and be more of a clinically relevant test of each field. I don't think this is a great idea though as it just creates too many tests for medical students to deal with.

The last issue is the first one you brought up that this will create a disparity between medical schools that can afford to progress to this model and those (particular MD schools limited by faculty tenure and DO schools with lack of rotation sites). I think that's a coordination issue and for that I say we shouldn't discount a better system because of complications in implementing it initially are troublesome. Each one of those complications will have to be addressed. I think the best way to handle it is for the LCME to just say, hey, this is how it should be. This will really put a test on medical schools and only the ones that can support this type of model would be allowed to be allowed to work. They rest can will have their LCME accreditation expire AFTER the last graduating class matches.