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Step 1 Pass-Fail: How to Get Into a Top Residency Now?

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by Alec Palmerton, MD in Step 1 Pass-Fail

Step 1 becomes pass-fail for administrations as of January 26, 2022. With Step 1 going pass-fail, you may wonder how to get into a top residency now? Previously, Step 1 was the most cited factor for getting an interview for residency. However, with the move to remove reporting of scores to admissions committees, what will happen? How do you match at the program of your dreams now?

In this article, we will discuss:

  • Why Step 1 became such a big deal – and what will take its place now it will become pass-fail,
  • How many program directors consider it a hindrance to not attend a prestigious school,
  • What kinds of applicants may benefit most from doing extra research and away rotations,
  • How many program directors disagreed with a pass-fail Step 1, and
  • Many more statistics from program directors on their views on how they will navigate the monumental changes to the residency application process.

Table of Contents

Why Was Step 1 So Important Before?

The residency you attend has a dramatic effect on your future. The specialty will determine what kind of medicine you practice. That has enormous implications for your day-to-day life, time on call, lifestyle flexibility, salary, and other considerations. The location/prestige of the program you attend, too, will impact what kind of fellowships and likely influence where you live.

As such, the competition for residencies is fierce. Over the years, programs have received more and more applications without a commensurate increase in program slots.

Here are some quick statistics from 2020:

  • The average IM residency program had 3,383 applications
  • The mean number of applications received per program was 789.
  • 55% of residency program directors (PDs) reported having a target score for Step 1.
  • Each program sent out an average of 107 interview invitations (14% interview rate)
  • 45% of applications were rejected based on standardized screening measures like Step 1 score, background (US MD vs. DO vs. IMG), and other criteria
  • 41% more applications were rejected after a more careful reading

When program directors list what is most important for getting an interview, Step 1 was consistently at the top of the list:

FactorPercent Citing FactorAverage Rating of Importance
USMLE Step 1 score90%4
Letters of recommendation in the specialty84%4.3
USMLE Step 2 CK score78%4
Personal Statement78%3.9
Medical Student Performance Evaluation (MSPE/Dean's Letter)76%4
Perceived commitment to specialty70%4.4
Grades in required clerkships69%4
Audition elective/rotation within your department66%4.3
Any failed attempt in USMLE66%4.5
Class ranking/quartile65%4
Personal prior knowledge of the applicant65%4.3
Leadership qualities63%4.2
Grades in clerkship in desired specialty62%4.2
Evidence of professionalism and ethics62%4.5
Perceived interest in program61%4.2
Passing USMLE Step 2 CS60%4
Other life experience57%3.9
COMLEX-USA Level 1 score (DO only)56%3.9
Alpha Omega Alpha (AOA) membership52%3.7
Any failed attempt in COMLEX-USA (DO only)51%4.4
Volunteer/extracurricular experiences51%3.8
COMLEX-USA Level 2 Clinical Evaluation (CE) score (DO only)50%4
Consistency of grades48%4
Awards or special honors in clinical clerkships47%3.5
Graduate of highly-regarded medical (MD/DO) school46%3.6
Evidence of continuous medical education without gaps45%4
Gold Humanism Honor Society (GHHS) membership44%3.7
Awards or special honors in clerkship in desired specialty41%3.8
Passing COMLEX-USA Level 2 Performance Evaluation (DO only)40%4
Demonstrated involvement and interest in research36%3.7
Applicant was flagged with Match violation by the NRMP31%4.7
Visa status (IMG only)28%4.1
Away rotation in your specialty at another institution25%3.9
Fluency in language spoken by your patient population21%3.6
Interest in academic career20%3.8
Awards or special honors in basic sciences20%3.2
USMLE Step 3 score15%3.3
COMLEX-USA Level 3 score (DO only)10%3.5

Source: National Resident Matching Program, Data Release and Research Committee: Results of the 2020 NRMP Program Director Survey. National Resident Matching Program, Washington, DC. 2020.

So why was Step 1 was important? Because it was a quick, objective screen that program directors could use to make applicant selection less overwhelming. It allowed them to reject nearly half of all applicants so that they could turn their attention to the remaining half.

Program Directors Aren’t Happy That Step 1 is Pass-Fail

Step 1 was the most commonly cited factor in residency admissions by program directors. As such, it’s not surprising that taking away a scored Step 1 would cause program directors to gnash their teeth.

Here is a sampling of how program directors have voiced their opinions of the change to a pass-fail Step 1:

  • 61.4% of dermatology PDs said they believed it was a bad idea (and only 12.3% thought it was a good idea)
  • 77.2% of those same PDs figured it would make it more challenging to compare applicants objectively
  • 77.2% ALSO said it would make applicant screening more arduous
  • In a survey of IM PDs, 74% of respondents said they did not support the change to pass-fail Step 1
  • 68.3% disagreed with the statement that pass-fail Step 1 “will make it easier for residency programs to select which applicants to interview and accept.”
  • In yet another survey, 82.8% of orthopedic surgery PDs and 74.4% of IM PDs disagreed with the change to pass-fail Step 1

Step 2 CK Will Likely Become the New Screen

You could imagine an equation for program directors like this:

# of applications to review / # of hours to review ∝ need for an objective, quick screen

In other words, as the number of applications increases and/or the time to review them decreases, the need for an objective, quick screen rises.

Program directors will still need a screen until a cap on applications is introduced and/or more hours fall from the sky. The most likely candidate will likely be Step 2 CK.

Program Directors Are Already Coalescing Around Step 2 CK

I’ve read through the available program director surveys and have spoken with numerous PDs. Already, there is a strong sense that Step 2 CK will take on the role of Step 1. Here is a sampling of some of the views shared by program directors:

Without significant changes to the residency application process, Step 2 CK will likely become the “new Step 1.” The need for residency program directors to make the pool of applicants more manageable is too intense.

Step 1 Is Pass-Fail: Do All the Other Factors Become More Important Equally?

Let’s look again at the 2020 NRMP Program Director Survey results. These are the factors that PDs cited as most important for getting an interview.

FactorPercent Citing FactorAverage Rating of Importance
USMLE Step 1 score90%4
Letters of recommendation in the specialty84%4.3
USMLE Step 2 CK score78%4
Personal Statement78%3.9
Medical Student Performance Evaluation (MSPE/Dean's Letter)76%4
Perceived commitment to specialty70%4.4
Grades in required clerkships69%4
Audition elective/rotation within your department66%4.3
Any failed attempt in USMLE66%4.5
Class ranking/quartile65%4
Personal prior knowledge of the applicant65%4.3
Leadership qualities63%4.2
Grades in clerkship in desired specialty62%4.2
Evidence of professionalism and ethics62%4.5
Perceived interest in program61%4.2
Passing USMLE Step 2 CS60%4
Other life experience57%3.9
COMLEX-USA Level 1 score (DO only)56%3.9
Alpha Omega Alpha (AOA) membership52%3.7
Any failed attempt in COMLEX-USA (DO only)51%4.4
Volunteer/extracurricular experiences51%3.8
COMLEX-USA Level 2 Clinical Evaluation (CE) score (DO only)50%4
Consistency of grades48%4
Awards or special honors in clinical clerkships47%3.5
Graduate of highly-regarded medical (MD/DO) school46%3.6
Evidence of continuous medical education without gaps45%4
Gold Humanism Honor Society (GHHS) membership44%3.7
Awards or special honors in clerkship in desired specialty41%3.8
Passing COMLEX-USA Level 2 Performance Evaluation (DO only)40%4
Demonstrated involvement and interest in research36%3.7
Applicant was flagged with Match violation by the NRMP31%4.7
Visa status (IMG only)28%4.1
Away rotation in your specialty at another institution25%3.9
Fluency in language spoken by your patient population21%3.6
Interest in academic career20%3.8
Awards or special honors in basic sciences20%3.2
USMLE Step 3 score15%3.3
COMLEX-USA Level 3 score (DO only)10%3.5

Source: National Resident Matching Program, Data Release and Research Committee: Results of the 2020 NRMP Program Director Survey. National Resident Matching Program, Washington, DC. 2020.

With Step 1 – the previously most commonly cited factor for getting an interview – going pass-fail, you might wonder, “will all the other aspects become more important equally?”

Interestingly, the answer appears to be no. Step 2 CK will take on a disproportionate share of the added importance, as noted above. As we discussed, this leap in emphasis is likely because program directors essentially 1) need a quick, objective screen, and 2) they are unhappy with the change of Step 1 to pass-fail.

Next, we will look at some of the factors that program directors say will take on more importance now that Step 1 is pass-fail.

Step 1 Pass-Fail: How Do Program Directors View Research?

Research has always been an important metric for many residency programs. With Step 1 going pass-fail, will research take on increased emphasis?

  • In one survey, orthopedic PDs (39.7%), compared to IM PDs (9.6%), were more likely to believe a pass/fail Step 1 will encourage applicants to pursue more research experiences.
  • Another survey of IM program directors concurred. Only 13.8% believed that research experience would become more critical in evaluating residency applicants. 81.3% were neutral, and 4.9% said research would become less critical.

With Step 1 going pass-fail, you might expect program directors to care more about research experiences. Interestingly, the picture is more nuanced and less heavily skewed towards research.

Audition Rotations May Take On Greater Significance, Especially for Competitive Specialties
  • Compared to IM PDs (28.8%), orthopedic PDs (58.6%) were more likely to think that the Step 1 pass/fail change would encourage students to attend more audition electives (p < 0.001).
  • In a separate survey of IM PDs, 64.2% thought audition electives would be more critical.
Clerkship Grades
  • 77.6% of orthopedic and 67.2% of IM PDs say grades in required clerkships will be more significant
  • 66.7% of IM program directors in another survey agreed, saying that grades in required clerkships will become more important
Personal Knowledge of Applicants
  • The majority of both orthopedic and IM PDs believe that personal knowledge of the applicant will be more essential.
  • Another survey of IM PDs yielded 66.7% believing that personal knowledge of applicants will be more critical.

 

Pass-Fail Step 1: What to Do to Get Into a Highly Competitive Specialty?

What if you’re interested in a highly competitive specialty? What do you need to do now to stand out?

Interestingly, one survey compared responses from orthopedic surgery and internal medicine. Orthopedic surgery is one of the most competitive specialties in the NRMP (National Resident Matching Program, or “Match”).

This is what they found:

Compared to IM PDs, orthopedic PDs were significantly more likely to say the following components would be of greater importance after the change to pass/fail Step 1:

  • research experience (p < 0.001);
  • letters of recommendation from faculty they know (p < 0.0.001);
  • Alpha Omega Alpha (AOA) membership (p < 0.001);
  • leadership/extracurricular activities (p < 0.001);
  • personal knowledge of the applicant (p < 0.001) and
  • audition electives (p < 0.001).

These things – research, insider knowledge of the applicant from faculty they know/audition rotations – were more critical to highly competitive specialties before Step 1 became pass-fail. Therefore, it is not surprising that they would take on even greater significance afterward.

Program Directors: Who Is At a Disadvantage from Pass-Fail Step 1?

I’ve read multiple surveys of PDs views, and they all seem to agree on this point: if you don’t attend a highly regarded medical school, a pass-fail Step 1 will probably hurt you. Specifically:

  • The majority of orthopedic and IM PDs believe that allopathic (MD) students not attending highly-regarded medical schools, osteopathic (DO) students, and international medical graduates (IMGs) will be disadvantaged by the change of Step 1 to pass/fail.
  • Compared to IM PDs, orthopedic PDs were more likely to believe that MD students who do not attend highly-regarded medical schools (p = 0.011) and DO students (p = 0.001) will be disadvantaged in the match processes due to the Step 1 pass/fail transition

IM PDs specifically stated that disadvantaged students included:

  • MD students not attending a highly-regarded medical school (63.4% of respondents)
  • DO students (52%), and
  • IMG students (82.9%)

So what does this mean? Of the available data, PDs believe that not attending a highly regarded medical school is a hindrance now that Step 1 is pass-fail. The disadvantage seems to be even more significant according to orthopedic surgery PDs, implying that the reputation of one’s med school may matter even more to the most competitive specialties.

Implications and Concluding Thoughts: Step 2 CK for Everyone + Personal Connections/Research for Competitive Specialties

In reading multiple PD surveys – and communicating with a number individually – I’m struck with how stark their words are. In the beginning, I assumed that everything – research, elective rotations, Step 2 CK, etc. – else would gain in importance equally. That doesn’t seem to be the case.

Instead, most program directors seem to be coalescing around Step 2 CK. When we consider their dissenting views on Step 1 turning pass-fail – as well as the enormous burdens of sorting through residency applications – this shift to Step 2 CK is not surprising.

What does this mean for you? No matter who you are, you need to be preparing for Step 2 CK. This focus on Step 2 CK is particularly significant if you don’t go to a prestigious medical school.

Are you interested in a competitive specialty or location? Getting to know the people on the admissions committee – via audition rotations, personal interactions, or letters from connections to PDs – would be valuable. Getting to know applicants beyond their CV has always been particularly important for competitive specialties. However, with Step 1 going to pass-fail, this personal knowledge seems to become even more critical.

Finally, research likely will remain valuable. However, if we take PDs at their word, it seems like it may not become MORE valuable to all specialties. Instead, orthopedic surgery PDs’ views that research will become more critical may represent other competitive specialties’ views.

Are you worried about studying for Step 2 CK now that Step 1 is pass-fail? Do you feel nervous? Do you have a long time until your test – or haven’t even taken Step 1 yet? Sign up for a free consultation and learn how to master – not memorize – for impressive Step 2 CK scores and more meaningful careers.

Want FREE Cardiology Flashcards?

Cardiology is key for impressive USMLE scores. Master cardiology from a Harvard-trained anesthesiologist who scored USMLE 270 with these 130+ high-yield flash cards. You’ll be begging for cardio questions - even if vitals make you queasy.

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