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Is Step 2 CK the New Step 1? Objective Facts and a Survey

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by Alec Palmerton, MD in Step 1 Pass-Fail

Step 1 will become pass-fail for tests administered on or after January 26, 2022. It marks a massive change for those seeking residency in the US, as Step 1 had become a de facto cut-off for applications. Some of the big questions concerning this change are: How will this move affect the role of USMLEs in residency applications? Will Step 2 CK become the new Step 1?

In this article, we will discuss why Step 1 became so crucial in residency applications. We will then look at early objective data on whether Step 2 CK will become the new Step 1.

Residency Programs Get Too Many Applications to Read Carefully

Let’s start with two facts:

  1. Some specialties are more competitive than others for various reasons (prestige, money, time spent on call, lifestyle flexibility, etc.)
  2. The number of applications to all programs continues to explode

Because of the deluge of applications, program directors have little choice but to screen applicants. In 2021, the average IM program had 3,383 applications each.

3,383. Applications. Each. Program.

That is insane. It also means that there is no way that residency programs can read every application carefully. So instead, they make the pool smaller by applying selective screens—things like having Step 1 or Step 2 CK cut-offs. Or they raise the bar for giving an interview to IMGs (see more below).

Step 1 became a natural screen. It was the only USMLE that all applicants had taken by the time they applied for residency.

USMLE Scores Offer Simple Numeric Screens

In 2020, 55% of residency program directors (PDs) reported having a target score for Step 1. It’s not hard to see why, either. For example, the mean applications received per program was 789. That’s too many applications for many programs to review carefully. So, 45% of applications were rejected based on standardized screening measures like Step 1 score, background (US MD vs. DO vs. IMG), and other criteria. On average, each program only sent out 107 interview invitations, implying a 14% interview rate (107 interviews/789 applications). In other words, programs rejected roughly 45% of applications via screens, and a further 41% more after a more careful reading.

Programs Crave Objective Data to Counter Application Inflation

Program directors will always crave objective data. The need for apples-to-apples data is even more acute for highly competitive specialties which need to choose among many uber-qualified applicants. Rather than the more subjective (read: manipulatable) things like the MSPE or letters of recommendation, PDs crave objective measures. Making Step 1 pass-fail won’t change the need to compare applicants.’ While many hope that programs will magically look at applicants more holistically, the numbers suggest otherwise. Program directors need objective ways to compare thousands of applicants, so Step 2 CK will likely become the new Step 1.

Why is there such a desire for objective data? While opinions certainly vary, it’s hard to ignore medical schools’ self-interest in making their students stand out. “MSPEs are garbage,” is what one assistant PD said. MSPEs – the Medical Student Performance Evaluation – is essentially a summary of a student’s entire med school experience written by their med school.

Med Schools Have a Vested Interested in Making Their Students Look Amazing

Let’s say you were a med school dean and knew that one of your students was far below average. Does it help you to broadcast that fact to the programs they are applying to? No. On top of the natural desire to help others, there are objective and subjective benefits to having students match at the best programs possible. The same is true of letters of recommendation. If I can choose my letter writers, I will only select those who 1) like me the most and/or 2) will write the strongest letter for me.

Residency programs know this and counteract it in various ways. One way is to parse the words of the MSPE and letters of recommendation carefully for not only what is said but what isn’t said. At MGH, where I trained, sometimes it seemed as if the standard was, “the absence of evidence IS the evidence of absence.” For example, the committee would openly wonder about someone’s clinical competence if there weren’t positive things said about it.

Another way, however, that programs use to counteract highly subjective measures of evaluation is by using things like the USMLE. That is unlikely to change now that Step 1 is pass-fail, as we will see next.

Early Data Suggest Program Directors Already Shifting Towards Step 2 CK

No one has a crystal ball. However, already there appears to be a shift towards Step 2 CK among program directors. In a survey of dermatology PDs, 86.0% (49/57) indicated they would increase their emphasis on Step 2 CK. 78.2% (43/55) of these PDs also reported they would begin requiring Step 2 CK for all applicants.

What to Do Now Step 1 is Pass-Fail: Peak on Step 2 CK

Given the likely shift towards Step 2 CK becoming the new cut-off for residency applications, what is your goal?

Peak on Step 2 CK (and don’t fail Step 1).

The first thing to remember is to try to avoid failing Step 1 if at all possible. While not the end of the world, failing Step 1 is an automatic rejection at many programs, particularly for more competitive specialties. (Note that the Step 1 passing score is unlikely to change). If you did fail Step 1, all is not lost (read this article here).

Second, while you are studying, focus on mastery and long-term retention. Deep understanding and retention are critical for Step 1, which covers roughly two years’ worth of material. However, this is even more true for Step 2 CK, which covers things from essentially four years of medical school.

In other words, you want your peak test-taking performance to be during Step 2 CK. Don’t cram and forget everything from your first two years. Instead, make your Step 1 learning useful for clerkships, shelf exams, and Step 2 CK.

For example, Minali, who despite her below-average Step 1 score, retained and built on her foundation. She went from a 228 on Step 1 to a 260+ Step 2 CK score. She’s currently a resident at Harvard (MGH/BWH).

Concluding Thoughts: Both Step 1 and Step 2 CK are Rewards for Mastery and Retention

Research on scarcity demonstrates that when we have too little time, we “tunnel” on the most pressing thing in front of us. These blinders make it very difficult to prepare for the long-term since we focus on the short-term.

Medical school is overwhelming, with massive amounts of material to cover and too little time/help in mastering it properly. Making Step 1 pass-fail won’t change that. It will, however, make it easier to fall into the trap of cramming for each school exam. If you’ve spent all of med school cramming for each test, will that suddenly change for Step 1, which has greater depth and breadth? Unfortunately not. As such, I expect more students to cram for Step 1, then forget most of what they’ve learned.

For those crammers, clerkships and shelf exams will be a rude awakening since there is a lot of overlap between Step 1 and clerkship/shelf material. However, the more people cram for Step 1, the more they benefit and create opportunities for those seeking mastery and retention. In addition, if your goal is to understand medicine deeply, you should welcome the fact that Step 2 CK rewards understanding even more than Step 1 did.

Every day, slow down and take the time to master more, including when studying for Step 1. Make excellent Anki cards to ensure retention. Then when it’s time to take Step 2 CK, reap the rewards of your understanding and application.

Free Consultation: How to Peak on Step 2 CK (Even if You Haven’t Taken Step 1)

Want to peak on Step 2 CK, even if you won’t take it for months (or even years)? Sign up for a free consultation to know how you can maximize your studies to peak on Step 2 CK. We help med students master – not memorize – for a strong foundation that will help them peak on Step 2 CK and have more meaningful careers.

What do you think? Will Step 2 CK become the new Step 1? Does this change your emphasis and studying? Let us know in the comments.

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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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