What Step 1 Means to Me Now

sb10069454ac-001Editor’s Note: For more on using USMLE Step 1 scores to screen applicants for residency, see the commentary by Prober et al in the January 2016 issue.

By: Jessica G. Fried, MD, PGY-1 Preliminary Medicine Resident, Lankenau Medical Center, Wynnewood, PA

I remember the night before I took Step 1 of the United States Medical Licensing Exam (USMLE). I knew that the way I performed the next day would play a large part in what the next forty years of my life would be like. At the time, it seemed like the most important thing in the world. One day, one eight-hour exam, would tell me what specialties I would be “qualified” for when it came time to apply to residency. I knew going in that top programs and competitive specialties screened residency applications using minimum exam scores. Minimum exam scores far above the pass rate. I knew going in that my liberal arts education had prepared me for many things but that multiple-choice exams were not my strong suit. I knew going in that as a minority, I was likely to score lower than my peers, regardless of how well I prepared. I knew going in that all I could do was try my best, like I had for my entire life.

I was deemed “average” by the USMLE. When I opened my results letter, I cried. Despite being deemed average amongst the brightest and most talented medical students across the country, I felt that many doors had been shut to me. I was apprehensive when I submitted applications to my dream residency programs–they had become long shots based on my Step 1 score. I was grateful for the phone calls made on my behalf by my department chair and mentors, so that I wouldn’t be entirely overlooked due to my average score. When I interviewed at one of the top radiology programs, the program director asked me to explain my unexpectedly low Step 1 score in comparison to the rest of my fantastic resume. I asked him if he was worried I would not pass the radiology boards, and he said no–in his experience, residents with my score had no trouble passing the core exam. I asked him why he cared what my Step 1 score was, and he had no answer. I was surprised when he called to tell me that I was ranked to match in his program, that my leadership skills, communication abilities, and impressive academic record would make me a fantastic resident. I was surprised when I decided not to rank that program highly, because, despite the phone call, I did not feel that I belonged in the program.

Now, six weeks into my residency, Step 1 is a distant memory. Yesterday, halfway through my intensive care unit rotation, my first patient passed away. Nothing I learned in medical school prepared me for this experience. An eight-hour exam that establishes competency in medical knowledge did not prepare me for this experience. I had seen other patients pass. Patients I had done chest compressions on, who I knew little about but had to pronounce. This patient was different. I had met her when she first came into our unit. She had told me how scared she was, how much she wanted to get well enough to go home, to see her grandbaby who would be born in two weeks. I had cared for her for six days. I had been there when she decompensated overnight, twenty hours into my call night. I had done everything I could to save her. And it was not enough.

Despite the time, energy, and anxiety that I poured into Step 1, my average score meant very little when I was standing in front of someone whose life depended on me in the middle of the night. My average score meant nothing to me when I finally took time to grieve for my patient, who will never see her grandbaby. All that my average score means is that I am good enough to keep going, to keep trying my best every day.

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  1. Rhed
    September 9, 2015 at 12:24 PM

    You fell victim of “stereotype threat” and trait priming. Someone who focuses on societal expectations for someone of your background (minority) or subjective skill set (“bad at multiple choice”) actually will end up doing worse than you could otherwise. If you perhaps primed yourself on your positive traits (eg future leader of a major student group in organized medicine, PBK level performance in an undergraduate education in science, going to a good medical school), you could have had less self-defeating anxiety and you could have scored slightly above average.

    Your story suggests that the overt use of Step 1 scores for resident selection will alienate those who are otherwise strong candidates. Residency programs would do well to not publicize score cutoffs or inquire interviewees about their score (there’s usually little insight to be gained anyway). For instance, Penn Radiology does not post a cutoff on FRIEDA or its website.

    • Allene Swienckowski
      September 10, 2015 at 10:54 PM

      I can’t tell if you’re being snide on purpose, or that you are just merely clueless? I assume that you’re being snide. Either you completely missed the point of the essay, ie, Step 1 and one’s score has little to do with being an excellent physician or you just decided to practice a brand of elitism “You fell victim of “stereotype threat” and trait priming. Someone who focuses on societal expectations for someone of your background (minority) or subjective skill set …” that perpetuates the myth that test takers that score high are the most qualified? You purport to know the author because you have no problem describing specific parts of their past academic and professional accomplishments and therefore makes me question your motive? To tell an individual that “and you could have scored slightly above average”, really, “slightly higher” is indicative of an individual that is more focused on tearing someone down rather than being supportive. I can only hope that you absorb how to be more of a human being than what your veiled attack suggests, in your interactions with patients than your comment implies.

  2. Junjie "Jay" Liu
    September 10, 2015 at 1:29 AM

    Jess, I hope you’re doing well. I envy that you have energy to write, while all I can do at the end of day is to eat and sleep. I enjoyed reading this blog you wrote. My step 1 score is also average, and I totally agree that it has nothing to do with my clinical performance. I just have to disagree on one sentence “Nothing I learned in medical school prepared me for this experience”. To the contrary, I strong feel that our medical school (Dartmouth) educated me very well for handling patient death. I still remember at least 5 patients encountered during my surgery and medicine clerkships, who were lucid and pleasant at admission but deteriorated quickly and died in several days. I finished my cardiac ICU rotation recently, and had a patient similar to yours, under my intensive care for a week before passed away. I felt ready to do what a doctor can do to make him “dying well”. While Step 1 did not prepare me for this, the experiential learning in medical school certainly did the job. And I believe you’re well prepared too. You must have done an outstanding intern job, do not doubt it. Best, Jay

  3. Charles
    September 13, 2015 at 5:32 PM

    Thank you for writing this essay about your experiences. I am a physician faculty at a US medical school and have been involved in medical education for almost 20 years. I think that the degree to which USMLE-1 scores have been catapulted into career-shaping importance is horrible, and that this test has become one of the greatest barriers to real improvements in medical education. I hope people listen to your essay, and realize that the things we need to teach modern physicians are far more important than what is tested on the USMLE-1.

  4. What’s New and In the Queue for Academic Medicine | AM Rounds
    January 4, 2016 at 8:01 AM

    […] A Plea to Reassess the Role of United States Medical Licensing Examination Step 1 Scores in Residency Selection Prober and colleagues strongly recommend a move away from using test scores alone in screening applicants and towards a more holistic evaluation of future health care providers. A blog post to this article written by a resident is available. […]

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