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.