What's up ... ummm ... doc?
May 19, 2016 11:40 AM   Subscribe

Help me understand my daughter's medical school situation.

Okay, so our daughter – who has, since 5th grade, wanted nothing more than to be a doctor – has just finished her second year of med school. Unfortunately, as I understand many do, she has hit a significant hurdle. She has received the scores of her STEP 1 test and while passing, they are significantly below the mean. From what I gather from her, this is a major bombshell dropped smack on future doctoring plans; something that can prevent her from getting matched for residency two years from now and possibly scuttle her goal of becoming a physician at all. She is, understandably, unconsolable and has leaned on her mother and me for counsel. I don't understand the significance of this well enough to put things in context and provide advice. Sooooo ... what DOES a bad STEP 1 score mean? Does it really scrap her future? Mitigate it in some way? Are there avenues for her to rebound? I would welcome any and all advice from those who have gone through this, or know someone who has. Bonus points for what she can do for next steps. Thanks folks. I know she's an adult, but she's my kid, and her pain is my pain.
posted by lpsguy to Education (12 answers total) 3 users marked this as a favorite
She is catastrophizing. Good performance on clinical rotations, strong letters of recommendation, and a certain amount of schmoozing are what make the difference for getting a decent residency. If she had her heart set on a very competitive specialty such as dermatology, neurosurgery, orthopedics, etc, this might be a significant roadblock, though not entirely insurmountable. Virtually all graduates of American medical schools are matched into a residency.

She should speak to her faculty advisor to put together a plan for her clinical rotations and do some career planning.
posted by demons in the base at 11:56 AM on May 19, 2016 [35 favorites]

Does her medical school have career and academic counselors who can advise her better on what all this means to her? I know nothing about med school, but it would seem that as long as she's still in the program and is not due to go into residency for 2 years there would seem to be a fair amount of time to find out what she needs to do to become competitive again, or reset her goals. Very generalized examples, but as demons in the base alludes to, maybe it means she has to give up on general surgery but might still do fine as a family medicine doc, for example.

I mainly jumped in to mention that if the worst happens and she winds up coming out of med school now or down the road over this - there are still a ton of jobs in the medical and pharmaceutical industry that are very well paid, and many/most of them are filled by people who didn't quite make it through (or even into) med school, but had the strong pre-med creds that got them into the hunt for medical, dental, or related schools. For example, pharmaceutical sales, medical device sales, etc. Companies that sell pacemakers, artificial joints, etc. need highly trainable people, who sometimes (as I understand it), even scrub in and assist the surgeons in setting up the devices for the procedures. They're not surgeons, but they're helping surgeons, and making six figure incomes doing it sometimes. That doesn't sound shabby to me at all.
posted by randomkeystrike at 12:02 PM on May 19, 2016

I can't offer advice on this particular thing, but based on watching my sister navigate the med school world it is a bonkers crazy pressure cooker of brilliant perfectionists stressing each other out.

I'm betting that this is the first time your daughter has been "significantly below the mean" on anything, so the catastrophizing might be unwarranted, but it is understandable.

I'd tell you to remind her that you love her regardless of where she ends up, or that there are great careers that you can get into with an MD but no residency, but I highly doubt she wants to hear either of those things right now, so I'd wait.

I might remind her of all the people at her school who got in with lower MCAT scores than she had, or who got into her undergrad school with lower SATs and ACTs than she had. She might need to work harder in her rotations and build more networking connections to get the residency that she wants now, and maybe she'll need to do her residency in a less desirable part of the country. But if she still wants to, she's going to be a doctor (and probably a damn good one too).
posted by sparklemotion at 12:11 PM on May 19, 2016 [7 favorites]

A bad Step 1, like demons in the base said, probably (although not definitely) takes you out of the running for the uber-competitive specialities, but it's not the end of the world by any means. A friend of mine had a circuitous route to med school thanks to a run in with the law right before we left college, had subpar performances on Steps 1 and 2, and put hard geographical limits on their residency applications so they could stay close to their significant other, and they managed to match earlier this year (although they did have to scramble). This won't ruin your daughter's life, and it won't destroy her career choices. She just needs to keep grinding, and make sure she really works hard on her rotations.
posted by protocoach at 12:19 PM on May 19, 2016 [7 favorites]

The NRMP has a lot of data out there to help contextualize this situation much better than anecdata, this document is a great place to start.

The short story is that most US medical students match, period. However, while there are many things that can be done to mitigate a low Step 1 score it does meaningfully close some doors. There are programs that use Step scores as a screening tool and no amount of clerkship honors, publications, extracurriculars, etc will get past that. Not all programs are like that, but if your daughter's dream up until now was to do dermatology at MGH, that door is pretty much locked up.

I would really encourage you to provide emotional support and turn your daughter back to resources at her school for actual professional advising. It sounds like you're not in the medical field and frantic reading/Googling is not going to transform you into a good resource for her. Give her what she needs from you (unconditional love and reassurance) and make sure that she gets professional advising from a qualified source (or preferably multiple sources). The only people who really understand this process well are the ones who deal with it every day and those are the people who work at her school.
posted by telegraph at 12:22 PM on May 19, 2016 [23 favorites]

This is a good time to talk to your daughter about networking and making contacts. If she's still thinking "everything is test scores," she's still in the young student mindset.

She'd do well to go to more conventions, meetings, present at conferences and so on--meeting people is what will help her stop thinking about testing, testing, testing. No idea where she's in school, but I spent a lot of time in grad school going to (publicly announced in the Federal Register) FDA meetings on topics that interested me. The people I met at those meetings helped me find my niche (and, incidentally, away from medical practice and into research and regulatory policy). Thank heaven, too, because I had been so laser focused on the process that I hadn't much considered what I'd be doing day-to-day in my field after school until I started having those conversations with contacts.
posted by late afternoon dreaming hotel at 12:34 PM on May 19, 2016 [6 favorites]

Unfortunately she can't retake Step 1 because she passed.

However it's still better to pass : if she'd narrowly failed, and had to retake, the fussier institutions would still count the first fail against her, even if the second score was great. There's a nice thread about this on studentdoctor.net.

The plus points are that she passed first time, and gets to do better on Step 2. People like to see numbers that go up over time. There are a lot more measures of a person than one test score.
posted by w0mbat at 3:07 PM on May 19, 2016 [5 favorites]

This is a setback, but definitely not a catastrophe. There are certainly residency programs in certain specialties that are so competitive that they don't even look at applicants with board scores below a certain cutoff, but even these limits can be circumvented with some personal leverage such as a request to the program from her dean or an advisor in that specialty (as long as her other qualifications meet the program's criteria). If she has a good idea of what residency she wants to apply in, she should definitely be making connections in that department, finding a research project to work on, etc. As someone who reads a lot of residency applications, recommendations that start with something like "I have worked with Jane Doe for 2 years on a research project and I know her very well" just tend to be more detailed and compelling than "Jane rotated for a month with me on her X clerkship". If she really wants to do something super competitive she may want to consider a research year (lots of students do this anyway, especially people who came late to their preferred specialty).

She does need to do well on her key 3rd year clinical rotations (4th year rotations as well, but these count for less because honors in core clerkships are often capped at 25-30% of the class, so they are considered more meaningful). She should plan to take Step 2 as early as feasible and do well on it, so that her residency applications go out with both scores. If there are residency programs outside her home institution that she's particularly interested in, she should probably try to spend a month there as a 4th year student, since that usually leads to at least a courtesy interview and the faculty there will also be familiar with her.

I would definitely suggest that she make connections with her faculty advisor and maybe also with her dean, because as much as the whole grades/test scores thing sort of runs itself, when it comes time to send out residency applications, there is a certain amount of wiggle room for marginal candidates who have someone going to bat for them.
posted by The Elusive Architeuthis at 4:32 PM on May 19, 2016 [5 favorites]

Don't let your daughter be talked into a general practitioner residency (family medicine, internal medicine, pediatrics). Nurse practitioners and physician assistants will seriously erode salary levels and eventually outright job opportunities.
posted by MattD at 7:40 PM on May 19, 2016 [3 favorites]

So much good stuff here, both empirical and anecdotal. Just what I needed. Please keep the, coming. I am in your debt.
posted by lpsguy at 8:31 PM on May 19, 2016

Don't let your daughter be talked into a general practitioner residency (family medicine, internal medicine, pediatrics). Nurse practitioners and physician assistants will seriously erode salary levels and eventually outright job opportunities.
posted by MattD at 7:40 PM on May 19 [2 favorites +] [!]

This is simply not true. Primary care jobs will be around forever and with excellent salaries if she chooses carefully (IM or FP, maybe not peds). And as an FP I would do this job again in a heartbeat as long as it was in a clinic large enough to have support staff for the paperwork.

I'm sorry for your daughter's situation. But EVERY med student in my class changed their focus many times during their third year of training. She WILL become a doctor, and should stop worrying. Her work ethic will be the thing she will need in the coming years, not perfect test scores.
posted by docpops at 9:46 PM on May 19, 2016 [10 favorites]

From the residency program side: we often do sort applicants by Step 1 score. There are SO MANY applications, and we have to start somewhere (this last cycle I got >450 applications for 4 spots). The Step 1 score often fills this role because it is simple to use as a filter. This is clearly not ideal, and often not equitable (white men tend to outperform all other groups-it's a standardized test), but it's unfortunately true.

The good news, though, is that she can do lots to improve her chances. There are plenty of good ideas in this thread, but one thing I don't see is the importance of a good Step 2 score. If I see an applicant with a low Step 1 score but a solid Step 2 score listed right below it, I take another look at that application. Step 2 is considered "easier," which is why more emphasis is placed on 1, but it is still a concrete number. I would encourage her to construct a narrative surrounding her test scores for interview purposes: explain the Step 1 score, and what actions she took to improve after that, and then a good Step 2 score to demonstrate that those interventions worked.

She will have the option of scheduling Step 2 whenever she wants. I think students with low Step 1 scores often get nervous and delay Step 2 as much as possible. THIS WILL ONLY HURT HER, because if Step 2 scores are not available as soon as applications start, the only thing programs will have to go on is that low Step 1.

Another thing I don't see listed above-when she decides on her specialty, she should do everything she can to get a letter from the Chair of that department. Department Chair letters are differentiated in the application system from the other letters of recommendation, so they stand out. That person is also likely to be nationally recognized. She can also try to identify doctors with significant research or other contributions to their field (leadership roles in national organizations, for example). Even small schools often have people with reputations, and those people know other people. Networking sucks but it's real.

Step 1 is an incredibly hard test. She shouldn't beat herself up over this, but should start taking steps as everyone else has suggested: work on research, meet people in her desired field, and make an awesome impression on clinicals. These are undoubtedly better metrics for determining how a doctor will perform, but the ease of sorting applications by test score is an unfortunate truth.
posted by Missense Mutation at 9:14 AM on May 20, 2016 [7 favorites]

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