Standing Out in Residency Applications With a Pass/Fail USMLE Step 1

Although the recent USMLE switch to pass/fail scoring for Step 1 has been regarded as a largely positive change for most students, some of you may be wondering how this change will affect the overall appearance of your residency application. There are several key components to building a stand-out application for residency, and your USMLE pass/fail Step 1 and Step 2 scores are only one small part of the bigger picture. Whether you have made your way to this post as a first-year medical student pre-Step 1, a second or third-year medical student that just finished Step 1 (congrats!) or a rising fourth-year medical student tidying up your application before September – there are changes you can make now to improve your application before you hit submit! Let’s break it down into the 5 key components of any application:

1.     Medical School Grades (1st and 2nd-year grades, clerkship grades)
2.     USMLE Board Scores (Step 1 and Step 2CK)
3.     Curriculum Vitae
4.     Personal Statement
5.     Letters of Recommendation

Medical School Grades

Depending on where you are at in your training, this aspect of your application may or may not be modifiable. Most medical schools across the country have transitioned to pass/fail grading for the first 2 years of medical school, but the large majority continue to provide students with a grade for all required 3rd-year clerkships. If you are preparing to start your 3rd year now, be sure to reach out to your classmates and clerkship coordinators to get an idea of how your clerkship grades are determined. Most programs assign grades based on clinical evaluations from preceptors, as well as NBME shelf exam (family medicine, internal medicine, surgery, neurology, pediatrics, OB/GYN, and psychiatry) performance. Many residency programs look carefully at 3rd-year clerkship grades because they can be a surrogate marker of a student’s work ethic and ability to work well in a team environment. For example, if you are applying to a general surgery residency, you most likely do not have an interest in psychiatry, but if you receive an “Honors” grade in psychiatry, it may indicate that you are willing to work hard even when the task is not something you enjoy doing. In general, it is best to achieve the highest grades possible on all 3rd clerkships, and in order to do so, you need to be well informed about how your grade will be determined!

USMLE Boards Scores: The Switch to USMLE Step 1 Pass/Fail

USMLE Step 1 scores have previously been used as a quick, objective way to evaluate residency applications and determine which candidates to consider for an interview. This has primarily been the case for specialties that are highly competitive such as dermatology, orthopedic surgery, neurosurgery, otolaryngology, and plastics and reconstructive surgery. Many programs historically set a “threshold” score for Step 1 of 235 or 240 and would only consider applicants with scores above that threshold. With the recent switch to pass/fail USMLE Step 1, it is important to be strategic in your approach to USMLE Step 2. For the competitive surgical subspecialties and dermatology, it will be important to take Step 2 early and receive a score that can be listed on your application. Most programs will likely start requiring Step 2 scores to be listed in order to be considered for an interview, much in the same way that the Step 1 score was previously used.

If you’ve made it to this point in the article, and you’re on the verge of a panic attack – slow your breathing! The last three components of your application are what TRULY set you apart from other applicants, and these are the easiest components to modify!

Curriculum Vitae

Your curriculum vitae consists of your extracurricular activities i.e. involvement in organizations, volunteerism, and research. In general, medical school can be quite demanding, so it is often difficult to have multiple items listed in each of these categories. What is often more important than having 10 different volunteer or research experiences is having 1 or 2 longitudinal experiences that you have invested your time into. Realize that many students will list a research abstract, a research presentation of the same data, and a subsequent paper that was published as 3 separate research experiences, and this is completely appropriate to do, but it does artificially inflate the “average number of research experiences” as reported by the AAMC. Be sure to list any organizations or research projects you might have been involved with throughout medical school or in your time leading up to medical school. If you worked for a year in between your undergraduate education and starting medical school, list that as a work experience! If you worked in a research lab during undergrad for 4 years, list that as a work experience and list any abstracts or papers that might have been published under your research. If you volunteered at your school’s outreach clinic and served on the board or developed new initiatives for the outreach clinic, list that under volunteer experiences and leadership! Make sure to give yourself credit for the passions you have pursued while in medical school, and try to paint of picture of who you are as a person via the experiences you choose to include. Be prepared to talk about any and all experiences you list on your application, however, so try to avoid listing volunteer experiences that you participated in one time for an hour simply to fill space. At the end of the day, your work/volunteer/research experiences should appropriately convey your passions and engagement outside of your education without being too overbearing that the person evaluating your application skips right over key experiences because there is too much to read.

Personal Statement

Everybody’s favorite part of the application process…said no one ever. The personal statement should be viewed much like the classic interview question, “Tell me about yourself.” A good personal statement should AUGMENT the rest of your application, not simply reiterate the key aspects of your application in prose. I recommend approaching your personal statement by first considering your answers to the following questions:

1.     “Why do I want to pursue a career in ______ (insert your specialty)?”
2.     “What characteristics or traits do I possess that will make a good _______ (insert your specialty) resident?”
3.     “What stories or experiences in my life tangibly illustrate my desire to pursue _______ (insert your specialty)?”

The best personal statements are those that are easy to read, reveal something new or otherwise unknown about the applicant, and demonstrate that you, the applicant, have a clear idea of why you will be great in your chosen specialty. The personal statement is truly your opportunity to highlight what makes you, YOU, and what you love most about the specialty you’re pursuing. In order to make your personal statement stand out, you should include detailed anecdotes or stories that are unique to you and can demonstrate particular qualities that you possess or illustrate how you came to recognize your passion for your chosen specialty. Try to really dig deep and think about WHY you’ve chosen the specialty you’re applying to, and avoid making vague statements that could be applied to multiple specialties. For example, if you’re interested in orthopedic surgery, do not simply write, “Growing up I was always interested in sports, and it has been my goal from a young age to one day work with athletes.” There are many different types of health care practitioners who work with athletes including: Family Medicine/Sports Medicine trained physicians, Physical Medicine and Rehabilitation physicians, Orthopedic Surgeons, Physical Therapists, etc. If you convey your interests thoughtfully in your personal statement, it will be easier to read and feel more genuine to the reader!

Letters of Recommendation

This aspect of your application may be one that you feel you have the least control over to a certain extent, and that is why it is critical that you choose your letter writers carefully! Letters of recommendation add a great deal of depth to your application, and they can certainly make you stand out relative to your peers. The two most important things to consider when choosing who to ask for a letter of recommendation are:

1.     How well does the attending know me?
2.     Will he or she be able to write me a strong letter of recommendation?

Be honest with yourself when selecting your letter writers. If you want the surgeon with the biggest name at your hospital to write you a letter, but you have only worked with him or her once, the letter of recommendation may not say anything too specific about you, your work ethic or your skillset even if that physician agrees to write one. It is far better to request letters of recommendation from faculty that have worked with you closely throughout your medical school education and comment on different facets of you as a person and future physician. Consider asking for letters from any faculty you might have done research with or volunteered with, as well as attendings you rotated with. If you have yet to start your clinical rotations, identify attendings that you get along well with throughout your clerkships and keep a running list of letter writers you might consider in the future. If there is one person in particular that you hope to get a letter from specifically, then consider reaching out to that physician and seeking out additional opportunities to work together whether in research or shadowing. Select writers that will rave about you in the letters of recommendation and truly promote you to the residency programs you are applying to!

All in all – it is important to remember that your USMLE scores are only a fraction of your overall application! Use your pass/fail USMLE Step 1 score as an excuse to bolster the rest of your application and make yourself stand out with diverse extracurricular activities, a well-written personal statement, and glowing letters of recommendation.