Wednesday, August 14, 2013

How to overcome a low USMLE Step I score and become a surgeon

On my companion blog "Ask Skeptical Scalpel," a medical student asks how he can overcome a low USMLE Step I score and obtain a residency position in general surgery. Click here to view that post.


Anonymous said...

The lede is misleading. The student scored badly due to a one-time personal crisis, and performed well otherwise.

What if a medical student gets low scores consistently? Maybe he is just not that smart? Can he be a surgeon?

There are plenty of D.O.s and Caribbean grads who are surgeons. Just apply to BumFk programs. Once they graduate and work in places like Bakersfield or Dogpatch, they can be successful.

What should the bottom 10percentile do? Or grads of Louisiana State? Just go to Family Practice? Or Psych? Or Anesthesia?

Skeptical Scalpel said...

You have a point about the lede, but the student was asking a good question, which was how he could get residency PDs to look at his application. It is common knowledge that many PDs filter applications by USMLE Step I scores.

You are on your own regarding the rest. I'm not going there.

artiger said...

Pretty inflammatory remarks, Anon. It may shock you to learn that some people are perfectly happy in BFE.

I may have suggested it before, but it bears repeating. If a student has consistently low marks and not so great test scores, but has a notable work ethic and a burning desire to be a surgeon, the best way is to sign on for a one year prelim surgery spot, and show them what you got. It doesn't have to be an Ivy League program, or Mayo, or whatever, a state university or even a community program will still train you to be a surgeon. By working hard, reading a lot, and showing a good attitude, one might get the attention of the right attendings. It may take an extra year, but if the desire is there, it will be worth it. It should also be mentioned that some of the stellar (on paper) applicants don't always pan out after a year or two in residency, for a variety of reasons; you never know when a spot might open up.

Skeptical Scalpel said...

Artiger, doing a preliminary year or two is a crap shoot. Not everyone even if hardworking will get a categorical position.

I do agree that some good students do not fare well in surgery. In one study of the 31% of residents needing remediation, receiving "honors" in the third year surgery rotation was associated with the need for remediation. See

artiger said...

Scalpel, certainly there are no guarantees. My suggestion is just one for those that truly have the desire, who might also run across a little luck (like one needs at the craps table). If it's truly what one wants to do, it seems like the most viable alternative. Education wise, it's certainly not a bad way to spend a year.

If, after a year or two, Lady Luck hasn't smiled, I would say find something else to do.

surgery rocks said...

Want o good advice ...I am an Indian national aspiring to give USME.I want to be a surgeon.However I have been told there are a very seats available.Moreover I am not a good student in terms of academics like stuff of learning.However I grasp theories easily work and understand them easily and can also use them easily.I would like to know at what place do I stand for surgery.Also please let me know other residencies other than medicine and gynaecology.Please do advice me books and sites for my studies.Thank you...

Skeptical Scalpel said...

I'm going to do you a favor and be very honest. I think you have no chance of obtaining a categorical 5-year position in general surgery.

The fact that you admit you aren't a very good student in terms of academics would I think eliminate you from most other types of residencies too. It also suggests that you would have trouble with the USMLE exam.

I'm sorry.

Unknown said...

Hey i am a average med school graduate from nepal, would like to apply for general surgery if possible , what are the possibilities and the cut-off score i should be targeting. What other specialities are there ...for asian like me to get matched !!!!

Skeptical Scalpel said...

Kriten, I have written extensively on this subject. Here are links to 4 posts which I hope will answer most of your questions. If not, please feel free to ask again.

Unknown said...

First of all great blog! Just stumbled upon it. I have a rather specific question which I haven't been able to find an answer to and perhaps you can help. Say you have finished your residency abroad and are thus an IMG qualified surgeon; in the EU or UK for example, however you would now like to work as a surgeon in the US. It is my understanding that irrespective of your previous qualifications you still must complete the USMLE in order to be granted a licence to work in the US (even if already a surgeon abroad?). Now being a surgeon (and most other specialties for that matter) anywhere in the world is a very busy profession and takes up most of your time. Thus going back to studying the basic sciences and other pre-clinical subjects relevant to the USMLE (Step 1) full-time is next to impossible unless you stop working completely and start from scratch; which would then most likely cause you to neglect your specialty, but I digress. Would you still be able to get a position in the US with a mediocre USMLE score (a score which is below the cutoff point for surgical residency) as your international qualifications/experience/publications/etc. would now take precedent, or would you not be considered at all irrespective of this? I'm naturally assuming you wouldn't have to complete residency in that specialty again in the US, or am I wrong? Sorry for the length of this post and how specific it is but I hope you can help :)

Best Regards & Thanks

Skeptical Scalpel said...

Claude, I understand your question. I'm afraid I can't answer it. I have never personally known anyone who has done what you would like to do. I have two suggestions for you. One, contact the ECFMG and see if one of their advisers can help you. Here's a link Two, contact the American Board of Surgery (

There may also be an issue with licensing as every state has different requirements. You would have to find out what you have to do from the medical licensing board of the specific state you are considering.

I will ask around and see if anyone knows more about it that I do. I am sorry I can't be more helpful.

Unknown said...

Hi, sorry for the late reply. I understand it's very unusual but I really appreciate you trying to help with my inquiry. I'll be sure to contact the ECFMG & the American board of Surgery as soon as possible. If I find an answer I'll let you know. I didn't expect it to be so difficult, as I know quite a few doctors from the states who came to practice here but none vice versa. Many Thanks, Claude :)

Anonymous said...

Very impressive blog...
I am from india ,yog not yet left with internship which is a requirement for graduation no usce.i hav a low score in step1 204 should i go for step2 im very interested to get into obg residency.....I have good academic scores in med school..donno what went wrong during step1 prep guess bad prep schedule...
Plz advice on whether i shud go for step2 or get into my state medical entrance??? In a huge dilemma. Thnx in advance

Skeptical Scalpel said...

Anonymous, thanks for reading my blog.

I'm afraid the odds are against you. In the 2014 match,76% of the first year positions were filled by graduates of US medical schools. That means only 24% were filled by international graduates, both US and non-US citizens. As a non-US citizen with that score of 204, I doubt that you would be considered. Please be aware that this is just my opinion. I could be very wrong. Good luck.

Anonymous said...

I got a 193 on Step !. I am interested in family medicine. Do I have a change at residency?

Unknown said...

Hi i got my step 1 results today...193 sooo disappointed! I graduated medical school in Argentina last year with a great average and am interested in general surgery. Is it hopeless for me? can a better step 2ck score help? please i need advice! thanks

Skeptical Scalpel said...

Anon, I don't know much about the family medicine match. Since they often have unfilled positions, I would assume that no USMLE score would be too low. If you are persistent and went to a decent school, you should be able to find a position in the match or the post-match process.

Carolina, amazing coincidence about the scores. I guess nothing is ever completely hopeless, but I think you situation is close. You could apply to some lesser community hospital programs and see if you get any interviews. I would have a backup plan such as family medicine in mind. There are always many unfilled prelim general surgery positions. You could try to get one of those after the match or even apply to match as a prelim. It is not always the path to a categorical spot, but it may be worth a try.

Anonymous said...

Im a non-trad F US IMG with a disappointing step 1 score of 208, absolutely fell in love with surgery during rotations, and can't imagine doing anything else.

My step score isn't reflective of my abilities (I'm sure everyone says that). I had bad insomnia 2 nights in a row stressing b/c I was taking it too soon, was delirious and performed 30 points less than I did on the practice test two days before (232 ). I should achieve higher b/c my IQ is 141 and I was only able to do about 300 UW Q's and only less than the 1st half of FA). I was dealing with a lot during the time I was studying, didn't get to focus on it, worrying about finding stable places to sleep and study, and had to take it before I was ready. My parents decided to divorce while I was applying to med school and I came back to my mom's new onset alcoholism and I couldn't be around that and just kept all my things in my car bouncing from place to place, staying with friends (who had crying kids etc), and wasting time finding gigs pet-sitting because I couldn't afford my own place at that time. I also had to take Step1 before I was ready b/c to sit in time to start my electives in time to match for 2017 to avoid more financial obstacles.

As far as being intent on applying to surgery, I received more encouragement from both the residents and the attendings than I have about anything else in my life. One surgeon who was impressed by me finally (as I was dreading) asked my step score. When I told him he acted disappointed for a bit and suggested other things I could do but then the next day told me he thinks I should apply anyway.

I love surgery so much I'd do it in my spare time for free if that wasn't illegal. I can't imagine doing another specialty now. I was twice as fulfilled in that rotation than any of my other rotations even though I put in twice the hours. I picked up on it quickly, have good dexterity and spacial skills, and feel like residents and attendings enjoyed being in the OR with me.

I would love any suggestions of what I can possibly do because I have to make this work. I'm sure my letters will be good but that's all I have right now. Is there an efficient way to find hospitals that don't have 220 cut offs? Should I email them my 232 on the practice test? Should I explain my situation or will that seem like a sob story? I've had bad luck but just a string of it and I feel like it would sound like I was making too many excuses. Should I strategically book rotations during interview season and hope they decide they want me (does that happen and do you have any tips on this)?

My other question is, I'm hoping I can really kill step 2 and make up for step 1 a little, but I'm kind of in a similar boat as with Step 1. I started a business on the side to support myself (high cost of living where I'm rotating and student loans don't cover it, especially with non-trad bills) and I'm way behind on studying. I feel like I owe it to myself to at least review as much as an average student does before the test, however I only have 2 weeks to make it in time for ERAS. Should I just take my time and apply late with a killer step 2 score? Or is applying late even worse? I'm thinking it won't matter too much if I apply late since no one will look at my application anyway without me rotating there and asking them to right?

Can you help me come up with a plan? I'm made for surgery, I know it and think other people recognize it too. Unlike my peers, I'm not interested in it for the money or prestige. I just really love the work, being skilled in a craft like that and seem to have raw talent for it (especially laparoscopic), and I love the teamwork and intimate work environment of the OR. I had to force myself to go home at night (and many times I didn't).

Any advice would be appreciated. Please don't tell me not to do it, please give me any advice on how to do it. Thank you so much!

Skeptical Scalpel said...

You have a lot of questions. I will do the best I can. Disclaimer: I can only give you my opinion which may not be shared by the majority of surgical program directors.

Let me take your questions first.

Is there an efficient way to find hospitals that don't have 220 cut offs? In a word, “No.”

Should I email them my 232 on the practice test? I do not think that would be of any use.

Should I explain my situation or will that seem like a sob story? I've had bad luck but just a string of it and I feel like it would sound like I was making too many excuses. Honestly, as I read your story, it did sound like too many excuses. The problem for you is that there are numerous other candidates out there who don’t have these issues and have better scores.

Should I strategically book rotations during interview season and hope they decide they want me (does that happen and do you have any tips on this)? The value of so-called “audition electives” is controversial. I never put much stock in them, but I think many program directors do. If you decide to do some audition electives, you should focus on smaller community hospital programs. Many programs list where their residents went to medical school on their websites. You should pick places that have taken US IMGs recently.

Should I just take my time and apply late with a killer step 2 score? Or is applying late even worse? This is a tough question. It would certainly help if you can achieve a much better score on Step 2. I think it may depend on how late you apply. It seems that programs are scheduling interviews earlier and earlier and interview slots might be filled if you apply late.

I don’t know if you read my recent update on the residency prospects for IMGs. Here’s the link:

A Step 1 score of 208 is not fatal. Based on fairly recent NRMP data, I would say you have a 15% chance or so of matching in surgery. However, as I noted in that post, a lot depends on which school you are attending. If you are at St. George’s or Ross, you have a much better chance than if you are at a lesser known school. You may want to check with your school to see how many of its graduates have matched in categorical surgery.

Another useful measure would be to obtain letters of recommendation from surgeons who might be known outside of their own hospitals. If they can contact program directors by phone to personally recommend you, it would be a big help. As you correctly assume, many programs simply do not look at USMLE Step 1 scores below certain cutoffs.

The only thing you can do at this point is to excel in your surgical rotations and electives, get a good score on Step 2, and hope that your letter of recommendation writers are willing to help you. Send out the applications (as many as you can afford) to community hospitals and see if you get any interviews. If you aren’t offered many interviews, you should have a backup specialty in mind. You probably should have a backup specialty even if you do get several interviews.

I hope this helps. Good luck.

AMRE said...

American medical student in my second year of medical school. B average so far. What step score should I aim for when I take the test this summer? I am interested in surgery. Eventually to do transplantation surgery and research.

Skeptical Scalpel said...

You should try for the highest score you can get. However, a figure from a post I wrote last year shows that a US med school grad with a Step 1 score of 220 had an 80% chance of matching in surgery. [] It also depends on which programs you apply to.

You should discuss this with your school's residency program director and some surgeons at your school.

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