Friday, May 12, 2017

Can a med student who flunked Step 1 still become a surgeon?

I received these emails (italics) recently. The writer gave me permission to publish them. They have been edited for length and some details have been changed to protect his anonymity.

I'm a third year medical student at an allopathic state medical school. I've always wanted to do surgery. My problem is I failed USMLE Step 1 the first time and got a 207 on my second attempt. I hadn't failed anything else throughout first and second year, with the majority of my grades being my school's equivalent of Bs.

My surgery shelf exam was a week after I received my Step 1 score and, despite studying hard, my low score on that exam got me the equivalent of a C in surgery even with very good clinical evaluations. The rest of my third year has been good with most evaluations saying I'm well-liked and a team player.

Should I give up and go into a different specialty with better odds of matching? Apply to prelim surgery programs and categoricals? Or even apply to all of those things at once? I'm in a large pickle, paralyzed with indecisiveness, and would immensely appreciate your advice.

Disclaimer: This is my opinion. I do not presume to speak for all program directors. I'm going to be honest.

Since most programs have far more applicants than residency positions, they have to screen somehow. I believe the majority of program directors use USMLE Step 1 scores. Failing Step 1 drastically lowers your odds of being offered an interview.

The fail, the 207 on the retake, and a C in surgery are indicators of serious trouble.

If you can't face the future without being a surgeon, you could apply for a preliminary spot and take your chances on getting an opportunity to switch to categorical. Everyone who does this does not succeed. You could also send some categorical applications to community hospital programs that are not well-known and see if you are offered any interviews. Some programs prefer filling with US grads no matter what their scores and grades are.

If you have strong letters of recommendation, at least one of which is from a surgeon who is known outside of your institution, that might help—especially if that individual makes personal phone calls to some of the program directors.

You need to have a backup plan in place such as picking another specialty and applying there too. It does make your application complicated however because your letters are either going to be supporting your surgery application or the application to whatever other specialty you choose.

Don't apply for preliminary and categorical surgery positions at the same hospital. If you do, you will be batched with the prelims.

If you want to do something with your hands, gastroenterology or interventional radiology might be worth looking into. However, the GI match has been fairly competitive recently.

Would it be worth it to do surgery research between my third and fourth year, postponing the match/graduation or would that not really change the blemish of having failed Step 1?

You are unlikely to produce anything that could be published within one year, and I don't think it would help anyway.

Thank you very much for your honest response. Your advice is very similar as that from my school's general surgery director. If I did a prelim surgery year, would my Step 1 history still be a hindrance to getting a categorical spot?

I think the only way to erase the stigma of your Step 1 issues would be to crush the American Board of Surgery In-Training Exam (ABSITE). It is given at the end of January every year. By "crush" I mean score well above the 50th percentile—the higher the better.

Readers, any thoughts?


artiger said...

I think your advice to apply for both categorical and prelim spots (in different programs is spot on). Or, just apply to a bunch of categorical positions at community programs, then, if he/she doesn't match, scramble for a prelim spot (I had to do this). I think the best chance for this student is to accept the bad marks, get into a prelim spot somewhere with a decent (community) program, and work like hell. Sometimes the right attending notices a hard worker, and realizes that not all good surgeons have great grades and test scores. It's too bad so much emphasis is on that, but I guess we have to be evaluated somehow.

Anonymous said...

Agree as far as having a backup plan. You might consider family medicine. Some FM programs have you doing C-sections and colonoscopies, and most will have you doing at least minor procedures in clinic. A friend of mine is finishing FM now, and he got to do a lot of that during residency. If you practice in a small town, you might not be able to be a surgeon, but you might be able to do enough procedures to scratch that itch.

GI would be a gamble if you really want some amount of procedures in your practice. You might get through medicine and not be able to match into GI at all, and I think medicine would offer far fewer procedural experience for you except maybe for pulm/critical care with bronchoscopies.

Lastly, radiology is pretty competitive to get into (I'm a PGY-4 in diagnostic radiology now). There are a lot of opportunities for procedures in radiology (biopsies, aspirations, and drains), many of which are done by diagnostic radiologists and not interventional radiologists (depends on the institution). But the average Step 1 score is 235-240 last I checked, and your score will put you out of the running for a lot of programs. You could still match, but you'll have a tougher time if you're applying to multiple specialties -- it's one thing to take a chance on a weaker candidate who really wants to do radiology and something completely different to take a chance on a weaker candidate who doesn't really want to be there anyway. There tend to be at least a few dozen spots open in the SOAP each year, but you'll be competing against unmatched Ortho and Optho people who are rocking a 250 but would rather switch into radiology than delay another year to re-enter the match. I don't know what the statistics are for the direct IR programs, but I'd imagine that's also very competitive and you'll have a tough time getting an interview with a 207.

If you want to be a surgeon, by all means try what SS suggested. But I'd highly recommend you apply to several FM programs that offer good procedural training. It might not be exactly what you want, but you'll have a better chance matching into FM than the other backups, and you'll have the latitude to do a lot of procedures in your practice someday if you don't mind living in a more rural area. Radiology procedures can be way more satisfying than most people would think (I love procedures, and most medical students who rotate with me are pleasantly surprised by the active role you can play as a radiologist... we don't all just sit in a dark room all day). But you'll have an even more difficult time matching if it's obvious that radiology is a backup plan during your interviews.

Anonymous said...

I finished my General Surgery residency last year, and while I didn't fail Step 1, I did fail Step 2 (twice). Without going into a ton of detail, I was diagnosed with a reading disability late in medical school and after addressing that, I was able to do well on Step II the third time. As someone who had to go through the match three times and do a prelim spot to get where I am now, I'd have to agree with most of what has been said so far. Other comments:

-Unfortunately standardized tests are used to monitor "progress" in residency and ultimately are part of what gets you boarded in General Surgery. Similarly, many people say "I'm not a good test-taker" as a reason for poor preparation and focus, and I know from experience using this as justification for poor performance will not open any doors for you. I'm not suggesting this is your case, every resident I worked with in the last 5 years who did poorly on a test said this phrase...
-If you have had problems in the past, most programs want to know what was the problem was and that you have shown you've fixed it. Unless you have done well on Step 2 and the remainder of your rotations, I don't think you've shown that to be the case. Make sure you explicitly answer these questions in your work, in your applications and on your tests.
-Even community programs (I trained in a "hybrid" program) are taking applicants with Step 1 scores a lot higher than your second try score. So be prepared if few/no programs extend a prelim spot to you. I didn't match to a prelim spot twice, and had other less competitive residencies as a back up the third time a round when I matched to a prelim. Decided where your threshold for doing another residency is and stick to it.
-If you match to a spot (which at this point I think a prelim spot is your only real option) you must destroy the ABSITE your intern year. Many prelims will do well and if they are comparing two prelim residents with similar scores and one failed a Step, they will take the other. I would consider a bad/mediocre ABSITE score to be "strike three" for you as far as surgery residency is concerned.
-With all that said, I'm living proof that you can rise above failing a STEP, but you have to show that you have overcome that obstacle in your work ethic, clinical skill, and on your next set of standardized tests. Good luck, I'm rooting for you.

Skeptical Scalpel said...

Thanks to the 3 commenters above for their useful input. The student who emailed me is monitoring the comments.

Anonymous said...

I'm being brutally honest.
The fact that you got into an allopathic medical school in the first place means you are smart and knows how to take test. Therefore your poor performance on Step 1 is all on you. Own up to it.

Your surgery rotation "C" evaluation is even more concerning. I can't imagine not getting at least a "B" if you had really tried hard. "C" or PASS are typically reserved for the non-surgeon medical students who are just punching their clocks on the surgery rotation.

You should look into a non-competitive field like FM.

BTW, I'm a practicing surgeon about 20 years out of medical school, and am rather "old school". Pardon my bluntness.

Anonymous said...

I am almost in a similar situation and I was wondering if this student had any luck with applying and interviews?

Skeptical Scalpel said...

Anon, I never heard how the student who was the subject of the post fared in the match.

Some things have changed since I wrote this post. For example, interventional radiology is now the most competitive specialty of all including dermatology.

If you haven't read the comments, you should. Probably the only safe backup positions are in internal medicine or family medicine. Good luck.

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