In another of his insightful blogs, Elliott Campbell MD, Dermatology Resident at Mayo Clinic, Pastest question writer and high-scoring candidate, shares his views on the importance of board exams in relation to Residency Programs and how you should approach them.

Steps and the Residency Match

Residency programs have always relied on board examinations as a means of standardizing student’s academic abilities. There have been well-designed studies which demonstrate Step’s ability to predict a resident’s board pass rates. Programs care about their board pass rates. They understand that applicants pay close attention to this percentage. So bottom line – programs want applicants who perform well on tests. Step 1 has always been most correlated with board pass rates and has notoriously been a key factor in acquiring interviews. This will change with the new pass/fail scoring of Step 1. Whether or not your Step 1 is pass/fail, optimal planning of Step 1 and 2 CK is imperative. This article evaluates the different strategies for scheduling the Step exams based on your unique situation.

USMLE Step 1

Regardless of Step 1 being a pass/fail or graded, it’s still a challenging exam and should be taken seriously. Failure to pass on the first round significantly impacts an applicant’s ability to match. A strategic approach to scheduling this exam should be taken to minimize risk of failure.

Scheduling

Scheduling this exam depends on your previous work prior to intense study and your goals if you are taking the graded exam. Most medical schools provide a period of time to study for Step 1, called “Dedicated”. Medical schools allocate different maximum amounts of Dedicated time. It is usually the student’s decision on how to utilize this time. This section will be subdivided based on whether your Step 1 will be scored or pass/fail.

Scored Step 1

To determine optimal Dedicated time, it is important to reflect on how much preparation you have completed prior to Dedicated in the context of your goals. If you have focused on course work but have not spent a significant amount of time using a question bank, it may be wise to take up to 12 weeks. If you have already been through a question bank and have Dedicated time throughout your second year with Step in mind, eight weeks is the maximum that should be taken. Remember that you want to give yourself adequate time but not too much time. Burnout is real, and you will start to forget the information you learned at the start of Dedicated.

Pass/Fail Step 1

There are a few different approaches to scheduling Step 1 for those taking the pass/fail version. This is mainly based on your preparation ahead of the Dedicated period.

You have completed a question bank during your second year in anticipation for Step 1: You should give yourself a maximum of eight weeks. At the end of eight weeks, you will start to forget the finer details learned at the beginning of your Dedicated and may experience burnout.

You are just starting to study for Step 1 and have not used a question bank: There may be a utility in taking a NBME practice test prior to determining your test date/amount of Dedicated time. This may be stressful but will give you a realistic starting point. If you pass this initial practice test, don’t give yourself more than eight weeks of dedicated. If you fail, you may consider lengthening this period of time to up to 12 weeks. It is difficult to predict your trajectory without digging in and completing an additional NBME exam. Many students rapidly improve their scores once Dedicated begins.

One last rule

Once you pick a test date, try to stick with it. Unless you are on an upward score trajectory on your NBME practice tests AND haven’t reached your target score, it is better to take the test as planned. Alternatively, if you are well within the passing range with two consecutive NBME and you are taking it pass/fail, you may consider moving your test date up. A bold move but well worth the avoided pain.  

USMLE Step 2 CK

Ask 10 different mentors about scheduling Step 2 CK and you will likely get five different answers. This question should be considered in the context of several factors. If you are taking a pass/fail Step 1, your Step 2 CK will be weighted higher. Many students consider trying to “bury their Step 2 CK”, meaning take it late enough that it does not show up on their application. This will be discussed later.

General rules

1. The longer away from third year, the poorer students perform on Step 2 CK.

2. The majority of Step 2 CK is based on the medicine shelf. If this is your last rotation, consider taking Step 2 CK shortly after third year.

3. Students do not study nearly as much for Step 2 CK as Step 1. Studying hard for this test allows students to compensate for a poor Step 1 score. This may change with the pass/fail Step 1.

4. Programs care about Step 2 CK.

5. Programs will see your Step 2 CK score prior to ranking you. They may not see your score prior to sending out interview invites if delayed.

General approach

Bottom line, you still need to take Step 2 CK seriously. It will hang over your head and will ultimately be seen by programs prior to the rank. It is true that if you delay, the score will not be available when interviews are being offered. This may be advantageous for those that scored highly on Step 1 and those not applying to competitive specialties who do not want to put in the time to optimize results. For those that scored poorly or had a pass/fail Step 1, not having a Step 2 CK score at the time of interview allocation will be a disadvantage. In most cases, it is better to get done with it early. Remember, most students do better the closer they take it to third year.

Do I need Dedicated time to study?

Take a NBME practice test. If you are at goal, you likely don’t need Dedicated.  If you haven’t met your goal, it may be wise to take up to four weeks of Dedicated time. Many students have to determine their schedule before they know how much time they will need. It is safest to schedule a month for studying (if available) after third year to use as Dedicated if needed. Regardless, you should be utilizing a question bank and additional resources to study for this exam throughout your third year. As stated before, if you have your medicine rotation at the end of third year, the beginning of fourth year is an optimal time to take it. If you have medicine earlier in third year, it may be wise to take some time off during the beginning of fourth year to review.  

Specific questions that will aid your decision:

Are you trying to match into a competitive program?

If you are trying to match into a competitive program, you should be very particular about when you take your Step 2 CK. In the case where your Step 1 was graded, you may be trying to make up for lost ground or alternatively not damage a solid Step 1 score. Regardless of whether your Step 2 CK score is on your initial application, programs will see your score prior to ranking you. Programs have caught onto the concept of burying Step 2 CK and may ask you during interviews why your score isn’t on your application. Lesson here: Consider the general approaches above and try to optimize your score rather than risking a failed attempt and concealing it.

Are you planning on completing away rotations?

Away rotations require a tremendous amount of attention and dedication. If you are worried about studying for Step 2 CK, it is difficult to give these important rotations the attention they deserve. If possible for your schedule, take Step 2 CK before starting these rotations. You will thank yourself later. There are circumstances in which the timing doesn’t work out and it is necessary to delay Step 2 CK in order to go a desired away. This is certainly understandable.

How/when to bury my Step 2 CK

As alluded to before, some students may elect to take an exam after applications so that this score is not considered (burying Step 2 CK). First off, it is impossible to completely bury Step 2 CK. Programs will see it prior to ranking you. If you scored poorly on Step 1 or if your Step 1 is pass/fail, this approach should be avoided. If you dominated Step 1 and are applying to a competitive program/specialty, trying to bury Step 2 CK could be considered. The major downside is that it will hang over your head all of fourth year and there is a general trend toward doing worse as you distance yourself from third year. It is difficult to predict which programs will consider your Step 2 CK during the final rank and which will not. It’s safe to say that bombing the exam will not look good and could affect a program’s ranking of you. If you choose to attempt to bury, still take the exam seriously. Lastly, in the case of a failing grade, significantly delayed Step 2 CK can cause a problem if the applicant does not have enough time to repeat the test and receive a score prior to rank list finalization. Give yourself enough time to get your score and repeat the test if necessary.

Hope this proves useful and thanks for reading!

Elliott

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