So, you got your Step I score back, and it’s not what you were hoping for… What’s there to do next?
As an MD/PhD student, there are few experiences as difficult as completing your USMLE Step I exam, waiting the excruciatingly long wait period for your score, opening your results, and finding a number less than what you were hoping for. The most important thing you need to hear at this stage is, “This is not the end of the world.”
It is difficult to describe, to those who have not experienced it, why the Step I exam means so much, the emotional investment, the intense feelings of success or heartbreak upon receiving your results. One reason for the high stakes is that you have worked extremely hard to gain admittance to an MD/PhD program. Then, with apprehension and excitement, you begin the pre-clinical curriculum, an intellectual experience that is likely the most challenging thing you have experienced in a lifetime already full of academic challenges. You find course grades are your only outcome on which to base your success, your worthiness, your value to the community, and honor to your family who have helped you along the way. Beyond the pre-clinical curriculum looms the overly emphasized Step I standardized exam, which is used, rather unfairly, as a cutoff for residency application review in some specialties and at some institutions. It is tempting to assign a return on investment, or value of your education to this point, on the result of your Step I exam. Then the result is not high, it’s not right, it can’t be happening with you, and it’s not fair.
In my opinion, the emotion, if you feel it, of a lack of fairness is entirely valid. You have worked extremely hard to get to where you are. You gave your absolute best effort for the exam and certainly have impressive intellectual prowess. Why, then, did you not earn a commensurate result? I believe the answer lies within the inability of a standardized exam to holistically measure a candidate’s skills and potential. Standardized tests are useful for institutions. They allow a uniform assessment of a large group of people to make, in this case, review of residency applications more efficient. The fault with the over-emphasis of Step I exam results in residency applications lies with residency programs. As medical students have been incentivized to achieve higher percentiles to reach their goals, and residency programs, in turn, have increased their thresholds, and a detrimental feed-forward loop has ensued.
At what cost does this efficiency come? Immensely promising physician-scientist trainees across the country return less than optimal Step I results and then must put back together their shattered identity as they continue into their thesis work. This occurs at a fragile time in physician-scientist training, as candidates are beginning arguably the more important portion of their MD/PhD: their research. It is important for our community to emphasize that as independent, abstract thinkers, we do not value Step I standardized exam scores as much as the MD training community. We understand the inadequacies of the exam. We use it as a tool, as one piece in the entire application package, of diverse, impressive, well-rounded applicants as we determine whether they are committed and enthusiastic about joining our field(s) and who will likely make a positive impact.
With this understanding in mind, I recommend a few steps to take in the case your score was not what you were hoping it would be:
- Talk with your MD/PhD program director, or with a program administrator or faculty level mentor, who has experience with career advising MD/PhD trainees.
They will hopefully patiently listen to your concerns, your emotions, your heartbreak, and once they have validated your feelings, they can discuss with you examples of individuals who did not receive optimal Step I scores, but who went on to be very successful physician-scientists, maybe even in your field.
- Talk with supportive, emotionally intelligent friends, both inside and outside medicine.
Harnessing your support network and gaining perspective of those from outside medicine can be highly encouraging. What you have accomplished to this point is very impressive, and it is important you feel confident and a sense of pride and worth in what you have done. Often in this field, validation comes from within, so get yourself to a place where your perspective is in line with those ideas.
- If you have the slightest consideration of speaking with a mental health professional, you should do so.
Mental health professionals are expert listeners and validators. They also provide perspective from individuals who are outside healthcare. They will tell you anecdotes about others who have had professional struggles, about others who have had struggles in their lives that may make you feel less disappointment. They provide tools for coping with stress and dealing with negative emotions.
The physician-scientist training community often discusses the need to nurture and preserve our up-and-coming generation of tide-changers, innovators, and idea-people – you. We need you to continue. We need you not to feel a lack of self-worth. While this was an unexpected hurdle, it is imperative you persevere and work hard. As my research mentor likes to say, somewhat comically, but always with resolve, “Never give up. Never surrender.” I am wishing you the best as you continue on into your thesis studies. Go get ‘em!
-Jeremie Lever, GS-4