Match into Competitive Residency (with Low USMLE Score)

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You’re a medical student hoping to match into a highly competitive specialty, like dermatology, plastic surgery, neurosurgery, or something else that is highly sought after. The problem is that you didn’t quite nail your USMLE Step 1. But don’t worry, all hope is not lost.

Residencies are overrun with applicants, as we have too many freshly minted doctors graduating from medical school each year, but not enough residency positions for all of them.

Confronted with over 100 applicants for a single residency seat, residency program directors need a way to narrow down the list. For this reason, they use a “standardized screening process”, specific to each program, to reject approximately 50% of applicants. This includes USMLE scores among other factors.

We often focus on USMLE scores as the end-all in terms of residency competitiveness. But upon closer examination of the data, you’ll see there were a handful of students matching into plastic surgery or dermatology or neurosurgery with USMLE scores below 230. How is this possible?

 

What Residency Program Directors Want

If you’ve ever wondered how to get inside the mind of a residency program director to figure out what they care about, you’re in luck. Every two years, the NRMP surveys program directors from all residencies and publishes the NRMP Program Director Survey, showing what factors are most important in selecting applicants to interview. And this is a big deal – after all, only 13% of applicants are offered an interview, making it one of the most challenging parts of the application process.

USMLE Step 1 tops the list in the survey, with 94% of programs citing it as important with an average importance rating of 4.1. In other words, they care about it quite a bit. In fact, approximately 2/3 of all programs have a target score for Step 1. This cutoff score varies based on the specialty. On average, plastic surgery, orthopedic surgery, and dermatology programs will have a cutoff much higher, around 230 and sometimes even up to 240. On the other hand, programs like family medicine and neurology have cutoffs closer to 200.

And if you really crush Step 1, there are threshold scores above which you’re almost guaranteed an interview. For dermatology, that cutoff is on average 241, up to 251. For plastic surgery, it’s on average 248, up to 256 — the highest of any specialty. For family medicine, it’s 219, up to 223.

But wait a minute – USMLE Step 1 is becoming pass/fail, therefore will this even matter? As I’ve discussed on my personal channel, this will largely shift the importance of applicant selection to other factors, like Step 2CK. And besides, the message of this article isn’t that crushing USMLE is important. You already know that. We want to know how else you can stand out and still match into that competitive specialty without a 260.

If you take a step back, you’ll find that the most important factors in screening applicants for interviews are largely high-level broader assessments. The top 5 most important factors are

  1. USMLE Step 1/COMLEX Level 1 score
  2. Letters of recommendation in the specialty
  3. Medical Student Performance Evaluation (MSPE/Dean’s Letter)
  4. USMLE Step 2CK/COMLEX Level 2CE score
  5. Personal Statement

Again, these are primarily summative assessments. Your board exam scores are proxies in assessing your mastery of preclinical and clinical content. Your MSPE, or Dean’s letter, summarizes your performance as a student. At the end of the letter, they often use one of 4 keywords to indicate the class quartile in which the student ranked, even at supposed unranked programs. The letters of recommendation from physicians in that specialty summarize the opinions of experienced attendings who have worked closely with you. Are you a good “fit” for this field? And your personal statement reflects your story and motives.

 

Where Not to Focus Your Time & Energy

Without understanding the perspectives and priorities of residency program directors, most medical students poorly allocate their time and energy, placing too much emphasis on things that don’t matter, and too little on areas with a higher ROI.

Understand that applying to residency is a different beast than applying to medical school, and what matters to medical schools isn’t necessarily the same as what matters to residency programs. Let’s take extracurriculars for example. When applying to medical school, the depth of your extracurriculars are important — do you have clinical exposure? How about volunteering and leadership experience? Medical schools want to know you’re well rounded, that you understand what medicine is about, and that you’re going into the field for the right reasons.

But when you’re applying to residency, you’re already well on your way to becoming a doctor. Now the priority is seeing if you’ll be a good fit for that specialty and residency program. It’s not a priority to them if you were part of X or Y student group. In fact, extracurriculars and volunteering ranked at #19 in the survey.

I’m not saying to avoid interesting organizations, as they can offer value outside of your residency application. In fact, being a co-founder of the Future of Medicine student group at my medical school got the gears turning in my head, resulting in me founding the Blue LINC biomedical incubator that brought me to fall in love with entrepreneurship and innovation. And that led me to start Med School Insiders and Memm. However, none of my residency interviewers cared about the Future of Medicine group.

Similarly, many students obsess about their preclinical grades. Ask your school if the MSPE or dean’s letter is reflective of your preclinical grades. If so, strive to be in the top quartile. And if your school has AOA, an honors society that is based on ranking, try to meet the cutoff. But if the letter doesn’t reflect preclinical grades or you don’t have an AOA chapter at your school, focus on just passing and spending extra time preparing for USMLE or building your research publication list.

As a medical student, time is of the essence, and it’s imperative to be mindful of the opportunity cost of any given activity. Don’t be a robot, and don’t forget to live your life. At the same time, understand that time spent with a student club means less time on other goals that will move the needle on your residency application.

 

Where to Focus Your Time & Energy

You already know it’s important to do your best on USMLE Step 1, Step 2CK, and your clinical rotations. How did those students with sub 230 scores match into plastics, derm, and neurosurgery? It comes down to three areas that can override score cutoffs and compensate for deficiencies.

1 | Faculty Connections or Advocate

First, it’s a matter of who you know, and who is in your corner. It’s no surprise that students pursuing a competitive specialty have the highest odds of matching into their home program. It’s simple human psychology and risk assessment — you’ll have a higher degree of direct interaction with faculty and your program director, including the opportunity to rotate there. Assuming you exhibit strong performance and impress them through clinical rotations, research, and perhaps supporting them on their side projects or initiatives, chances are they’ll take a strong liking to you. Comparing two candidates, they’ll favor the one who they know personally and has a proven track record.

You can still do this with faculty at other programs, too. This is most traditionally done through away rotations. In 2020, that’s going to be less common, but you can still make connections outside the formal rotation setting. For example, say you find a faculty’s clinical interests from their website and reach out to them to assist with case reports or research articles remotely. If you’re part of a national organization committee, this is another worthwhile opportunity to interact with faculty committee members and build a relationship.

Beyond that, having faculty in your corner who are willing to bat for you at application time can massively influence your outcomes, particularly if you’re applying to a smaller specialty where most faculty more or less know one another. When you apply, they’ll reach out to their contacts in residency programs to specifically vouch for you and help you secure an interview.

These faculty advocates are most impactful when they have significant direct contact with you. After all, it’s much more meaningful when a faculty member has worked with you closely on research for 18 months and can speak to your amazing skills and how any program would be lucky to have you. This isn’t something you can simply figure out at the last minute. Rather, you’ll need to begin working on this earlier during medical school. A great place to start is simply pursuing research projects or interest groups in your particular specialty to find a faculty mentor. You can also ask medical students and residents who may offer more insight as to which faculty members would be more receptive and helpful.

2 | Prolific with Research

Next, it should be no surprise that being prolific with research can transform your application. Looking at the NRMP official match data, you’ll find that for many competitive specialties, there is a large difference in the total number of research items between those who matched and those who didn’t.

Research is attractive because it demonstrates initiative, work ethic, curiosity, and the pursuit of knowledge. Perhaps more importantly, it helps programs look good when their residents and faculty publish frequently, and it helps them secure funding.

Standing out in research is often a key differentiating factor. I have 65 publications and abstracts primarily in plastic surgery, and at every institution, interviewers loved talking about how I was able to be prolific with research at such an unusual level. Some even told me they were excited to have a future resident like me to help them push through various projects they’ve been working on.

Ever since the video on my personal channel explaining my research experience, I’ve had a large number of students asking for specifics on how they can do the same. There’s a great deal of complexity and nuance to it, much more than a single article can encompass, but you can glean valuable research insights here.

3 | Highly Compelling ERAS & Personal Statement

Lastly, a highly compelling ERAS application and personal statement can make a huge impact on your competitiveness. But this is much easier said than done. Many applicants write a personal statement or have other components of their ERAS application that holds them back in some way. Others write an application that doesn’t hurt or help them much. And only a small minority are able to craft an ERAS application and personal statement that truly serves as an asset to improve their chances.

Your application should make the reader want to meet you, while also highlighting the aspects of your application that would make you a great fit at their program. Depending on your experiences and the program’s priorities, this can be anything from specific research interests to advocacy work, and anything between. We have some example personal statements that can you help you determine a standard to work towards. One was so strong that the applicant was told their essay was the main reason they were offered an interview at MGH and a few other elite programs, despite having weaker USMLE scores and minimal research.

Getting into your dream specialty can be overwhelming – I was there not too long ago. But by intelligently approaching your application and prioritizing your energy and efforts based on relative yield, you should be able to better position yourself for a successful match. Keep in mind your stage in training too. In your preclinical years, focus on optimizing for USMLE Step 1 performance and dip your toes into research. In your third and fourth year, prioritize clerkship grades, because those matter, and set yourself up for success on Step 2CK.

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