I have been putting off the writing of this post for a while. I’m not sure why. I guess I wasn’t sure how to say anything genuine that would convince you guys that you shouldn’t be hard on yourself for falling short of the lofty goals that you set for yourself before beginning the arduous process of studying for the USMLE Step 1.
Perhaps it’s because I was in your shoes once, and no amount of reason could penetrate my longing for that perfect score, the one that I believed would either complete my application to dermatology residency (and therefore complete me), or dash my chances at my dream job against the harsh rocky shores of reality.
I’m currently on the residency interview trail, and I am gratefully tired from having not been home to New York for five weeks. At a chicken and waffles brunch in Dallas, Texas, yesterday (NOMS!), I was reunited with one of my best friends from medical school. He and I spoke more frequently during the USMLE Step 1 period than I spoke with anyone else. I remember visiting his room periodically to mutually vent about the ridiculous nature of the beast that left us sitting in chairs inside small, quiet rooms for 12 hours a day.
He would complain about the hours and remark with surprised candor about how poorly he was performing on his USMLE World question blocks. His numbers were frequently in the 30% range in those early days, and with acknowledged futility he asked me fortune-telling questions such as, “Do you think I’m going to be okay?” and “What does it mean that I’m getting two thirds of these questions wrong?” I was never sure what to say. I was on my second go through the question bank, and was feeling pretty good about my performance. I would usually smile and say something supportive about how students’ scores typically grew exponentially in the final weeks before the exam. It was true, but I couldn’t be certain that it applied to him any more than I could be certain about anything else.
Three years later and more than 1500 miles to the southwest, there we were, sitting at an outdoor brunch table shoving deep-fried everything into our faces. In thinking aloud about my list of things to do, I remarked to him, “I'm writing a blog post about how unrealistic it is to aim to score in the 260s on the USMLE Step 1.”
“So you’re still bitter, huh?” he smiled at me from across the table.
His reaction told me that he’d assumed I was writing the blog for personal reasons. All I could do was laugh at my silly past self, who, as an external processor, totally would have done that! And who totally was bitter when he eventually scored a point higher than me (a 255!) on the real deal!I have found that many of us live lives of comparison, seeking identities rooted as much in what we are not as in what we are. Likewise, many of us take comfort in seeing life as the logical, linear give and take of work put in proportionally equating to the benefits reaped. The structure with which we surround ourselves is one of the many ways we’ve learned to succeed in The Game of Life, so we continue to construct the world around us in order to perpetuate the myth that self-actualization is inevitable if we can only sacrifice and work just a little bit harder.
A lot of medical students, many of whom are, in my experience, more type A than they’re able to openly admit, are particularly good at playing The Game. I think this is because the process of getting into medical school self-selects for this. Part of playing the Game well involves setting arbitrary goals for ourselves and seeing them through, day after day, week by week, year to year.
But all the books and wisdom cannot fill the hole left by our loss of control.
My goal here today is to show you just how arbitrary the thresholds are for which we have been trained to strive, sometimes at the cost of our sanity. I don’t mean to wax philosophical here … okay, actually, yes I do… but, I think that accepting our lack of complete control over this process is one of the best ways to move forward toward a meaningful and productive study period.
Here are some numbers around which I would like you to wrap your brainy heads:
|Norm Table Based on US/Canadian First Takers*|
|USMLE Step 1|
*Above table from the USMLE's Score Interpretation Guidelines.
But what about that magical 240?"240" is the number so many of us have somehow come to establish as the score that, if achieved, will prevent us from automatically being blacklisted by certain residency programs.
What is the average Step 1 score?
According to USMLE.org, the 2018 mean Step 1 score for U.S. and Canadian first-time test takers was 230, with a standard deviation of 19.
To put things into even clearer perspective for you, here is the official residency match data showing the Step 1 score ranges for matched US applicants by their preferred specialty:
*Chart 6 from the NMRP's Charting the Outcomes in the Match for 2018
When it comes to setting goals for the USMLE Step 1, I think a lot of us are living in a virtual reality that coincides with the scarcity myths that dictate many of our decisions in life.
"Scarcity myths?" I recently finished a book called The Soul of Money, which suggests that our Western culture currently revolves around three myths:
I think that calling into question these myths, whether we’re confronting frustrating realities about money or battling expectations about test scores, is an active process that is far easier said than done. None of us want to close the doors to our dream careers by scoring lower than the averages illustrated above. But I would remind you that they are simply that – averages. This means that many people scored higher, yes, but also that plenty of people scored well below these values.
I encourage all of you to work meaningfully and productively throughout this study period, while rooting yourselves in the truth of who you are and what your story is. Because, beyond a certain score threshold—which is likely lower than you’re allowing yourself to believe at the moment—it is the story of who you are that will one day earn you a position in residency.