Three weeks and two exams later, I think I finally understand what the second year of medical school is all about, at least at my school’s traditional curriculum of two years pre-clinical plus two years clinical rotations. Six lectures in a day? Check. Two tests in less than two weeks? Check. It’s like having a fire under your bottom, that won’t be put out until the infamous USMLE STEP 1 test is over. USMLE STEP 1 is a national, 8-hour, 280-question test that all medical students must pass as the first in a series of board licensing exams.
Don’t get me wrong though, because sometimes you’ll have small “wins” that remind you why you committed to becoming a physician in the first place.
Some of the most rewarding moments of this year so far? Detecting a pre-ventricular/pre-atrial contraction when listening to a standardized patient’s heart. Hearing someone talk about their experience with Long Q-T syndrome (which affects the repolarization of the heart, with an increased risk of arrhythmias), and understanding the mechanism of the disease and what the EKG would look like. These moments are critical, not only because they affirm your own learning, but also leave you awestruck, that you can detect various normal vs. abnormal conditions and recognize what is urgent or not.
Out of curiosity, I asked some of those who are on the other side how it felt once they took STEP 1, or rather, after they found out their STEP 1 score.
“Worst couple weeks of my life ever.”
“I could go outside again and feel the sunlight touch my face.”
“Relief that it was over.”
The amount of pressure I feel to perform and at the very least, meet expectations in my school curriculum and excel on STEP 1 is pretty enormous. It’s like an unstated expectation I would think many of my classmates share, even if we don’t like to admit it. Why? Well, first of all, to pass second year. And, second of all, to have a “good enough” STEP score to get into your residency specialty/institution of choice. Some of us hardly think about the first priority and just focus on the second, for better or for worse. Others can’t even begin to think about STEP 1 and are just barely surviving class curriculum.
After this test, I finally had some free time to peruse the internet forums (i.e. reddit, online medical student blogs), to see what people had to say about studying for Pharmacology and Microbiology. It felt just like when I was a pre-med, and dared to venture into the Studentdoctor forums, a rather aggressive, perhaps even toxic forum that would more than likely douse your hopes for getting into medical school.
It’s all about the numbers on reddit and medical student blogs. If you got above a certain STEP score, you’re validated and the holy grail of all mentors. If you got below a certain STEP score, some people would rather you retreat to another part of the forum, with decidedly less traffic. Ironically, I am aware that my medicine-related blog posts are a part of this network of “resources”, useful or not. But I think this foray provided some clarity into what I want my blog space to be like: a non-judgmental, reflective outlet that sheds some light on the thought processes of a 24-year-old medical student/dancer/home cook/do-it-all who dares to dream that she can have it all. The rationale, hopes, and insecurities that might be missing from everyday small talk and online blanket statements.
Hilariously, STEP 1, the test that was originally intended to be used in a pass/fail fashion, has evolved to become the major objective criteria that residency directors use to differentiate medical school candidates. It became inevitable as the number of medical school matriculants rose, and the number of residency slots have remained more or less stagnant. As medical schools trended towards pass/fail curriculums and letters of recommendation are generally overwhelmingly positive, STEP 1 scores become the final “objective” measure of a student’s “competency”. Although not every residency director will agree that someone’s STEP 1 score will predict a student’s success in their program. Take a look at what a residency program director at University of Massachusetts Medical School has to say about their residency matching process:
“We now get 1,000 applications each year and match 12 residents,” says Steven Bird, MD, program director of emergency medicine at the University of Massachusetts Medical School. “We also are faced with fewer and less objective measures of applicants’ competency. There are several reasons for that, including because many schools have gone to pass/fail, which makes it difficult to see how a candidate compares to their peers,” he says. “And schools often write such positive letters of recommendation for their students that they are borderline worthless.” (AAMC, 2019)
Interestingly, studies have shown that males perform better than females on STEP 1, and whites perform highest among self-identified racial groups, followed by Asian/Pacific Islanders, Hispanics, then blacks (Rubright, JD, Academic Medicine, 2019). Controlling for MCAT scores, college selectivity, and undergraduate GPA may reduce, but not eliminate, these differences. If it makes a different, females moderately outperform males on STEP 2.
Clearly, much more work needs to be done to level the playing field. The Big 4 (UWorld, First Aid, Pathoma, Sketchy) Step 1 resource subscriptions cost hundreds of dollars, let alone the $600+ Step 1 registration fee and many other resources that are not easily accessible to students of varying socioeconomic status. There are also structural barriers in the medical system that perpetuate gender and racial gaps in academic performance, whether in the classroom or on standardized tests.
What I’m basically getting at, is that I am going to continue to seek advice from others on studying strategies and career goals, but am likely forging my own path. Every medical student comes from such different backgrounds, undergraduate institutions, and talents, that even if you tried to take the “best” advice from each source you talk to, all you’re going to end up with are disparate pieces of advice. The real trial comes from taking each one, applying it, and deciding for yourself if it works for you or not.