Med Student Q&A - Take a Year to Improve Record

Improve RecordThis question comes from a class of 2012 med student:

I failed my USMLE Step 1 but passed my COMLEX in the 33rd percentile.  I am interested in pursuing GI, Anesthesia, or Ophthalmology.  I know for Ophthalmology I am better off pursuing an osteopathic residency and for the medicine sub specialties it might be better for me to pursue an allopathic residency.

Because I don't have anytime to restudy for the USMLE Step 1 I am highly considering taking a year off between my 3rd and 4th years to retake the USMLE Step 1 and then properly study for the COMLEX Step 2- both with DIT.  Or maybe I will just focus on COMLEX Step II if I decide I want to pursue Ophthalmology.  I want to take 3-4 months off to study for these exams.  The rest of the time off during that year (8-9mo) would be used to enhance my clinical knowledge by completing rotations at certain institutions where I want to do my residency and also international experiences in third world countries.

Is this wise to do?  I have heard that residency programs do not want students taking anytime off between medical school.  I know there are some research programs specifically for medical students to take a year off but I am not interested in intense research.  I really just want to take that year off to enhance my clinical knowledge, take time to really do well on my boards, strategically plan out my audition rotations, and perhaps participate in some research on the side to beef up my resume.  It will also be a bit of a nice mental break.

Please let me know what you think about my plan and if Residency programs really do frown upon time off.

Thank you!

Thank you so much for your excellent inquiries. Making career decisions are not easy, especially when students have so little time to explore specialties before making that commitment to applying for a residency. More and more students are asking questions about taking a year off between Year 3 and 4, (or after Year 4) before applying for residency and beginning this challenging and demanding work experience. Student interest in balancing work and personal life has shown a great increase in the last decade and this accounts for some of the rise in exploring the option of taking a year off to pursue other interests or spend time with loved ones. Others want to take time to have additional experiences to make sure that they are making the “right” decision or to improve their application, which sounds more in line with your goal.

What residency program directors think about taking a year off from school will be largely dependent on what you decide to do with your year off and on what specialty to which you are applying. Osteopathic Ophthalmology would probably be a better match for you, as you mention above, but in general, it is still a competitive specialty. If we were to rank Ophthalmology (in general – whether Osteopathic or Allopathic) on a scale from 1-5 with 5 being most competitive, we would rank it at 4.3-4.5 for several reasons. (Dermatology and Plastic Surgery would be a 5 on this scale) There are a couple themes that we see in this specialty:

  1. There is greater variety in student academic performance and board score performance in applicants that match than in other competitive specialties. This makes it more challenging to predict success among applicants of the more competitive specialties and makes it a bit tougher on advisors and therefore a riskier application.
  2. Research seems to be an important component for a majority of the programs. The San Francisco Match data reports that on average, the medical student applied to 53 programs to receive an average of 4.3 offers. This essentially means that to improve their chances of being interviewed and receiving an offer, the applicant needs to be involved in research – and preferably ophthalmology research. (The other option if you absolutely hate research: the applicant needs to carefully research the residency programs they want to apply to a year before applying. Look for how much research is required of their residents to do in order to determine how much it will be emphasized for incoming applicants.)
  3. The average USMLE Step 1 score in 2010 for students that matched in Ophthalmology was 236 (= about a 96, 2 digit score) and for those that did not match was a 210 (= about an 86, 2 digit score) (75 is passing). We do not have an official average, but in our opinion a score of 580-600 on the COMLEX would be necessary to qualify for one of the few Osteopathic Ophthalmology programs. These are high standards to meet.
  4. There are also relatively few Osteopathic Ophthalmology programs which, combined with the lifestyle attraction, makes it a tougher match.

So, while we have established that Ophthalmology is a competitive specialty, how would program directors consider taking a year off? Typically, the more difficult the specialty, the less you want to have breaks in your application. However, look at the data in the NRMP 2010 Program Directors Survey at importance of “gaps in education” to residency application by specialty.  While Ophthalmology is not in the survey, Otolaryngology is, and a break in education is not a deal breaker. If you take the year to integrate quality research and away rotations and you are not especially happy with your COMLEX scores, it could help your application. However, if you have good COMLEX scores, you are better off staying on track and applying as usual.

Let’s consider the first scenario: quality research would include an NIH funded program if you wanted something that is very impressive. These are not easy to come by so you could do an 8-12 week project or longer if you took the year off and try to present your research or work on a publication in the remaining time along with additional experiences. If you do not enjoy basic science bench research, you may like clinical research more where you work with patients instead of organisms or animals. If you take a year to do away rotations, we are not sure if they will be sponsored or if you can get insurance coverage since you will be on a leave of absence. You should talk with your Student Affairs Dean or an administrator in Enrollment Services to assure that you will be able to take the year off and still do away clinical rotations and be sponsored by your institution.

Doing significant international service is a wonderful and generous addition to your application and could make you stand out as an applicant. This could also change your life and make a significant impact on your dedication to medicine. This is a decision that should be made from the heart: you should do it if is something truly meaningful to you and your moral compass. However, to make a significant difference in your application, your international experience needs to be noteworthy in terms of time, commitment, and population. It will not make a significant difference in your application to add a few weeks of international service to your CV.

If you have good COMLEX I scores and are going to stick with applying to Osteopathic programs, then it may be best for you to proceed with your application, rather than taking time off - if you are sure Ophthalmology is what you want to do (However, it sounds like you are still considering other options and may need some time to decide on a career).

If your decision is to apply to Allopathic Ophthalmology it will be a challenge to overcome the Step 1 difficulty. The number of applications is ever increasing as the allopathic graduates have increased but the government has not made accommodations for funding additional residency slots. The average number of applications a student must submit to match in Ophthalmology has grown from 45 in 2005 to 53 in 2010 according to The San Francisco Match. If we look at the statistics from Otolaryngology, which is similar to Ophthalmology (and in Osteopathy a sister College) in terms of academic performance, research, match rates, etc., in the most recent NRMP 2010 Program Directors Survey, we will find the relative importance of factors important to match decisions beginning on page 86 for this specialty. Here, the importance of the COMLEX and USMLE scores are detailed. Look here for some insight to whether the Step 1 score would make a difference in your application to Allopathic Ophthalmology programs.

We would discourage you from taking 3-4 months to study and re-take USMLE Step 1 to apply for Ophthalmology. However, this would be of benefit if you were to apply to anesthesiology or internal medicine Allopathic programs. An excellent Step 2 CK score would also help your application. Programs are beginning to move toward giving Step 2 more importance during the application process.

We are a bit confused about your report of your COMLEX score and would like to double check with you on the number. The two digit numbers are not percentiles and a 75 is passing, as on the USMLE, so I am thinking that your two digit score is probably not 33. A COMLEX score of 33% would = a two digit score of about 79 on the COMLEX. I would like some clarification on your score.

If you are considering Anesthesiology or Internal Medicine, they are less competitive.  Anesthesiology is slightly more competitive than Internal Medicine, but GI is a competitive fellowship following residency. At this point however, your first goal is to secure a residency position. With 174 unfilled AOA Internal Medicine residency programs after the 2010 match, this is a good choice for availability. We will be better able to advise you about your options once we have clarification on your COMLEX score.

Here are some links to information referred to in the above dialogue. Thank you for raising these important questions. We know our readers will be interested and have similar questions. - a link to NRMP study of factors that programs take into consideration when choosing applicants for their residency training programs. - data on the Allopathic Ophthalmology Match. - a link to the AOA match website for information on the Osteopathic match statistics for 2010. Choose “Match Results” from the left hand menu and then scroll to the bottom of that page and choose “2010”.

3 Responses to “Med Student Q&A - Take a Year to Improve Record”

  1. Jeff says:

    Thank you so much for answering my question!!

    You are right, my two digit score was 79 overall. Not a stellar score but I really feel it was a flop because my practice exam scores were higher and I think I can do very well on Step 2 because I will properly plan it this time.

    Here is what my fear is if I don't take the USMLE again. Lets say I decide Internal Medicine and decide to not retake the USMLE Step 1 and I instead focus for COMLEX 2 AND USMLE 2 and take and pass those and lets assume I do well because I take it very seriously. I am afraid that if I decide to apply and match into a dual Accredited IM residency and then pursue an allopathic fellowship afterwards they will not consider me because I failed Step 1 despite completing the ACGME certified MD residency and passing the COMLEX 1.

    I'd actually prefer a Dual accredited residency over an osteopathic internal medicine with fellowships even though I know its better to go somewhere that has a fellowship in what you want. This is mainly because my wife has family in British Columbia, Canada and we sometimes consider living there but not for certain. This is why I even took the USMLE in the first place. So this brings me to a very important question which I haven't been able to find the answer to:

    If I apply to a dually accredited IM residency in which I would apply via the OSTEOPATHIC match, technically they shouldn't even consider USMLE because it is an osteopathic program that is combined with an MD one. However will I have to report my USMLE failure because it I'd be ACGME certified afterwards? Essentially what I'm asking is if I go through the Internal medicine route and try to apply to a dually accredited program via the OSTEOPATHIC match, can I not report my failure of the USMLE Step 1 or will the program find out that I took the exam? I know it seems bad that I am trying to "hide" my USMLE failure while still trying to gain ACGME accreditation but its not that I am scared to re study for the exam I just don't think I have the time to study for it during rotations.

    Thank you for your help, I know a lot of other people have similar questions!

  2. DIT Team says:

    More great questions. First we want to encourage you and others that you are more than just your board score. While it is true that programs often place a lot of emphasis on board scores, program directors consider your whole application. Board scores can be a first screening tool and it can be limiting when applying to very competitive specialties, but if you match your board score, grades and experiences to the specialty you are applying, you should do well. If your scores are lower than what is usually expected for the specialty to which you are applying, then your grades need to be higher and you should excel in research and on Step 2, to balance out your record and make yourself a candidate that will bring something special to a residency program. The residency program wants to be assured that you will make them look good on their qualifying exam stats and that you have other knowledge, skills, or interests that will enhance their program. You should strategize by applying to more programs than someone with a stellar score to get past the screening stage and you might talk to your advisor to make sure your plan is well thought out.

    Now, to answer some of your questions. If you apply to a program and decide to report Step 2, all of your USMLE scores will be reported. You cannot report Step 2 and Step 3 scores without reporting your Step 1 score. USMLE will send a score report which will contain all of your scores to the institution.

    You are correct when you state above that if Osteopathic students apply to a dually-accredited programs that you would apply through osteopathic ERAS and they would report your COMLEX scores. However, some programs will also want USMLE scores, but this is uncommon. It is completely up to the program. This occurs most often if the student decides against applying through osteopathic ERAS and chooses to apply directly to allopathic part of the dually-accredited residency program through ERAS.

    On the dual application, it is our understanding that you do not need to report your USMLE Step 1 score. However, you need to check with the Dean that writes your Medical Student Performance Evaluation (MSPE) to see if your Step 1 difficulty will be included in the Academic Progress or Academic History section of your letter. In addition, you should check with Enrollment Services to see if your school reports your COMLEX and USMLE scores on your transcript. Otherwise, if you do not give them your USMLE number on your residency application and your transcript will not be sent from USMLE. (see the power point link at the bottom and go to page 10 of the pdf to see how the ERAS application asks for your board information).

    However, if you are applying to an allopathic IM residency program, they may inquire in the interview if have taken the USMLE exam. Your job will be to steer the interview toward your strengths on the COMLEX and to further evidence of your success on examinations. The residency program will just need to feel comfortable that they are getting a resident that will be successful on qualifying exams. Your job is to convince them that they have nothing to worry about and show them clear evidence of your hard work and test taking abilities.

    For fellowship, graduates of dually-accredited programs are eligible to take both the osteopathic and allopathic discipline boards and are therefore eligible for either type fellowship. If a DO graduates from a dually-accredited program, he/she is eligible for the ABIM internal medicine boards, and upon successful passage, the ABIM specialty board.

    If a DO applicant is accepted into an allopathic Internal Medicine residency without passing the allopathic Internal Medicine boards, they will not be able to sit for their sub-specialty boards until they pass their allopathic IM boards. We do not believe this means going back and taking Step 1-3.

    We have attached a PowerPoint of the current ERAS Osteopathic application. Here you can see what your residency application will look like and what kind of questions or data you will be requested to provide to ERAS. The allopathic application looks identical.

    Thank you again for your thoughtful questions. Some great news is that in my efforts to make sure I was answering your questions correctly, I checked in with some of my internal medicine program director contacts and they declared resounding support of DO applicants to their allopathic programs. They “love” DO students. If I hear of any updates, I will post them as additions to your question. Best of luck with your future plans.

  3. Jeff says:

    I just want you to know you have made a tremendous impact in decreasing my stress and anxiety. Thank you so much for taking the time to answer my questions that no one else seemed to be able to answer. I will let you know if I have anymore questions.

    Thank you so much once again!

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