Residency Applications in a Step 1 Pass/Fail World

  • /Reviewed by: Amy Rontal, MD
  • Step 1 has been a source of immense stress for medical students since the 1990s. The day you start medical school (or even before that) your peers start talking about Step 1, how to study for it, and how nothing is important in the pre-clinical years except what is high-yield on the test. You start to believe that the entire rest of your life, career, and happiness depends on this single exam, and it can lead to severe burnout, anxiety, and depression.

    While it is true that Step 1 has historically been used to screen applicants, students have overcome low Step 1 scores by building up other parts of their application. Now that Step 1 will be pass/fail, these other components become more important. Someone on an admissions committee for a highly competitive specialty once told me, “There are a few different ‘buckets’ we look at for each applicant: board scores (Step 1 and Step 2 CK), clerkship grades (clinical grade and shelf score), volunteerism, research, letters of recommendation. Not every bucket can be perfect but we definitely look at more than just board scores.”

    This was news to me, as I was convinced that nothing mattered except the score. Now that there is no score, this blog post will discuss other components of your residency application that are definitely more important now.

    The Most Important Parts of Your Residency Application After Step 1 Becomes Pass/Fail:

    1. Step 2 CK 

    Step 1 might be pass/fail, but do not forget that Step 2 CK is not pass/fail. Your Step 2 CK score still matters, especially since this is the only USMLE score residency programs will have.

    Step 2 CK is known to be easier to study for than Step 1. However, it is still a board exam and not to be underestimated. Step 2 CK is also a bit easier to study for because some high-yield information carries over from Step 1.

    If you do not take Step 1 seriously because it is pass/fail, you will struggle with your shelf exams and Step 2 CK. You have to become accustomed to board-style questions and identifying high-yield information from test questions. Now, obviously not everything from Step 1 carries over to Step 2 (I’m talking about topics like biochemistry), but the clinical information and being able to identify diseases definitely does, so be sure not to slack on things like that during your Step 1 studies.


    2. Clerkship Grades

    There are two components to clerkship grades: clinical grades and shelf exam scores. Clinical grades are given in the form of an evaluation and are used by residency programs to determine what you are like in the clinical setting.

    Clinical grades can be frustratingly subjective. Different attendings at different rotation sites will have different opinions and, unfortunately, it is not always fair.

    The only thing to do is try your very best to be “able, affable, and available.” This means:

    • showing up on time
    • completing tasks you are given
    • maintaining a good/positive attitude
    • reading up on your patients (download the UpToDate app on your phone)
    • asking an appropriate amount of questions (but avoid asking anything that can easily be looked up)
    • and being kind to patients, fellow students, and staff

    You cannot always control subjective grades but you can show up and do your best.

    Rotation duties have to be balanced with studying for the shelf exam. The most important thing to remember here is to keep a reasonable schedule and stick to it daily.

    It’s all about the UWorld and OnlineMedEd. Doing 20-40 UWorld questions per day and watching a couple of OME videos is more reasonable than trying to cram them all in the last week. This will also serve you well when it comes time to study for Step 2 CK.


    3. Volunteering

    Back in the day when Step 1 had a score, someone told me in the first week of medical school, “Don’t waste your time volunteering. Five extra points on Step 1 is more valuable than any volunteering you’ll do.”

    I disagree with this. And especially now with the pass/fail decision, the volunteering component of your application becomes more important. You obviously won’t have time to volunteer all day all the time, but spending time on one or two things that you care about and can talk about on your application or during interviews is actually really valuable!

    Beyond the numbers and grades, residency programs like to see well-rounded applicants who have interests and passions beyond their studies. This component of your application is not to be ignored! Plus, volunteering is good for the soul.


    4. Research

    Depending on your specialty, research is more or less important. Highly competitive specialties (such as dermatology, ENT, orthopedic surgery, etc.) tend to look favorably upon research.

    First of all, doing research shows your commitment to the field and also shows that you are able to produce academic work, even if you don’t plan on doing much of it in your career.

    Second, research is great for networking and getting to know academic physicians within a particular field. This is helpful if applying for smaller, more competitive specialties, because you want to make yourself known to as many people as possible and the best way to do that is by working with them on research and doing a good job!

    Research years are popular for this reason, especially if you lack a home department. There are several ways you can get involved in research, starting with your home department and not being afraid to ask. You do not lose anything by asking and sending emails of interest, even to people not in your home department. Attendings involved in research will likely enjoy working with an eager mentee. Always keep your eyes and ears open for opportunities to write something up while on clinical rotations, things always come up!


    5. Letters of Recommendation

    Letters of recommendation also relate to research. These are important, as people trust letters from colleagues they know in academia.

    Again, for smaller specialties, letters of recommendation are more valuable. Establishing a relationship with mentors within your home department (or a nearby department if you do not have one) is valuable.

    You can establish relationships with attendings by asking to spend time working with them in clinic, working on research with them, or rotating with that department when you have electives during your fourth year.

    If you are interested in something, find a mentor involved in academics and work hard so when the time comes to write you a letter, it is no problem for them to write about how great you were to work with!


    6. Personal Statement

    Do not underestimate the importance of a powerful personal statement. Applicants have earned interviews to programs that they matched into solely because their personal statement caught someone’s eye.

    You never know what is going to be of interest to a member of an admissions committee! Everything mentioned above gives you material to write about in your personal statement: seeking opportunities to become more involved in a particular field whether it be through research, volunteering, or rotating during an elective month.

    Also, don’t forget about the other aspects of yourself outside of medicine. The personal statement is a place to share a bit more about yourself that might not be apparent in the rest of your application—your life story and how you got to where you are.


    Residency programs will have to adjust how they evaluate applicants this year without a Step 1 score. This automatically will likely make Step 2 CK and clerkship grades more important as an initial screen when someone is quickly skimming your application.

    Beyond that, how you spend your time outside of studying and clinical rotations will also become more important, so take advantage of opportunities to establish yourself with a department in the field you might be interested in pursuing, get to know attendings and do research with them, and give even just a bit of time to a cause you are passionate about. Because when all is said and done, you want to show residency programs that you are a well-rounded, balanced applicant.