What To Do After Low USMLE Score?

For applicants seeking to match into a competitive specialty, it can be challenging.  In fact, it’s not uncommon for programs to receive over 100 applications for a single residency position.  To sort through that many applications, many programs use filters. One type of filter is a USMLE “cut-off” score:  applicants who don’t score above a certain minimum won’t be considered further.

That’s why, for applicants with lower-than-average USMLE scores, my advice always starts with “get past the filter.”  Even if a program doesn’t have a formal cut-off score, it can be challenging to match with scores below the mean. The right strategies, however, can help.

Take the field of dermatology, currently one of the most competitive specialties. NRMP data from 2018 for matched dermatology applicants indicates that the largest segment of USMLE Step 1 scores were those between 251 and 260. Those are high scores, but it’s important to look at this data more closely. There were still seven applicants with scores of 220 or below who successfully matched.

This is the case for nearly every specialty. In fact, the website for the Stanford Radiology residency program states that the mean Step 1 score for matched applicants was 249. However, “we … have interviewed candidates with Step 1 scores below 200.”

I’ve spoken to many applicants who have successfully matched despite lower-than-average USMLE scores, and I’ve spoken with faculty who have advised these students. In doing so, it’s clear that they made it “past the filter” via several key strategies.  For students who are deeply committed to a particular field, these strategies may help—although given the highly competitive climate for some specialties, there are no guarantees.

Strategy 1: a strong personal connection to a program’s faculty members or program director

There’s a reason why your home program has historically been one of your strongest chances to match into a competitive specialty. You have a much higher chance of directly interacting with the faculty and program director at your home program. You’ll have rotated there, and faculty will be able to observe your clinical performance directly. You may also have done research with faculty at your home program, volunteered with faculty through some of their initiatives, or may have met them after a lecture. Faculty who know your qualities and strengths personally are far more likely to recognize your strong potential.

Beyond your home program, you can still establish a direct relationship with faculty across the country. In the past, the strongest way to do this was via away or “audition” electives. As I write this in 2020, away electives are rarely an option. However, it’s still possible to make connections even if you can’t meet in person. And certainly, as travel resumes in the future, you can make those in-person connections even outside of a formal rotation.

I have had students reach out to me via my website because of their interest in nutrition and dermatology, and I have worked remotely with multiple students on case reports and review articles. Some medical students serve on national organizations’ committees, which allows them to interact with faculty committee members. Sometimes, it’s as simple as discussing research or clinical cases with a conference faculty member. At one national conference, a medical student spoke to me after my poster presentation, expressing an interest in the topic.  She later forwarded me her own case report, and additional references on the topic, and her knowledge, insight, and intellectual curiosity left a strong impression.

Strategy 2: a personal recommendation from a faculty advocate

Some faculty are mentors who provide great guidance and information. Other faculty serve as what I call advocates. These are faculty members who believe strongly in your ability to make future contributions to the field, and they may choose to advocate for your application. This may involve emailing their contacts in other residency programs to specifically ask if the program would consider looking at your application. Over the 17 years that I served on the dermatology residency selection committee, I received several of these emails.

The strongest communications were the ones in which the advocate had significant direct contact with the applicant. For example, a faculty advocate may speak about their research fellow with whom they have worked closely over the course of a year. That advocate can make a persuasive case that this student possesses amazing skills and qualities that would warrant a program taking another look at their application. That in-depth knowledge of an applicant is essential. It doesn’t matter how much they like you: a faculty advocate emailing about a student who did a single case report with them would not be persuasive.

How do you work with this type of faculty member? This, of course, goes back to strategies that must be implemented in a much earlier stage of the application process. At every school, we know faculty members known for being strong advocates for their medical students. Start by asking current and former medical students and residents, who often have great insight and/or experience working with these faculty members.

Strategy 3: a compelling ERAS application and personal statement that speaks to your strong fit with the program

The final strategy is to make them want to meet you. The strongest applications highlight aspects of your application that would make for a great fit with this particular residency program.  Your ERAS application and personal statement can highlight your potential to make significant or unique contributions to this particular residency program. Applicants have done so by highlighting specific research experiences and interests, advocacy work in a particular area, an interest in health care disparities relevant to this particular program, an interest in emerging technologies, and other types of interests.

The NRMP data is very important when considering your chances for a successful match, but it should always be considered just one factor in crafting your application strategy. If your USMLE scores are below the mean for your target specialty, implementing these additional strategies can make a large difference in your chances for an interview invitation and, ultimately, a successful match.

Rajani Katta is a dermatologist and author of Conquer the Medical School Interview and The Successful Match

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