Since the announcement that Step 1 will go pass/fail, there’s been a growing false narrative that USMLE scores allowed IMGs to compete on a level playing field with U.S. MDs for competitive residencies.

Here is the uncomfortable truth - and what to do about it.

(thread)

Even with a scored USMLE Step 1, DOs and IMGs were not “beating out” U.S. MDs for competitive residency positions or specialties.

Does this look like a level playing field?

Almost all IMGs match in specialties in which there are not enough U.S. MD graduates to fill the available positions. The number of IMGs who match in competitive fields (like surgical subspecialties) is vanishingly small.

And only 42% of residency programs even consider non-U.S. citizen IMGs.

https://www.nrmp.org/wp-content/uploads/2018/07/NRMP-2018-Program-Director-Survey-for-WWW.pdf

Do individual IMGs benefit from high Step 1 scores? Yes.

Do IMGs *as a group* benefit from Step 1 scores? I doubt it.

For every IMG who wins, innumerable others have their careers irreparably harmed - because of a number that does not predict what we really care about.

Here is the more nuanced truth:

High Step 1 scores are the best way to get noticed in a world where PDs are overburdened with applications and unable to look at each applicant individually.

But... do we have to live in a world of limitless applications?

I say no.

I’ve argued before that we need application caps.

It’s the only way to give PDs a manageable pile of applications - and an incentive to carefully consider each applicant’s unique strengths. https://thesheriffofsodium.com/2019/06/14/application-fever-the-movie/

And before you say, “But IMGs **HAVE** to apply to >100 programs so we can Match!,” I want you to think about the downstream consequences of overapplication.

Stay with me here, because this is an extremely important point.

When applicants overapply, PDs become overburdened with applications.

When PDs are overburdened with applications, they rely on convenience screening metrics.

When they rely on screening metrics, programs over-invite the same group of applicants who look good on paper.

This means that a relatively small group of applicants uses up most of the interview spots.

Fun fact: did you know that just 12% of internal medicine residency applicants consume 50% of all available internal medicine residency interviews?

https://www.ncbi.nlm.nih.gov/pubmed/30408192 

*This* is why application caps will level the playing field for IMGs more than a scored Step 1 ever did.

We don’t need to fear a pass/fail USMLE. We need to fight for caps and holistic review - and help PDs see all applicants as individuals, not just a three digit number.

Politically, we probably have to start with a high number and work down. But honestly, I don’t think there’s any reason to apply to >10 carefully-chosen programs. (And as I’ve said before, programs must do a better job of showing applicants what they’re about and who they want.)