I received these emails recently. The writer gave me permission to publish them. They have been edited for length, and some details have been changed to protect his anonymity.

I’m a third-year medical student at an allopathic state medical school. I’ve always wanted to do surgery. My problem is I failed USMLE Step 1 the first time and got a 207 on my second attempt. I hadn’t failed anything else throughout first and second year, with the majority of my grades being my school’s equivalent of Bs.

My surgery shelf exam was a week after I received my Step 1 score and, despite studying hard, my low score on that exam got me the equivalent of a C in surgery even with very good clinical evaluations. The rest of my third year has been good with most evaluations saying I’m well-liked and a team player.

Should I give up and go into a different specialty with better odds of matching? Apply to prelim surgery programs and categoricals? Or even apply to all of those things at once? I’m in a large pickle, paralyzed with indecisiveness, and would immensely appreciate your advice.

Disclaimer: This is my opinion. I do not presume to speak for all program directors. I’m going to be honest.

Since most programs have far more applicants than residency positions, they have to screen somehow. I believe the majority of program directors use USMLE Step 1 scores. Failing Step 1 drastically lowers your odds of being offered an interview.

The fail, the 207 on the retake, and a C in surgery are indicators of serious trouble.

If you can’t face the future without being a surgeon, you could apply for a preliminary spot and take your chances on getting an opportunity to switch to categorical. Everyone who does this does not succeed. You could also send some categorical applications to community hospital programs that are not well-known and see if you are offered any interviews. Some programs prefer filling with U.S. grads no matter what their scores and grades are.

If you have strong letters of recommendation, at least one of which is from a surgeon who is known outside of your institution, that might help — especially if that individual makes personal phone calls to some of the program directors.

You need to have a backup plan in place such as picking another specialty and applying there too. It does make your application complicated however because your letters are either going to be supporting your surgery application or the application to whatever other specialty you choose.

Don’t apply for preliminary and categorical surgery positions at the same hospital. If you do, you will be batched with the prelims.

If you want to do something with your hands, gastroenterology or interventional radiology might be worth looking into. However, the GI match has been fairly competitive recently.

Would it be worth it to do surgery research between my third and fourth year, postponing the match/graduation or would that not really change the blemish of having failed Step 1?

You are unlikely to produce anything that could be published within one year, and I don’t think it would help anyway.

Thank you very much for your honest response. Your advice is very similar as that from my school’s general surgery director. If I did a prelim surgery year, would my Step 1 history still be a hindrance to getting a categorical spot?

I think the only way to erase the stigma of your Step 1 issues would be to crush the American Board of Surgery In-Training Exam (ABSITE). It is given at the end of January every year. By “crush” I mean score well above the 50th percentile: the higher, the better.

“Skeptical Scalpel” is a surgeon who blogs at his self-titled site, Skeptical Scalpel.

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