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Director’s Commentary: Weight of Exam Scores

Adam Friedman, MD, answers Azam Qureshi, MD, question on whether good exam scores determine if someone will make a good dermatology resident.

Dr Gonzalez Lopez is a first-year dermatology resident with the department of dermatology at George Washington School of Medicine in Washington, DC.

Dr Qureshi is a first-year dermatology resident with the department of dermatology at George Washington School of Medicine in Washington, DC.

Dr Friedman is the director of the residency program at George Washington School of Medicine in Washington, DC.


Dr Azam Qureshi: All right, Dr Friedman, I think it’s time to turn the tables on you a little bit here.


Dr Adam Friedman: That’s crazy.


Dr Qureshi: Obviously, when it comes to applying to residencies, there’s a large emphasis for better or for worse on the exam scores. Dermatology is infamous for a field that has the applicants with pretty high test scores. Now, I want to hear your personal opinion on [laughs] do you think good exam scores correlate with being a good dermatologist?

Dr Friedman: The way you’re saying that or asking that, it sounds like you already know my answer, which is absolutely not. I’ve had a couple thoughts on this. The easiest one is I think extremes are always problematic.

If someone does very, very poorly or possibly fails, that could potentially suggest that they may be a fail risk for the certification exam, which, as a program director, we have to be concerned about. If you have a resident failed a certification exam, you come under fire from the ACGME, you can go on probation, you get a site visit, things you never want to hear. A lot of it is self‑preservation.

On the flip side, if someone gets like a 290, I worry that they’re a total sociopath and have no social skills whatsoever, because how on Earth does anyone get that highest score? I think the sweet spot is [laughs] somewhere right in the middle.

We know that there’s going to be a transition that Step 1 scores are going to go away to pass‑fail, which I think is great, but then my worry is will Step 2 just become the new Step 1? That actually will create even more pressure to get your stuff to score before interviewing, which is hard. You have a much narrower window than Step 1. There’s obviously cost and time involved in that.

I worry the point of doing this is not going to actually result in an easier, less anxious and more equitable environment, rather it’s going to make things even worse. I hope that’s not the case.

I really implore my fellow residency directors ‑‑ that’s the words I’m looking for ‑‑ my fellow residency directors, and chairs, and academic faculty to really take that approach that a Step 1 or 2 score is just one small piece of the real puzzle that makes up an applicant.

Now, I can argue the side of we need these scores because we only have so many faculty and there’s so many people who want to go into dermatology. It’s believed that this is a standardized metric in order to evaluate every applicant against one another.

The reality is, as I’m sure, it may be the same test, but it doesn’t mean that everyone had the same exact opportunity to get Step study guides or tutors, or maybe their med school tailored first and second year towards the Step, whether it’d be 1 or 2 exams. Although it’s the same questions, everyone’s situation is different.

I get it. There are only so many, and there are so many applications. It’s very hard, but it’s our job to come up with innovative ways to review every application, not to set filters that are arbitrary and really will miss the diamonds in the rough who would be stellar dermatologists that may not necessarily the best test takers.

Maybe they had a bad day. Maybe they were ill. Maybe there’s a death in the family. One day or two days in the sense of two tests should not define someone’s career.

Certainly, I’m a great example of that. I did not do well in Step 1. I’m proud to say that because it doesn’t dictate your future. It doesn’t establish your destiny. You make your own destiny.

I think we really need to use the ideology of holistic review, not just as a fancy term or to be used in a drinking game, but really take that holistic approach. When we look at application, look at everything from leadership, volunteerism, publications, research experiences, even own personal experiences.

That molds someone into a potential resident rather than just a number because that completely demeans our candidates, and it undermines our ability to be an extraordinary specialty.

Dr Qureshi: I’m glad that you feel that way, Dr Friedman. [laughs] Because I think obviously a holistic approach. As someone who’s a current resident and who would like co‑residents that he enjoys working with, I think a holistic approach is kind of the only way to get that.

I thought it was a funny decision to make Step 1 pass‑fail while keeping Step 2 graded. I think that. I don’t know. I just agree with you that it might place more emphasis on the score of Step 2. If anything, make both pass‑fail or just keep both of them graded. It’s a funny middle ground, but they’re probably in the processes of kind of shifting one way or another.

Dr Friedman: It’s probably evolving, that’s for sure. I think it’s important that in the dermatology community, we uniformly say that we will look at the whole person, not just one small tidbit and that’s it. That would be the exam. I think everyone needs to get on board with that.

I’m seeing that general trend at the level of the association professors in dermatology. I think that change is among us. The future will be brighter and not so pigeonholed in terms of did you get a 270 or not?

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