AANS Neurosurgeon | Volume 29, Number 2, 2020

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So What Now?

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The following is a response to the article USMLE STEP 1 Pass/Fail Scoring: A Paradigm Shift for Neurosurgical Resident Selection

The authors bring up a very interesting topic largely from the perspective of the medical student applicant. To gauge the response from neurosurgery programs, four senior neurosurgery educators Dr. Robert Harbaugh: Penn State University, Dr. Matt Howard: University of Iowa and Drs. Mark Hadley and Winfield Fisher: University of Alabama at Birmingham were informally queried about the impact of the USMLE Step 1 change.  Several recurring themes emerged.  With regard to the utility of Part I scores:

  • The USLME Part One score has been useful as a “filter” to help sort through the large numbers of applicants for highly competitive residencies and limited numbers of interview slots.
  • It is one of the few objective pieces of data that can be compared across all applicants regardless of medical school attended.
  • While a high score alone was not sufficient for selection, it provided important evidence of intellectual capability and effective work habits.

When looking at the broader issue of selecting students that will go on to be successful neurosurgery residents (and ultimately neurosurgeons), the group concurred that the following attributes were desirable:

  • Intellectual capability
  • A profound interest in learning and intellectual curiosity
  • A commitment to the care of patients
  • A very solid character, devoid of any prominent character flaws or destructive behaviors
  • Perseverance
  • Initiative
  • Resilience

It was recognized that a number of alternate data points are helpful in the resident selection process including:

  • Interviews, especially those conducted by the incumbent residents. Those residents are often very motivated to ensure that a candidate will be chosen that can work effectively with the team.
  • Letters of Recommendation, particularly from other neurosurgeons and program directors/chairs,. The inclusion of certain phrases often clearly communicates the sentiments of that author with regard to the candidate’s likelihood of success. In addition, many letters now include a specific tiered ranking, e., the applicant is in the top 5 or 10% for example, to add some objectivity to the recommendation. An expansion of that practice may prove useful in more clearly conveying the recommendations of the author. There are limitations with letters; however, in that the students often have the opportunity to select the author, introducing bias into the process.
  • Performance on clinical rotations, especially surgical rotations.
  • While research productivity as a medical student is valued, it is secondary to both clinical acumen and character, and may not predict academic productivity in residency and beyond. Further, without first authorship, the actual degree of involvement of the student can be hard to assess.

This change to the scoring of the USMLE will undoubted cause a change how applicants are considered but it is clear that it is incumbent upon all neurosurgeons to look for better and more accurate ways to identify those candidates who will become successful neurosurgeons.


The views expressed in this article are those of the author and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Government.

I am a military service member.  This work was prepared as part of my official duties. Title 17 U.S.C. 105 provides that “Copyright protection under this title is not available for any work of the United States Government.” Title 17 U.S.C. 101 defines a United States Government work as a work prepared by a military service member or employee of the United States Government as part of that person’s official duties.

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