Step 1 filters for IM subspecialties - might they INCREASE in the future?

[IMtoBeforme]

I am an AMG M3 who will be applying to IM, and based on my brief performance so far on rotations (and research and discussion with IM residents/faculty) I feel comfortable to match at mid tier university IM program in midwest despite my low Step 1 in the 210-220 range.

First, I know that right now my current goal should be to be the best med student possible so I can match at the best IM program possible, and then be the best IM resident possible and do productive research and get excellent letters to be a good fellowship applicant. My step 1 is what it is, and I just need to move on. Finally, I know will never match in something if I don't apply (quote from @gutonc )

However...

I see the current TOP of the "range" reported in the 2016 sub-specialty PD survey for step 1 CUT OFFS for many IM sub-specialties is AT or slightly above my current step 1 score (GI (p. 100, 52% use target score), Cardiology (p. 46, 54% use target), Endo (p. 82, 45% use target), HemeOnc (p. 136, 37% use target), Pulm/CCM (p.352, 46% use target), etc). Also, I'm aware of the Charting Outcomes for Fellowship match data, but that's from 2011, and things are very likely different now.
Fellowship PD 2016 survey:
http://www.nrmp.org/wp-content/uploads/2017/02/2016-PD-Survey-Report-SMS.pdf

I also read on one of the GI forums that 220 for AMG is a typical cutoff, which is higher than reported on the PD survey. Conversely, I found this thread from 2015 which said for Cardiology not to worry about filters if you go to a top IM program Importance of Step 1

SO, do you think, by the time I get to applying to fellowship (if I even choose to do a fellowship vs. IM) that my seemingly low but benign step 1 score will actually hold me back from certain specialties by virtue of a screen? Also, do most programs with filter use a filter for each step, or just filter by AVG? I'll be rotating in many of the IM subspecialties during my 3rd and 4th year, and would like to get some research going in the area that I might want to pursue for fellowship (especially if I stay at my home institution for residency, which is likely) since time for anything during residency is very limited.

I also see that the 2016 match rate for GI for US graduates was only 66.9% (GI Fellowship Match | American College of Gastroenterology) and the 2017-18 Cardiology interview thread seems like a freaking bloodbath (ERAS 2017-2018 Cardiology Fellowship Application Cycle). This is another reason why I am concerned that the filters might be raised as applications go up and match rates go down...

I'd appreciate your thoughts/predictions on the future, and thanks for your input!

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[jhamaican]

There is definitely a filter and you will be out at many programs for cards and GI based on your step one score.

Just being honest with you.

Doesn't mean you can't match into GI or cards just a little more difficult.

Read the last page of the current GI interview thread for some good posts by program directors on how they screen through the hundreds of applications they receive (pro tip: it has a lot to do with step scores)

 

[IMtoBeforme]

There is definitely a filter and you will be out at many programs for cards and GI based on your step one score.

Just being honest with you.

Doesn't mean you can't match into GI or cards just a little more difficult.

Read the last page of the current GI interview thread for some good posts by program directors on how they screen through the hundreds of applications they receive (pro tip: it has a lot to do with step scores)

Thanks for your honest and helpful reply, yes I see that now on the GI interview thread, those recent posts pretty much answered all my questions, they were posted after I started this thread lol (posts 461-473) Official 2017-2018 GI Fellowship Application Cycle

Hopefully I "fall in love" during residency with general IM (I know I already love general IM as a med student) or another less competitive subspecialty in the future, we'll see what happens....

F/u question: if I know I'm gonna be screened out by step 1 score at a program, would a call from my IM PD or a subspecialty PD that I've worked with allow me to get past a screen? I'm sure this is program dependent at best, or not at all possible at worst...

 

[jhamaican]

Thanks for your honest and helpful reply, yes I see that now on the GI interview thread, those recent posts pretty much answered all my questions, they were posted after I started this thread lol (posts 461-473) Official 2017-2018 GI Fellowship Application Cycle

Hopefully I "fall in love" during residency with general IM (I know I already love general IM as a med student) or another less competitive subspecialty in the future, we'll see what happens....

F/u question: if I know I'm gonna be screened out by step 1 score at a program, would a call from my IM PD or a subspecialty PD that I've worked with allow me to get past a screen? I'm sure this is program dependent at best, or not at all possible at worst...

Important people who are willing to go to bat on your behalf can open all doors.

Life is about who you know, not what you know. Medicine included

 

[IMtoBeforme]

Important people who are willing to go to bat on your behalf can open all doors.

Life is about who you know, not what you know. Medicine included

Thanks for your reply, good to know!

 

[JLC]

Don't worry about what the applicants are saying every year about the current competitiveness of this years fellowship cycle. Every year, the applicants claim that things are harder and harder...just the nature of the internet. Not saying its not true, but the ratio of cardiology spots per applicant has actually been increasing for the past several years, would support that cardiology is getting less competitive.

 

[IM2GI]

As PDs get wise to the grade inflation on step 1, from better and better study tools, 230 is not what it used to be. You will start seeing 240 as the cutoff if it is not already at many top places for competitive specialties in a buyers market.

 

[Anicetus]

Should those of us with scores in the 230's just give up on GI/cards given this suspicion about the step filters?

 

[IM2GI]

Should those of us with scores in the 230's just give up on GI/cards given this suspicion about the step filters?

No

 

[bashwell]

Should those of us with scores in the 230's just give up on GI/cards given this suspicion about the step filters?

Yes, give up. Give up now. Give up because 230s is so low by SDN standards. Give up because everyone else on SDN has 260s+. Give up because only people with 260s, AOA, from Harvard or Hopkins, with an MD/PhD, several first author papers published in JAMA and NEJM, strong LORs from Nobel Prize winners who are also their closest mentors and friends, previously was a Navy SEAL, Olympic gold medal winner, climbed Mt. Everest, started Google from their mom's basement, did medical missions to help kids in Asia and Africa, etc, even have the slightest hope of matching GI/cards. Most importantly of all, give up because that will give me one less person to compete with for that coveted GI/cards spot!

Seriously though you'll be okay if you're a US MD with 230s, you'll be able to match into a good academic IM program, then it's about how well you do during residency that will determine whether you'll match GI/cards or not. Approximately 90% of US MDs get into cards, and 85% into GI, at least based on the latest NRMP (2017). That doesn't tell us how competitive each applicant was, but it does at least suggest you have a fair chance if you perform on par with most people applying to GI/cards.

Cardiology
-U.S. Grads 482/537 (89.8%)

Gastroenterology
-U.S. Grads 319/377 (84.6%)

 

[lost777]

if a resident has a board failure and unimpressive scores otherwise, is fellowship out of the question? what about endo/rheum/allergy?

 

[bashwell]

if a resident has a board failure and unimpressive scores otherwise, is fellowship out of the question? what about endo/rheum/allergy?

Are you a US MD? If so, you could still match into competitive IM subspecialties despite low board scores if you've done well in residency, have good LORs, have done some research, etc.

Here's the data from NRMP (2017):

Cardiology
-U.S. Grads 482/537 (89.8%)
-Total 855/1147 (74.5%)

Endocrinology
-U.S. Grads 103/108 (95.4%)
-Total 270/342 (78.9%)

Gastroenterology
-U.S. Grads 319/377 (84.6%)
-Total 493/742 (66.4%)

Hematology and Oncology
-U.S. Grads 287/332 (86.4%)
-Total 544/729 (74.6%)

Infectious Disease
-U.S. Grads 162/169 (95.9%)
-Total 312/335 (93.1%)

Nephrology
-U.S. Grads 64/68 (94.1%)
-Total 284/308 (92.2%)

Pulmonary and Critical Care
-U.S. Grads 289/323 (89.5%)
-Total 524/742 (70.6%)

Rheumatology
-U.S. Grads 94/114 (82.5%)
-Total 210/332 (63.3%)

 

[DubbiDoctor]

Are you a US MD? If so, you could still match into competitive IM subspecialties despite low board scores if you've done well in residency, have good LORs, have done some research, etc.

Here's the data from NRMP (2017):

Cardiology
-U.S. Grads 482/537 (89.8%)
-Total 855/1147 (74.5%)

Endocrinology
-U.S. Grads 103/108 (95.4%)
-Total 270/342 (78.9%)

Gastroenterology
-U.S. Grads 319/377 (84.6%)
-Total 493/742 (66.4%)

Hematology and Oncology
-U.S. Grads 287/332 (86.4%)
-Total 544/729 (74.6%)

Infectious Disease
-U.S. Grads 162/169 (95.9%)
-Total 312/335 (93.1%)

Nephrology
-U.S. Grads 64/68 (94.1%)
-Total 284/308 (92.2%)

Pulmonary and Critical Care
-U.S. Grads 289/323 (89.5%)
-Total 524/742 (70.6%)

Rheumatology
-U.S. Grads 94/114 (82.5%)
-Total 210/332 (63.3%)

Why is rheum so competitive even though they make less than hospitalists?

 

[bashwell]

Why is rheum so competitive even though they make less than hospitalists?

It's not always about the money. For example, rheum can have a great lifestyle too, whereas being a hospitalist can be really hard. Plus lots of huge advantages in being a subspecialist vs a PCP or hospitalist.

 

[DubbiDoctor]

It's not always about the money. For example, rheum can have a great lifestyle too, whereas being a hospitalist can be really hard. Plus lots of huge advantages in being a subspecialist vs a PCP or hospitalist.

I really like the idea of becoming an expert in one field -- keeping up with all the latest research and providing consult to generalists -- rather than being more of a jack of all trades. But I'm not too keen on doing two years more of training only to earn less. What other advantages does subspecializing confer?

 

[IM2GI]

I really like the idea of becoming an expert in one field -- keeping up with all the latest research and providing consult to generalists -- rather than being more of a jack of all trades. But I'm not too keen on doing two years more of training only to earn less. What other advantages does subspecializing confer?

I dont think you can generalize that rheum earns less. ID/endo/nephro potentially, but I think Rheum makes a decent income depending on your practice setup. Theres a rheum warrior that Im sure will post and tell you how awesome it is. There is a lot of income potential from infusions centers, some rheumatologists pretend to be allergists and will do allergy shots, etc.

 

[gutonc]

Thanks for the info. FWIW, I shadowed an allergist, and you should not need to complete a fellowship to do that job. It's mainly allergy shots, which honestly a mid-level could do. But the shots need to be performed in office due to the risk of anaphylaxis, providing the allergist with procedural compensation. It's a great job, but honestly too boring for me to pursue.

Well, as long as you shadowed an allergist, I'm sure you've got the whole thing figured out.

 

[IM2GI]

Well, as long as you shadowed an allergist, I'm sure you've got the whole thing figured out.

Psh, I have visisted my remicade patients in the infusion center. I'm pretty much good to go to give chemo, looks easy.

OP, sure once you have a stable patient on allergy shots it is just like giving a flu shot and many PCPs offices can and will give the shots once prescribed by an allergist. Don't disrespect our allergy colleagues by saying any idiot knows how to properly prescribe, mix, dose, step-up, stop, therapy.

I feel like across the board people on these forums are quick to discount the skills and value of others fields. If physicians don't stick up for each other that our training has value and improves patient care and safety, then the aggressive midlevel community will continue to erode physicians scope of practice.

 

[bashwell]

OP looks like @IM2GI gave you some great info.

 

[gutonc]

Psh, I have visisted my remicade patients in the infusion center. I'm pretty much good to go to give chemo, looks easy.

You actually know where your infusion center is? Congratulations!

But yeah...you're totally down for the FOLFOX and the R-CHOP...go nuts man. It's definitely not as hard as it looks.

 

[DubbiDoctor]

Psh, I have visisted my remicade patients in the infusion center. I'm pretty much good to go to give chemo, looks easy.

OP, sure once you have a stable patient on allergy shots it is just like giving a flu shot and many PCPs offices can and will give the shots once prescribed by an allergist. Don't disrespect our allergy colleagues by saying any idiot knows how to properly prescribe, mix, dose, step-up, stop, therapy.

I feel like across the board people on these forums are quick to discount the skills and value of others fields. If physicians don't stick up for each other that our training has value and improves patient care and safety, then the aggressive midlevel community will continue to erode physicians scope of practice.

In retrospect, my comments were rather flippant, and I regret them. It does SEEM like an easy specialty when there are no major problems, but you will of course need specialist training when things don't go according to plan. And perhaps stepping up the concentrations of the allergy shots in a safe manner is more complicated than I assumed. You are right that physicians should not insult the degree of expertise of other physicians. And as someone who isn't a physician yet, I should be more careful when making assumptions.

 

[mercaptovizadeh]

In retrospect, my comments were rather flippant, and I regret them. It does SEEM like an easy specialty when there are no major problems, but you will of course need specialist training when things don't go according to plan. And perhaps stepping up the concentrations of the allergy shots in a safe manner is more complicated than I assumed. You are right that physicians should not insult the degree of expertise of other physicians. And as someone who isn't a physician yet, I should be more careful when making assumptions.

I happen to be applying to A/I and can say that the clinical scenarios are often trivial (e.g. food allergy, allergic rhinitis) in the community but that is not the case in the tertiary care centers. A/I is a very different beast there, where allergists/immunologists are diagnosing and/or managing SCID, athymic patients, CVID, post-ritux hypogammaglobulinemia, hyper-IgE syndrome, CGD, LAD, Wiskott-Aldrich, interferonopathies, systemic mastocytosis, APECED, NK cell deficiency, NEMO deficiency, hereditary and acquired angioedema, severe chronic urticaria with a plethora of triggers, severe eczema, hypereosinophilic syndromes such as DRESS or eosinophilic myocarditis, EoE, and asthma which can range from the routine to severe. These are all major problems and some are in fact lifethreatening, not to mention that one of the inherent risks of food challenges and immunotherapy (or heck skin testing) is anaphylaxis, and every year there is a number of people who die of anaphylaxis despite being challenged with allergen in a controlled setting with epi on hand and emergency medical services readily accessible.

The fact is immunotherapy pays, just like screening colonoscopies pay, which is why this is something you would see often done in the community. It doesn't mean that's all there is to a specialty.

 

[rokshana]

Why is rheum so competitive even though they make less than hospitalists?

have you ever been a hospitalist?

if you have, then you would know...

 

[rokshana]

Well, as long as you shadowed an allergist, I'm sure you've got the whole thing figured out.

maybe he stayed at a Holiday Inn too...

 

[IM2GI]

Yes, the allergist who I shadowed was very clear, when I asked, that academic allergist/immunologists see plenty of complex immunological disorders that are far beyond my understanding. But in her private practice, she dealt primarily with allergies, asthma (in consultation with pulm) and urticaria, and occasionally other disorders like mastocytosis, but almost never the immunological disorders you mentioned. She explained that academic practice is harder, and requires a different kind of physician. Is that what you are interested in? What is the pay relative to PP?

Bread and butter is just that, the most common things you will see in your practice. A lot more people have seasonal allergies and asthma than CVID. Sure people in quaternary academia may see more zebras but they are still treating a lot of bread and butter/common stuff.

Don't pick a field for the zebras because your day to day life is going to be the common stuff. Frankly once you start getting busy in practice you want some common/easy stuff to get through the day.