US Medical Licensing Examination Step 2 Clinical Knowledge Score in Dermatology Resident Selection

Acceptance into dermatology residency is competitive, requiring programs to select residents from among highly qualified applicants.¹ While nearly all dermatology residency programs consider the importance of US Medical Licensing Examination (USMLE) Step 1 scores and clerkship grades, their use of USMLE Step 2 Clinical Knowledge (CK) scores is less defined.² Tested content in Step 1 consists of basic science concepts that underlie clinical practice,³ whereas content in Step 2 CK aims to measure knowledge of clinical principles required for the supervised practice of medicine.⁴ The objective of this study was to assess use of Step 2 CK scores in resident selection in US dermatology residency programs.

We developed and distributed a 7-question survey using software (Research Electronic Data Capture hosted at the University of Pennsylvania, version 7)⁵ to dermatology faculty via email discussion group (Association of Professors of Dermatology email listserv) in March to May 2017, with 2 follow-up reminders. The initial invitation was sent on March 20, 2017, and the 2 follow-up invitations were sent on April 17 and May 2. Responses were anonymous. The 7 questions asked about use of Step 2 scores, any requirements to take Step 2 for application, and rationales for those policies. All statistical analyses were conducted using an analysis program (Stata, version 14.1; StataCorp LLC). This study was deemed exempt from informed participant consent by the University of Pennsylvania institutional review board.

In total, 75 responses were received from 36 program directors, 7 department chairs, 31 other faculty members, and 1 respondent who did not indicate a position. The content of responses did not differ substantively between program directors and nonprogram directors. Most respondents reported using Step 2 scores if available but not requiring them, in both the 2011-2012 (60 of 75 respondents [80%]) and 2016-2017 (65 of 75 respondents [87%]) application cycles (Table 1). Among respondents whose programs required or used Step 2 scores, 12.9% (9 of 75) applied a minimum cutoff score (mean, 226; range, 210-235).

Respondents in programs that required Step 2 reported using it to compare applicants objectively (4 of 5 respondents [80%]) (Table 2). Respondents in programs which reported using but not requiring Step 2 scores generally wanted to measure improvement on Step 2 relative to Step 1 (42 of 65 respondents [65%]). The primary reason for not requiring or using Step 2 was insufficient value in predicting clinical performance (4 of 5 respondents [80%]).

Seventeen of 75 respondents (23%) offered additional comments. The most common themes included the predictive value of Step 2 in future examination performance (5 of 17 respondents [29%]) and clinical performance (3 of 17 respondents [18%]), preference for roughly consistent performance on Step 1 and Step 2 or improvement on Step 2 if Step 1 was below average (5 of 17 respondents [29%]), and disapproval or concern when applicants delay Step 2 (3 of 17 respondents [18%]).

Our findings suggest that Step 2 CK scores are widely used but not commonly required in the selection of dermatology resident applicants. Moreover, our study indicates that programs employ Step 2 for different purposes (eg, evaluation of improvement relative to Step 1 score or objective comparison between applicants). These findings are limited by the degree to which survey responses reflect actual selection criteria and the degree to which they represent all dermatology residency programs. Because dermatology residency applicants typically apply to 60 to 80 programs⁶ and are therefore likely to apply to at least one of the programs that require or prefer Step 2 scores, advisors to dermatology applicants should encourage them to take Step 2 before applying. Those applicants with below-average Step 1 scores might especially benefit.

Corresponding Author: Jules B. Lipoff, MD, Department of Dermatology, University of Pennsylvania, Penn Medicine University City, 3737 Market St, Ste 1100, Philadelphia, PA 19104 (jules.lipoff@uphs.upenn.edu).

Published Online: August 23, 2017. doi:10.1001/jamadermatol.2017.2924

Author Contributions: Dr Lipoff and Mr Jayakumar had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Both authors.

Acquisition, analysis, or interpretation of data: Both authors.

Drafting of the manuscript: Jayakumar.

Critical revision of the manuscript for important intellectual content: Lipoff.

Statistical analysis: Jayakumar.

Administrative, technical, or material support: Lipoff.

Supervision: Lipoff.

Conflict of Interest Disclosures: None reported.