By Emily Green

Anyone who advises medical students about USMLE Step 1 will be familiar with the metaphor of “closing doors”.  Upon receiving their Step 1 score, worried students wonder if the sound they are hearing is the slamming shut of gateways to particular specialties.  The problem with the pervasive “closing doors” metaphor is that it presents career options as being either available or unavailable, with little in-between.  In a student’s mind, a score of 240 might mean that the door to a particular career is open, but a 239 means that it is closed.  Convincing students the wrongness of this thinking is a challenge.

First, the metaphor robs students of their own power.  This is perhaps why they find it so distressing.  In the metaphorical scenario, doors are being closed by unseen forces while the student stands helpless in front of them.  The scene it conveys ignores the proactive steps a student can take to make him/herself competitive for a given field.  We all know of students with relatively low board scores who matched in competitive specialties on the strength of their research, clinical evaluations, or performance on away-electives.  Regardless of, or perhaps in addition to, particular Step 1 scores, students are active participants in their own career planning.

The “closing doors” metaphor also presents career choice as one-directional, as if students end up in a particular specialty simply because that is the only one that would take them.  Nowhere in the metaphor appears the notion of “fit” between a student and a career path.  Students should and do choose specialties that best match their interests and skills.  They assess programs on interview days, as they themselves are being assessed.  They rank programs where they feel most challenged or most at home.  The “match” is meant to be just that – a pairing of student and program in which fit is paramount.  Unfortunately, a second year student may not understand that the program that uses a Step 1 screen of 245, or where the average number of publications per applicant is in the double-digits, is a program that might not be right for them for a host of reasons.

Finally, the metaphor fails to portray the many routes to a satisfying and fulfilling career. There is not one single pathway that is right for a student, with a single door that is either open or closed.  Instead, there are likely many pathways that lead to productive and rewarding careers.  These pathways develop over time, and contain opportunities to proceed in other varied directions.  A career in medicine evolves into a focus on medical education.  A pathway to surgery takes a detour into consulting.  A generalist becomes a specialist.

Students move incredibly quickly from the stress of taking the exam, to the stress of interpreting their exam results.  “I just want a score that won’t close any doors” quickly becomes, “I feel like doors are now closed to me”.  As advisors we sometimes struggle to catch up.  Many students do not yet have the clinical experience required to make informed career decisions, or to see their careers as developing over a lifetime.  In reality, none of us exist in a world of truly infinite possibilities.  Each of us adapts to our own set of physical, mental and circumstantial limitations across a lifetime.  However, Step 1 may represent the first time some of our students hear (or think they hear) the message, “You can’t do that”.  Our task is to debunk the myth of the closing doors, and help students incorporate their Step 1 scores, whatever they may be, into the complex and dynamic process of planning a career.

Emily P. Green, PhD, MA, is the Director of Student and Faculty Development at the Alpert Medical School of Brown University, Providence, Rhode Island.  She co-directs the USMLE Step exams support program.