USMLE Step 1 score: a pissing contest

What Score do I need for my Specialty?

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There is one highlight pertaining to USMLE Step 1 scores worth mentioning, located on a chart in the document above (page 16 of the pdf, page 11 in print) There appears to be 2-3 tiers of scores with the most competitive specialties falling under the highest tier. A potential breakdown is:

Tier 1 (Median USMLE Step 1 Scores of 233-243):

* Plastic Surgery
* Dermatology
* Otolaryngology
* Diagnostic Radiology
* Radiation Oncology
* Orthopaedic Surgery
* Transitional Year

Tier 2 (Median USMLE Step 1 Scores of 217-222):

* Internal Medicine
* Pathology
* General Surgery
* Emergency Medicine
* IM/Peds
* Anesthesiology
* Neurology
* Pediatrics

Tier 3 (Medan USMLE Step 1 Scores of 208-213):

* Ob/GYN
* Family Medicine
* PM&R
* Psychiatry

I'm all for reporting what score you need to get to be considered for a specialty you're interested in. However, it really irks me that the most challenging specialties (of breadth) are in the bottom "tier."

It's the culture of medicine, working at its best.

Here's the way it works for those of you who haven't been inducted into the secret society of white-coat-dom:
Everyone pisses and whoever can piss the farthest wins.
The guy who pisses for the longest wins also.
Wins what? The easiest and cushiest lifestyle, of course.
Why? Because that's the reason we all applied for medical school, right? Who wants to work long hours for no reward when you can do elective procedures and break the bank?
Why not let everyone win if they aren't pissing red blood or albumin? That's my win-win definition of a pissing contest -- yay, you can pee healthy!

For some reason I keep talking about piss, but I assure you, I'm not pissed.

Even people who don't subscribe to the "lifestyle" theory of natural residency selection agree with its prestige: it is much more difficult to land a derm or radiology residency spot than it is internal medicine or pediatrics. (The unspoken therefore: the people who go into derm or radiology are smarter/better! Too bad supply and demand economics doesn't drive students into the professions we need the most.)

Now, I'm not bashing people who truly love Plastics or Rad Onc. On the contrary, I DO have a great amount of respect for them for having the ambition that I clearly lack to aim for one of those spots. Me, I'm envisioning myself being content to have a small group of patients that I will help give birth to, raise and grow old with (and blog on the side.)

I still want to do my best and that means:
I will counsel the HELL out of people who are determined to lose weight and start exercising!!
I will be an awesome educator for all sorts of common ambulatory complaints!!
I will strive to catch all of the rare zebras in their horse clothing and send them off to the right specialists so I won't be one of the dull-wits in primarycareville.
I will spend that extra time to see the last-minute walk-in or the guy without insurance.

Why? I decided to become a doctor because I want to do the right thing. That's righteous (hopefully without seeming too self-righteous.)

THAT is a first tier goal in my mind. (GOAL being the key word. I doubt I'll live up to any expectations, but I hope to never lose sight of them.) These goals are much more forward looking than a step board score determining what I will do for the rest of my life.