The Archives

I. Topic Collections

Application Fever
The Match
USMLE scoring
Winners & Losers

II. All Posts

In chronologic order…

Checking the references: the evidence in support of Step 1

  • We’re told that Step 1 scores predict measures of physician quality. But do they? Let’s check the references.


USMLE Step 1: leveling the playing field – or perpetuating disadvantage?

  • Do students from “lower tier” medical schools benefit from a scored USMLE? Or would they be better off by playing a different game altogether?


USMLE Step 1: the “antidote to implicit bias”?

  • Under-represented minorities in medicine score lower on Step 1. So why do NBME executives think it’s a cure for bias?


Raising the bar: encouraging trends in USMLE Step 1 performance, 1997-2017

  • Are rising Step 1 scores just “score creep” – or a sign of improving physician quality?


A peek inside the USMLE sausage factory: setting the Step 1 minimum passing score

  • Why is the minimum passing score for Step 1 frequently increased? To understand why, we first need to understand how the passing standard for is set. Let’s find out how the sausages get made.


A two-step plan for a better USMLE Step 1

  • If you turned Step 1 over to me, here’s what I’m gonna do.


A non-MBA’s guide to NBME revenue in 9 simple charts

  • The NBME has a financial conflict of interest in maintaining a scored USMLE. Here’s why.


A MCQ exam on the USMLE

  • I’ve studied the business of the NBME. Ready to take the exam?


The new USMLE score report

  • Since January 2019, USMLE score reports have looked different. What changed – and why?


On pi and Step 1 Mania

  • What would happen if we asked medical students to memorize digits of pi?


The intellectual opportunity cost of USMLE Step 1

  • Students spend a lot of time studying for Step 1. What else could we do with that time?


The etiology of Application Fever

  • Medical students are submitting more residency applications than ever before. Why? Who benefits?


Symbiosis: the USMLE, ERAS, and medical education

  • Step 1 Mania and Application Fever need each other.


The mythology of USMLE Step 1 scores and board certification

  • Do Step 1 scores predict success on the boards? Yes… but maybe not in the way you expect.


The InCUS is coming – are we ready?

  • The corporate sponsors of the USMLE have organized an invitation-only conference to determine the future of USMLE scoring. The InCUS is nigh.


InCUS wrap

  • What happened at InCUS? Who knows. Attendees have been asked to stay silent.


What’s on USMLE Step 1?

  • Physicians who took Step 1 more than 5 years ago honestly have no clue what’s on the exam. Want to remind yourself what’s really tested on Step 1?


Stonewalled: A brief update on InCUS, the NBME, and financial COI

  • I asked the NBME whether InCUS attendees received financial compensation. The answer? Silence.


What can the NFL Draft teach us about residency selection?

  • Getting into residency programs is competitive… but nowhere near as competitive as the NFL. What can we learn from the metrics used to select NFL players?


Step 1 Mania: The Case for #USMLEPassFail

  • Links to a video podcast of a Grand Rounds presentation with an overview of the case for a pass/fail USMLE.


Another MCQ Test on the USMLE

  • Most of us do not interpret USMLE Step 1 scores appropriately. They’re not as precise and reliable as you might imagine.


What’s the Antipyretic for Application Fever?

  • We have a major problem with Application Fever. The question is, what do we do about it?


A Field Guide to USMLE Step 1 Apologists

  • You know what you never hear in the USMLE Pass/Fail debate? The full-throated defense of USMLE Step 1 as a great test. Here’s your field guide to the various USMLE Step 1 Apologists.


Application Fever: The Movie

  • It’s not really a movie. More like a video podcast compiling my thoughts on the mess we’ve made with residency application inflation – and how we can get out of it.


InCUS: The Conversation Continues

  • Preliminary recommendations from InCUS were just released. Unfortunately, they don’t tell us much – and what they do tell us isn’t what I hoped to hear.


Applying Smarter, Part I: Breaking Down the AAMC’s Apply Smart Campaign

  • The AAMC’s Apply Smart campaign perpetuates misinformation, employs faulty logic, presents biased probabilities of residency entry, and is likely to encourage medical students to submit even more residency applications.


Applying Smarter, Part II: How to Give Students the Information They Really Need

  • For informational strategies to reduce Application Fever, the information provided has to be… well, informative. Here’s how to provide the data that students really need when they’re applying for residency.


Why Can’t I Retake USMLE Step 1?

  • It’s a question I’m often asked. But there’s a fundamental difference between the USMLE and other tests used for admission, and this explains why the NBME is highly unlikely to ever allow re-takes.


How Much Does Step 1 Mania Cost Medical Schools?

  • For one prominent U.S. medical school, it’s $495,000/year. Where does that money go? And more importantly, is it worth it?


What’s the REAL Match rate?

  • The NRMP reported record-setting statistics for Match rates in 2019. Are things as good as they appear? Or do the NRMP’s figures overestimate the real likelihood of success for certain applicants, like IMGs?


The USMLE for DOs: How to Stop Fleecing Osteopathic Medical Students

  • In 2018, 4186 osteopathic medical students took USMLE Step 1, and the NBME made $4,399,320 on DO students who took USMLE tests. Thing is, these tests are not required for osteopathic licensure. How can we stop DO students from paying twice for licensing exams?

Why do we have residency training?

  • You might think that residency training evolved as a natural outgrowth of undergraduate medical education. Think again. The real forces that led to the requirement for residency training were a bit more complicated.

Step 2 CS, Part One: How Did We Get Here?

  • Medical students today have to pay $1300 and travel to one of only a handful of testing centers to take the USMLE Step 2 CS exam. This is the story of how the CS exam came to be.

How is the three-digit USMLE score calculated?

  • The NBME does not disclose how it generates an examinee’s three-digit USMLE score from the percentage of questions answered correctly. However, I stumbled on a key clue from the psychometric literature that sheds light on how this is done for USMLE Step 2 CK.

Step 2 CS, Part Two: The Resistance

  • From its inception, medical students have been opposed to USMLE Step 2 CS. This is the story of organized opposition to the CS exam – and why it always failed.


The Match, Part 1: Why do we have a Match?

  • The Match is so ingrained into medical education that it’s hard to imagine life without it. But when you step back and think about it, it’s a question worth asking. Why is getting a residency position so different than applying for any other job?


The Match, Part 2: Getting under the hood – how does the Match work?

  • When you are matching students and programs, the devil is in the details. This post begins the discussion about how the Match algorithm works – and the medical student who led a successful rebellion against the NRMP.


The Match, Part 3: On proposals and the fight for a student-optimal Match

  • In the old days, the Match algorithm systematically favored the preferences of hospitals over students. I’ll explain how – and review the unsung hero who fought for a student-optimal Match.


#USMLEPassFail: A Brave New Day

  • On February 12, 2020, the USMLE announced that Step 1 would become pass/fail as soon as 2022. After the initial shock wore off, I wrote about where we go from here.


The Lecture that Never Got To Be

  • How can residency program directors make the Match process better – in a post-Step 1 world?


On Toilet Paper and Application Caps

  • It’s time to separate myth from reality when it comes to application caps. And we’ll do it through the lens of the COVID-19-induced run on toilet paper.


The Last Lecture (2020)

  • Every year, fourth-year students at the school where I teach select faculty to give their “Last Lecture” of medical school. This year, they picked me.


Virtual Interviews: Winners and Losers Edition

  • The Coalition for Physician Accountability has recommended that all residency interviews for the 2020-2021 application season occur virtually. So who wins – and who loses?


Step 2 CS, Part Three: Winners and Losers Edition

  • The NBME just announced that USMLE Step 2 CS is suspended for 12-18 months – a decision that has far-reaching implications for many in medicine. So let’s break it down, winners and losers style.

Journal Club: COMLEX-USA and Physician Discipline

  • Lately, I’ve been hearing a lot about how the National Board of Osteopathic Medicine’s clinical skills exam – the COMLEX-USA Level 2-PE – provides useful data to medical boards regarding the likelihood of later physician discipline. Does it?

The Residency Selection Arms Race, Part 1: On Genghis Khan, Racing Trophies, and USMLE Score Creep

  • Many residency programs today screen out applicants with USMLE scores that would have been stellar 25 years ago. This piece focuses on how residency selection has become an arms race where relative accomplishment matters more than absolute performance.

Step 2 CS, Part Four: The Future of USMLE Step 2 CS

  • Most medical students want to end Step 2 CS. I don’t think it can be done. Here’s why – and what we should fight for instead.

Grand Rounds: The Rise and Fall of USMLE Step 1

  • How did USMLE Step 1 become the most important test in all of medical education – then collapse under the force of its own weight? This is a video of a lecture I did for Grand Rounds at another institution.

Preference Signaling: Winners & Losers Edition

  • In August 2020, the Otolaryngology Program Directors Organization announced that they’d implement formal preference signaling in this year’s Match. So who wins – and who loses – when applicants can send tokens of interest to programs?

ECFMG Finances, Part I: On Purell and Profiteering

  • After the USMLE Step 2 CS exam was suspended, the Educational Commission on Foreign Medical Graduates (ECFMG) needed a new way to certify international medical graduates. They came up with alternative pathways – each with a $900 price tag. How on earth did they arrive at this figure?

ECFMG Finances, Part II: By the Numbers

  • The ECFMG is, in the very literal sense of the term, a coercive monopoly. They can charge whatever they want, and people have to pay. Here, we’ll take a closer look at their finances.

ECFMG Finances, Part III: The Movie

  • If you liked Part I and Part II, you’ll love Part III: a video podcast covering the ECFMG’s pricing and profits.

The NBOME, Part 1: On COMLEX-USA and Off-Label Marketing

  • According to the Food & Drug Administrations strict rules, pharmaceutical companies aren’t allowed to market their products “off label” for purposes for which they have not been proven effective. Should we hold the NBOME to the same standard when they market COMLEX-USA?

The NBOME, Part 2: Osteopathic Medicine’s Vestigial Organ

  • DOs have often fought an uphill battle to receive the same practice opportunities and professional recognition received by MDs. But now that [intelligent] people regard MDs and DOs as equivalent, does the NBOME help or hurt osteopathic physicians?

Mailbag: Virtual Interview Advice, Interview Caps, and USMLE Pass/Fail Updates

  • Real questions, from real readers.

Mailbag: Ending Step 2 CS, Application Caps, and In Person Interviews

  • More reader questions answered.


Mailbag: Interview Hoarding Special Edition

  • A special edition mailbag focusing exclusively on over-interviewing/interview hoarding.


The Top 10 from 2020

  • The most popular posts on the Sheriff of Sodium over the past year.

The Case for Residency Application Caps

  • When I talk to people who oppose application caps, they often seem to imagine a world in which their personal applications are limited – but nothing else changes. To understand how application caps provide systemic benefit, I made a video (~45 minutes).

USMLE Step 1 Pass/Fail: How Did We Get Here?

  • This is a video from a brief (~12 minute) talk providing an overview of how the USMLE Step 1 exam rose to dominate medical education and residency selection, then imploded.

The End of USMLE Step 2 CS: Winners and Losers Edition

  • On January 26, 2021, the USMLE announced that they were permanently discontinuing efforts to bring back the Step 2 CS exam. Naturally, this shocking news demanded an emergency winners and losers edition.

The Match, Part 4: Unraveling, and Going All In

  • The residency match is a designed market – and as such, is at risk of unraveling if too many applicants or programs are willing to conduct their business elsewhere. Here, we’ll review how fears about unraveling have influenced the NRMP’s policies in two important areas.

The Match, Part 5: The Lawsuit

  • On May 7, 2002, a group of resident physicians filed a lawsuit in the U.S. District Court in Washington, DC. Styled as Jung v. AAMC, the suit alleged an anticompetitive conspiracy that kept resident wages low and work hours high. The Match was on trial.

Mailbag: Match Day delay, USMLE score rechecks, Step 2 CS score reporting, and preparing for the SOAP

  • More reader questions, answered.

Match Day 2021: Winners and Losers Edition

  • It was a residency application cycle unlike any other. Time to tally up the winners and losers.

The Residency Application Arms Race, Part 2: Anatomy of an Arms Race

  • Video from a webinar where I got to discuss the current landscape of residency selection.

The Last Lecture (2021)

  • For the second year in a row, I got to give the last lecture for our medical students. I wrestled with what their last lesson should be. Here’s what I came up with.

The Coalition for Physician Accountability’s UME-GME Transition Recommendations: Winners and Losers Edition

  • The CPA made 42 specific recommendations to improve the transition from medical school to residency. So who wins – and who loses – if these recommendations are implemented?

Breaking the Magic: The USMLE Three-Digit Score

  • How does the USMLE generate a three-digit score? Here’s the basic methodology.

The 2021 Match, By the Numbers

Mailbag: ERAS secondary applications and preference signaling

  • Residency applicants in internal medicine, general surgery, and dermatology will get to send preference signals to programs of interest – and will complete a new secondary application. Your questions, answered.

Mailbag: Second Looks, the USMLE Step 1 “Curve,” and Residency Placement Rates for DOs

  • Are “second looks” for ophthalmology applicants as good as they appear? Should you worry that examinees racing to take Step 1 before it goes pass/fail will “break the curve”? And what’s strange about the statistics AACOM is touting about the residency placement rate for DOs?

Recommendations from the Coalition for Physician Accountability’s UME-to-GME Review Committee: Winners & Losers Edition

  • The UGRC was tasked with recommending how to improve the transition from medical school to residency, and came up with 34 specific recommendations to do so. Let’s separate the winners from the losers.


  • There are troubling and frequent allegations that ERAS has not transmitted certain letters of recommendation that have been assigned by applicants. What should the AAMC do?

The Vulnerabilities of Osteopathic Medicine

  • Suppose you woke up one day in the future and found that osteopathic medicine occupied a very different place than the one it now occupies in the house of medicine. How could we have gotten there from here? This is a talk I gave to a group of osteopathic medical school deans to assist with their strategic planning.

The Top 10 of 2021

  • Let’s count ’em down – these are the ten most popular posts on The Sheriff of Sodium over the past year.

Predictions and Prophecies for 2022

  • It’s that time of the year when pundits and prognosticators make their predictions for the coming year. Here are mine, with thoughts ranging from the Match to USMLE score passing thresholds to virtual interviewing to medical school applicant numbers.

How Much Are Resident Physicians Worth?

  • Yeah, you heard me. In real dollars and cents, how much value does the average resident physician add to their hospital?

On the Flynn Effect and Merit in Medicine

  • Whenever I talk about USMLE score creep, someone always says, “It’s the Flynn effect!” Is it really?

The Match: The Movie

  • Across this sprawling six-part video series, we’ll cover the history of the Match, and finally answer the most important question of all: do we need it? Or would we be better off without it?

Match Day 2022: Winners and Losers Edition

Winners & Losers

The Last Lecture (2022)

  • For the third year in a row, I got to give our medical school’s “Last Lecture.” Here’s what I talked about.

Remarks from the Alpha Omega Alpha Induction Ceremony

  • I got to give the keynote address for our school’s AOA induction ceremony, and took the opportunity to point out the biggest challenge facing AOA.

Just So Stories for Medical Education

  • How did certain things – like resident work hours, the implementation of the resident match, or the ‘cap’ on GME funding – get to be the way they are?

A Two-Stage Match: Winners and Losers Edition

  • The NRMP is considering eliminating the SOAP and replacing it with a two-stage matching system. So who wins – and who loses – if this proposal is implemented?

Resident Unionization, Part 1: Lessons from Hamburger University

  • A McDonald’s worker in Denmark earns 50% more per hour than their American counterparts – along with six weeks of paid vacation, a year’s paid maternity leave, and a pension plan. What can resident physicians learn from their experience?

Is there an emergency for Emergency Medicine?

  • The big surprise in Match 2022 was the availability of over 200 emergency medicine positions in the SOAP. This year, applications are down even further. What does it mean for EM applicants and programs?

Budgetary Gerrymandering

  • Hey doctors! Have you ever been told you don’t bill enough to cover the cost of the salary you receive, or that your entire department or division is a money-loser? If so, give me 7 minutes and 47 seconds of your time and let’s recalibrate your B.S. detector.

Should all residents publish research?

  • I stumbled upon a paper that argues – with a straight face – that every residency and fellowship program should be required, as a condition of accreditation, to have each of their trainees publish at least one scientific paper in the peer-reviewed literature. Sigh.

The USNWR Medical School Rankings Mass Exodus: Winners & Losers Edition

  • Recently, some of the biggest names in medical education have announced they’ll no longer participate in the U.S. News & World Report rankings. And you know what that means…

Match Day Mailbag: What if I don’t Match?

  • As we get closer to Match Day, this is one of the most common questions I get from applicants. Although everyone’s circumstances are different, here’s my general approach.

Match Day 2023: Winners & Losers Edition

  • Another Match Day is in the books. Time to break it down, Winners & Losers style.

Journal Club: Comparative Data in the MSPE

  • In the inaugural edition of The Sheriff of Sodium Journal Club, I’ll cover a paper describing the frequency of comparative performance data in the dean’s letter.

The NRMP’s Voluntary Rank Order List Locking Proposal: Winners & Losers Edition

  • Should the NRMP calendar be reconfigured to allow residency programs to submit their final rank order list before applicants submit theirs? If it was, it could allow applicants to have in-person ‘second look’ visits without fear that their decision to attend (or not) would impact their ranking by the program. So who wins – and who loses – if this proposal is approved?

The Last Lecture (2023)

  • The Class of 2023 picked me to give their “Last Lecture” of medical school. Here’s what I tried to teach them.

Bypassing U.S. Residency Training for IMGs in Tennessee: Winners & Losers Edition

  • Historically, international medical graduates seeking licensure in the United States have been required to complete at least 1-3 years of U.S. residency training. But now, a new law in Tennessee will allow certain IMGs to bypass U.S. residency training altogether. This is big news – and we’re gonna break it down, Winners & Losers style.