What PDs Actually Weigh More: MS3 Clerkship Grades vs Step 2 CK

The belief that Step 2 CK has completely replaced clerkship grades as king is wrong. Program directors pay obsessive attention to both—but not in the way most students think.

You’re trying to answer a very specific question: if you have to “optimize” one thing for residency apps—your MS3 clerkship grades or your Step 2 CK—what do program directors actually care about more?

I’ve sat in those rank meetings. I’ve watched PDs scroll through ERAS at 11 p.m. on a Sunday, muttering things like, “Why is this kid Honors in everything with a 234?” and “Great score, but these evals are brutal.” The way they weigh these two pieces is more systematic—and more political—than anyone tells you.

Let me walk you through how this really works behind the scenes.

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The First Truth: They Don’t Weigh Them Equally at Every Stage

Step 2 CK and clerkship grades don’t matter the same way at every point in the process. That’s the first mistake students make—they talk as if some global “X > Y” rule exists.

Inside a real PD’s workflow, it looks more like this:

How PDs Use Step 2 CK vs Clerkship Grades

Step	Description
Step 1	Application Submitted
Step 2	Initial Screen
Step 3	Auto screen out or low priority
Step 4	Deeper Review
Step 5	Borderline / debate
Step 6	Interview invite priority
Step 7	Rank List Meeting
Step 8	Clerkships & narratives break tie
Step 9	Overall gestalt decides
Step 10	Step 2 CK above cutoff?
Step 11	Clerkship grades & narrative strong?
Step 12	Tie or borderline?

Here’s the blunt breakdown:

Early screening:
Step 2 CK usually matters more. It’s fast, sortable, and “objective,” so coordinators and PDs can use it to thin the herd.

Interview invite decisions:
Now it’s closer to a tie. A strong Step 2 may carry you through weaker surgery evals—or vice versa.

Rank list:
Clerkship performance, narratives, and consistency start to weigh more heavily. That’s where PDs ask, “Do I trust this person on my wards at 2 a.m.?” Test scores don’t answer that.

So the real question is: where is your bottleneck—getting interviews or converting interviews into a high rank?

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How Step 2 CK Really Functions in PDs’ Heads

Step 2 CK has become what Step 1 used to be: the fastest blunt instrument.

No one will say it this plainly in public, but I’ve heard it in closed rooms more times than I can count:
“Just sort by score and start there.”

The unspoken score bands

Most programs don’t have a single “cutoff.” They have informal tiers that shape how your file gets treated. It looks something like this:

Step 2 Range	How PDs Often React
≥ 255	Auto-respect; “top-of-pile” attention
245–254	Strong; not a concern, never a liability
235–244	Fine; neutral, context dependent
225–234	Mild concern at competitive places
< 225	Red flag for many academic programs

Is this written anywhere? Of course not. But watch a PD scroll their ERAS filter and you’ll see exactly this logic in motion.

What Step 2 actually signals

To PDs, Step 2 is shorthand for a few things:

1. Ceiling for boards/pass rates.
   Programs are terrified of their board pass rates. A 255 reads like “this person will not be the one who fails the ABIM/ABS/ABEM exam and messes up our statistics.”

2. Stamina and test-taking resilience.
   They know Step 2 comes after a brutal MS3 year. A strong score says you can still perform under fatigue.

3. Redemption or confirmation.

   • Low Step 1, high Step 2 → “Good. They improved. Probably figured things out.”
   • High Step 1, mediocre Step 2 → “Huh. Maybe Step 1 was a fluke.”
   • Mediocre both → “Probably average test taker.”

4. Risk management.
   PDs are surprisingly risk-averse. A borderline score in a competitive specialty doesn’t just make them worry about knowledge—it makes them wonder if you’ll struggle with ABSITE, ITEs, and specialty boards.

So yes, Step 2 is heavily weighted. But it’s doing a specific job: gatekeeping. It gets you read. It reassures them you won’t be a board liability. It doesn’t convince anyone you’ll be a good resident on its own.

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What Clerkship Grades Actually Tell PDs (When They Read Between the Lines)

Clerkship grades are messy, political, and wildly variable between schools. PDs complain about this constantly. But they still care. Deeply.

Here’s the part students underestimate: PDs don’t just look at the letter grade. They look at the pattern, the narrative language, and how your grades line up with your chosen specialty.

The pattern is the real story

They’re not just counting Honors. They’re asking questions:

• “Did they honor Medicine but only Pass Surgery?”
• “Did they tank OB and Peds but ace Psych and Neuro?”
• “Are they consistently top tier or all over the place?”

If you’re applying IM and you’ve got:

• Honors in Medicine, Neurology, Surgery
• High Pass in Psych, OB, Peds

That reads as, “Clinically strong where it matters. Good on the wards. Solid trajectory.”

If you’re applying Ortho and:

• Honors in Surgery, Ortho sub-I, EM
• Pass in Medicine, Peds

They don’t really care that you passed Peds. They care you crushed the surgical context. They’ll shrug at the rest.

The political reality PDs know but never say

Here’s an insider truth: PDs know some schools are grade-inflated jokes and some are bloodbaths.

I’ve literally heard, in one meeting:
“Yeah, but [School X] gives Honors to half the class. At [School Y], getting one Honors is a feat. Adjust mentally.”

At larger academic centers, PDs keep an informal mental map of:

• Schools where almost everyone is “Excellent, pleasure to work with.”
• Schools where the default is “Solid but room to grow.”
• Schools with no grades, only tiers or narratives.

So when you obsess over having one extra Honors, they’re often mentally discounting it because they know your school’s reputation.

What they don’t discount is this: consistency. If everyone else from your school over the last few years has been “mostly High Pass,” and you’re Honors across the board—that pops.

The narrative comments are the real gold

The text in those evals? That’s where PDs lean forward in their chair.

They look for recurring themes:

• “One of the top students I’ve worked with in 10 years” → that gets quoted aloud in rank meetings.
• “Required frequent prompting” or “struggled with efficiency” → this is the kiss of death, even if the grade says High Pass.
• “Will be an outstanding resident in [specialty]” → PDs love explicit specialty endorsements.

I’ve watched PDs ignore a borderline Step 2 CK because the Medicine clerkship director wrote:
“Would be in the top 5% of residents in our program if matched here.”

They trust their peers more than your test score.

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When PDs Prefer Step 2 CK Over Clerkship Grades (And Vice Versa)

Now we get to what you actually care about: which one wins when they conflict.

Case 1: Great Step 2, middling clerkships

Scenario: Step 2 CK 252.
Medicine: High Pass. Surgery: Pass. OB: High Pass. Peds: Pass.
Narratives: “Quiet but reliable,” “Good fund of knowledge,” “Needed some direction early in the rotation.”

Here’s how this plays:

• For competitive academic programs in your specialty:
  They’ll say, “Bright, clearly tests well, but not a rockstar on the wards.” You’ll get interviews at mid-tier and some top programs if your letters are decent, but you won’t be a first-round draft pick on the rank list without stronger narratives.

• For community or mid-tier programs:
  Your Step 2 will likely carry more weight. They’ll feel reassured you’ll handle boards and didactics, and they’re more willing to overlook that you weren’t universally adored third year.

Verdict: Step 2 can paper over some, but not all, clinical mediocrity. It gets you in the door; it doesn’t fully erase weak impressions.

Case 2: Stellar clerkships, mediocre Step 2

Scenario: Step 2 CK 229.
Medicine: Honors. Surgery: Honors. EM: Honors. OB/Peds: High Pass.
Narratives: “Top 10% of students,” “Functions at intern level,” “I would be thrilled to have them as a resident.”

Now the conversation looks different:

• PD in an academic IM program:
  “Score is a little soft but they clearly crush it clinically. If we rank them, are we worried about boards?” Someone else pipes in: “With those comments? We’ll get them through.”

• PD in a procedure-heavy competitive field (say, Ortho, ENT):
  The low-ish Step 2 stings more. They worry about in-service exams. But strong clinicals and specialty letters still keep you in serious contention—especially if they know your home school well and trust their faculty.

Verdict: For rank decisions, strong clerkships plus glowing narrative comments can absolutely outweigh a borderline Step 2. You may lose a few interviews at ultra-score-obsessed programs, but where you are interviewed, you’ll be trusted more.

Case 3: Mismatch with specialty

This is where clerkship grades dominate.

You’re applying IM with:

• Pass in Medicine
• Honors in Psych, Peds, Neuro
• Step 2: 245

PDs see that and say, “Why Medicine? They look like a Psych/Peds person.” They worry you’re chasing prestige, or that you didn’t actually shine where it mattered.

Step 2 won’t save you from looking like a mismatch. Specialty-aligned clerkship performance matters more than you think.

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How Different Specialties Tilt the Scale

Let’s not pretend all fields weigh these equally.

Here’s how I’ve seen it break down across broad categories:

Relative Weight of Step 2 CK vs Clerkship Grades by Specialty Category

Category	Value
Highly Competitive (Derm, Ortho, Plastics, ENT)	70
Moderately Competitive (EM, Anes, Rads)	60
Core Cognitive (IM, Peds, FM)	50
Lifestyle Fields (PM&R, Psych)	50
Surgical but less hyper-competitive (Gen Surg, OB/Gyn)	60

Let me translate that into what actually happens.

Highly competitive (Derm, Ortho, Plastics, ENT, NSG)

These fields are unapologetically score-driven up front. They’re often flooded with 250+ applicants.

• Step 2: Huge for screening. A 260 will buy you attention even with a few High Passes.
• Clerkships: Crucial at the top of the list. Once you’re past the Step 2 filter, the PDs will dissect your surgical evaluations, sub-I performance, and narrative comments, especially from home and away rotations.

At final rank meetings, letters and clerkship narratives are the tie-breakers between the 255s and 260s. The score gets you into that final cohort; your clinical reputation decides whether you’re #3 or #30.

Moderately competitive (EM, Anes, Rads)

These are increasingly score-conscious, but not hopelessly obsessed.

• Step 2: Used aggressively to sort and filter.
• Clerkships: EM cares a ton about SLOEs and “in-the-trenches” performance. Anes/rads use Medicine and Surgery comments to guess what you’ll be like in the OR/ICU/reading room.

Here, it’s closer to a true 50–50 once you’re in interview territory.

Core cognitive (IM, Peds, FM)

These care more about what kind of doctor you are and whether you’ll function on wards or in clinic.

• Step 2: Needs to be “good enough” for their board worries. Above that, it starts to plateau in value.
• Clerkships: IM, Peds, FM directors live and die by clinical evaluations. The third-year Medicine clerkship grade with a detailed narrative can overshadow your Step 2 by a long shot.

If you want a strong academic IM spot, being “the best student the attending has seen in years” on Medicine is worth more than an extra 8 points on Step 2.

Surgical but less hyper-competitive (Gen Surg, OB/Gyn)

They care about both. Strongly.

• Step 2: They want to know you’ll survive ABSITE / CREOG exams.
• Clerkships: They pay intense attention to Surgery and OB/Gyn clerkship comments: work ethic, OR attitude, teachability, reliability.

I’ve seen PDs in these fields drop high scorers on the rank list because their clerkship comments screamed “lazy,” “disengaged,” or “thinks they’re above scut.”

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How PDs Use Both Together To Judge “Trajectory”

You’re not just a static snapshot of scores and grades. PDs love the idea of “trajectory.” Are you on an upward slope or downward one?

This is where the interaction between Step 2 and clerkship grades becomes powerful.

Common Trajectories PDs Look For

Category	Value
Pre-Clinicals	1
Clerkships	2
Step 2 CK	3

They won’t call it “trajectory analysis,” but listen to them:

• “Rough first year, but they crushed clinicals and really turned it on by Step 2.”
• “Strong preclinical, average clerkships, Step 2 just okay—they might have peaked early.”
• “Improving clerkships and rising scores—this one is still on the way up.”

The best combo?

• Early clerkships: High Pass, then Honors later in MS3
• Step 2: Stronger than Step 1
• Narrative comments: “Grew tremendously,” “Rapid improvement,” “Independent learner by end of rotation”

That story—growth, resilience, upward trend—reassures a PD more than just raw numbers.

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If You’re Forced to Prioritize: Where to Bet Your Energy

Let’s be blunt. You don’t have infinite bandwidth. There are points in MS3/MS4 where you’re forced to sacrifice.

The honest hierarchy, from a PD’s real-world perspective:

• If Step 2 CK is still ahead of you and you’re in danger territory (sub-230 on practice exams):
  Fix that first. A truly weak Step 2 can lock you out of entire tiers of programs before anyone reads your glowing evals.

• If Step 2 is already “good enough” for your target specialty (say, 240+ IM, 250+ for competitive surgical) and you’re in the middle of core clerkships:
  You will get more marginal value by protecting your clinical performance. Show up early. Read at night. Get seen as the reliable, hungry student. Those comments echo for years.

• If you already took Step 2 and it’s mediocre but not catastrophic (230-ish), and you’re still in clerkships:
  You’re not fixing the score now. Your only play is to become the student attendings rave about. That can absolutely neutralize a meh score for many programs.

Think of it like this:

• Step 2 is your ticket into the arena.
• Clerkship grades and narratives decide whether you actually win once you’re in.

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One More Ugly Truth: Letters Weaponize Your Clerkships

Letters of recommendation are just clerkship grades with teeth.

The PD doesn’t know what “High Pass” really means at your school. But they absolutely understand:

• “I would rank this student in the top 5% of trainees I’ve ever worked with.”
• “I have mild concerns about time management and reliability.”

Those comments creep into rank-list discussions more than any number.

And guess where those letters come from?
Your clerkships and sub-Is. The people you impressed—or annoyed—while you were exhausted, hungry, and pretending you didn’t care about grades.

So when you ask, “Which matters more, clerkships or Step 2?” understand this: clerkships echo twice.

• Once in the grade.
• Again in the letter.

Step 2 echoes once. Loudly, but only once.

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The Short Answer You Actually Want

If I strip away all the nuance and force a single sentence for most students in most core specialties:

Step 2 CK matters more for getting your foot in the door; clerkship grades and narratives matter more for how high you’re ranked once you’re there.

You need Step 2 to clear the floor.
You need clerkship performance to raise your ceiling.

If you’ve got time before both? Build your clinical reputation first while carving out a disciplined path to a solid Step 2.
If you’re staring down a weak Step 2? Salvage it as much as you realistically can, then lean hard on being the best MS3/MS4 your attendings have seen in years.

Program directors are reading both.
But when they argue in that closed conference room about whether you’re #5 or #25 on the list, they quote your comments and letters—not your score.

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Remember these three things:

1. Step 2 CK is the gatekeeper; clerkship grades and narratives are the trust meter.
2. Specialty and program type shift the weighting, but for rank lists, strong clinical performance and letters repeatedly overpower small Step 2 differences.
3. Clerkships echo into your letters; your test score doesn’t. That echo is what PDs remember when they decide if they want you on their team at 2 a.m.