Step 1 of the United States Medical Licensing Examination (USMLE) is often touted as the most important test a medical student will take during training. The three-digit score can either open doors to a variety of residency prospects or end one’s hope of achieving that coveted competitive residency spot. The pressure and anxiety surrounding Step 1 is one of the main reasons cited by the USMLE to justify its adoption of a pass-fail grading system, expected to be implemented at some point following January 1, 2022. However, many medical students are met with more trepidation about their future as this major anticipated change in Step 1 takes effect.
So, what is the USMLE Step 1 and why is it important? Step 1 is a licensing exam taken by students after their second year of medical school. The test covers basic science topics ranging from biochemistry to physiology, including the pathology of every organ system of the body. An applicants’ score on this exam has consistently served as a major factor for selection into residency programs, especially in more competitive institutions and specialties.
Each year the National Resident Matching Program issues a survey to residency program directors to find out what factors they deem important in selecting applicants to interview or offer acceptance. According to the 2020 program director survey, 90% of program directors cited an applicant’s USMLE Step 1 score as a factor in selecting whom to interview, putting it ahead of letters of recommendation and students’ grades in third year clerkships. For those applying for residency, this demonstrates the importance of scoring high on the exam: a high score can set you apart from other applicants, or at the very least give you a chance to interview within a certain specialty.
Changing to a pass-fail grading system for Step 1 would cause students to search for other ways to stand out to residency programs. Participating in extracurricular activities such as research or club leadership can be difficult for students who are trying their best to stay afloat with the rigors of medical school. These factors are already weighted heavily in forming a competitive application for residency, but they will be more important when Step 1 exam scores are not listed on a student’s application. Therefore, this would effectively lead to a hidden curriculum that requires students to take on more and more responsibilities in order to compensate for this change. This begs the question: will switching to pass-fail scoring remove or add to students’ stress?
As it currently stands, Step 2 Clinical Knowledge (CK), the second licensing exam a medical student takes, remains numerically scored. Many argue that after Step 1 becomes a pass-fail test, this exam will take its place in terms of comparing similar applicants with an objective test score. However, whereas past students have been able to demonstrate their ability to perform well on both standardized tests, students will now have only one shot to prove themselves.
The increased pressure around Step 2 may even surpass the pressure that is felt by students taking a numerically scored Step 1, as they recognize that they won’t have another test on which to fall back. Proponents of Step 1 becoming pass-fail argue that medical licensing is the goal of the exam and “licensure requires only a pass/fail outcome;” however, that raises the question why Step 2 CK remains numerically scored.
Furthermore, this change could disproportionately impact osteopathic and international medical students who apply for the same residency spots as allopathic students. Prior to the merger between osteopathic and allopathic residency programs, Doctor of Osteopathic Medicine (D.O.) students would take the USMLE Step 1 to boost their chances of securing a spot in an allopathic residency.
By switching to a pass-fail system, an objective measure of academic ability is removed from these students who oftentimes feel they need high scores in all aspects of their applications in order to compete with allopathic students. For various reasons, such as lack of residency affiliations and mentorship opportunities, match rates into competitive specialties are significantly lower for osteopathic students when compared to students from allopathic medical schools. Consider, for example, the match rates for neurological surgery in 2020, in which just 20% of D.O. students matched, compared to 75% of their MD counterparts.
The intention behind making Step 1 a pass-fail licensing exam is an altruistic one. Burnout is rampant among the medical community, and finding ways to improve well-being for students is imperative. Data has shown that high board scores do not correlate with better clinical competency or performance in residents or fellows.
Nevertheless, the full ramifications of the change to a pass-fail system for USMLE Step 1 has to be considered. These consequences include finding more extracurricular activities to add to the curriculum vitae, increasing the weight of the Step 2 CK numerical score, and disproportionately negatively impacting the future careers of international and osteopathic medical students. With this major change already set to take place, medical students applying to residency will have no choice but to adapt to the ever-evolving environment of post-graduate education admissions.