As a fourth-year medical student from a new medical school who just finished interviewing for ophthalmology residency, I can credit much of my interview season experience to intentional career planning and preparation early on. The ultimate impact of the upcoming changes to the USMLE Step 1 to pass/fail is yet to be fully determined. However, in my perspective, this monumental shift in medical education will place a greater emphasis on the need for thoughtful career planning earlier in medical school.
For context, my medical school is recently established and lacks a home ophthalmology department. I recognized that it would be challenging to match into a competitive medical specialty, such as ophthalmology, back in my first year of medical school as I would not have robust institutional connections and research opportunities. Since then, I worked carefully to connect with mentors across the United States to cultivate research experiences and thoughtful advice that would ultimately allow me to successfully apply to ophthalmology residency. Nevertheless, like many of my peers, our emphasis was placed early on the need to perform well on the USMLE Step 1 exam. The USMLE Step 1 exam score was classically viewed as a major marker for successfully matching into ophthalmology, with the national average in 2021 as 245. In all specialties that use the NRMP system to match in 2021, 86.2% of program director survey respondents endorsed the USMLE Step 1 score as a way to decide who to interview at their program.
I believe many of my peers would agree that the Step 1 exam is a relatively challenging exam to study for, with the necessity to study mechanisms of diseases down to their biochemical pathways and memorize minutiae associated with scores of different medications or (often rare) disease processes. Nevertheless, the three-digit score allowed one to distinguish themselves — objectively — against other applicants. From a new medical school, this was a dream — the exam score allowed me to walk onto the same stage as other students from more established programs.
With the shift of the USMLE Step 1 to pass/fail, this objective marker will be effectively eliminated. The big question is — what will be the next significant indicator for matching into ophthalmology? To me, the most significant question is: How will medical students from new medical schools, especially those that lack institutional specialty departments and resources, distinguish themselves to be able to apply successfully to residency?
Step 2 CK is generally a more clinically-focused examination compared to Step 1, which focuses more closely on basic sciences. Step 2 CK average scores are typically higher across all medical specialties compared to Step 1. In the past, the USMLE Step 2 CK was an optional component of the application and its absence did not adversely impact ophthalmology applicants.
The new theory is that the emphasis on the Step 2 CK exam will hold greater emphasis on an application in the absence of a scored Step 1 exam. In a survey completed by 56 ophthalmology residency program directors, most did not support binary Step 1 scoring and many raised concerns regarding the overemphasis on Step 2 CK. These concerns were similarly echoed in a survey of dermatology residency program directors. This makes sense — the desire for an objective marker will always exist when residency programs are receiving hundreds of applications created by talented students. There will always be a natural desire to ‘screen’ for the students that displayed the most academic potential with an ‘objective’ measure.
All of the other components of our applications — such as letters of recommendation, rotations, clinical clerkship grades — are highly variable and subjective measures that depend significantly on one’s institutional policies and available resources. These educational performance aspects and personal characteristics have been voted by program directors as highly influential aspects in the interview and ranking process in a 2021 survey of NRMP specialties. I imagine the emphasis on these other components will increase with the Step 1 changes. Other medical students have expressed that the binary Step 1 scoring system will likely impact certain groups (such as international medical graduates and osteopathic applicants) since institutional prestige will take on a greater emphasis.
In my perspective, the binary scoring system will underscore a greater need for applicants from new medical schools — like myself — to determine their intended specialty early on in medical school to maximize their chances of applying successfully to a competitive field. I would advise not to be fooled by the perception of alleviated anxiety that a pass/fail scoring system provides — I predict the applicant pool will become more competitive as students double-down on the other application characteristics. Since the emphasis will likely be magnified on aspects such as research experiences and letters of recommendations, students that lack institutional resources in their specialty of interest will need to thoughtfully and carefully discover opportunities outside of their institutional boundaries in order to craft an application robust enough to compete against applicants from highly established programs.
If you are entering medical school or are currently a first year medical student, I would take it upon yourself to independently explore various medical specialties — especially competitive ones — to see if you happen to have an interest in any of them. A little shadowing goes a long way. Even if you aren’t certain about one specialty as you are early on in medical training, I would still begin to discover research opportunities and mentors in that field of interest. I’ve written elsewhere in greater detail about specific strategies for getting involved in a medical field that is lacking at your medical institution. With careful planning earlier on in medical school, the ultimate impact of the Step 1 binary scoring system will not need to surprise you in a negative way. The key is to start now.