How USMLE Step 1 Pass/Fail is Changing Medical School

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As of January 26, 2022, the USMLE Step 1 exam has officially become pass/fail. The goal of this change was to improve wellbeing and decrease burnout among medical students, but has it succeeded in achieving this goal? How has it actually changed the medical school experience?

The United States Medical Licensing Examination, or USMLE, is a 3-part test designed to assess one’s medical knowledge and application of said knowledge to patient care. Step 1 is typically taken at the end of the second year of medical school and is followed by Step 2 CK at the end of the third year or sometime during the fourth year.

Up until now, Step 1 has been arguably the most important test a future physician will ever take. It was initially designed to assist state authorities in granting medical licenses; however, it evolved far beyond the intended pass/fail indication of competence.

These scores became heavily weighted during residency applications to assess a candidate’s strength. So much so in fact, that low scores became prohibitive for students wishing to pursue highly competitive specialties.

If you wanted to become a dermatologist or a plastic surgeon, for instance, but you didn’t score high enough on Step 1, you could pretty much kiss your dream specialty goodbye. Many medical students have had to completely change their career trajectory due to a low Step 1 score and pursue entirely different specialties than they had initially intended.

As of January 2022, however, this will no longer be the case. USMLE Step 1 will be graded as pass/fail and will no longer be the primary determinant of one’s competitiveness as a residency applicant.

 

Stress

The main reason for this change was to improve the well-being of first and second-year medical students by decreasing stress around the Step 1 Exam. Burnout and depression are a big problem amongst medical students and having one exam pretty much determine your entire career trajectory was, unsurprisingly, incredibly stressful for most students.

Historically, the first two years of medical school have been spent stressing and grinding for this exam. The thought process is that by making it pass/fail, much of that stress will go away.

This is a reasonable assumption, as pass/fail medical school curriculums, which have been around for quite some time, have been shown to improve mood and group cohesion. When you aren’t feeling like you have to compete against your classmates for the top grades, there’s much less pressure to perform and you’re more likely to collaborate and help each other out.

Although reducing stress may be the intention, in reality, I don’t believe it’s necessarily the case. Instead, making step 1 pass/fail just kicks the can down the road and puts additional stress on Step 2 CK, which is still graded on a numerical scale.

The stress surrounding Step 1 was never a function of the exam itself, but rather a function of the fear that you wouldn’t be able to get into your desired residency program – and that fear is still there. The most competitive specialties will continue to be competitive as there are more medical students interested in those specialties than there are spots available. Step 1 becoming pass/fail doesn’t change that.

In addition, this change may make Step 2 CK even more stressful than Step 1 was. Before, if you didn’t do well on Step 1 then you at least had Step 2 CK to help bolster your application. Now, if you mess up on Step 2 CK you don’t have another exam to help offset your lackluster performance.

To further complicate things, your schedule for away rotations is determined at the end of your third year, usually before taking Step 2 CK. If you intended on derm or plastics but don’t perform well on the test, you might no longer be aiming for those specialties. With Step 1 being graded, there was more lead time to know where you stood. With competitiveness now relying heavily on Step 2 CK, that lead time is no longer there.

Step 2 is also taken after clinicals – when your schedule is incredibly busy. As such, many students will likely have an even more difficult time balancing Step 2 preparation with their clinical responsibilities.

That being said, many schools will likely allocate more time to Step 2 preparation now that Step 1 is pass/fail; however, programs that don’t adapt their curriculum in time will make it very tough for their students.

Step 2 isn’t the only metric that’s being given more weight either. Subjective measures like letters of recommendation and clerkship grades will also be more important for residency applications moving forward. These measures may introduce another unintended level of stress as medical students have less control over them.

For instance, clerkship grades are highly variable between programs with some programs grading more heavily based on your shelf scores and others emphasizing subjective evaluations from preceptors.

In addition, some clerkships give out high honors like candy, whereas others make it near impossible. This can further increase stress for students when these metrics are more subjective and less standardized.

 

Time-Allocation

The transition of USMLE Step 1 to pass/fail has also changed how students are allocating their time during medical school.

Since Step 1 will no longer be weighted as heavily on residency applications, students are spending less time studying for Step 1 and more time on the components of their applications that will make them more competitive. This includes Step 2 CK prep, research, extracurricular activities, and medical school performance.

Step 2 CK is essentially becoming the new Step 1 in terms of residency application importance, so it stands to reason that many students are allocating less time to Step 1 prep and more time to Step 2 CK prep. This can be seen as a big win for medical students as the material tested on Step 2 CK is much more clinically relevant than Step 1. So instead of spending hours studying the Kreb’s cycle, they can now spend that time reinforcing material that will be more relevant during residency.

Another way for students to stand out on their residency applications now is to maximize their research experience. Having more publications and research projects is typically seen as more impressive. It is also an easy metric for residency programs to use to sort applicants since the number of publications and research projects is numerical.

Extracurricular activities such as volunteering in underserved medical clinics, taking on leadership positions in clubs or interest groups, and getting involved in unique opportunities will be other ways that students allocate their time now that they don’t have to spend as much time studying for Step 1.

Dean’s lists and class rankings will also become more important as they are an objective way of comparing students amongst their peers. As such, students will likely allocate more time and effort to doing well in graded pre-clerkship classes and clerkship rotations.

One hope with the pass/fail transition is that it will force residency programs to take on a more holistic application review process instead of using score cutoffs. But this is just wishful thinking. What you have to remember is that residency programs receive far more applications than they have residency spots. As such, they don’t have time to go through every single application in detail. They need ways to objectively compare applicants to each other and numbers are often the easiest way. For this reason, primarily Step 2CK, but also research and clerkship grades as it relates to class ranking, will all become more heavily weighted in residency applications.

 

DO Students and IMGs

Much of what we’ve talked about up until this point is mainly relevant for students in U.S. MD programs; however, USMLE Step 1 becoming pass/fail also has implications for DO students and international medical graduates as well.

The main concern for DOs and IMGs is that they will have a harder time standing out to residency programs now that USMLE Step 1 is pass/fail. In the past, a strong Step 1 score has allowed DOs and IMGs to compete more readily against MD students for residency positions.

That being said, I don’t believe this should be too much of a concern as Step 2 CK is still graded on a numerical scale and will essentially replace Step 1 as an application metric. As such, DOs and IMGs will still be able to stand out by having a stellar Step 2 score.

And just like their U.S. MD counterparts, they’ll still be able to stand out through their research experience, extracurricular activities, and letters of recommendation. Strong letters of recommendation, in particular, have been and will continue to be important for IMGs and DOs to stand out. These solid connections are often made by impressing research or clinical mentors who go to bat for them during the residency application cycle, or by having family or other connections. It is unfortunate, but nepotism continues to play some role in residency match outcomes.

As you can see, USMLE Step 1 becoming pass/fail changes the details a bit but it doesn’t change the overall picture. Just as before, medical students will need to take steps to make themselves stand out above their peers if they wish to pursue a competitive specialty. Specialties are not becoming more or less competitive from this change, and the stress that accompanies that competition and uncertainty is not going away, despite what passionate medical students and residents may tweet.

When changes like this occur, it’s important to remember that it is better to focus on the things you can control than the things that you can’t. You don’t want to fall into the trap of having a victim mentality and blaming your inability to get into your desired residency on external factors.

It is only by adopting an internal locus of control that you can make yourself the best applicant, and more importantly, the best version of yourself. This mentality is what will allow you to get through the gauntlet that is medical school and residency.

Some residency programs will always be more competitive than others and there will always be metrics that they use to pare down the pile of applicants. What separates those who are successful from those who are not is a willingness to adapt and push forward.

“Life is 10% what happens to you and 90% how you react to it”  –  Charles R. Swindoll

Instead of worrying about the 10% that you can’t control, figure out how you can make the other 90% that you can work in your favor.

If you find yourself getting discouraged because your dream specialty is highly competitive, stop right there. Your ability to crush Step 2 CK and have dozens of research articles is less a function of your intelligence and more a function of proper preparation, constantly improving, and putting in the work. Having a stellar residency application and crushing the interviews is no different.

At Med School Insiders, our mission is to empower a generation of happier, healthier, and more effective future doctors. From medical school or residency application help to crushing your MCAT or USMLE, we’ve got your back. We know what you’re going through and can help you excel on your exams and help put you in the best light possible with your medical school and residency applications. And our results speak for themselves. We’ve become the fastest-growing company in the space with the highest satisfaction ratings and would love to be a part of your journey in becoming a future physician.

If you enjoyed this article, be sure to check out my piece on the Top 5 Most Competitive Doctor Specialties or How I Scored 265+ on Step 2CK.

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This Post Has One Comment

  1. María palacio

    Good morning
    I want to prepare for the usmle test step 1. that it be in person and in a medical university you have something like this?
    Thank you

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