USMLE Step 1 Has Become Pass/Fail!


Last week, on February 12th, the FSMB and NBME announced that USMLE Step 1 would move from score reporting to pass/fail beginning no sooner than January 2022. But there’s a tremendous amount of misinformation about the subject already. Let’s set the record straight.

A few months ago I made a post about whether or not USMLE Step 1 should be Pass/Fail. Turns out it’s become a reality and it’s massive news.


The Changes

There are three components to the changes.

First, the number of attempts on any USMLE exam is now limited to 4, rather than 6 previously. This isn’t a big deal for US students since over 90% pass on their first try.

Second, you must take Step 1 and pass prior to taking Step 2CS, which makes sense and isn’t that big of a deal.

Third, and this is the one everyone cares about, USMLE Step 1 will become Pass/Fail, and this is huge news.


Why Is This Important?

USMLE Step 1 was the most high-stakes and stress-inducing exam of a doctor’s life. More important than the MCAT, more important than Step 2, Step 3, and all the other board exams. The first two years of medical school were heavily focused on preparing students for optimal performance on Step 1 since it’s one of the objective factors heavily weighted by residency admissions committees. If you don’t have a high Step 1 score, you may not be able to match into something hypercompetitive like dermatology or plastic surgery. Residency programs have cutoffs for Step 1, and a low Step 1 score often means you aren’t even granted an interview.

This is also big news for a lot of prep companies whose entire business model was built around preparing students for Step 1. I’m talking about the likes of USMLERx, First Aid, UWorld, Goljan, Picmonic, Sketchy, Board and Beyond, and so many more. Does this mean they’ll go out of business? No, and I’ll talk more about that shortly.

If you go on Reddit, you’ll see a lot of IMG’s, DO’s, or students at lower-ranked medical schools worried that it will be harder to differentiate themselves without being able to crush Step 1. I don’t necessarily agree with this either.


Why Did This Happen?

Per the official report, a significant part of the decision came down to improving student wellbeing and helping to create a better transition from medical school to residency. As you guys know, medical student and resident burnout, depression, and suicide are huge issues, and it’s something I care deeply about. They’re hoping that by making the test Pass/Fail, the reduced stress and anxiety will curtail some of the negative effects on student mental health.

Proponents of making Step 1 Pass/Fail also emphasize how the test isn’t a reliable indicator of how good of a doctor you’ll become. After all, there’s a lot of biochemistry and very nuanced details that aren’t all that clinically relevant.


What Does This All Mean?

Alright, now my favorite part. Let’s set the record straight.

I’ve seen a couple of videos and read some comments on Reddit about the topic. What most people are failing to understand is that in a complex system such as residency applications, there are multiple variables at play. Changing one variable does not happen in a vacuum. You have to consider how it influences the other variables as well.

Similarly, a lot of people advocating for a Pass/Fail on Step 1 point to the stress and burnout and anxiety they felt. But here’s the thing. The stress of Step 1 is a symptom of a system that doesn’t work, not the actual problem itself. I understand Step 1 is stressful. I’ve been there. But making Step 1 Pass/Fail doesn’t make plastic surgery residency any less competitive, and now other metrics will become prioritized in its place. Competition doesn’t change with Step 1 being Pass/Fail. Now other factors will get weighted more heavily, and there are pros and cons that come with that.

First, most obviously, Step 2CK, which for now is retaining its numerical scoring, will essentially replace Step 1 in terms of importance. The good news is that Step 2CK is much more clinically relevant than Step 1. The bad news is that if you bombed Step 1, you could often use Step 2CK as a second chance to prove yourself to residency adcoms. But if you bomb Step 2CK now, you won’t have any chance to make up for it. For that reason, you could argue that this would actually further increase stress and anxiety.

I think a large part of the argument that Step 1 being pass/fail would be beneficial for student mental health is driven by emotions rather than logically thinking through the repercussions. Next thing you know, we’ll be saying fetuses are too stressed by newborn screening Apgar scores and we should make that Pass/Fail as well. Shout out to mr_fartbutt on Reddit for that insight.

So to the DO’s and IMG’s and students at lower-ranked medical schools who are concerned about not being able to set themselves apart, understand that Step 2CK is still numerical and will in large part replace Step 1.

It’s also likely that other factors in your application will become far more important. For example, the literature looking at program directors in plastic surgery suggests that letters of recommendation are the highest weighted and most important factor. This makes sense particularly in smaller fields such as plastics where all faculty more or less knows each other. But this varies from specialty to specialty, and most are far larger than plastics.

But more subjective or less standardized measurements such as clinical evaluations aren’t easily standardized, and without objective data, it’s difficult to sort and sift through high numbers of applicants.

This will play up the importance of the Dean’s letter, which generally uses language to rank a student amongst classmates. For example, calling the student excellent versus good indicates what quartile within the class they performed at. Some letters can get more granular than that.

Research will become more important too, and the sad thing is that research is very much a game that is played and optimized, rather than something people use to actually add value to the scientific community. And I’m guilty of that too. I had to play the game. I have over 60 publications and abstracts which was a huge talking point during my plastic surgery interviews, and you can see the full list on my personal website, but how much was clinical care actually changed by those studies? Putting greater emphasis on the game of research has its own problems too.

Standardized evaluation forms will also likely become more popular. Emergency Medicine uses the Standardized Letter of Evaluation, or SLOE, and plastic surgery had a similar form for letter writers. This adds some layer of objectivity and scoring to one’s evaluation.

We don’t know if there will be additional changes to the application process, like limiting the number of programs you can apply to, or if Step 2CK will also become pass/fail. If these changes do arise, that obviously would change the conversation.

Regardless, this isn’t happening until Jan 2022 earliest. In the meantime, keep focusing on being the best student you can be and optimizing your research, impressing your seniors, and just doing the best you can. If you need help with Step 2CK, we at Med School Insiders specialize in tutoring for that exam. I scored a 267 and have further honed my own systems and strategies for the exam such that some of our students have even surpassed me on the exam. Which is awesome.


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