After Rounds
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Step 1 Score Change: One Small Step for USMLE, One Giant Leap for Medical Student Well-Being

The USMLE Step 1 score change should reduce the level of stress medical students encounter in the period leading up to the residency application season.

When I was studying for Step 1, every day my medical school friends and I would traipse from Brookline to the Harvard Law Library in Cambridge: We feared that running into colleagues at the medical school utilizing different prep materials would compound our worry that we were preparing insufficiently. Among the less threatening law students, we would each locate an empty carrel and study on our own for three hours. We’d reunite for lunch together, go back to isolation for four hours and then head home with plans to return the next day. This went on for weeks.

With that dreadful memory in mind, I was thrilled to hear about the United States Medical Licensing Examination® (USMLE) Step 1 score change: The test will now be pass/fail.

Up until now, USMLE reported Step 1 scores with a three-digit number. Note that this change does not impact how other elements of the USMLE will be scored:

  • Step 2 Clinical Knowledge (CK) will continue to be scored numerically.
  • Step 2 Clinical Skills (CS) will continue to be reported as pass/fail.
  • Step 3 will continue to be scored numerically.

The new USMLE Step 1 pass/fail policy will go into effect as early as January 1, 2022, according to USMLE.


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Why Did USMLE Make Step 1 Pass-Fail?

USMLE cites multiple reasons the decision was made to halt three-digit number reporting for Step 1. First, it is generally understood that there is an overemphasis on USMLE performance. Currently, the three-digit score is heavily weighted by residency programs. According to the 2018 National Resident Matching Program® (NRMP) Program Director Survey, 94% of residency directors from all specialties reported that USMLE Step 1 (or COMLEX Level 1) was a factor they used in deciding whom to interview; on a scale from 1 to 5, the mean importance rating for USMLE Step 1/COMLEX Level 1 was 4.1. The test score is especially scrutinized for competitive fields. If you plan to apply in orthopedics or dermatology, for instance, know that the mean Step 1 scores for those fields are an impressive 248 and 249, respectively. Consequently, one day becomes do-or-die for some students.

Additionally, the USMLE points out that three-digit score reporting requires medical students to study so much that it precludes their having time for other important professional development activities like research and volunteerism.

Medical student mental health is another priority that the USMLE emphasizes, saying that the focus on numeric scores negatively impacts student well-being. From the large 2020 Medscape National Physician Burnout and Suicide Report, we know that 42% of surveyed physicians report burnout and nearly 1 in 5 report depression. Similarly, in 2016, JAMA published a paper showing that 27.2% of medical students surveyed were depressed, and — of great concern — 11.1% had had thoughts of suicide in the last 12 months. The Step 1 scoring change appears to be intended to reduce the level of stress medical students encounter in the period leading up to residency application season.

Why Do Some Oppose the Step 1 Score Change?

My take on the USMLE Step 1 score change — as a former assistant residency director, current practicing physician and professional pre-med adviser — is extremely positive. However, not everyone shares my perspective.

Critics of the plan have argued that the three-digit score offered a reliable assessment of a medical student’s ability, allowing residency directors to compare apples with apples, so to speak. They point out that it can be difficult to judge the capabilities of medical students across different schools since grades and evaluations may have varying rigor at different institutions.

Critics also argue that the exacting studying necessary for the current Step 1 system stimulates learning in a way that the USMLE Step 1 score change will not. In other words, those able to brutally grind through the challenge of achieving top Step 1 scores are best able to demonstrate the grit that will be necessary to survive a competitive residency program.

Another defense of the status quo is that program directors can use an applicant’s score to predict national in-training and specialty board scores. However, the USMLE points out that, although standardized testing scores predict future standardized exam performance, they do not forecast future clinical acumen or general capabilities. Being a good test-taker now predicts being a good test-taker in the future, but this may not predict being a good doctor ever.

Finally, some opponents fear that the emphasis program directors place on Step 1 will simply be shifted to a focus on other metrics like Step 2 scores or the reputation of a student’s medical school. Those factors are already highly scrutinized, however: According to the 2018 NRMP Program Director Survey, 80% of residency directors from all specialties reported that USMLE Step 2 (or COMLEX Level 2) was a factor they used in deciding whom to interview; on a scale from 1 to 5, the mean importance rating for USMLE Step 2/COMLEX Level 2 was 4.0. “Graduate of highly‐regarded U.S. medical school” is a factor for 50% of program directors surveyed and ranks a 3.8. It’s possible that interview performance will be emphasized more, although one could argue that that would be a positive change in the admissions calculus.

Timeline for Implementation

Although there was a big lead up to the decision, including a conference in March 2019 when stakeholders were invited to contribute to the discussion on the potential change, we do not have details about the definitive implementation date of the switch. The USMLE reports that the transition from a three-digit number to pass/fail will take place no sooner than January 2022, with further details expected later this year.

In my mind, if medical student well-being were the sole reason for the Step 1 scoring change to pass/fail, that would be more than adequate. The USMLE has made a wise choice, supporting medical students and reducing the emotional toll of the high-intensity medical education system. If residency directors need to work a little harder to sort through the best applicants, and more nontraditional candidates have the opportunity to be considered for competitive specialties, in the best case we might sacrifice test-taking ability to increase the emotional well-being of the physicians in the pipeline.

Feeling better cared for as medical students may well lead to more of us feeling better cared for as patients, too.

Michelle A. Finkel MD

Michelle A. Finkel MD

Dr. Finkel, the founder of the medical school and residency admissions consulting firm Insider Medical Admissions, is a graduate of Stanford University and Harvard Medical School. On completing her emergency medicine residency at Harvard, Dr. Finkel was asked to stay on as faculty at Harvard Medical School and spent five years teaching at the world-renowned Massachusetts General Hospital. She was appointed to the Assistant Residency Director position for the Harvard Affiliated Emergency Medicine Residency where she reviewed countless applications, personal statements and resumes. In this role, she also interviewed applicants and made key admissions decisions. For over nine years Dr. Finkel trained Harvard medical students, residents, and fellows, yielding her three Harvard Medical School faculty teaching and mentorship awards, including Best Faculty Mentor. In 2007, she founded Insider Medical Admissions and has helped well over 1000 candidates for medical school and residency. In addition to her medical accolades, Dr. Finkel has professional writing experience. She was selected for the prestigious Mass Media Fellowship in Science Writing sponsored by the American Association for the Advancement of Science. She has published in academic journals, on-line textbooks and as a science news writer for the Oregonian newspaper. She has edited thousands of documents for her clients. Dr. Finkel is also a board-certified, practicing emergency physician.

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