April 24th, 2020

Pass or Fail — USMLE Step 1

Allison Latimore, MD

Dr. Latimore is the Education Chief Resident at the MedStar Washington Hospital Family Residency Program in Washington, DC

We All Take Tests

In January 2020, it was announced by the US Medical Licensing Examination that USMLE Step 1 scoring would change from a 3-digit score to pass or fail. I’m sure some budding and current medical students are jumping for joy. Some residents and attendings probably are brooding jealously, thinking of all the stress, depression, and anxiety that they developed or exacerbated as a result of Step 1 testing. I’ve heard people say, “if you are a doctor without anxiety, something is wrong.”

A large part of the anxiety that medical students and doctors face stems from the constant testing. We take the MCAT, NBMEs, USMLE Steps 1-3, subject boards, in-training exams, and, finally, boards for our specialty. All of those exams are necessary to become a board-certified physician. Personally, I felt that every time I turned around, I was inputting my credit card information to pay for a new test. As inconvenient as it is, being tested constantly as a physician is necessary. People want to know that the person treating them is intelligent and up to date on the latest research. However, have we proven that all these standardized tests correlate to how “good” a doctor someone is or their potential to become a good doctor?

Good Doctor or Good Medical Student?

According to a study published in the Advances in Medication Education and Practice Journal in April 2019, “USMLE Step 1 and Step 2 CK scores moderately correlate with the number of honors grades per student in core clinical clerkships. This relationship is maintained even after correcting for gender, institution, and test-taking ability. These results indicate that USMLE scores have a positive linear association with clinical performance as a medical student” (Adv Med Educ Pract 2019 Apr 26; 10:209).

Why the change from a 3-digit score to pass/fail, if this test correlates with how well people perform in medical school? The USMLE released the following statement from Humayun Chaudhry, DO, MACP, President and CEO of the FSMB, in regard to the policy change: “These new policies strengthen the integrity of the USMLE and address concerns about Step 1 scores impacting student well-being and medical education. Although the primary purpose of the exam is to assess the knowledge and skills essential to safe patient care, it is important that we improve the transition from undergraduate to graduate medical education.”

Peter Katsufrakis, MD, MBA, President and CEO of NBME, stated, “The USMLE program governance carefully considered input from multiple sources in coming to these decisions. Recognizing the complexity of the environment and the desire for improvement, continuation of the status quo was not the best way forward. Both program governance and staff believe these changes represent improvements to the USMLE program and create the environment for improved student experiences in their education and their transition to residency.”

Transition to Residency

I must confess, my initial response to this change was jealously that this didn’t happen while I was crying incessantly over Step 1. Then, I began to read some of my colleagues’ thoughts on social media. I read people recount their suicidal thoughts after Step 1. I also read about people who had no issues with Step 1 at all and who couldn’t relate to these feelings. What surprised me were the people who disagreed with the change completely. At first, I could not understand why anyone would disagree. But when I think of minority students, students aiming for very competitive residencies, and international medical graduates, I realize that 3-digit score is the key to their destiny.  Some feel that the one way to separate themselves from the others in the stacks of residency applications lies in a 3-digit score — which is not wrong. People who don’t have a big-name school behind them might count on their step 1 score to get them into the door. What sets your application apart from anyone else with a pass?

Long-Term Effects

It’s possible that this change will push medical schools to change their curriculums and schedules. Will students need to take Step 2 CK early enough to have an impressive 3-digit score to match into their desired specialty? Will this make medicine even more of a “who you know” field? Away rotations already are expensive for students. Will everyone need to complete more away rotations to increase their likelihood of matching? I’d love to hear your thoughts. Do you think changing Step 1 scoring to pass/fail will be conducive to the medical school experience or detrimental?


NEJM Resident 360

3 Responses to “Pass or Fail — USMLE Step 1”

  1. West Coast Medical Student says:

    As long as desirable residency spots are limited, there will be more competition than we would like. Reducing the number of data points that residency programs have to evaluate students leads to increasing the weight on the remaining data points, and also increases the overall amount of noise (randomness) when programs rank applicants. In the case of Step 1, the material is not very clinically relevant so maybe this is a good thing. But overall, we cannot make everything pass/fail. Medical students should be given numerous opportunities to demonstrate their strengths and improve over time, so that everything doesn’t come down to a single test or a single rotation. Unfortunately, for that reason, making Step 2 CK into a more high-stakes test is not entirely positive. Similarly, at schools that have made third year rotations pass/fail, it has become even more important to excel in the fourth year acting internships that occur before the ERAS deadline. Due to the partly subjective nature of grading, this is not entirely positive.

  2. Rebecca Ruud says:

    I’m all for it. This had little to do with my clinical acumen

  3. William DeMedio says:

    There is no good reason to hide a student’s score from the student or the instructors and potential GME programs. A student would have no way of knowing how close they are to failing and whether they need to improve their fund of knowledge with a pass/fail system. This will lead to a least common denominator quality level and also will promote political and other non merit based selection of residents. Generally good students become good doctors, and the best predictor of future performance is still past performance, which does include test grades.

    A numerical grade gives the student, teachers, and GME programs raw data to evaluate.
    A pass/fail grade gives all concerned parties “muddy water” and no direction.

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