Social media platforms lit up when sponsors of the U.S. Medical Licensing Examination (USMLE) announced Step 1 score reporting will change from 3-digit numerical scores to pass/fail by January 1, 2022. First-year Harvard Medical School student LaShyra Nolen tweeted, “this could reinforce the hierarchy among med schools,” arguing the score change could encourage residency admission directors to favor applicants from prestigious medical schools over equally qualified applicants from less competitive ones. Second-year Stanford University School of Medicine student Anna Goshua tweeted, “Will making Step 1 pass/fail merely kick the stress can down the road?” suggesting residency admission directors are scrambling to find other standardized metrics to use in assessing candidates. Twitter buzzed to life, as other medical students tweeted out frustrated—in a few cases, hopeful—reactions to the change.
With many medical student bloggers predicting the change will complicate the residency admission process, Nolen and Goshua may be giving voice to your own anxieties that this change alters the playing field. If you are a future or first-year medical student like me, you may fear this change encourages what it seeks to eliminate: arbitrary hoops for us to jump through in hopes of matching to a residency. Frustrated residency directors point out the change will encourage nepotism in the admissions process, as well-connected applicants lean on their connections to squeeze past well-qualified, less-connected ones into competitive programs. Where is the equity in that? They note there is now an incentive to favor applicants from medical schools known for admitting high standardized test-scorers. In deducing who can handle residency’s rigors, they fear disenfranchising equally, if not more, qualified students at low and middle-ranking schools. While advocates predict the change will up student wellbeing, their good intentions will not buffer the likely effect: Applicants scrambling to differentiate themselves from their school’s reputation using ill-distributed resources.
The scoring change comes with side-effects. To put it bluntly, though, few of us are acknowledging it is here to stay, and as such, it might be worth understanding its upside. By acknowledging the change’s benefits, we can accept the inevitable—USMLE Step 1 pass/fail scoring is here to stay—while finding ways to make it work for us.
Recent studies suggest pass/fail scoring will diversify the physician workforce. We know racial and gender differences exist in Step 1 performance despite accounting for MCAT performance and undergraduate grade point average. Race and gender impact a student’s performance on this examination in ways unrelated to their actual cognitive abilities, likely due to socioeconomic, housing, and mental health inequalities. It is easy to study in a private apartment; it is much harder to study with a multi-generational family in a shared living space, yet disparities like this one affect many medical students. Why use numerical scores to screen applicants demonstrating potential in ways unrelated to their test scores? This change allows qualified minority and female students to demonstrate ability in ways that work for them, increasing the odds that they will be fairly screened to enter the physician workforce and enhance its diversity.
With a score reporting change, we no longer have to wonder if students are unfairly admitted to residency programs based on their demographic differences in standardized assessment performance. Residency admissions directors will be incentivized to conduct a holistic review process, ensuring applicants of various histories and contexts are evaluated in ways that reward their merit. Today’s patients come in all shapes and sizes; why not celebrate the change as a way to ensure a diverse resident cohort converses and learns together about patients mirroring their complexity?
Pass/fail score reporting also gives us medical students leeway to learn skills not tested on Step 1 yet necessary to meet the current needs and challenges of patient populations. We all hear horror stories of second-year medical students studying every day for fourteen hours in a stuffy library, Monday through Friday, for six months until the day of their examination, competing for a coveted residency slot. Studies back this up, indicating medical students increasingly skip lectures as their Step 1 examination date draws near. Many of these medical students point out Step 1 covers unnecessarily complex content not needed for residency training, but they say the benefits of a high score outweigh those of learning non-related Step 1 class content. While we need a foundational knowledge in the basic sciences, passing the examination requires that knowledge and allows us to attend lectures covering innovative care-delivery models and the humanistic side of medicine—sources of insight into how our modern health care processes can best serve patients.
Pass/fail score reporting allows us to learn the basic sciences and have time to learn softer skills. The American Medical Association (AMA) backs the change for this reason, announcing “overemphasis on a three-digit score distracts medical students from developing other critical competencies such as teamwork and communication skills.” How would you like to learn effective communication strategies, leadership skills, and public health strategies knowing you only need to study high-yield information on your Step 1 examination? By removing the pressure to score high on Step 1, medical students will likely have the time to explore a broad range of issues facing global and national health, empowering us to care for patients with knowledge and warmth.
Yes, the Step 1 pass/fail score reporting change has its faults, but it also suggests needed reforms, like a holistic review process, are on the way. The change may pull us future medical students into a more nuanced understanding of medicine during the first two years of medical school, as we get to study while having time to care for and learn about those whose parts are so figurable on textbook pages, so messy when working together in real life. The change is here to stay. Is that a bad thing? Not entirely.
Bethany M. Erb is a premedical student.
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