Historically, students’ three-digit scores on the United States Medical Licensing Exam (USMLE) Step 1 were a main factor in determining competitiveness for residency programs. In February 2020, the world of medical education shifted drastically when it was announced that the USMLE Step 1 would transition to a pass/fail scoring system. One of the main factors driving this change was that medical students and residency programs were attributing too much weight to an exam meant to assess competencies for medical licensure but never meant to be a stratifier for residency programs. A secondary result of this change was the idea that it would lessen the amount of stress placed on students and support their well-being, but we argue that for the first few classes of medical students to be affected by this change, it has done the opposite.
Our class, the Class of 2024, was the first to matriculate into medical school following this announcement, prompting intense discussion and numerous questions about how students should respond to this change. While program directors from various specialties have been surveyed to ascertain their thoughts on how this will change the match process, students have only infrequently weighed in on this transition. As current medical students eyeing a range of specialties, we wanted to share what we have observed among our classmates as a result of this change.
This change is in line with a recent move away from the decades-old medical school curriculum in which students spend two years in the classroom, followed by two years in the hospital. According to an AAMC survey of medical school curricula, for 2017-2018, 46 percent of schools reported that they were shortening their students’ pre-clerkship years, with some even condensing what was previously two years of material into a single pre-clinical year. These innovative models allow students to enter the hospital earlier and provide students with greater time to explore different fields before choosing a specialty to pursue. While many schools haven’t made this transition, we anticipate more will adopt a similar model in the coming years as students and administrators realize the importance of applying the foundational medical knowledge learned in the preclinical years and seeking to maximize the amount of time students have to solidify that knowledge in the context of real-life patient cases.
Due to Step 1 becoming pass/fail, students have shifted their focus to extracurriculars to strengthen their residency applications. While students have always joined interest groups or completed research projects, the feeling among the majority of our class is that these activities will be among the highest-weighted factors in applications to programs opting for a more holistic review process. Research and volunteer opportunities in our class, especially in the midst of lockdown, were highly competitive due to seemingly increased interest. While it remains to be seen if a longer list of entries on our CVs affects our ability to match into competitive programs, we continue to immerse ourselves in them, not willing to risk our future career should it be true.
Many students also fear that greater emphasis will be placed on their medical school’s prestige. While students from middle- to lower-tier medical schools could historically set themselves apart by achieving a high Step 1 score, that opportunity has vanished. Students at lower-ranked schools may now face greater disadvantages in the match process.
Program directors agree that a high Step score does not guarantee an excellent resident, yet most programs utilize Step scores to filter students because it’s unrealistic to perform a holistic review of every application without a baseline screening metric. Program directors at the 2022 American Urological Association meeting recently stated that Step 2 scores will essentially replace Step 1 scores for the purposes of residency applications. While they hope that programs will also evaluate other aspects of a candidate’s application, such as research, volunteer work, and leadership roles, those of us in the early stages of this transition are unsure how to proceed.
Due to this monumental and unprecedented change, medical school advisors and faculty understandably lack the data required to direct students appropriately. As the first class to graduate without a scored Step 1 exam, our class is unsure how to approach Step 2 CK, especially when most schools provide no dedicated study period prior to the exam. Most students feel they must have a score in hand by the ERAS deadline, months earlier than it was previously needed. Furthermore, anyone who earns a subpar Step 2 score has minimal time to edit their application and pivot into another specialty.
Despite its drawbacks, the decision to move to a pass/fail grading system for Step 1 isn’t all doom and gloom. A scoreless exam lessens a major stressor among students, decreases the pressure to memorize and regurgitate information for an exam, and allows them to focus on the most relevant facets of clinical medicine. It provides schools with greater flexibility to increase early clinical experience, specialty exploration, and even opportunities to obtain knowledge and skills in a particular area of medical practice through intensive “tracks” in leadership, global and public health, clinical research, or community-based medicine. It is conceivable that the change in Step 1 scoring might spur some medical schools to move to an abbreviated preclinical curriculum. Doing so could offer students more time to get to know clinical faculty, form relationships, and gather strong letters of recommendation.
It will be years until we understand the full effects of the transition to a pass/fail Step 1 exam. In the long run, we anticipate it will promote student wellness during the preclinical years and greater opportunities for long-term career development. However, while the immediate consequences and implications of this change are still undetermined, we continue to progress through what can only be described as an increasingly stressful and highly uncertain era of medical education and hope that our efforts will be enough to ensure a successful match.
Megan R. Moore, Sarah E. Toates, and Prasun Sharma are medical students.
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