The new USMLE Step 1: How your medical school and residency will change

With the advent of countless resources and study aids over the years to help medical students prepare for the USMLE Step 1 exam, ranging from the venerable First Aid review book and Anki flashcard decks, to online tools such as UWorld, Pathoma, SketchyMicro, Firecracker, Amboss, and countless more, the entire process of studying for Step 1 has become an arms race. At the same time, Step 1 scores have established themselves as the de facto standard metric for residency competitiveness, not only in terms of specialty selection, but also as the primary method by which residency program directors filter through the increasingly massive number of applications year after year. Things have gotten to the point where the concept of skipping classes and lectures in order to study for Step 1 as early as possible has gone from a meme to a serious, viable strategy.

Is it any surprise, then, that the National Board of Medical Examiners (NBME) has officially moved to turn Step 1 into a pass/fail exam and ditch the current three-digit numerical score? While this transformation is at least a couple of years out — “This policy will take effect no earlier than January 1, 2022 with further details to follow later this year” — we can already envision some of the major consequences and effects of this change, for better or for worse.

1. Increased emphasis on Step 2 CK and core shelf exams. Without a numeric Step 1 score, residency program directors are suddenly without a primary metric by which to compare and filter applicants with. The most likely scenario is that program directors will place an increased emphasis on the USMLE Step 2 CK (or COMLEX Level 2 CE for DOs), as it will end up being the only numerically-scored board exam taken prior to medical school graduation. Is this a good thing or a bad thing? That remains to be seen, but one thing is for sure – it will likely have a major impact on the structure of medical school curricula. Additionally, we can predict that the current cottage industry that has sprung up around Step 1 prep will move to expand and envelope Step 2 CK due to its increased importance for residency applications.In addition, student performance on standardized end-of-rotation shelf exams offered by the NBME/NBOME may start to play a more significant role. Traditionally, these have been overshadowed by Step 1 and Step 2 scores.

2. Major restructuring of medical school curricula. Under the traditional 2+2 model of two preclinical/basic science years and two clinical years of medical school, students usually take Step 1 at the end of second year and Step 2 CK around the end of third year. With their Step 1 score in hand, students are able to tailor their clinical experiences toward the specialties their Step 1 score makes them competitive for. With relatively few exceptions (perhaps emergency medicine) the Step 2 CK score has traditionally been regarded by most specialties as less important, unless there is a massive gap between one’s Step 1 and 2 CK score. But if Step 2 CK becomes the sole numerically scored board exam available before graduation, medical schools will inevitably have to shorten their preclinical curriculum (down to 1.5 years, if not shorter) in order to provide students with earlier, longer clinical training that serves as the appropriate context for Step 2 CK study. After all, Step 2 CK places a much greater emphasis on clinical content as opposed to basic sciences. Furthermore, students will likely have to take Step 2 CK significantly earlier than before (halfway through the third year, or even soon after Step 1) so as to be able to get their score back and have sufficient time to narrow down their specialty interest(s) based on their score.With the decreased length and emphasis on preclinical/basic sciences, the more cynical among us might argue that future doctors will be worse off knowledge- and training-wise. Whether this will actually be the case remains to be seen. Indeed, we have all heard stories about physicians that barely passed Step 1 yet back in the day yet are still highly successful, so the significance of this concern may be somewhat overblown.

3. Use and development of alternative metrics for residency applicant comparison. Without the key metric of Step 1 scores, residency program directors will likely want to seek alternative metrics (besides just Step 2 CK scores) by which applicants to their programs can be efficiently compared. One potential (albeit poor) proxy for applicant caliber is the applicant’s medical school. Needless to say, the Harvard applicant will beat out the applicant from No-Name State if they both “passed” Step 1, but of course, there is always the consideration that the Harvard applicant will naturally gravitate toward more prestigious residency programs. In effect, what may end up happening is that residency programs become increasingly homogeneous in terms of the names and relative rankings of the medical schools their residents hail from. As such, “upward mobility,” i.e., the ability for a student from a low-tier medical school to successfully match at a more prestigious residency program might be severely diminished. Moreover, graduates of foreign/international medical schools might find it increasingly difficult to match at all. A more equitable alternative might be to standardize the process by which faculty and preceptors evaluate a medical student’s clinical performance.

Indeed, the field of emergency medicine has attempted to do this for many years now with the Standardized Letter of Evaluation (SLOE), which directly asks the evaluator (or panel of evaluators) to compare the student/applicant to others and where they might end up on a prospective rank list. Naturally, this might be problematic in that medical schools would have an incentive to give their home students good evaluations. The field of EM has tried to balance this by more or less requiring EM-bound applicants to do away rotation(s) at other institutions, but of course, making away requirements for every specialty would incur substantial administrative and financial burdens, particularly on cash-strapped medical students. And of course, as is often discussed anecdotally on online forums popular with medical students and applicants, there is the question of whether the SLOE is truly objective and what impact personality or cultural traits (including non-clinically relevant ones) might have on one’s evaluation.

We are still at least two years away from the advent of pass/fail USMLE Step 1 scoring (on the osteopathic side, there are signs that COMLEX may follow suit). But one thing is for certain – such a change will have a major impact on both the medical school experience and the residency application process.

Kevin Zhang is a transitional year resident.

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