Amid COVID-19, make USMLE Step 1 pass/fail now

COVID-19 continues to require unprecedented disruptions to medical education. On March 17, the Association of American Medical Colleges (AAMC) and Liaison Committee on Medical Education recommended that medical schools release all students from clinical duties for two weeks. This effort will both decrease the risk of exposure for students and relieve stretched-thin residents of teaching responsibilities. On the heels of this announcement, the National Board of Medical Examiners (NBME) informed medical students that Prometric would close all testing centers at least 30 days beginning March 18. Medical students on dedicated study periods for their US medical licensing exams (USMLEs) have understandably expressed confusion and concern about what this means for their academic advancement. For some, a passing score on USMLE Step 1 is required to begin clinical coursework. The Step 1 score itself continues to play a large role in career selection and the residency application process for current students. The uncertainty of the moment is likely to have a negative impact on students’ test performance. Taking that into consideration, and given the recent decision to move towards a pass/fail system for Step 1 in 2022, the NBME should consider accelerating its timeline and grading licensing exams impacted by COVID-19 as pass/fail.

The well-documented deficiencies of the three-digit Step 1 scoring system are likely to be exacerbated by the extraordinary emotional, mental, and financial stressors students and their families are facing during this pandemic. Despite being imprecise with a standard error of 8 points, residency programs often use score cutoffs to screen applicants. There may not be a meaningful difference between two students who score, say, a 230 and a 245. The three-digit score also contributes to racial disparities in career advancement, including specialty selection and residency placement. A 2019 study of orthopedic surgery residency applications showed that although they were overall as competitive as their White and Asian counterparts, only 61 percent of Black and Hispanic applicants were accepted into residency, versus 73 percent of white applicants, a difference attributed in part to the overemphasis on Step 1 scores. Orthopedic surgery, one of the more competitive, is also the least racially diverse specialty among residency programs. 

There are few worse moments to be preparing for a career-determining test, and yet medical students at all stages are stepping up in a heartening show of solidarity. Many are educating their communities outside of school about COVID-19. This may be particularly demanding for those who do not come from medical pedigree, or come from the low-income communities and communities of color that often disproportionately lack access to quality medical care and information, and where people have been historically skeptical of the medical establishment, due to a long history of discrimination and abuse.

Others across the country have created a volunteering system to help health care workers at their respective institutions with much-needed services such as childcare and picking up groceries. Some are organizing blood drives, as blood banks are starting to face a shortage of a wide range of blood products. These actions capture the spirit of our profession and should be bolstered by relieving those facing the pressure of needing a high step 1 score. The specifics of how to reschedule all test dates impacted will remain, as will the implications for clinical curricula and the residency interview season. Nonetheless, students will have the opportunity to more meaningfully demonstrate their readiness for residency by contributing to COVID-19 efforts rather than worrying about having to review the minutiae of Step 1.

Some will argue fast-tracking Step 1 to pass/fail now devalues the test. To be sure, Step 1 remains an important milestone in undergraduate medical education. Indeed, the NBME has already decreed that Step 1 will move to pass/fail in the near future. Given the extraordinary circumstances of this pandemic and the adaptability the medical education community has already demonstrated, the time to make this change is now. Allowing students to fully meet this moment in their own way is the right thing to do, and this generation of future physicians will be the better for it.

Max Jordan Nguemeni Tiako and Rodrigo Muñoz are medical students.

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