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After Step 1 scoring change, what residency programs look for now

Aug 3, 2022

In late January, the influential Step 1 of the United States Medical Licensing Examination (USMLE) changed from numerical to pass-fail scoring. Program sponsors wanted to shift the emphasis away numeric scores but preserve the exam for determining physician licensure eligibility.

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In the AMA’s view, the previously used three-digit numeric score was detrimental to student well-being because it created a parallel curriculum to prepare for the exam and distracted medical students from developing teamwork and communication skills.

While the exam content hasn’t changed, medical students have questions about the switch. It’s already leading to some challenges for residency program directors. For the next few residency application cycles, some applicants will have numerical scores whereas others will have pass-fail results on Step 1.

“The current MS2—now becoming MS3 class, as they took it—if they wanted to take it particularly early, they could still get a numerical score. But at the timeline where most students across country take it, it would be pass-fail for that class,” explained Daniel Dent, MD, who is professor of surgery and medical education at the University of Texas Health San Antonio Joe R. & Teresa Lozano Long School of Medicine.

He discussed what’s ahead for the USMLE Step 1 exam and what it means for program directors, medical students and residency applicants during a recent episode of “AMA Moving Medicine.”

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USMLE Step 1 score switch: Answers to medical students’ top questions

Several factors drove this change, Dr. Dent said. The numerical format was creating stress over getting a particular score. Medical students felt they were being evaluated by a singular test result instead of what they accomplished in their coursework over two years.

Medical students who didn’t do the previous iteration may not appreciate “that there is maybe significantly less stress in your life now because you're not getting a pressure to get a 250 on Step 1,” he noted.

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Some concerns have surfaced over how the change might affect applicants from lesser-known schools who were counting on an outstanding numerical score to get noticed.

“Ultimately, I guess you can distinguish yourself via Step 2. Many schools have class rank. Many don't. And schools that are not just pass-fail but have honors, high pass, pass, or A, B, C type grading—you can distinguish yourself with those grades,” said Dr. Dent.

Get study tips and insight on the future of USMLE Step 2.

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Why failing Step 1 exam shouldn’t end your dream of being a doctor

Program directors will be looking at other aspects than the Step 1 score in a medical student’s application, such as clinical rotation grades and shelf exam scores, said Dr. Dent.

Doing well on exams about clinical medicine will be just as important as a Step 1 score “because you're going to be taking tests on clinical medicine for the rest of your life” such as the board exam, he said. A letter of recommendation that speaks to a person’s medical knowledge and work ethic is crucial.

“Ultimately, what you're looking for is somebody you want on your team at 2 in the morning, taking care of a sick person,” said Dr. Dent.

Residency programs also value leadership roles, team sports and volunteer work. That includes participation in organized medicine and health policy advocacy, Dr. Dent noted.

“Any of that is viewed positively. I want to make that clear. But significant commitment to it is viewed much more positively,” he said. “And so, if you're the AMA rep for your school, or you've done other things within the AMA and have worked with—to do some local volunteer work for the AMA and your community and those sorts of things, whether it's AMA or your state medical association—that is definitely viewed positively as well.

“But again, there's the people that show up so they can check a box and put it on their CV,” Dr. Dent said. “And then there's the people that show up and pay attention and commit. And that's really who we're looking for.”

Learn more with the AMA about medical student leadership opportunities.

AMA Moving Medicine” highlights innovation and the emerging issues that impact physicians and public health today. You can catch every episode by subscribing to the AMA’s YouTube channel or the audio-only podcast version, which also features educational presentations and in-depth discussions.

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