The goals in switching Step 1 of the United States Medical Licensing Examination® (USMLE®) to pass-fail were manifold. Among the chief aims was reducing the burden of exam preparation for medical students and creating a more holistic residency-application selection process.
So, where do things stand after one full testing cycle into the switch, which took effect in January 2022?
Any impact on residency selection has yet to bear fruit. Students typically take the exam up to three years before applying to residency, so a cohort of applicants with pass-fail outcomes has yet to go through the process of applying to programs.
A thorough understanding of the exam’s impact on student well-being, and the amount of bandwidth medical students committed to exam prep is also unclear. Yet anecdotal accounts of the process show some progress.
An MD-PhD student on an eight-year medical school track, Natasha Topolski initially planned to take Step 1 during her second year of training in 2020. That time frame coincided with significant testing disruption during the height of the COVID-19 pandemic. Because of this disruption, the flexibility of a longer runway in medical school and several other factors, Topolski opted to take the exam after it went pass-fail.
“I had originally thought that I would be able to multi-task and study while working in my [third year] clinical rotations and subsequently on my research full-time along with my extracurricular commitments,” Topolski said. “However, at a certain point, I realized that my divided focus was causing more harm than good in multiple aspects of my life. For the sake of all of my commitments, I ultimately forced myself to take a true dedicated study period where I fully cut off all other obligations for a few weeks in order to take the exam and have it off my plate for good.”
For Topolski, an AMA member who is chair-elect of the AMA Medical Student Section, taking the exam pass-fail did not end up being a less stressful process. However, she believes that if approached correctly, the process can be beneficial to students.
“I do not think it was less stressful for me, but I do think it could be for others, and it is a step in the right direction and the step that the medical community needed to take,” she said. “That it was becoming one of the single most important factors for residency decisions is not OK.”
In the AMA’s view, the previously used three-digit numeric score was detrimental to medical student well-being because it created a parallel curriculum to prepare for the exam and distracted medical students from developing teamwork and communication skills.
Early evidence comes in the form of a single-institution study comparing students who took Step 1 pass-fail with those who stuck with the three-digit score test that was published in Medical Science Educator.
Comparing stress levels among the two groups, researchers found that the pass-fail change “appears to have decreased the stress specifically related to this examination experienced by second-year medical students.” However, the study’s authors concluded, that “reduction in stress was not sustained as students entered their study period to prepare for Step 1.”
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Pass rates on the USMLE Step 1 fell slightly in 2022, but that can be attributed to a number of factors. The exam’s passing score increased by two points, to 196, the same day the change to pass-fail scoring went into effect. There also was a rush of students who took the exam after the switch, according to Daniel Jurich, PhD. He is associate vice president of USMLE at the National Board of Medical Examiners, the organization that administers the test.
Those factors make it difficult to determine exactly how much of the 3 percentage-point dip in the pass rate for first-time test-takers from medical schools accredited by the Liaison Committee on Medical Education could be attributed to the move to pass-fail.
In a self-reported, post-exam survey, “the amount of time per day students are studying and the amount of weeks in advance they begin studying decreased in 2022 relative to some previous years,” said Jurich. “We view this through the lens that one objective of Step 1 changing to pass-fail was to lower the burden and pressure associated with obtaining an extremely high score. I don't want to imply that this decrease reflects a lack of adequate preparation, however.”
In the switch to pass-fail—and the change to the required passing score—exam content remains unchanged, Jurich noted. Considering that, diligent prep remained the course of action that Topolski said was most prudent in her case.
“There’s a strange dichotomy in medical school where despite striving to cultivate altruistic professionals, high stakes exams like this force students to adopt a self-centered approach to succeed,” she said. “While students try to predict the ‘high yield’ topics, the vast scope of material renders predicting exam content a dangerous gamble.
“You might end up with a test filled with unexpected questions targeting your weaker areas or simply have a bad test day, so you still are probably going to want to follow a study plan, take practice tests and give your preparation period the time and attention needed for you to feel very confident you are going to pass.”