With Step 1 of the United States Medical Licensing Examination (USMLE) going pass-fail, major changes could be afoot in medical education assessment. The Step 1 score was a stress and anxiety driver for students and has raised concerns about negative effects on diversity in medicine. Changing that exam to pass-fail was aimed at increasing well-being and encouraging a more holistic view of performance.

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“With so many people applying for residency positions, one of the things we heard from residency program directors was they needed some means by which they could screen through all these hundreds, if not thousands, of applications,” Humayun J. Chaudhry, DO, president of Federation of State Medical Boards (FSMB), said in a JAMA podcast. “While Step 1 of the USMLE may not be the screen, maybe one measure should not be the screen either. And so the goal is not to substitute a single measure as a substitute, but look at an assortment of measures.”

What are the challenges that residency programs and medical schools will need to confront to make up for the absence of a numerical Step 1 scores? Two AMA experts offered their thoughts.

The Step 1 numerical score had taken on an unintended role. All three levels of the exam are required— and intended—for physician licensure. While score reporting of Step 1 became a key metric for residency selection, that was never the exam’s purpose.

USMLE’s owners, the National Board of Medical Examiners and the Federation of State Medical Boards—in partnership with the AMA and additional medical education stakeholders—in 2019 convened to examine the issue from multiple perspectives, which ultimately led to the decision to move to pass-fail. There was consensus that the system of residency selection is flawed and not serving applicants or programs well.

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The Coalition for Physician Accountability, a group of which the AMA is a member, is charged with examining the systemic issues of the residency-selection process in full. This work will include considering a potential replacement—or replacements—for Step 1 scores in residency-selection metrics.

“My wish would be that the review of any applicant’s application would be comprehensive,” said John Andrews, the AMA's vice president for GME innovations. “It wouldn’t just devolve to a number that was readily accessible. I can’t say that there’s an objective metric that should replace it.”

Get the answers to seven other key questions as USMLE Step 1 moves to pass-fail.

Viewing an applicant as more than a numerical score has always been the goal. De-emphasizing Step 1 will reduce the pressure of the “parallel curriculum” in which students prioritize board prep over other learning experiences. This could give medical school faculty members more meaningful experiences with students that in turn could help them offer additional insight on a student’s development.

“Schools already invested in competency-based medical education would like to be able to safely share a given student’s strengths across domains beyond medical knowledge, as well as share areas of ongoing development that should be supported by the receiving [residency] program,” said Kim Lomis, MD, the AMA's vice president for undergraduate medical education. “Ideally, the learner is engaged in this process to encourage self-directed growth.”

Learn how schools are developing flexible, competency-based pathways for students.

Medical schools and residency programs have been attempting to create a smoother transition to residency for years. Residency programs are looking for an understanding of a learner’s readiness and development areas. Medical schools attempt to provide that in the Medical Student Performance Evaluation, commonly referred to as the dean’s letter.

“A barrier to holistic competency review has been a lack of trust on both sides of this transition,” Dr. Lomis said. “[Medical schools] fear jeopardizing a student’s potential selection by reporting areas needing improvement, thus residency programs doubt the credibility of information they do receive. If both sides were more focused on a shared responsibility to support a continuum of development, greater transparency would allow students to grow across the transition.”

Residency programs need to know what they are getting on day 1. For that reason, there is a movement to create some sort of standardized competency framework that all medical schools utilize in a similar fashion.

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“The altruistic view is that schools would provide some standardized assessment of the evolution of a student’s trajectory toward competence,” Dr. Andrews said. “If there was a metric like that that was comparable across institutions, that would be really valued. Then, it isn’t you got a good score, you got a bad score, it’s about what you can and cannot do. That would be helpful in planning, in not just residency selection, but in planning the curriculum for someone once they reach residency.”

Creating a smooth transition from medical school to residency is among the major priorities of the AMA Reimagining Residency initiative. The $15-million grant program aims to promote systemic change in graduate medical education.

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