USMLE®

USMLE Step 1 moves to pass-fail: Answers to 7 key questions

The United States Medical Licensing Examination (USMLE) recently announced that its Step 1 exam would move from numerical scoring to pass-fail. The change was one for which educators and students had long been advocating.

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Here are answers to seven questions that will give medical students and premeds key information they need to know about this change and what will come next.

What went into the change?

The conversation to move the exam from numerical scoring to pass-fail gained major traction in the aftermath of a 2018 AMA Accelerating Change in Medical Education Consortium meeting, during which a pro-con debate format was used to consider whether to continue reporting USMLE Step 1 as a three-digit score or to convert to pass-fail scoring. Following the group discussion, representatives from the National Board of Medical Examiners (NBME) agreed to convene stakeholders to explore options.

In the spring of 2019 key stakeholder organizations, including the AMA, the Association of American Medical Colleges (AAMC), the Educational Commission for Foreign Medical Graduates (ECFMG), and the USMLE parent organizations, which are NBME and the Federation of State Medical Boards (FSMB), convened the Invitational Conference on USMLE Scoring (InCUS) to seek broad input on the topic. This report summarizes the key findings from that meeting.

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In the subsequent months, the FSMB and NBME engaged educators, regulators, test-takers and the public to solicit feedback on exam scoring and the recommendation from InCUS. In reaching the decision to make the USMLE Step 1 pass-fail, specific consideration was given to supporting the educational engagement and overall experience of medical students.

Why the shift to pass-fail?

The conversation around moving the USMLE Step 1 to pass-fail centered on making a positive systemic change in medical education. It’s important to point out that the Step 1 exam was originally designed to be pass-fail, and its primary purpose was and remains medical licensure. Concerns were less about the examination itself, and more about how the score has been misapplied in the residency selection process.

From the AMA’s perspective, overemphasis on a three-digit score is damaging to student well-being, creates a parallel curriculum to prepare for the exam, and distracts medical students from developing other critical competencies such as teamwork and communication skills.

Will the numerical score be visible?

You may be wondering, if you have a three-digit numerical score, whether it will be visible on your transcript and residency application materials. That remains to be seen. But for current medical students, with the USMLE-sponsoring organizations asserting that the change will not take place until January 2022 at the earliest, you are most likely going to take Step 1 under the numerical scoring format.

Step 2 (CK) and Step 3 will continue to be reported with numerical scores. Step 2 Clinical Skills (CS) will continue to be reported as pass-fail.

What will replace Step 1 as a differentiator?

Without the USMLE score as a metric, trusted quantitative and qualitative assessments of a candidate’s competencies and unique characteristics will be tracked in other ways. Other elements of a prospective resident’s application, such as the medical student performance evaluation (MSPE, aka “dean’s letter”), may take on a new importance.

However, many residency programs face a challenge in that it is difficult to differentiate medical students given that medical schools are increasingly moving to pass-fail grading systems to avoid ranking. Programs also don’t place high stock in the information reported in dean’s letters.

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The AMA intends to collaborate with others to develop standardized competency reporting to enhance the holistic information available to program directors and will explore other systems approaches to improve the residency selection process.

Will scores be released more quickly?

Step 1 scores are typically released within three to four weeks of a test date. The sponsoring organizations expect that to remain the case going forward.

Does the AMA support the move?

As one of the key organizations behind InCUS and one of the leading voices in medical education reform, the AMA “supports the decision to move to a pass-fail reporting structure for the USMLE Step 1 as a first element in improving” the transition from medical school to residency, said Susan Skochelak, MD, MPH. Dr. Skochelak is the AMA’s group vice president for medical education.

“Our student, resident and physician members voted to endorse a pass-fail policy, in part, because we know our current residency selection system is causing significant distress for our students, Dr. Skochelak added. “The AMA is currently supporting new ideas in the transition from medical school to residency through our funding of the AMA Reimagining Residency initiative and our AMA Accelerating Change in Medical Education Consortium. We look forward to working with our colleagues across the continuum of medical education in developing improvements in physician education transitions.”

What comes next on this?

The Coalition for Physician Accountability, comprised of national organizations (including the AMA) bearing responsibility for the oversight, education and assessment of medical students and physicians throughout their medical careers, has accepted a request from InCUS sponsors to further examine the transition from UME to GME. This group is meeting April 7 and will launch a Review Committee with broad representation.

The USMLE program has developed a list of frequently asked questions and provided an explanation of its decision to move to pass-fail scoring for Step 1.