In late January, Step 1 of the United States Medical Licensing Examination® (USMLE®) moved from numerical score reporting to pass-fail scoring. The move was years in the making and was one that had come after much consideration from the medical education and licensing communities.
From the AMA’s perspective, overemphasis on the previous three-digit numeric score was damaging to student well-being, created a parallel curriculum to prepare for the exam, and distracted medical students from developing other critical competencies such as teamwork and communication skills.
The switch to pass-fail scoring has left medical students with many questions. In an attempt to resolve some of them, here is what some key stakeholders in medical education had to say.
Why the move to pass-fail?
The Federation of State Medical Boards (FSMB) and the National Board of Medical Examiners (NBME) sponsor the USMLE program. After frequent conversations with a number of stakeholders in medical education, the program made the decision in 2020 to make the exam pass-fail. The move was to take some of the emphasis off numeric scores while retaining the ability to use the exam for its original purpose of determining physician licensure eligibility.
“We were mindful of the overall pressure students were feeling of the high-stakes nature of the exam and the impact that was having on wellness and the curricular impact of the exam,” said David Johnson, FSMB’s chief assessment officer.
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The answer is it’s far too early to tell, according to Chantal Young, PhD, who is director of medical student well-being at the Keck School of Medicine of the University of Southern California (USC), a member school of the AMA Accelerating Change in Medical Education Consortium.
“I don't think any of us knows yet what this change will mean for student well-being,” she said. “We need more time and more data to look at the impact. Of course, we are hoping that it improves well-being by reducing the pressure to obtain specific numerical scores, particularly when students are trying to get into specialties they view as highly competitive.” Young added that, anecdotally, “students seem less anxious about the exam this year.”
Should pass-fail change prep level?
The exam content hasn’t changed, so most experts in medical education seem to believe that students should prepare the same way, even if residency programs will not see a numeric score.
David A. Marzano, MD, is an associate professor and director of the ob-gyn residency at Michigan Medicine.
“It shouldn't be disregarded because it's pass-fail,” he said. “If you're studying and preparing just to pass, there's a chance you might actually fail,” compared with the people who are “preparing to try to get a really high score.” The latter approach is “the kind of vim and vigor I would prepare with,” said Dr. Marzano.
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What happens if you fail?
First, consider that to the great majority of medical students pass the Step 1 exam. In 2020, 98% of DO and MD students passed the exam on their first try. But if you don’t, you are given four attempts to pass each different level of the USMLE exam. If you fail, you receive a score report that offers feedback on the areas in which you struggled.
“What we have found, most of the time, is that examinees who failed have performed poorly in a number of content areas, so that means that a different study strategy [is likely necessary],” said Alex J. Mechaber, MD, vice president of USMLE at NBME.
Your best bet if you receive a failing score is to work with an academic adviser at your medical school to rectify the issue.
How will residency programs react?
There will be several residency application cycles in which some applicants have numerical scores and others have pass/fail results on Step 1. That presents a potential challenge for residency program directors.
At Michigan’s ob-gyn program, passing Step 1 is a criterion for interview consideration. Scores aren’t used as a filter other than that. But other residency programs could view the matter differently, Dr. Marzano said.
It’s possible, he said, that the Step 2 exam, which is still going to be scored numerically, will fill the role of Step 1 as a filter for residency applicants to some programs.
“I do foresee, from a national standpoint, that Step 2 is going to become the new Step 1—with the ability to filter as large numbers [of applicants have numerical scores on only Step 2],” Dr. Marzano said. “That’s our worry is we are trading one type of apple for another.”
