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Writing to the Medical Community About USMLE Step 1 Scoring Change

A graduation cap with a diploma and stethoscope.

In February, my medical student colleagues at Johns Hopkins and all across the world received a bombshell announcement that Step 1 of the United States Medical Licensing Examination (USMLE) would become pass/fail beginning, at the earliest, in January 2022. This is the first of four standardized exams (Step 2 CK, Step 2 CS, and Step 3) that students must pass in order to attain licensure to practice allopathic medicine in the United States. It is also generally considered the most difficult and high stakes of all the USMLE exams, as a student’s score on Step 1 largely dictates how competitive their applications will be for their desired residency programs. A 2020 survey of program directors for U.S. medical residency programs found that an applicant’s Step 1 score was the most widely cited factor in determining which candidates they would invite for an interview. The implications are rather jarring — a student desiring to practice interventional radiology, for instance, will need to score at least in the 70th–80th percentile to be a competitive applicant, which means they’d better not have an upset stomach the day of their exam.

With the announcement that Step 1 scores would soon become pass/fail, many of my classmates and I in the graduating class of 2023 breathed a huge sigh of relief — until we realized that the change in grading would likely impact students beginning with the graduating class after ours. Nonetheless, we quickly noted the myriad downstream effects this massive change in a historically scored exam could have on medical education. My classmates Matthew Crane, Razvan Azamfirei and I pondered and discussed many questions. Would this change accomplish its intended goal of promoting medical student wellness by relieving the pressure of an inordinately high-stakes exam? Would residency program directors simply transfer the importance they formerly placed on Step 1 onto Step 2, clerkship grades, letters of recommendation or medical school prestige? Would these ramifications be equitable for students? What other steps must be taken in light of this decision to promote as fair a set of residency selection criteria as possible? And how should medical curricula be revised in response to these changes, if at all?

Matthew, Razvan and I collaborated to write a JAMA Viewpoint article in which we began to address some of these questions. The idea to do so emerged from our shared sentiment that medical student voices — whether they be voices of applause, dissent, anxiety, constructive feedback or criticism — must be heard by the USMLE program and medical educators in order to mitigate the negative ramifications of this decision and fortify the intended positive outcomes. Brainstorming and crafting this piece gave us a valuable opportunity to hear each other’s perspectives, decide on where we held common ground, and cooperate to produce as persuasive an argument we could for the outstanding steps that we felt still had to be taken to optimize the benefits of the scoring change.

The USMLE has yet to announce the exact date that this scoring change will be initiated and — most importantly — how it would be implemented. In the meantime, students all over the world continue to wait patiently for more specific details on a decision that could very well change the trajectory of their medical school experience.

Read the full JAMA Viewpoint article:

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