USMLE Step 1 Pass/Fail Reporting Change: Top 5 Concerns from the Medical Community

usmle step 1 pass fail

The January 2022 USMLE Step 1 Pass/Fail score-reporting changes have sparked online debates across social media channels such as Twitter, Reddit, STAT News and KevinMD. 

In February 2020, the Federation of State Medical Boards (FSMB) and the National Board of Medical Examiners® (NBME®) announced their decision to change Step 1 from a three-digital number score to Pass/Fail. In making the change, the co-sponsors cited the need to “balance student learning and student wellbeing,” and to “minimize racial demographic differences that exist in USMLE performance.” 

Following the announcement, social media conversations seem to center around five key issues:

1. Rewards for Hard Work

Step 1 scores are currently used as a primary metric for medical residency selection, and many students believe that the move to Pass/Fail will not reward those who study harder for a stand-out score. Also, those who have already taken the numerically scored Step 1 worried that their high scores will not adequately count in their upcoming residency applications*. On a Step 1 Reddit thread, one student comments: “It’s a generation of participation trophy winners that have lobbied for this.”


2. Objective versus Subjective Metrics

The argument: Step 1 Pass/Fail grades will shift the emphasis to a set of more subjective or qualitative assessments, such as preceptors’ clinical grades, medical school pedigree, research experience, personal statements and references. Or, as one Twitter commenter asks, “Will transition to P/F Step 1 increase (the) role of “audition rotations?”

The counter-argument: USMLE Step 2 and 3–particularly Step 2 Clinical Knowledge (CK)—are more reliable and accurate measures of a physician’s true skills and competencies.

3. Consequences for IMGs, DOs and Students from Lower-Tier Schools

Historically, many doctors of Osteopathic Medicine (DOs), International Medical Graduates (IMGs) and U.S. students from lower-tier medical schools relied on their excellent Step 1 scores to compensate for what often weighed as an educational deficit. Or, as one Reddit thread commenter argues, “Step 1 was the one thing lower-ranking MDs, DOs, and IMG/FMGs could work for and do that would prove their worth.” After January 2022, these students fear that the Pass/Fail score will make it harder for them to get matched into their first-choice residency programs in the U.S. 

4. Postponed Student Stress

On his KevinMD blog post, Ryan Okonski, a New-York-based medical student writes, “The time preparing for Step 1 is one of the most stressful times of a medical student’s tenure in medical education.” However, others argue that, by shifting the residency-placement emphasis onto Step 2, student stress will be postponed, but not decreased—particularly in light of the fact that Step 2 scores are released just before the deadline for residency applications. 

“The time preparing for Step 1 is one of the most stressful times of a medical student’s tenure in medical education.” – Ryan Okonski, Medical Student

5. Racial and Demographic Equity in Medical Education

Medical students and doctors are divided on how a Pass/Fail Step 1 can achieve the co-sponsors’ goal to reduce inequities. Citing historical underrepresentation in certain residency programs, a Yale University fourth-year student comments on STAT News: “I worried I might fail (Step 1) and be exposed as a fraud, proving to whoever might have thought it before that I didn’t deserve a seat at Yale as a Black medical student.” Meanwhile, a first-year female Black medical student posits that the new, over-reliance on qualitative clinical grades will exacerbate, not mitigate, disparities in medical education.  Regarding his medical training, one lower-income white male physician on Twitter cites the Step 1 numerical score as “the true equalizer.”

“I worried I might fail and be exposed as a fraud, proving to whoever might have thought it before that I didn’t deserve a seat at Yale as a Black medical student.” – Max Jordan Nguemeni Tiako, MSIV, Yale School of Medicine

Between now and 2022, when the USMLE Step 1 Pass/Fail changes take effect, it’s likely that program directors will work to develop more holistic ways to assess medical students’ competencies and their eligibility for the most sought-after residencies. The USMLE website features an announcement page, with all its board exam updates, including the fact that all scores for Step 1 exams taken prior to the date of the policy change will continue to be reported using the three-digit numeric score on all USMLE transcripts*.

Áine Greaney Ellrott, M.A., is a former health communications leader and award-winning writer living in the Boston area. She has led communications initiatives for a large health system and has written features, blogs, web content, physician and clinician profiles. She has also written consumer guides on topics such as mental health, addiction treatment, integrated primary care treatment, teen health, population health, technology-supported care models, palliative medicine, psychiatry, end-of-life care, advance care planning and narrative medicine. Her bylines have appeared in The Boston Globe Magazine, The New York Times, World of Psychology, Salon, Huffington Post, KevinMD, Edutopia, WBUR/NPR, and other publications.

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