Should USMLE Step 1 Change from Numeric Score to Pass/Fail?

What if the United States Medical Licensing Examination (USMLE) Step 1, the test developed by the National Board of Medical Examiners (NBME), for which every medical student has studied diligently since the 1990s, was no longer released with a numeric score, but rather taken as pass/fail?

The journal Academic Medicine recently published an invited commentary in which six medical students from across the country suggested just that (Acad Med. 2019;94:302–304). Their article was published along with a response from Peter Katsufrakis, MD, MBA, president and CEO of the NBME, and Humayun Chaudhry, DO, MS, president and CEO of the Federation of State Medical Boards (FSMB) (Acad Med. 2019;94:305–308). 

The student commentary described a negative academic climate to which they said the exam was contributing, a climate increasingly addled with competition and anxiety over matching into competitive subspecialties, as well as a stigma for those choosing to specialize in less competitive areas, such as primary care (the assumption being that they didn’t score high enough on Step 1 to have better choices).

“For many students, participation in the Step 1 climate is a profoundly negative experience,” the commentary said. “In our view, the Step 1 climate contributes to the ongoing mental health crisis affecting the medical community, characterized by increased rates of anxiety, depression, burnout, and suicide among physicians and physicians in training.”

I spent six weeks [studying] for Step 1 solely. I went and stayed with family in the country and lived and breathed Step 1 for the entire time. —David Lee, MD

Anand Devaiah, MD, an associate professor of otolaryngology–head and neck surgery at Boston University School of Medicine and president of the Society of University Otolaryngologists, thought the medical students’ commentary was thoughtful and a “well-reasoned treatise” that brought up excellent points on the merits and disadvantages of moving to a pass/fail system.

David Lee, MD, a fourth-year otolaryngology resident at University of Cincinnati Medical School in Ohio, felt the pressure to do as well as possible on Step 1. “I really don’t think I can speak for anyone else,” he said, “but if an applicant knows they want to do otolaryngology, then knowing it is one of the most competitive specialties and the Step 1 score is one of the most consistent factors that residencies use, the otolaryngology residency applicant needs do what they feel necessary to match.”

tacey T. Gray, MD, program director of the otolaryngology residency program at Harvard, said the issues at hand highlight the fact that there should be a more in-depth conversation between students and the people who are in the position of creating assessment examinations so that students better understand what is being assessed and why it is important to the field of medicine. “I think if students better understood how scores were being used to assess their application for residency, there would be less anxiety about the match process. As educators, being open to a conversation with our students about their concerns is crucial, as they represent the future of this specialty and will ultimately be the educators in the next generation,” she said.

While many physicians a generation ago prepared for Step 1 on their own in just a couple of weeks while also attending medical school classes, students today are taking a different route, some even taking time off from their med school classes entirely. “I spent six weeks [studying] for Step 1 solely,” said. Dr. Lee. “I went and stayed with family in the country and lived and breathed Step 1 for the entire time.”

A test prep cottage industry has formed around Step 1, as many consider it a key indicator of a medical student’s preclinical medical education and very important to matching into the student’s top choice residency program. Dr. Lee said that, for him, taking a test prep course was necessary. “The course I chose kept me structured and regimented in my review of the enormous [amount of] study material, and I needed that,” he said. “Not everyone may feel the same, but the fear of a subjectively bad Step 1 score is real and may drive those who wouldn’t need it to break down and make the purchase.”