Scores for Step 1 of the United States Medical Licensing Examination (USMLE) will be reported as pass/fail, not as numeric scores, the two organizations that sponsor the test Wednesday.
The change, which will , aims to reduce overemphasis on Step 1 performance while allowing licensing authorities to continue to use the test to determine medical license eligibility, the Federation of State Medical Boards (FSMB) and the National Board of Medical Examiners (NBME) said.
"I am stunned," said Bryan Carmody, MD, of Eastern Virginia Medical School in Norfolk, who has advocated for more meaningful evaluations to select medical students for residency programs. "By itself, making Step 1 pass/fail doesn't fix much, but it does give us the opportunity to make changes," he said in an interview with 鶹ý.
"If we do nothing, Step 2 mania will be the natural result of a pass/fail Step 1," he added. "Unless we give residency program directors more useful information and the time to thoughtfully review all the applications they receive, they'll gravitate to another convenience metric out of necessity."
The USMLE consists of three "step" tests:
- Step 1, typically taken midway through medical school
- Step 2, which has both clinical knowledge (CK) and clinical skills (CS) components and is taken before matching into a residency program
- Step 3, taken during residency
Candidates who pass all USMLE step tests may apply for a license to practice medicine in the U.S.
In addition to the change in Step 1 score reporting, the policy changes announced Wednesday will reduce the allowable number of exam attempts on each step component from six to four and require success on Step 1 before taking the Step 2 CS component.
Step 1 was implemented in the 1990s. For state licensing purposes, the exam always has been pass/fail, but over the years, its three-digit numeric score has become a key part of screening and selecting residents.
Last year, a group of medical students wrote an for Academic Medicine, pointing out unintended consequences of Step 1's numeric scoring process on education, diversity, and student well-being.
Step 1 had created a rift in medical education, those authors argued, encouraging students to disengage from medical school curricula to study for what would be on the Step 1 exam. In this climate, courses about medical ethics and social determinants of health were considered "low yield" for Step 1. Students could spend $1,000 in commercial resources to prepare for Step 1, and not all students can afford that, the commentary pointed out.
In a that ran alongside it, Peter Katsufrakis, MD, CEO of the NBME, and Humayun Chaudhry, DO, CEO of the FSMB, argued that numerical scores can help residency programs differentiate among thousands of applicants for a limited number of slots.
In an early version of the essay, they noted that if students spent less time preparing for Step 1 and "more time to activities that make them less prepared to provide quality care, such as binge-watching the most recent Netflix series or compulsively updating their Instagram account, this could negatively impact residency performance and ultimately patient safety." Within a few days, Katsufrakis and Chaudhry issued an and removed the phrase, but the comment fueled a Twitter storm, bringing Step 1 scoring to the forefront.
Step 1 scoring was addressed later that year at the Invitational Conference on USMLE Scoring (, hosted by the FSMB, NBME, American Medical Association, Association of American Medical Colleges, and Educational Commission for Foreign Medical Graduates, which invited representatives from education, state medical boards, and others to participate.
"If there's one thing I took away from my experience at InCUS, it was that changing Step 1 to pass/fail will not solve every problem," said Christle Nwora, a fourth-year medical student in Houston.
"The process of transitioning to residency is complicated and everyone is trying to figure out how to identify which residents are the best fit for their program," Nwora told 鶹ý. "Every program has a different flavor and every applicant is unique, and it's difficult to determine what metrics are best to use."
The new policy change has generated mixed responses from medical students, which an informal Twitter poll this week by Leo Brueggeman, a University of Iowa MD, PhD student, highlighted.
"After 24 hours, 551 votes had been cast, with 19% supporting the change, 54% not supporting the change, and 27% undecided," Brueggeman told 鶹ý. "Given that studying for Step 1 is generally considered the low-point of medical school, the results surprised me."
"I think a large part of the negative response may be centered on drawbacks of other possible metrics for residency applications," Brueggeman added. "I'm in the undecided camp, but am hopeful that this will serve as an opportunity to refocus on quality medical education and making further changes to improve the residency selection process."
But for others, the policy is a step in the right direction. "As far as I'm concerned, it's the single biggest shift to occur in medical education since the introduction of the first version of the exam," noted David Chen, a fourth-year medical student at the University of Washington in Seattle. "It shows that advocacy makes a difference, and change is possible in medical education."