As of January 26, 2022, the USMLE Step 1 exam has officially become pass/fail.
The goal of this change was to improve wellbeing and decrease burnout among medical students,
but has it succeeded in achieving this goal?
How has it actually changed the medical school experience?
Let’s talk about it.
Dr. Jubbal, MedSchoolInsiders.com.
The United States Medical Licensing Examination, or USMLE, is a 3-part test designed to assess
one’s medical knowledge and application of said knowledge to patient care.
Step 1 is typically taken at the end of the second year of medical school and is followed
by Step 2 CK at the end of the third year or sometime during the fourth year.
If you want to learn more about the USMLE step exams and their timelines, check out
my 4 years of medical school explained video.
Up until now, Step 1 has been arguably the most important test a future physician will
ever take.
It was initially designed to assist state authorities in granting medical licenses;
however, it evolved far beyond the intended pass/fail indication of competence.
These scores became heavily weighted during residency applications to assess a candidate’s
strength.
So much so in fact, that low scores became prohibitive for students wishing to pursue
highly competitive specialties.
If you wanted to become a dermatologist or a plastic surgeon, for instance, but you didn’t
score high enough on Step 1, you could pretty much kiss your dream specialty goodbye.
Many medical students have had to completely change their career trajectory due to a low
Step 1 score and pursue entirely different specialties than they had initially intended.
As of January 2022, however, this will no longer be the case.
USMLE Step 1 will be graded as pass/fail and will no longer be the primary determinant
of one’s competitiveness as a residency applicant.
The main reason for this change was to improve the well-being of first and second-year medical
students by decreasing stress around the Step 1 Exam.
Burnout and depression are a big problem amongst medical students and having one exam pretty
much determine your entire career trajectory was, unsurprisingly, incredibly stressful
for most students.
Historically, the first two years of medical school have been spent stressing and grinding
for this exam.
The thought process is that by making it pass/fail, much of that stress will go away.
This is a reasonable assumption, as pass/fail medical school curriculums, which have been
around for quite some time, have been shown to improve mood and group cohesion.
When you aren’t feeling like you have to compete against your classmates for the top
grades, there’s much less pressure to perform and you’re more likely to collaborate and
help each other out.
Although that may be the intention, in reality, I don’t believe it’s necessarily the case.
Instead, making step 1 pass/fail just kicks the can down the road and puts additional
stress on Step 2 CK, which is still graded on a numerical scale.
The stress surrounding Step 1 was never a function of the exam itself, but rather a
function of the fear that you wouldn’t be able to get into your desired residency program
- and that fear is still there.
The most competitive specialties will continue to be competitive as there are more medical
students interested in those specialties than there are spots available.
Step 1 becoming pass/fail doesn’t change that.
In addition, this change may make Step 2 CK even more stressful than Step 1 was.
Before, if you didn’t do well on Step 1 then you at least had Step 2 CK to help bolster
your application.
Now, if you mess up on Step 2 CK you don’t have another exam to help offset your lackluster
performance.
To further complicate things, your schedule for away rotations is determined at the end
of your third year, usually before taking Step 2 CK.
If you intended on derm or plastics but don’t perform well on the test, you might no longer
be aiming for those specialties.
With Step 1 being graded, there was more lead time to know where you stood.
With competitiveness now relying heavily on Step 2 CK, that lead time is no longer there.
Step 2 is also taken after clinicals - when your schedule is incredibly busy.
As such, many students will likely have an even more difficult time balancing Step 2
preparation with their clinical responsibilities.
That being said, many schools will likely allocate more time to Step 2 preparation now
that Step 1 is pass/fail; however, programs that don’t adapt their curriculum in time
will make it very tough for their students.
Step 2 isn’t the only metric that’s being given more weight either.
Subjective measures like letters of recommendation and clerkship grades will also be more important
for residency applications moving forward.
These measures may introduce another unintended level of stress as medical students have less
control over them.
For instance, clerkship grades are highly variable between programs with some programs
grading more heavily based on your shelf scores and others emphasizing subjective evaluations
from preceptors.
In addition, some clerkships give out high honors like candy, whereas others make it
near impossible.
This can further increase stress for students when these metrics are more subjective and
less standardized.
The transition of USMLE Step 1 to pass/fail has also changed how students are allocating
their time during medical school.
Since Step 1 will no longer be weighted as heavily on residency applications, students
are spending less time studying for Step 1 and more time on the components of their applications
that will make them more competitive.
This includes Step 2 CK prep, research, extracurricular activities, and medical school performance.
Step 2 CK is essentially becoming the new Step 1 in terms of residency application importance,
so it stands to reason that many students are allocating less time to Step 1 prep and
more time to Step 2 CK prep.
This can be seen as a big win for medical students as the material tested on Step 2
CK is much more clinically relevant than Step 1.
So instead of spending hours studying the Kreb’s cycle, they can now spend that time
reinforcing material that will be more relevant during residency.
Another way for students to stand out on their residency applications now is to maximize
their research experience.
Having more publications and research projects is typically seen as more impressive.
It is also an easy metric for residency programs to use to sort applicants since the number
of publications and research projects is numerical.
Extracurricular activities such as volunteering in underserved medical clinics, taking on
leadership positions in clubs or interest groups, and getting involved in unique opportunities
will be other ways that students allocate their time now that they don’t have to spend
as much time studying for Step 1.
Dean’s lists and class rankings will also become more important as they are an objective
way of comparing students amongst their peers.
As such, students will likely allocate more time and effort to doing well in graded pre-clerkship
classes and clerkship rotations.
One hope with the pass/fail transition is that it will force residency programs to take
on a more holistic application review process instead of using score cutoffs.
But this is just wishful thinking.
What you have to remember is that residency programs receive far more applications than
they have residency spots.
As such, they don’t have time to go through every single application in detail.
They need ways to objectively compare applicants to each other and numbers are often the easiest
way.
For this reason, primarily Step 2CK, but also research and clerkship grades as it relates
to class ranking, will all become more heavily weighted in residency applications.
Much of what we’ve talked about up until this point is mainly relevant for students
in U.S. MD programs; however, USMLE Step 1 becoming pass/fail also has implications for
DO students and international medical graduates as well.
The main concern for DOs and IMGs is that they will have a harder time standing out
to residency programs now that USMLE Step 1 is pass/fail.
In the past, a strong Step 1 score has allowed DOs and IMGs to compete more readily against
MD students for residency positions.
That being said, I don’t believe this should be too much of a concern as Step 2 CK is still
graded on a numerical scale and will essentially replace Step 1 as an application metric.
As such, DOs and IMGs will still be able to stand out by having a stellar Step 2 score.
And just like their U.S. MD counterparts, they’ll still be able to stand out through
their research experience, extracurricular activities, and letters of recommendation.
Strong letters of recommendation, in particular, have been and will continue to be important
for IMGs and DOs to stand out.
These solid connections are often made by impressing research or clinical mentors who
go to bat for them during the residency application cycle, or by having family or other connections.
It is unfortunate, but nepotism continues to play some role in residency match outcomes.
As you can see, USMLE Step 1 becoming pass/fail changes the details a bit but it doesn’t
change the overall picture.
Just as before, medical students will need to take steps to make themselves stand out
above their peers if they wish to pursue a competitive specialty.
Specialties are not becoming more or less competitive from this change, and the stress
that accompanies that competition and uncertainty is not going away, despite what passionate
medical students and residents may tweet.
When changes like this occur, it’s important to remember that it is better to focus on
the things you can control than the things that you can’t.
You don’t want to fall into the trap of having a victim mentality and blaming your
inability to get into your desired residency on external factors.
It is only by adopting an internal locus of control that you can make yourself the best
applicant, and more importantly, the best version of yourself.
This mentality is what will allow you to get through the gauntlet that is medical school
and residency.
Some residency programs will always be more competitive than others and there will always
be metrics that they use to pare down the pile of applicants.
What separates those who are successful from those who are not is a willingness to adapt
and push forward.
“Life is 10% what happens to you and 90% how you react to it”.
So instead of worrying about the 10% you can’t control, figure out how you can make the other
90% that you can work in your favor.
If you find yourself getting discouraged because your dream specialty is highly competitive,
stop right there.
Your ability to crush Step 2 CK and have dozens of research articles is less a function of
your intelligence and more a function of proper preparation, constantly improving, and putting
in the work.
Having a stellar residency application and crushing the interviews is no different.
At Med School Insiders, our mission is to empower a generation of happier, healthier,
and more effective future doctors.
From medical school or residency application help to crushing your MCAT or USMLE, we’ve
got your back.
We know what you’re going through and can help you excel on your exams and help put
you in the best light possible with your medical school and residency applications.
And our results speak for themselves.
We’ve become the fastest-growing company in the space with the highest satisfaction
ratings.
See for yourself and learn more at MedSchoolInsiders.com.
Thank you all so much for watching!
If you enjoyed this video, check out the Top 5 Most Competitive Specialties or How to Crush
Step 2 CK.
Much love and I’ll see you guys there.