Social media platforms lit up when sponsors of the U.S. Medical Licensing Examination (USMLE) announced Step 1 score reporting will change from 3-digit numerical scores to pass/fail by January 1, 2022. First-year Harvard Medical School student LaShyra Nolen tweeted “this could reinforce the hierarchy among med schools,” arguing the score change could encourage residency admission directors to favor applicants from prestigious medical schools over equally qualified applicants from less competitive ones. Second-year Stanford University School of Medicine student Anna Goshua tweeted “Will making Step 1 pass/fail merely kick the stress can down the road?” suggesting residency admission directors are scrambling to find other standardized metrics to use in assessing candidates. Twitter buzzed to life, as other medical students tweeted out reactions marked by frustration and—in a few cases—hopeful reactions to the change.
With many medical student bloggers and promoters predicting the change will complicate residency admission processes, Nolen and Goshua may be giving voice to your own anxieties that this change alters the playing field. If you are a future or first-year medical student, like myself, you may fear this change encourages what it seeks to eliminate: arbitrary hoops for us to jump through in hopes of matching to a residency. Will we, and those after us, waste time brown-nosing deans and professors to score recommendation letters? Will we do unoriginal research and stress even more over the USMLE Step 2 assessment—the remaining standardized assessment used to screen residency applications—in vying to impress admissions officers now scanning us for subjective markers of aptitude? What if this change is our loss, incentivizing a surface knowledge of the basic sciences and lots of self-promotion during our first two years in medical school?
We fear the Step 1 pass/fail scoring change looks bad because it is so. As my farm-raised father says, “if it looks like a duck, swims like a duck, and quacks like a duck, it’s probably a duck.” Frustrated residency directors point out the change will likely encourage nepotism in the admissions process, as well-connected applicants lean on their connections to squeeze past well-qualified, less-connected applicants competing to enter residency programs. Where is the equity in that? They note there is now an incentive to favor applicants from medical schools known for admitting high standardized test-scorers. In deducing who can handle residency’s rigors, they fear disenfranchising equally—if not more—qualified students at lower-ranking medical schools. While advocates predict the change will up student wellbeing, their good intentions will not buffer the likely effect: applicants scrambling to differentiate themselves from their medical school’s reputation using ill-distributed resources.
Step 1 pass/fail scoring will likely have negative side-effects. But few of us are admitting that–to put it bluntly—the change is here to stay, so it might make do us good to find its silver lining. While not denying its threat to life as we know it, I can think of several reasons why this change benefits medical students: it addresses disparities in high-stakes testing, fosters student participation in community activities and classes, and encourages a holistic review process by which to screen residency applications. If we focus on these benefits, we can acknowledge the inevitable—Step 1 pass/fail scoring is here to stay—while finding ways to make it work for us.
You might be hearing popular medical student YouTube bloggers, among other self-proclaimed influencers, argue eliminating Step 1 numerical scores will perpetuate disparities in medicine, allowing residency directors to make “gut-calls” on equally qualified applicants based on arbitrary variates, like ethnicity and gender. While this is a common argument against the change, it fails to hold weight. Recent studies suggest pass/fail scoring will diversify the physician workforce. We know racial and gender differences exist in Step 1 performance despite accounting for MCAT performance and undergraduate grade point average. Race and gender seem to impact a student’s performance on this examination in ways unrelated to their actual cognitive abilities, likely due to socioeconomic, housing, and mental health inequalities. It is easy to study in a private apartment; it is much harder to study with a multi-generational, bilingual family in a shared living space, yet disparities like this one affect medical students across the country. Why should we use numerical scores to screen residency applicants demonstrating potential in ways unrelated to their test scores? This change allows qualified minority and female students to demonstrate ability in ways that work for them, increasing the odds that they will be fairly screened to enter the physician workforce and enhance its diversity.
With a score reporting change, we no longer have to wonder if students are unfairly admitted to residency programs based on their demographic differences in standardized assessment performance. Residency admissions directors will be incentivized to conduct a holistic review process, ensuring applicants of various histories and contexts are evaluated in ways that reward their merit. Today’s patients come in all shapes and sizes; why not celebrate the change as a way to ensure equally diverse residents get to talk and learn together about patients mirroring their complexity? While we can agree applicants must demonstrate their merit, eliminating Step 1 numerical score helps us use more reliable means of judging this merit to usefully diversify the physician workforce.
Pass/fail score reporting also gives us medical students leeway to learn skills not tested on Step 1 yet necessary to meet the current needs and challenges of patient populations. We all hear horror stories of second-year medical students studying every day for fourteen hours in a stuffy library, Monday through Friday, for six months until the day of their examination, competing for a coveted residency slot. Studies back this up, indicating medical students increasingly skip lectures as their Step 1 examination date draws near. Many of these medical students point out Step 1 covers unnecessarily complex content not needed for residency training, but say the benefits of a high score outweigh those of learning non-related Step 1 class content. While we need foundational knowledge in the basic sciences, passing the examination requires that knowledge and allows us to attend lectures covering innovative care-delivery models and the humanistic side of medicine—sources of insight into how our modern healthcare processes can best serve patients.
Pass/fail score reporting allows us to learn the basic sciences and have time to learn softer skills. The American Medical Association (AMA) backs the change, for this reason, announcing “overemphasis on a three-digit score distracts medical students from developing other critical competencies such as teamwork and communication skills.” How would you like to learn effective communication strategies, leadership skills, and public health strategies knowing you only need to study high-yield information on your Step 1 examination? By removing the pressure to score high on Step 1, we medical students will likely have the time to explore a broad range of issues facing global and national health, empowering us to care for patients with knowledge and warmth.
As a first-year medical student, I am frustrated by the Step 1 pass/fail scoring change, longing to skate by on merit and not the thin ice of charm. The change might stabilize me and you in useful ways. It may give us time to study, serve, and socialize–to see others at cocktail parties and scrutinize their parts in textbooks, helping us learn to navigate the complex and messy parts of being human in lectures, libraries, and lingerings.
Thanks to Step 1 pass/fail score reporting, my time in medical school will probably involve climbing social ladders, preparing to take examinations, and working in the bowels of a laboratory. I plan to work at a free health clinic during the first year, learning to aid people without a home. I will keep volunteering during my second year, juggling study sessions in the library with vaccinating migrant workers in a parking lot, learning to speak basic Spanish after studying metabolic processes. I will take time to talk with professors after lectures, motivated to ask and act out their advice on ways of being. The change will challenge me to grow in many directions at once, helping me learn the language of science and social bodies to best care for my patients.
The Step 1 pass/fail score reporting change has its faults, but it also suggests needed reforms, like a holistic review process, are on the way. The change may pull us, medical students, into a more nuanced understanding of medicine during our first two years, as we get to study while having time to care for and learn about those whose parts are so figurable on textbook pages, so messy when working together in real life. The change is here to stay. Is that a bad thing? Not entirely.