Authored by Diego Cebrian MD and Ariadna Perez Sanchez MD
Edited by Samir Desai MD
The USMLE Step 1 is transitioning to Pass/Fail scoring: How will this change your path to residency?
After a long discussion period, the National Board of Medical Examiners (NBME) in February 2020 officially announced a major change in the scoring of the USMLE Step 1 exam. The Step 1 report will change from a three-digit numeric score to a pass/fail outcome. A numeric score will continue to be reported for the Step 2 Clinical Knowledge (CK) and Step 3 exams. This policy will take effect no earlier than January 1, 2022, with further details to follow later this year. This is a groundbreaking statement by the NBME, considering the importance of the Step 1 exam in U.S. medical education. There are a number of debates on whether this is an improvement or a step back in an already polarizing discussion, most of them revolving around the economic and psychological impact that Step 1 has on medical students. But judgment on that behalf should be postponed until all the details are made available by the NBME. Right now, we would like to focus on those aspects that affect residency applications. Step 1 has for years been considered the most important factor in the evaluation of candidates for residency spots. In fact, it's even considered in the application process for competitive fellowships. The reasoning behind this encompasses two aspects of the test:
The USMLE Step 1 is an easily available and objective universal measure that may be used to compare candidates. Step 1 is taken at the end of the second year or the beginning of the third year of medical school, making it widely available for program directors (PDs) to review. Step 2 CK, on the other hand, is taken later. Some students have not yet taken Step 2 CK by the time they apply for residencies. This makes Step 1 the most widely available criterion. While there are a number of arguments against the use of Step 1 scores, and a number in favor, we will abstain from such debates to address an important question. What will be the new single most important factor for residency matching now?
Step 1 may possibly transfer its importance to Step 2 CK
The most logical solution for the absence of a numerical Step 1 score is that the Step 2 CK score increases in terms of importance. This has been noted in the last few years, with many studies citing that Step 2 CK better predicts the ability to be a successful resident. Even though this might therefore be considered a positive change, there are still issues with the Step 2 CK score. The main issue is timing.
Currently, medical students dedicate their first two years to maximizing their Step 1 scores. As clerkships begin, they are then able to transfer that focus to clerkship performance as well as other activities that strengthen their CV, especially in terms of seeking out a particular specialty.
Now, with a greater weight placed on the Step 2 CK score, medical students hoping to match into competitive residencies will have to pay even more attention to their academic and extracurricular accomplishments in the first two years of medical school. As clerkships begin, they will need to also dedicate time to maximizing performance on the Step 2 CK.
Other aspects of your application will be scrutinized to make up for the absence of a Step 1 Score.
It is important to remember that Step 1 isn’t the only factor considered when evaluating candidates. There are a number of factors that may be used to compare and rank applicants for competitive specialties and programs. These other aspects of a candidate's application will now become even greater of a priority, replacing the Step 1 three-digit score.
Specifically, it is probable that letters of recommendation, performance on away rotations, and volunteer and service activities will be more heavily evaluated. And more emphasis will be likely placed on the number and quality of publications and research experiences.
Even if the Step 2 CK score doesn't replace Step 1 in terms of importance, it would be wise for medical students to start working on these other aspects of their application early in their medical career. Unfortunately, this will add further stress to the already difficult first years of medical school.
This adds another potential challenge. Since students may begin working on research projects and publications before their clinical years, they may expend considerable effort on projects that may not ultimately align with their preferred specialty. It is well-recognized that a significant percentage of students ultimately choose fields that are different than those they expected to choose when entering medical school.
The rise of school reputation and personal connections?
Some people have raised the concern that with increased importance placed on less objective measures, preferences for prestigious schools and personal connections could start to shape the new selection process. However, this is mere speculation.
At this point in time, it is wise to wait for further communications from the NBME since they may well have crafted a solution to these potential issues.
IMGs: How will these changes impact International Medical Graduates?
Traditionally, IMGs have a number of disadvantages that they must overcome in order to match successfully. Some begin their residency search late. Also, simply locating opportunities to gain clinical experience in the U.S. medical system can be very challenging for IMGs. Lastly, the simple fact that their school is located outside of the US has a huge impact on the perceived reputation of the school when being judged by US faculty.
IMGs seeking residency positions have traditionally used their Step 1 score to demonstrate that they are as valuable as their U.S.-trained counterparts. It would be safe to say that they would be one of the most affected groups in this new scenario. From the moment that this measure is put into effect in 2022, IMGs should pay even more attention to improving other aspects of their applications, especially such factors as obtaining US clinical experience in recognized institutions as well as productive research experience.
In addition to excelling on the Step 2 CK exam, IMGs should aim to take Step 3 before applying to residency. This will provide an additional objective measure that may be highlighted in their application.
In Summary
In summary, this decision by the NBME has the potential to make applicants redesign their pathway to their chosen residency. The bottom line is that in the next two years, the path towards residency will essentially remain the same while we await more information from the NBME. We hope these changes are for the best, but we will need years to witness the impact of this new measure on the quality of our physicians.
Dr. Cebrian is a Radiology Resident at the University of Texas Health Science Center at San Antonio
Dr. Perez Sanchez is a Internal Medicine Resident at the University of Texas Health Science Center at San Antonio
Dr. Desai is a faculty member of the Baylor College of Medicine and the author of "The Succesful Match"