USMLE Changes: One 'Step' at a Time

Alok S. Patel, MD


April 29, 2020

This transcript has been edited for clarity.

After years of heated debate, the dreaded, notorious USMLE Step 1 exam is officially going to be pass/fail as early as January 1, 2022. No more three-digit score! When the news broke on February 13, 2020, the Internet went nuts and everybody was talking about it.

This is the biggest change to the US medical education system in decades. Current and future students are wondering what's going to happen to them. Those of us already practicing are having flashbacks of that terrible exam and wondering how this will affect the evaluation of our future peers. Now, all of this sounds like a good thing, at least in theory.

The Pros and Potential Cons

One major pro is that residency programs will now have to consider the total candidate beyond Step 1 scores. A score that a student earns in one day will no longer have such a bearing on their entire career. Why are doctors so riled up about this? With this announcement come some big unknowns and potentially negative side effects.

First, consider how many applicants certain residency programs get. The most competitive specialties, including surgical subspecialties and dermatology, are going to have to find new ways to compare applicants. This inevitably is going to put more emphasis on letters of recommendation, research publications, extracurricular activities, personal statements, and so forth. Although a more thorough application review sounds like a good thing, it also means way more work for selection committees.

Also, although Step 1 is going to be pass/fail, Step 2 is not. All of the anxiety and problems associated with Step 1 are going to be passed down the line—it's hard to see how this won't happen. When it does, timing is going to be an issue because most students take Step 2 the summer before they apply to residency. I'm sure the Step 1 prep companies who are currently freaking out are about to shift all of their focus to Step 2.

Think about how this change may benefit some students while disadvantaging others. People have long championed that Step 1 is a way to level the playing field across schools. Without it, selection committees may favor students from higher-ranked medical schools. Those students from higher-ranked medical schools have access to better resources, better letters, and so forth.

Think about how this affects students from international medical schools, DO applicants, or students from lower-tiered MD schools. Non-US international medical students statistically score higher on Step 1 than US medical students. Without it, some students may face an unfavorable bias.

How could this affect basic science education? In many medical schools, basic science classes are already pass or fail. If Step 1 also becomes pass or fail, this may mess with the educational drive for some students. I've heard from medical school professors who are really concerned that without a score attached to Step 1, fewer students will strive to truly master subjects like anatomy, physiology, or pathology.

Share Your Thoughts

At the end of the day, medical education reform is a good thing, not only to prevent burnout, but also to help create a more well-rounded future generation of doctors. However, it should be done in a holistic way. As many people on social media and online forums have already mentioned, this change to the USMLE didn't account for several variables.

Maybe it'll wind up being a great thing, maybe not. The jury's still out. We won't know for three more years how this is going to affect students and the residency application process.

In the meantime, if you have an opinion—and I know you have an opinion—make it heard. Start here and comment below.

Dr Alok S. Patel is a pediatric hospitalist, television producer, media contributor, and digital health enthusiast. He splits his time between New York City and San Francisco as he is on faculty at both Columbia University/Morgan Stanley Children's Hospital and the University of California San Francisco, Benioff Children's Hospital. Alok hosts The Hospitalist Retort video blog on Medscape and is a medical producer at CNN.

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