Relief and Concern Over Step 1 Exam's Switch to Pass/Fail

Donavyn Coffey

April 22, 2022

For the first time this spring, second-year medical school students left their initial board exams worried about just one factor: passing. The infamous 7-hour Step 1 exam is now pass/fail. Scores once used to select students for the most competitive specialties no longer exist.

While the change removes the pressure to score at a certain level, it also left students who were aiming for competitive specialties unsure how to get there. Residents, recent docs, and students weighed in to Medscape Medical News on how the change will affect students and the resident selection process in the years to come.

After passing the exam in February, a second-year student at Georgetown University School of Medicine, who asked not to be named for fear it might affect his academic or residency prospects, said the elimination of the three-digit score changed the way he studied. "I don't need to study as hard as I would have had to if I wanted to get into a super competitive specialty," he said.

Nadia Addasi

Nadia Addasi, a second-year medical student at New York Institute of Technology's (NYIT's) College of Osteopathic Medicine, who will take Step 1 in June, said, "I'm relieved that it's not important to be in the 70th percentile or 90th percentile, especially since I have to take two board exams."

DO students like Addasi aren't required to take Step 1 to graduate; they take a different exam, called COMLEX. But they all prep and pay to take Step 1 too so that they are competitive on residency applications. So the switch to pass/fail takes significant pressure off her plate, she said.

Deciding Factor or Benchmark?

For some programs, Step 1 scores were just one of many factors on a residency application. But for other competitive specialties, such as dermatology, neurosurgery, or orthopedic surgery, there were unofficial score cutoffs. Only students with a certain Step 1 score or higher were considered for certain programs.

Dr Lena Josifi

"I was told if you [scored] under 240, you should be wary of applying [to orthopedic surgery programs]," recalled Lena Josifi, MD, a fourth-year orthopedic surgery resident at Southern Illinois University. She heard that the benchmark continued to inch upward after she took the exam in 2017. "For comparison, the national average was around a 230 or 220" at the time, Josifi said.

The Association of American Medical Colleges reported that among 2019–2020 first-year residents in thoracic surgery, orthopedic surgery, and otolaryngology, the average Step 1 scores were 247.3, 246.3, and 246.8, respectively. The average scores for residents in emergency medicine, family medicine, and internal medicine pediatrics were 230.9, 215.5, and 235.5.

A 2021 survey of program directors of orthopedic surgery reported that 68% of programs viewed the three-digit Step 1 score as extremely or very important in applicant selection for an interview.

Students who scored below the cutoffs often felt they should rethink their future, according to the students and doctors interviewed for this story. "It's a test that used to make or break careers ― it could really change your options," said Addasi, the second-year student at NYIT.

Dr Priya Jaisinghani

"Step 1 became analogous to organic chemistry during pre-med," said Priya Jaisinghani, MD, an endocrinology fellow at New York–Presbyterian Weill Cornell Medical Center. It was a means of "weeding out individuals by score for competitive specialties," she said. But like organic chemistry, Step 1 was not a perfect measure of an individual's fitness to practice medicine in her opinion.

The US Medical Licensing Examination (USMLE) finalized its decision to switch the exam to pass/fail in December. USMLE said the exam is a benchmark, but it was never designed to differentiate between applicants. And students had come to emphasize their Step 1 scores at the expense of other curricula and their own well-being, USMLE reported.

"It's a step in the right direction," Jaisinghani said. A score attained before students have even had clinical exposure cannot be the sole measure of what makes a good physician, she said.

But now that the score is out of the way, the roadmap to top specialties is a bit murky, said the second-year student from Georgetown, who hopes to specialize in surgery. Step 1 scores were the gateway to surgery or dermatology. The change to pass/fail removes a huge piece of data from the equation, Addasi said, and no one is sure which metrics will take on more weight in its absence.

The USMLE has indicated that with the removal of scores, programs will transition to a more holistic review of candidates, though there's no guidance on what that will look like in practice.

Top residency programs traditionally used Step 1 scores as a screening tool because there are so many applicants to review, according to the survey of orthopedics programs. Orthopedic surgeon Randy Cohn posted on Twitter that 2022 National Residency Match Program data show there were 1470 applicants for 875 spots in orthopedic surgery, so 40% were unmatched. The number of candidates that programs have to filter through is expected to increase as the change to pass/fail widens the candidate pool further.

Leveling the Playing Field

Some students are concerned that other biases will pop up as programs try to abbreviate their candidate search. The second-year student from Georgetown, for instance, fears that letters of recommendation will now carry a disproportionate amount of weight. Program directors might be more likely to go with students they are familiar with or who come recommended by physicians they know, he said.

Although a person's future shouldn't be based on a single exam score, Josifi, who benefited from Step 1 scores, concedes there are downsides to the pass/fail transition.

Before the change, if students came from programs with less mentorship, fewer connections, or a smaller institution, their Step 1 score could help, Josifi said. She had limited access to mentorship in orthopedics during her medical training, so her Step 1 score was a way to demonstrate her aptitude, she said.

Without a standardized measure, "it makes it harder if you are coming from smaller institutions. It becomes about who you know and who's making phone calls for you," Josifi said. "Students with great medical pedigrees may have more advantages."

In the survey of orthopedic programs, 37.7% of program directors reported that the change to Step 1 scoring would "probably" or "definitely" decrease the likelihood of applicants from lower-ranked medical schools being selected for an interview. And 81% predicted that Step 2 results will become increasingly important now that Step 1 scores are out of the picture.

Addasi said she's interested to see how the application vetting progresses now that programs are shouldering a larger burden in the resident selection process.

The shift to pass/fail has potential to reshape the early med-school experience, Jaisinghani said. The immense pressure to secure one's future by doing well on Step 1 shifted the focus of those 2 years; it was all about beating the exam, she said. With the score removed, many of the core competencies of medicine, such as interpersonal skills, critical thinking, curiosity, and compassion ― which had become undervalued ― can resurface, she added.

"There was so much onus on the exam. Now [students can] shift focus to experiences, organizations, community health, research."

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