Passing the Caduceus: A Medical Student Perspective on USMLE Step 1 Reform

Abstract

The USMLE Step 1 exam provides a standardized metric by which medical schools and residency programs can assess a medical student’s preclinical medical education. In 2021, the grading of Step 1 changed to pass/fail, in an effort to improve student wellbeing and reduce the exam’s undue influence on the residency match process. This commentary provides a medical student’s perspective on the new grading system, highlighting recent studies on Step 1 student wellbeing, financial stress, and residency influence.

Introduction

For MD medical students in the United States, the conventional curricular approach relies on two years of classroom learning focused on the scientific foundations of clinical practice. At the end of this phase, students are required to take the United States Medical Licensing Exam (USMLE) Step 1 (“Step 1”) to demonstrate their foundational medical education and qualification for clinical coursework and residency. Step 1 was originally designed in the 1990s to provide a standardized preclinical licensing benchmark for medical students. However, Step 1 rapidly became a disproportionate influence on residency applications, generating a “Step 1 Climate” of stress [1]. In September 2021, citing student wellbeing and an undue influence in residency placement, the USMLE decided to change Step 1 results from a 3-digit score to a pass/fail outcome [2, 3]. This change saw a significant and ongoing decrease in the pass rate for Step 1, which was attributed to an increase in the required score threshold for a passing grade and changes to student preparatory behaviors [4, 5]. Even after the change to pass/fail, Step 1 remains an important factor in residency applications, particularly for international medical graduates (IMGs) to demonstrate their qualification and competitiveness for residency programs in the United States. While the change to pass/fail was a step in the right direction, there remain significant issues with the current Step 1 examination process, as medical educators seek to equip the next generation of practicing American physicians.

Step 1 Still Has a Detrimental Effect on Medical Student Wellbeing

Most US medical students spend between 4 and 8 weeks in a period of dedicated exam preparation. The isolation, expense, and stress of preparing for Step 1 has been associated with decreases in student wellbeing [3]. A recent, multi-institutional survey of medical students found that there remained a significant negative impact from preparation for Step 1 licensing examinations. Three out of four students reported a significant decrease in quality of life, and four out of every five students reported symptoms of burnout and anxiety [6]. Beyond emotional health, three out of every four students were unable to maintain healthy levels of sleep during Step 1 preparation [7]. While few studies have explored the practical outcomes of these quality of life changes, such experiences have been directly associated to suicidality among medical students [8, 9]. Moreover, this stress disproportionately affects underrepresented minorities and individuals from socioeconomically disadvantaged backgrounds [10]. Gender may also be associated with increased stress, particularly for female classmates who are older than the mean age of their classmates [11].

Step 1 Places an Undue Financial Burden on Medical Students

Currently, without any financial waivers, registering for NMBE licensing exams costs thousands of dollars, not considering the possibility of incurring hundreds of dollars in rescheduling fees [12]. Under pressure to rapidly accumulate the necessary knowledge for the exam, increasing numbers of students feel pressured to purchase commercial preparatory courses for Step 1 [1, 13]. Beyond reflecting the discordance between Step 1 and modern undergraduate medical education, such preparatory materials can cost thousands of dollars. Twenty-five percent of medical students reported that the costs associated with USMLE step 1 placed significant financial stress on their lives. This financial stress was directly associated with worsened factors affecting student wellbeing [6].

Step 1 Still Has a Disproportionate Impact on Residency Applications

Multiple studies have demonstrated that USMLE Step 1 is not a reliable predictor of clinical skills or performance during residency [14, 15]. USMLE and COMLEX exams were designed as tools to standardize physician licensure, not serve as a benchmark for residency competitiveness [16]. Meta-analyses have demonstrated that USMLE scores at best are weak predictors of residency preparedness [17–19]. While a pass/fail Step 1 result has decreased the emphasis on Step 1 score performance, some signs indicate that residency programs still use Step 1 and Step 2 results to screen potential applicants [20]. Even after the change to pass/fail, this process particularly hurts underrepresented groups in medicine, as well as individuals from socioeconomically disadvantaged backgrounds [10]. In this way, a single bad exam can render an otherwise qualified applicant unable to match into several competitive specialties.

Discussion: Potential Solutions

If Step 1 is not a meaningful benchmark for US medical students and hinders student wellbeing, what changes could improve the current system? First, licensing authorities should consider waiving the USMLE Step 1 requirement for graduates of accredited US MD programs. For DO, a similar decision could apply to COMLEX level 1. Greater alignment between medical school curriculum and licensing requirements may also mitigate the need for requiring Step 1 for US medical students [6].

Second, the USMLE should change the content representation on USMLE Step 1 to more accurately reflect the practice of medicine in the twenty-first century. This would include a focused effort to reconcile exam content with the materials presently being taught in medical school, as well as investigating the role of technology in modern medical practice.

Third, until major changes to Step 1 are made, medical schools must make a concerted effort to prepare students for and support students through Step 1 examinations. High-stakes examinations are a time of isolation and suffering for the vast majority of medical students and represent an important window for interventions aimed to improve student quality of life. Additionally, the decreased pass rate remains poorly understood, and should be examined further.

Fourth, residencies should recognize the limitations of USMLE examinations, and remove Step 1 requirements for their holistic review of applicants [21]. The USMLE exams were not designed to be an indicator of preparedness for residency, and screening applicants who have a Step 1 fail uses the exam in a way that is outside of its designed purpose. Some program directors are concerned over the lack of empirical means to distinguish qualified applicants; however, the empirical simplicity of USMLE scores underlies the danger of their misapplication. Just because a USMLE score is able to precisely distinguish scores of applicants does not mean that the results are meaningful. Alternative exams such as In Training Exams or Specialty Boards may serve as a more reliable and accurate predictor of residency performance [18, 22, 23].

Such changes to pre-clinical USMLE examination process are important steps toward maintaining an outstanding level of physician education, while simultaneously protecting future providers from burnout. There is a significant need for further research into current conditions and outcomes of Step 1 pass/fail results, as well as COMLEX Level 1 score reporting. The pass/fail decision demonstrates that change is possible, but future changes are necessary to protect the most vulnerable members of the US medical student community.

Declarations

Conflict of Interest

The author declares no competing interests.