Why Pass/Fail Step 1 is Really Only Step 1

The atmosphere was electric last Wednesday as medical students across the nation celebrated the news that the United States Medical Licensing Exam Step 1 will be evaluated as pass/fail, potentially as early as January 2022 — I was one of them.

Colloquially known as “Step 1,” the eight-hour, up to 280-question exam tests basic science fundamentals, like biochemistry and genetics, and is typically taken after the second year of medical school. Since its inception in 1992, the test has become ubiquitously recognized as an essential factor that determines a medical student’s future as a physician. Though the test was not originally designed for residency selection purposes, the test is weighted heavily by many residency programs.

The exponential weight placed on the results of this marginally clinically relevant standardized exam has contributed to the toxic, hypercompetitive environment that must be eliminated in medical education. Therefore, I was elated to see the National Board of Medical Examiners will do away with its three-digit scoring system and implement pass-fail evaluation instead. However, while this switch may lead to positive gains in the health and wellness of medical students, there is still additional work to be done in order to ensure these changes lead to true improvements of our broken system.

Firstly, Step 1 is just one of three required USMLE licensure exams. As the policy currently stands, Step 2 (CK) and Step 3 will continue to be evaluated with a three-digit numerical score. While most residency programs don’t require students to sit for Step 2 prior to residency applications, this could change with the new policy. Residency directors could require Step 2 be completed before the application period and then emphasize Step 2 scores more heavily during the application process. Test material companies, which have built a lucrative business for themselves, could then react by creating more over-priced Step 2 prep supplies promising “high yield” material and higher scores. While the latter seems inevitable, I am comforted by the fact Step 2 is a more clinically relevant exam than Step 1, making it a better proxy for clinical acumen.

I am overjoyed we are doing away with the flawed scoring system, but I do worry about the unintended consequences this will have for students at lesser-known medical schools. Every year the U.S. News and World Report ranks the top medical schools in the country. And though there has been criticism about the validity of these lists, they still, unfortunately, hold value in how we perceive medical institutions. Therefore, many students at so-called “low-tier” medical schools and osteopathic medicine programs have used the USMLE exam to make themselves more competitive for residency programs. A pass/fail system inherently privileges students like me at subjectively higher-ranked medical programs. I worry about the effect this system will have on future students’ decisions over where to attend medical school. Will they incur crippling amounts of debt just to attend higher-ranked programs?

Finally and most importantly, changing Step 1 to pass/fail will not address the racial and systemic inequities entrenched in the residency application process. As medical schools across the country have implemented their own pass/fail curricula, Step 1 was the last major objective metric residency programs could use to evaluate candidates. With this gone, more emphasis will be placed on research experience, publication, and subjective evaluations, which are often a reflection of a student’s access to mentors, funds, and opportunities, which tend to be limited for students from lower socioeconomic backgrounds. To make matters worse, studies have shown that students of color tend to receive lower scores on subjective evaluations during their clinical years. If a student’s chances of getting into their dream residency program hinge on the opinion of racially biased preceptors, what does that mean for the future of medicine?

These are the tough questions we will have to find the answers to as we respond to this change and ponder how to restructure medical education to best fit our society’s needs. While there will be many challenges ahead, I see this change as an opportunity for medical programs and residency directors across the country to redefine what makes a “good” doctor in the twenty-first century. For far too long standardized exams have been the crux of this evaluation. Now is the time for students, educators, and leaders to rise to the occasion and advocate for a selection process that values inclusion, humanity, and community. In lieu of Step 1 scores, residency applicants could be evaluated based on their community involvement, leadership, and more humanistic attributes. Students could dedicate more time in medical school to learning relevant clinical medicine and pursuing meaningful extracurricular activities that will enhance their skills as a physician.

These changes will not come overnight, and it will take time and advocacy to make them happen. However, I am inspired by the student leaders and advocates that have preceded me in making what seemed impossible, possible. Great work has been done; change has been made; now it’s up to us to keep pushing the envelope.

LaShyra T. Nolen is in her first year at Harvard Medical School.