Anticipating the Impact of the USMLE Step 1 Pass/Fail Scoring Decision on Underrepresented-in-Medicine Students

Abstract

Three-digit United States Medical Licensing Examination (USMLE) Step 1 scores have assumed an outsized role in residency selection decisions, creating intense pressure for medical students to obtain a high score on this exam. In February 2020, the Federation of State Medical Boards and the National Board of Medical Examiners announced that Step 1 would transition to pass/fail scoring beginning in 2022. The authors discuss the potential advantages and disadvantages of the pass/fail scoring change for underrepresented-in-medicine (UiM) trainees. UiM students may benefit from this change because it reduces the effect of an inequitable exam; helps correct for students who attend medical schools with a curriculum heavier on nontested formative elements; and decreases stress, improves quality of life, and undermines imposter syndrome. However, this change may also precipitate unforeseen challenges, such as increased discrimination toward UiM trainees, an increase in high-stakes test failures due to a reduced focus on preparing for standardized exams, or the development of new (e.g., subject exams) or overreliance on existing (e.g., school ranking) metrics that would make UiM residency candidates less competitive. To enhance UiM representation in the future health care workforce, it is imperative that national organizations (e.g., accrediting, licensing, regulatory, professional, honor, student, and faculty), hospitals, residency programs, and patient advocacy groups undertake a shared, rigorous approach in assessing the impact of the pass/fail scoring change on UiM applicants’ selection to specialty and subspecialty residencies.

Educational and Personal Opportunity Costs of Medical Student Preparation for the United States Medical Licensing Examination Step 1 Exam: A Single-Center Study

“…Although we asked about students skipping these activities to quantify the impact, we believe this underrepresents the level of disengagement toward these topics as students may have chosen to be physically present at a lecture but review Step 1 practice questions rather than attend to the lecture's content. Our findings are limited in that they do not clarify the exacerbated implications of USMLE exam preparation on international medical graduates, students from underrepresented in medicine (URiM) groups, and trainees from other marginalized backgrounds, which have been discussed in other recent works [14,15]. Finally, while we have described the extent to which students disengage from the UNMC curriculum in order to study for Step 1, our study was not designed to evaluate the adequacy of UNMC's preclinical curriculum to train young physicians.…”

Potential Implications of the New USMLE Step 1 Pass/Fail Format for Diversity Within Radiation Oncology

“…Under this premise, the upcoming change to the USMLE Step 1 scoring system may tilt the balance in favor of racial and gender diversity in our field. 9 …”

A Renewed Call for a More Equitable and Holistic Review of Residency Applications in the Era of COVID‐19

“…Underrepresented‐in‐medicine students are also subject to structural bias in standardized testing. Educational inequities, systemic racism, household income disparities, and housing insecurities have all been shown to negatively influence the standardized test scores of URiM students 15 . Using the USMLE to screen residency applicants becomes increasingly problematic as Step 1 scores are not a reliable predictor of residency success 15 .…”

“…Educational inequities, systemic racism, household income disparities, and housing insecurities have all been shown to negatively influence the standardized test scores of URiM students 15 . Using the USMLE to screen residency applicants becomes increasingly problematic as Step 1 scores are not a reliable predictor of residency success 15 . Obstetrics/gynecology literature demonstrated that while testing scores predicted rank on the residency program match list and matching success, they failed to correlate with residency performance 16 .…”

“…Because USMLE Step 1 was never intended to be a stratification tool and will soon be reported as pass/fail, residency programs should deemphasize this test by eliminating score filters and treating the exam as pass/fail now. This approach may result in a more diverse pool of applicants from which residency programs can select 15,18 …”