What does Pass/Fail Step 1 mean for you?

Bliss Chang

Bio: Bliss is a fourth-year medical student at Harvard. He applied into Internal Medicine with hopes of pursuing a Cardiology fellowship. He is an avid mentor and passionate medical educator currently working on two books for medical students. In his spare time, he travels the world with the hopes of visiting every country.

March 2, 2020 |

On February 12, 2020, the USMLE Step 1 exam was announced to become pass/fail starting no earlier than January 2022. As you might imagine, there were outbursts of both joy and anger at this decision. But how does this impact you?

Impact on Step 2 CK Value

Let’s start with what purpose the Step 1 exam serves. In the simplest sense, it is used by programs as a measure of an applicant’s work ethic foremost but also to some degree their ability to master medical content. Programs are well aware that there are people who are not able to test well, and those who can test well but are underwhelming clinically. However, programs must have some tool to differentiate these qualities in applicants, thus the utility of Step 1 since every student recognizes its importance and gives it their all.

With Step 1 becoming pass/fail, all eyes now turn towards Step 2 CK which used to be an exam that many senior medical students took lightly. This will likely be one way for the programs to get an assessment tool similar to Step 1 because all students will begin taking the exam more seriously and trying their best. The benefit to this is that the Step 2 CK content is much more relevant to clinical practice and better examines whether a student is equipped for internship. The down side is that the National Board of Medical Examiners NBME’s intended impact of changing Step 1 to pass/fail (allowing more holistic application review, less emphasis on scores) will not be realized. In fact, this puts more pressure on students to ace this one exam, whereas previously a subpar performance on Step 1 could be made up with a stellar Step 2 CK performance. It is a curious decision in my opinion to only make Step 1 pass/fail since their philosophy should apply to all of their licensing exams with numerical scores.

Effect on Applications

Does this change impact how applications are judged? I believe that early on, the name brand medical schools will have an advantage as it will likely take a while for Step 2 CK score numbers to equilibrate and become reliable because currently not all students take the exam seriously, meaning the current averages are lower than it would be after this change occurs. As such, school caliber is an easy proxy for what the average student’s test score would be, had it not been masked by the pass/fail nomenclature (there is a fairly good correlation with higher ranked schools having higher Step 1 scores). For those that will be first impacted by this change (entering classes of 2020 to 2022), my recommendation is to place slightly larger emphasis on the medical school pedigree when deciding between schools, assuming the cost differential is not too steep. This change is an unfortunate consequence to students seeking mobility, such as for international medical graduates (IMG) who relied hugely on Step 1 scores for admittance to US training programs. Students at lower ranked schools, either MD, Caribbean, or DO, will also feel the impact as it will be difficult to stand out without a Step 1 equivalent for the first few years.

Impact on Mental Health

As I stated above, there will be now one, as opposed to two, opportunity to excel on a numerically-scored standardized exam. This will likely increase the stress and pressure on students during their core clerkship rotation year which is already enormously stressful for most students. It is unclear what the tangible effects will be, but this change does not seem in the right direction for mental health. This is one area where parents, friends, and students themselves will need to monitor cautiously in the next few incoming medical student classes. If you will be in one of the upcoming medical school classes (entering 2020-2022), I encourage you to be open about your emotions throughout your medical school journey – people are there for you left and right, but they cannot know how you feel.

Shift in Student Focus

With the shift towards valuing Step 2 CK, I believe there will be some very positive and negative shifts in medical education. Currently, because of the emphasis on Step 1, most of the industry is focused on innovating learning techniques and methods geared towards the basic sciences. I can foresee a significant shift in focus towards improving students’ Step 2 CK performances which will be partly through improving the clinical competency of students. This will also be a large incentive to schools who have not revamped their clinical curriculum to do so. However, the lack of emphasis on basic science and understanding mechanisms of disease will be a huge consequence to students in the long run if they are unable to reason through cases that deviate from the norm using their critical thinking skills and knowledge of basic pathophysiology.

Student Work Ethic

A pass/fail curriculum is well known to result in less effort by students. Though proponents of pass/fail claim that students are self-motivated, students are human with many conflicting priorities, and through observing its natural course, pass/fail does lead to a noticeable decrease in effort. Whether that decrease is significant enough to matter in clinical care is uncertain. However, it is clear that medical students will likely warrant some other form of motivation to engage with the basic sciences and think critically about why clinical phenomena are the way they are.

Summary

Overall, I think things are headed in the right direction with this change, but I do believe better steps could have been taken and should be taken to reduce some of the unintended consequences discussed above. I am most excited about this change as a great opportunity for medical education reform. If you’re a premed reading this, be sure to follow this blog as I will continue to post my thoughts as they come up!

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