It is an annual ritual in medical education. Thousands of second-year students throughout the United States spend a month or more preparing for their very first board exam, the USMLE Step 1. A notoriously difficult test, Step One measures their knowledge of the sciences and pathology that they have been taught throughout the first two years of medical school.

On February 12, 2020, the board overseeing this and other medical board exams announced that they will transition to a pass or fail format. What does this mean for aspiring doctors who have traditionally relied on this test to show off their medical knowledge?

USMLE Step One: A Rite of Passage

As the first of many board exams, this test was more than just a test to students hoping to score a residency and ultimately a medical license. The score on this exam defined residency options for several generations of medical students, with the high scorers being placed in competitive residencies and the low scorers scrambling for less prestigious positions. 

Because this exam has traditionally been so important to residency match, students have focused a great deal of effort and time in getting the best possible score. More than just a rite of passage, one’s board score can open up new options or crash dreams. As a result, students every year spend thousands on board preparation materials and spend a month or more in 24/7 dedicated study. 

Medical school deans and other people involved in medical education have begun to express concern about the disproportionate importance of this exam. Study begins earlier every year, with many medical students neglecting their second-year coursework to get a head-start on board cramming. Because there are many costly programs dedicated to hacking the test, performance is often a measure of privilege as much as a measure of scientific knowledge. 

Critical Reception to New Changes in Medical Education

Although this shift in focus away from standardized testing was received well by many in medical students, there has also been a great deal of criticism. Residency directors, who use this exam as a major factor in ranking student applicants, were particularly critical. 

There will need to be new ways to determine who is worthy of prestigious residencies. Class rank has always played a role and is likely to continue being an important factor. It is also likely that the second board exam, the Step 2 CK, will become even more important in determining residency placement.

As the only remaining standardized method of ranking students from different schools, the Step 2 CK will likely become more important. Taken at the end of third year, after a year of clinical rotations, the Step 2 has always been given less importance than the science-heavy Step 1. Now, students will need to take time away from crucial clinical education and purchase additional board prep materials to remain competitive as they enter the residency match. 

Will School Prestige Become More Important Than Ever?

One of the most important roles of the first board exam was to even the playing field and provide a standardized means with which to compare students from a variety of different medical training programs. Students from small or less prestigious schools routinely outrank students from Harvard and other top-ranked medical schools in this crucial exam. As a result, a great Step 1 score played an important part in allowing students from different backgrounds to compete in an increasingly crowded field.

Students from lesser known state colleges, DO schools, and international universities may find that the shift to a pass/fail USMLE leaves them struggling to compete against students with a well-known name on their diploma. This may be a negative change in a field that needs to move away from elitism and focus instead on quality and diversity.

Letters of recommendations also will likely play a greater role in the match once the first board exam no longer gives a numerical score. This too could be a disadvantage to students from less prestigious schools, who have less access to well-known faculty and rotations at name-brand institutions. Students from privileged backgrounds also have more access to research opportunities, internships, and other opportunities that will give them an advantage in residency application.

Although the first Step exam was a stressful experience, it offered a way for students to compete on an even footing. Without it, less-advantaged students may find themselves struggling to get into competitive specialties and more prestigious residency sites. 

A New Metric for Residencies

The NBME, which regulates medical education as well as standardized board exams, has said that they want residency applicants to be evaluated more holistically rather than ranked by a single test score. However, this can be difficult for residency staff screening hundreds of applications every season. In order to support this more holistic process, residencies may need to hire more staff, adding more overhead to an already bloated and high-priced system of postgraduate education.

Without a way to rank students based on knowledge of the basic sciences that are the focus of second year, there is also a good possibility that students will take these studies less seriously. Previously, many students “over-study” for the science classes of the first two years of medical education knowing that these facts will also be a major part of their first round of board exams. 

In addition, it is feasible that American medical schools will stop taking basic sciences as seriously. Many medical schools are already shifting away from the rote memorization needed to excel in basic science toward a focus on clinical skills and professionalism. Without the Step One exams as both a carrot and a stick, the basic sciences may become even less important. 

Medicine: A Constantly Changing Field

Medicine and health care together comprise one of the most respected fields in the modern world. Every year, tens of thousands of our best and brightest students apply for a chance to prove themselves in American medical school. Those who make it through the funnel-neck of medical school then compete for spots in competitive residencies. The Step 1 has long been an important part of this process. However, a shift to pass/fail grading will make it far less of a focus in second year.

Medical education is becoming increasingly more competitive and challenging every year. The changes to the USMLE will likely affect not just medical students, but PA students and students in other health care fields. Attaining a successful career in health care is difficult work, but more than worth the effort to aspiring doctors and PAs. If you are looking to be more competitive in a field that is focused increasingly on clinical education over academic learning, consider completing a Pre-Med Internship or a Pre-PA Internship