When the USMLE Step 1 transitioned to pass/fail, medical schools across the country celebrated the change as a win for student wellness. The assumption was that removing a single high-stakes score would lower stress and foster collaboration among classmates. But as anyone applying to residency in this new era can tell you, the stress didn’t disappear, it just changed shape.
In today’s landscape, competitiveness for residency programs is largely determined by a combination of factors: Step 2 Clinical Knowledge scores, research productivity, letters of recommendation, and class rank. Together, these metrics have filled the vacuum left by Step 1. Aside from Step 2 scores, which are typically released a few months before residency applications are due, class rank is often the only metric students don’t learn until just before applications are released, leaving little time to use that information to guide away rotation planning or finalizing specialty decisions.
Across allopathic medical schools, roughly 75% report class ranking of students to residency programs in their Medical Student Performance Evaluations (MSPEs). Although the way in which these rankings are communicated may vary (from individual rank to quartile placement), residency programs consistently factor relative class performance into their selection of candidates to interview and ultimately rank. Despite the obvious importance of this metric, many medical schools have adopted a rank-masking policy in which our class standing isn’t shared with students until mere weeks before residency applications are due.
The result is a strange kind of blindness at the very moment when we’re making the most important decisions of medical school and often our professional careers. As a current medical student navigating this process, I’ve experienced firsthand the anxiety and uncertainty created by not knowing where I stand academically while trying to plan my future. My classmates and I debated endlessly about whether we were aiming too high or too low, but none of us actually knew. Choosing a specialty, especially a competitive one like plastic surgery, dermatology, or orthopaedic surgery, becomes far more difficult without any updated sense of where we stand academically. By the time class rank is actually released to us, the window to adjust career plans has long closed.
The timing is even more problematic when it comes to away rotation applications, which are often submitted near the end of the third year. Away rotations offer students a month-long audition with an outside institution that they would like to eventually match at. There is often significant strategy involved in selecting where to conduct your away rotations as you do not want to waste a valuable opportunity auditioning at a place that would not seriously consider you for residency due to factors such as your class rank. When I was preparing to apply for away rotations, I spent weeks trying to estimate my competitiveness based solely on rumors, scattered grade reports, and whispered comparisons. As a result, even for students who already know their specialty, there’s wide variation in competitiveness among programs within the same field. Without early transparency around rank, students are left to guess whether they’re aiming too high or too low at certain programs, decisions that can determine the eventual success, or failure, of their Match.
Administrators defend this policy by saying it protects student wellness and that withholding rank fosters collaboration and reduces stress. But that logic confuses the cause of anxiety with the awareness of it. The stress associated with class rank doesn’t come from knowing your rank. It comes from the ranking process itself. Concealing that information doesn’t create a kinder environment. It simply replaces clarity with speculation.
Among classmates, rumor often fills the void. Conversations drift into whispered comparisons: who’s getting more honors, who’s likely top quartile, who might make Alpha Omega Alpha (AOA). Without transparency, uncertainty becomes its own source of tension. Instead of removing competitiveness, the policy just cloaks it in secrecy.
Even when a medical school does not share class rank with residency programs, the effects of this concealment still extend to other aspects of competitiveness. The likelihood of AOA selection, which is almost always tied to class rank, remains equally difficult to assess for students. Because AOA status can significantly influence interview offers and residency rankings, this uncertainty carries significant consequences. When students are left guessing where they stand academically until late in medical school, they can’t make informed decisions about whether to dedicate an additional year to a research fellowship to strengthen their research portfolio, pursue an additional degree, or apply to less competitive programs. The absence of timely, transparent feedback doesn’t just obscure performance; it deprives students of the ability to make informed, strategic decisions about their futures. Without a clear sense of where they stand, many are left to navigate specialty choice, research commitments, and application planning through speculation rather than data.
Transparency should be a cornerstone of professional education. Students deserve to know the criteria by which they are evaluated and the results of those criteria, especially when those criteria are shared externally with residency programs. The idea that ignorance reduces stress is both outdated and paternalistic. In clinical medicine, we condemn paternalism because it assumes patients are too fragile or uninformed to participate in decisions that affect their health. Yet, ironically, medical education often applies the same logic to its own trainees. By withholding information under the guise of protecting student wellness, schools implicitly suggest that we lack the maturity or resilience to responsibly manage our own performance data. Students already compare grades, clerkship evaluations, and honors designations. If schools believe ranking students undermines wellness, they should remove rank entirely. But if they continue to maintain and transmit it, withholding that information from students is indefensible. Wellness and transparency are not mutually exclusive. Real wellness comes from trust and from knowing the system assessing you is honest and forthright.
At the end of the day, no matter what reforms we introduce, competition and stress will always be intrinsically tied to medical education. The stakes are simply too high, and the number of desirable training positions too limited, to ever remove it completely. We must therefore build a system that allows residency programs to fairly stratify applicants while treating students with transparency and respect. I have no objection to ranking itself. It is a just and objective way to convey performance. What I reject is the idea that hiding this information somehow protects us. Medicine is, by its nature, a profession grounded in accountability, precision, and performance. We cannot coddle our future physicians from the stress of competition because competition is woven into the very fabric of what we do. Instead, we should focus on improving wellness within that reality by fostering mentorship, community, and resilience while preserving the metric-driven safeguards that keep our standards high and our profession strong.
Forrest is a fourth-year medical student interested in rural medicine and how to best address the physician shortage in these areas, as well as being particularly interested in health policy and the way it is applied to different groups of people in the U.S. Forrest is a 2025-2026 Doximity Op-Med Fellow.
Animation by Jennifer Bogartz
