In an education characterized by endless tests, USMLE Step 1 managed to stand out. It was the big kahuna, the last hurdle separating the unwashed masses of first- and second-year medical students from the enlightened beings permitted to actually, you know, talk to a patient. This test marked the transition between years of near-unadulterated bookwork and applying this knowledge in the real world. Perhaps more importantly, it helped shape your career trajectory. A lackluster Step score could mean your dream of becoming an orthopaedic surgeon or dermatologist was over before you put one foot in the hospital.
Then came the COVID-19 pandemic. With limited access to testing facilities, American colleges moved to make the ACT/SAT, a central component of admissions for 50 years, optional. By fall 2023, roughly 83% of four-year U.S. schools utilized test-optional or score-free admission.
The weight placed on Step 1 scores similarly came under scrutiny, with key medical education organizations questioning whether it led to neglect of other valuable areas of student learning, such as research, leadership, and volunteer work. Other concerns included the negative impact of a high-pressure exam on student well-being and its failure to emphasize so-called soft skills like communication and emotional intelligence. By early 2022, Step 1 was changed to pass/fail.
To some, this move was a triumph. It heralded the advent of a more holistic approach to medical education, one which placed appropriate emphasis on other characteristics that make up a successful physician.
But to students on the forefront of these changes, the decision to make Step 1 pass/fail has brought with it a new blend of uncertainties and pressures. It fundamentally reshaped the medical education of medical students both at my institution and across the country. As the second class to go through the residency match process without a Step 1 score, I have been on the front lines of the implementation of this change.
Three years out from this landmark decision, it's time to check back in.
One of the concerns cited in the rationale to remove scoring of Step 1 was the "potentially negative impact of preparation for high-stakes testing on student well-being." Removing a score from Step 1 likely does improve stress levels for those going into less competitive specialties at less desirable institutions. However, for those going into competitive specialties or targeting prestigious programs, this change has the opposite effect. Taking away one of the few objective measures of content mastery, especially when many medical schools no longer provide grades, places increasing importance on extracurriculars.
For many this means one thing: research. While research has long been an important component for matching into competitive specialties, it is likely to become even more critical as the number of publications becomes one of the few objective measures on a student's CV. A study done shortly before the USMLE change found that 60% of students planned to put time previously spend studying for Step 1 into their research activities. This may have positive ramifications for increasing an institution's scientific impact but pushes students to spend more and more time on pursuits that, for many, will not be a large part of their future career. Additionally, institutions often fail to provide adequate formal training for students to build research skills, such as statistical analysis, leading them to fumblingly attempt to teach themselves. As one of my classmates (a dermatology hopeful) said semi-jokingly when asked how medical school was going, "I feel like I'm getting my PhD in Statistics." Self-taught, of course.
With so much pressure to be heavily involved in leadership, service, and research, it is easy to lose sight of the primary goal of medical school: namely, developing the skills and knowledge to competently treat patients. Before, modest involvement in extracurriculars could be excused by solid mastery of the curriculum. Now, in schools that have made the entire curriculum pass/fail (such as my own), there is nothing to distinguish a student that studied just enough to pass the test from someone who truly mastered the material. The former is likely experiencing the greater well-being and mental health administrators envisioned in removing a score from Step 1. The latter, on the other hand, is diligently exhausting themselves to truly learn the material while also competing in the worsening extracurricular arms race.
Making Step 1 pass/fail doesn't reduce the effort or stress of medical school. It redirects it. Often in less important directions.
So where do we go from here?
Several changes would restore the proper focus to medical school while still promoting holistic evaluation of candidates during residency applications.
Reinstitute scores for Step 1. Making Step 1 pass/fail followed nationwide trends to deemphasize standardized scores in college admissions. Many prestigious colleges have since reversed course, recognizing that important role of test scores as one of many data points when evaluating candidates. The AAMC can do the same.
Fine tune the signaling process for residency applications. One of the main barriers for holistic review of residency candidates is the sheer number of applications. Signaling, when used correctly, can greatly reduce the number of applications a program director has to review. This allows for more time with, and thus more holistic review of, applications.
Increase residency application transparency. This past spring, the program director for the Yale Internal Medicine Program went viral after posting the formula he uses to rank candidates. The spreadsheet outlined how each component of the application, from Step 2 score to leadership, was weighed in evaluating their position on the list. Such transparency is refreshing and provides a model for how to holistically review applicants. If more programs were to embrace this trend, it would also give candidates the information they need to wisely allocate their time and efforts during medical school and application season.
Making Step 1 pass/fail was a worthwhile experiment. Most fair-minded persons can see the shortfalls of emphasizing a test score above all else. The best doctors are those with both clinical acumen and excellent soft skills, which are regrettably difficult to evaluate on a multiple choice test. However, making Step 1 pass/fail has had the effect of deemphasizing learning in medical school to an intolerable degree while failing to achieve many of its stated goals regarding student well-being and burnout. It also has not made residency programs, particularly in competitive specialties, appreciably more holistic, as Step 2 scores have become the new Step 1.
Medical professionals are, by nature, scientists. We see problems and think of interventions to fix them. We have the curiosity to ask "What if?" and the temerity to venture into the unknown. But part of being a scientist is recognizing when things aren't working. To be able to look at our most cherished theories, the ones we have loved since they were a mere twinkle in our eyes, and clearly see they are wrong. To be a scientist is to recognize when an experiment has failed. And to try again.
Do you think making Step 1 pass/fail was a failed experiment? Share why or why not in the comments.
Eliza Broadbent recently graduated from the University of Utah School of Medicine. She is a current PGY-1 in otolaryngology at the University of New Mexico.
Image by Alphavector / Shutterstock
