The recent announcement that beginning in January 2022, the USMLE program will change score reporting for its Step 1 from a three-digit numeric score to reporting only a pass/fail outcome has sparked vigorous debate across all platforms and stages of medical training. This is a topic on which everyone in the medical profession seems to have an opinion as every doctor who practices in the U.S. has taken the exam. One of the points brought up repeatedly involves how this change will affect international medical graduates (IMGs) when compared to American medical graduates (AMGs).
Anecdotal evidence gathered from an analysis of social media posts indicates that many of the avid defenders of a scored Step 1 fall into one of the following categories: test-takers who scored exceedingly well; test-takers whose residency applications would be lacking without an impressive score; and individuals who have been benefiting financially from the test. These include tutors and exam prep course teachers. Understandably, these people support a scored exam. But how about everyone else?
Many residency programs utilize Step 1 as a “screening” metric. You need only read the requirements for application to a handful of programs to know this is true. This means that students whose scores fall below a predetermined number would not be considered at any program utilizing that metric. The use of a standardized metric for residency screening is not problematic in principle, but the issue lies in the validity of this particular test. There is no evidence that Step 1 score correlates with success in a given specialty, yet a low score makes matching into many specialties impossible.
Step 1 also has a significant margin of error in score reporting. Dr. Bryan Carmody, who has been a vocal proponent for a pass/fail Step 1, has done the math to demonstrate that if a student went back in time to retake the Step 1 knowing the same medical information, the score could deviate within a staggering 12-point margin (one standard deviation). Advance to a second standard deviation, and you have a 24-point error margin. This is just too imprecise to close so many doors to a medical career. This is particularly true for IMGs.
As physician shortage continues to rise especially in rural communities, there are mounting clues that it might worsen if drastic measures are not instituted. IMGs are eager to serve these communities and help lower the physician shortage. Unfortunately, there are too many barriers in the way of fulfilling this mission. The scored USMLE Step 1 is one of those factors.
Because most residency programs utilize the scored Step 1 as a screening tool, applications submitted every year by thousands of otherwise well-qualified IMGs never get looked at. The consequences are the frustration of international applicants, unfilled residency programs, and persistent physician shortages.
The frustration of IMGs who do not get accepted into residency training must be understood in context. Before attempting the USMLE tests, many IMGs already have several years of clinical practice experience in their home countries. Many IMGs also have other advanced degrees in disciplines such as public health, administration, and the sciences.
Unfortunately, the years of foreign clinical experience that IMGs bring often becomes a disadvantage. This is because another screener that residency programs use to pre-select applications is the number of years since graduation from medical school. As if these obstacles were not enough, IMGs also face the uncertainty of visa approvals and the sheer financial cost of undertaking all the USMLE steps required for certification and licensing. Most IMGs come from India, Pakistan, and Nigeria — countries where educational loans are difficult to access or even non-existent.
Thus, any proposal that relieves IMGs of any of the above obstacles would be a welcome development. Reporting the result of the USMLE Step 1 as either pass or fail is a good start. This will give residency programs access to thousands of high quality, well-motivated IMGs who would previously have not gotten a chance to have their applications reviewed.
It is our understanding that this change will open the door to a bright medical career for promising AMGs and IMGs alike. It will also move the United States closer to resolving the physician shortage issue,
Kayla Flewelling is an American medical student at Central Michigan University.
Eno-Obong Effiong is an international medical graduate. She has been accepted into Internal Medicine residency at St. John's Riverside Hospital, Yonkers, New York.
Utibe Effiong is an Internal Medicine physician with Mid Michigan Health and Clinical Assistant Professor of Medicine at Central Michigan University. He is also a Global Health and Development Senior Fellow at the Aspen Institute.