Why the USMLE Step 1 Should Remain Scored

The discussion surrounding the United States Medical Licensing Exam (USMLE) and whether or not it should be moved to a pass/fail system has been ongoing for the past several years. The key factors most people reference when speaking in favor of changing the exam to pass/fail include:

  1. Step 1 was not designed to, nor does it, predict success as a physician.
  2. Because of the significant emphasis placed on Step 1 USMLE scores in the residency selection process, Step 1 “prep” programs have hijacked the pre-clinical curriculum of many medical schools. 
  3. Students opt to disengage from institutional curricula in favor of intensive exam preparation by commercial resources. 
  4. Commercial products now define the de facto national curriculum of preclinical medical education.
  5. Commercialization of medical curriculum puts students of low socioeconomic status (SES) at a disadvantage because they cannot afford the same resources as those of higher SES students. 
  6. Student well-being is compromised by the intensity required by such a high stakes exam. 

With the general sentiment trending in favor of moving the exam to pass/fail it has become increasingly rare to see a rebuttal in favor for keeping the exam scored. There are however compelling reasons for maintaining the status quo.

  1. The USMLE Step 1 is difficult by design and integrates knowledge from every organ system in complex ways that encourage problem solving rather than rote memorization. It requires significant time and effort in order to pass and even more effort to score in a competitive range. A clear positive correlation has been demonstrated between a student’s grades on pre-clinical curriculum and their score on the USMLE. Students who perform well, have a pattern of consistent effort throughout the pre-clinical years.  One of the most common arguments against the USMLE is that it is not predicative of the future “success” of a physician. There are dozens of characteristics that go into the development of a “successful” physician. However, each field of medicine places value in different characteristics, so any attempt to predict “success” by the means of one standardized test would likely be an exercise in futility. What the USMLE does indicate is how hard an individual is willing to work – a quality which is universally valued in medicine. Removal of the USMLE score in favor of a pass/fail system will consequently demerit the students who work harder and put in more consistent hours over a longer period of time. Without this relatively objective statistic, residency programs will have to resort to other more questionable statistics such as an institution’s reputation and clinical evaluations. With such varied methodologies between schools in ranking and evaluations it would be impossible to accurately compare on a national level. Student residency applications then become less like comparing apples to apples, and more like comparing apples to panda bears. 
  2. There is no doubt that the pre-clinical environment of medical school has become inundated with commercialized USMLE study resources. There are now hundreds of options students can choose from as they first begin their medical education. Many students have opted to entirely forego traditional learning methods such as in-house lectures in favor of these commercialized resources. In the information age we live in this mass exodus away from traditional resources should come as no surprise. 
  3. Instead of asking why students are no longer engaging in the traditional institutional curricula, it should be asked “why are students turning to the commercialized USMLE industry?” Wonderfully concise, professionally curated, and expertly delivered lectures are available on every topic covered in pre-clinical curriculum. Most students have found it far more efficient to watch a 10-minute online video than to attend an hour-long in-house lecture on the same topic (often with hit or miss results). The bottom line is that the commercialized USMLE industry does a better job teaching than most medical school lecturers. This shift should not be assumed as inherently evil, as it actually provides better learning for the next generation of medical students. 
  4. With the commercialization of the pre-clinical curriculum, many argue that we have ceded control over medical education to the test preps companies. These companies are extremely results-driven (i.e. higher USMLE scores). Their content is developed solely based on what is covered on the USMLE. Thus, in reality the control over what it taught in the pre-clinical years rests very heavily within the realm of the test makers, not with the test prep companies. 
  5. How expensive are these products? How much money do students have to pay out of pocket to get the best resources? From personal experience, I probably spent around $800. But compare that number to the $40,000 price tag of the first two years of medical school tuition, and the 0.02% addition is laughable. With many other schools charging significantly more for tuition, the cost of these online subscriptions becomes even more negligible. If a student can pay for medical school, they can pay for the extra cost of test prep products regardless of socioeconomic status.  
  6. Grim statistics are published about how ever greater numbers of medical students are experiencing burnout. Some contribute this to the environment surrounding the increasingly high stakes USMLE exams. Medical education is a transformative experience. Students enter the hospital doors on day one as medically illiterate and walk out at the end of medical school as licensed physicians. Painful experiences are part of the growing process. Being able to perform when the risks of failure are high is an essential part of becoming a competent physician. There is no doubt that wellness should be considered but it needs to be balanced with a healthy amount of pain.

Many of the “problems” associated with the USMLE, when looked at with a less dogmatic lens, are not problems at all but valuable assets. The USMLE has its flaws but devaluing the test by implementing a pass/fail system would likely create more issues than it would solve.  

Bryce Owen is a third-year medical student at The University of New Mexico.

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