Last month, for the first time, the U.S. Medical Licensing Examination (USMLE) administered the Step One exam to second-year medical students in a pass-fail format. The USMLE finalized the decision to replace the scoring last December, explaining that the exam was intended for use as a benchmark and not to differentiate between students. They also acknowledged that students were prioritizing Step One preparation “at the expense of other curricula and their own well-being.”
Priya Jaisinghani, MD, an endocrinology fellow at New York-Presbyterian Weill Cornell Medical Center, called the move, “a step in the right direction” in an interview with MedPage Today. She suggested that early medical students can now re-prioritize critical medical skills as opposed to burying themselves in test preparation. "There was so much onus on the exam. Now [students can] shift focus to experiences, organizations, community health, and research," she said. DO students may also feel some relief at the update. While they are required to take the COMLEX, many elect to take the Step One in order to increase the competitiveness of their residency applications.
Others suggest that the move will negatively affect some students seeking to differentiate themselves as applicants to highly-competitive residencies. While unofficial, many specialties are known to have score cut-offs for residency applicants. Among the 2019-2020 first-year residents, Step One scores among thoracic surgery, orthopedic surgery, and otolaryngology averaged 247.3, 246.3, and 246.8, respectively. Residents in emergency medicine (230.9), family medicine (215.5), and internal medicine pediatrics (235.5) received lower scores on average. A 2021 survey of orthopedic surgery program directors confirms this point, with 68 percent calling the Step One score “extremely or very important” for applicant interview selection.
According to USMLE, removing the scores will encourage programs to review candidates more holistically. Practically, however, it is unclear what that may look like in the near term. Some students, speaking to Medpage Today, suggested that letters of recommendation and school rankings may play a more outsized role in residency considerations. "It makes it harder if you are coming from smaller institutions. It becomes more about who you know and who's making phone calls for you. Students with great medical pedigrees may have more advantages,” Lena Josifi, MD, a fourth-year orthopedic surgery resident at Southern Illinois University, said.
A survey of orthopedic surgery program directors confirms Josifi’s hunch. Over one-third (37.7 percent) agree that the changes to Step One scoring would “probably” or “definitely” decrease the likelihood that applicants from lower-ranked medical schools would be selected for interviews. The majority, 81 percent, also agreed that Step Two results will grow in importance.