The United States Medical Licensing Examination (USMLE) Step 1 is a standardized test that assesses a medical student's knowledge of basic science concepts and their application to clinical medicine. The exam is one of three components required for medical licensure in the United States and is typically taken by students after their second year of medical school.
The USMLE Step 1 consists of 280 multiple-choice questions administered over an eight-hour period. The exam covers topics such as anatomy, biochemistry, pharmacology, and physiology, among others. Scores used to be reported on a three-digit scale, but as of February 2022 is reported as pass/fail.
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Before 1992, the NBME Part I examination was the primary basic science examination for medical students at the end of their second year. When the three-part United States Medical Licensing Examination was launched, the NBME Part I exam was incorporated into its new format, the USMLE Step 1 examination. Over time, the exam has evolved into a more clinically applied examination of the foundational sciences. The exam became computer-based several years later. In May 2015, the USMLE began emphasizing concepts related to patient safety and quality improvement across all parts of the USMLE exam series, including Step 1.[1]
While traditionally, students took the USMLE Step 1 exam after completing foundational sciences and before core clinical clerkships, in the past decade, a growing number of medical schools have reformed their curricula to have students take the USMLE Step 1 after core clinical clerkships or preliminary clinical training.[2]
In response to concerns about the role of USMLE Step 1 scores in residency selection and the negative impact on medical student mental health, the United States Medical Licensing Examination (USMLE) announced significant changes to the exam in 2020. One of the major changes was the transition to a pass/fail scoring system from the previous three-digit score reporting system. The change was made to encourage a shift in focus from "high-stakes testing" to "learning and individual improvement," as well as to alleviate some of the stress associated with the exam.[3][4] These changes were implemented starting in January 2022, with the first USMLE Step 1 scores reported in the pass/fail format in February 2022.
The changes to the USMLE Step 1 exam have elicited mixed reactions from the medical education community. While some see the shift to pass/fail and the shorter exam format as positive steps toward reducing the pressure on medical students and promoting a more holistic approach to residency selection, others are concerned.[4]
The United States Medical Licensing Examination (USMLE) Step 1 is a computer-based test that assesses whether medical students or graduates can apply important concepts of the foundational sciences fundamental to the practice of medicine. The exam consists of 280 multiple-choice questions, divided into seven 40-question blocks, and takes eight hours to complete.[5][6][7]
Step 1 is designed to test the knowledge learned during the basic science years of medical school as applied in the form of clinical vignettes. This includes anatomy, behavioral sciences, biochemistry, microbiology, pathology, pharmacology, and physiology, as well as to interdisciplinary areas including genetics, aging, immunology, nutrition, and molecular and cell biology.[8] Epidemiology, medical ethics and questions on empathy are also emphasized. Each exam is dynamically generated for each test taker; while the general proportion of questions derived from a particular subject is the same, some test takers report that certain subjects are either emphasized or deemphasized.
Prior to this change, students received a score ranging from 1 to 300, with most scores ranging from 140 to 260. The passing score was 196, and the national mean and standard deviation were approximately 232 and 19, respectively. The scoring system used to be percentile-based[citation needed], but in 1999 it was phased out in favor of the three-digit and two-digit scaled scoring system. Two-digit scores were eliminated from the score report in 2013.[9]
It was announced on February 12, 2020, that beginning no earlier than January 2022, USMLE Step 1 would transition to a Pass/Fail scoring system.[13] In July 2020, the USMLE announced that prior transcripts would not be retroactively altered."[14]
The medical community has criticized the USMLE and residency programs for using Step 1 scores as the main screening tool in selecting applicants for a residency interview.[16] Residency program directors had historically utilized the scores as a means of filtering applications down to a more manageable number that allowed for a more thorough review of the remaining ones. A significant amount of residency program directors believe that the conversion to Pass/Fail will make applicant screening more arduous.[17][18] In fact, an applicant's Step 1 score has been cited by residency program directors as their most important criterion in selecting graduating medical students for their residency program.[19]
Studies on Step 1 performance found that "Step 1 is neither precise nor does it predict student performance beyond a certain threshold. With a standard error of eight points, two applicants with scores as far as 15 points apart may not be meaningfully different and yet several programs use singular cutoff points as screening tools."[20]
Since 2001, there has been a strong plea to remove the Step 1 score barrier that disproportionately affects select racial and ethnic groups. "Using Step 1 scores to screen residency applications puts students who are underrepresented in medicine at a disadvantage."[22] Black and Latino students receive markedly lower scores on Step 1 than white students.[16] The mean USMLE step 1 score was significantly greater among white applicants (223) as compared to black and Hispanic applicants (216).[23] Depending on the threshold score, an African American was 3-6x less likely to be offered an interview.[24]
A 2001 study in internal medicine residency showed that "when Step 1 scores were used to screen applicants for interviews, a significantly greater proportion of Black students were refused interviews."[25] A 2019 study on Orthopedic Surgery residency programs (the specialty with the lowest percentage of underrepresented students) showed that between 2005 and 2014, Black and Latino applicants were accepted into residency programs at a significantly lower rate (61%) than white applicants (71%).[26]
The American Academy of Family Physicians and Association of American Medical Colleges supported changing Step 1 to pass or fail to reduce racial bias.[28][29][30] The AAFP wrote that changing Step 1 to Pass/Fail creates a "more equitable student evaluation and residency selection process, as it will reduce the impact of racial and other biases on residency selection. Factors that impact student experience with standardized testing (such as access to test preparation) perpetuate inequities and disparities that impact test performance, but do not predict or capture competency or skills for future physicians."[28] The American Medical Student Association recommended changing scoring to Pass/Fail to reduce the adverse impact of the current overemphasis on USMLE performance in residency screening as well as the associated racial bias.[31] The ECFMG and AMA supported this transition as well.[32]
According to the NMBE's InCUS survey results, there were mixed responses regarding support for "consideration of changes such as pass/fail scoring categorical/tiered scoring, and composite scoring." Per the survey, those in agreement with changes include 26% of residency program directors, 32% of current or former state board members, 39% of interns, residents, and fellows, 39% of medical school faculty, 44% of medical students, 67% of course directors, and 75% of Associate/Assistant Deans (of medical schools).[33] Notably, medical students and program directors were among parties with only a minority in favor of this change, despite being the most directly affected. Parties associated with medical schools, namely course directors and Deans were noted to have the most support for changes.
The USMLE parent organizations, including the AAFP, AMSA,[29] and AAMC wrote letters to the USMLE recommended broad, systemic changes to the medical program including changing Step 1 to Pass/Fail. "The current overemphasis on USMLE Step 1 is having an overwhelmingly negative impact on students. This should be addressed immediately. A Pass/Fail score will help provide a more meaningful learning environment, improved emotional climate, and better student-student interactions, which can lead to better academic performance that includes USMLE tests (see Cause or effect?). Additionally, it will decrease racial bias for programs that use USMLE Step 1 scores to grant interviews."[34] Further, they supported the move to Step 1 Pass/Fail citing unintentional negative impact of a single standardized exam on career exploration and selection.[35]
According to the NMBE's InCUS survey results, there were mixed responses regarding support for "consideration of changes such as pass/fail scoring, categorical/tiered scoring, and composite scoring." Per the survey, those in agreement with changes include 26% of residency program directors, 32% of current or former state board members, 39% of interns, residents, and fellows, 39% of medical school faculty, 44% of medical students, 67% of course directors, and 75% of Associate/Assistant Deans (of medical schools).[33] Notably, medical students and program directors were among parties with only a minority in favor of this change, despite being the most directly affected. Parties associated with medical schools, namely course directors and Deans were noted to have the most support for changes.
Immediately following the announcement by USMLE that Step 1 would become Pass/Fail in 2022, concern has been expressed from several parties in the medical community, namely residency program directors and medical students, both among US graduates and international graduates. 152ee80cbc
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