This medical exam tried ditching test scores to help students. It backfired

Nearly two years after USMLE's change, students and educators report that the stress has transmuted to other holistic aspects of Step 1, hindered students' preparation for Step 2 and hurt underprivileged and at-risk students' chances of performing well.

Second-year medical students who historically took Step 1 of the United States Medical Licensing Examination (USMLE) had long viewed the exam results as the deciding factor for which institution they’d match to pursue residency and fellowship training. The first of three exams, it was infamously cutthroat.

To kick off 2022, the National Board of Medical Examiners and the Federation of State Medical Board modified Step 1 to help alleviate student stress and promote well-being. Their solution was to eliminate the three-digit numeric test score and replace it with a pass/fail model.

The American Medical Association backed the change, calling the three-digit numeric score “detrimental to student well-being,” saying it distracts students from focusing on teamwork and communication skills.

But the change may have moved medical students out of the frying pan and into the fire. Nearly two years later, students and educators report that the stress has transmuted to other holistic aspects of Step 1, hindered students’ preparation for Step 2 and hurt underprivileged and at-risk students’ chances of performing well.

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Poorer performance

After the USMLE enacted the pass/fail model, Step 1 pass rates fell 6% from the year prior. Daniel Jurich, associate vice president of USMLE at the National Board of Medical Examiners, noted that the amount of time students studied decreased and the number of weeks out that they began studying also shortened. Yet, he believes that, while the pass/fail modem is responsible, this is not necessarily a negative consequence.

“We view this through the lens that one objective of Step 1 changing to pass-fail was to lower the burden and pressure associated with obtaining an extremely high score,” he said. “I don’t want to imply that this decrease reflects a lack of adequate preparation, however.”

On the contrary, TrueLearn, a USMLE test prep company, found that 58% of medical educators believe their students will also spend less time preparing for Step 2 due to the habits they’ve created from more lenient Step 1 demands.

“Changing USMLE to pass/fail seems like a disaster waiting to happen,” wrote one respondent. “They are less likely to study hard for Step 1 if it’s pass/fail. I’ve already heard that from students. They need to wake up and realize this change might not be an improvement in medical education.”

Whether students are experiencing less stress during Step 1 is not entirely conclusive. A study out of Georgetown University School of Medicine and published in Medical Science Educator found that while the pass/fail model produced less stress for students in pre-clerkship, it rose to the same level as students preparing for the numeric test score during the study period.

Persistent stress

Similarly, students preparing less for the Step 1 test are now just focusing more on other aspects of the exam, such as displaying more research, getting letters of recommendation and acquiring an impressive CV and list of extracurricular activities, according to AMBOSS, a USMLE test preparation service.

“I’m not sure the switch of Step 1 to pass/fail has had the intended consequences, at least not on student wellness,” wrote one respondent in TrueLearn’s report. “Our students have simply increased efforts to ‘stand out’ through other means (i.e., anxiety levels remain the same), such as greater involvement in research or community outreach.”

Lack of test scores hurts equitable student outcomes

Lastly, 40% of medical educators believe the USMLE’s change will strain underresourced students’ ability to match their top residency choices. In fact, their chief concern with the change was adequately identifying students at risk of failing; just 26% of respondents said they had the tools necessary to identify them.

Coincidentally, institutions have been choosing to ditch standardized tests to create a more equitable college admissions process.

While changes to the USMLE were supposed to promote developing more well-rounded medical students less burdened by gatekeeping exams, the road continues.

“There’s a strange dichotomy in medical school where despite striving to cultivate altruistic professionals, high stakes exams like this force students to adopt a self-centered approach to succeed,” said Natasha Topolski, chair-elect of the AMA Medical Student Section. “While students try to predict the ‘high yield’ topics, the vast scope of material renders predicting exam content a dangerous gamble.

Alcino Donadel
Alcino Donadel
Alcino Donadel is a UB staff writer and Florida Gator alumnus. A graduate in journalism and communications, his beats have ranged from Gainesville's city development, music scene, and regional little league sports divisions. He has triple citizenship from the U.S., Ecuador, and Brazil.

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