Impact of USMLE Pass/Fail Step 1 Scoring on Current Medical Students

Abstract

Objectives: The aim of this study was to examine students' perceptions of pass/fail scoring for Step 1, particularly when applying to competitive specialties. This study also investigated whether this transition increased anxiety among medical students and elicited student perspectives on the most critical components of residency applications.

Introduction: The United States Medical Licensing Exam (USMLE) Step 1 Board Exam transitioned from a traditional numeric score to pass/fail for exams taken on or after January 26, 2022. One justification for this change, according to a statement from USMLE, was to ease the transition between undergraduate and graduate medical education. Although many factors are considered when selecting candidates to interview for residency, Step 1 scores were historically used as an important metric. Few studies specifically evaluated medical student's attitudes toward the change in Step 1 grading.

Methods: An online survey was distributed to Penn State College of Medicine medical students in the 2024 to 2027 classes. Statistical analysis was conducted on responses to research plans, attitudes regarding Step 1 pass/fail, match rates, and importance of application components.

Results: There was a 21.3% response rate (127/596) to the survey with 30.7% pursuing a competitive specialty. Students applying into competitive specialties felt their chances of matching changed significantly compared to students applying to other specialties (either increased (25.6% vs 10.2%, P < .001), or decreased (28.2% vs10.3%, P < .001). Majority of students (73.2%) agreed with the decision to make Step 1 pass/fail, however, students reported increased anxiety surrounding Step 2 scores. There was a significant association between which aspects students believed were most important for matching (letters of recommendation and performance on Acting Internships) and those they believed program directors would weigh heaviest (P < .001).

Conclusion: Medical students report increased anxiety with Step 2 after Step 1 became pass/fail, although students overwhelmingly agreed with this change. To address this, medical schools should offer further guidance and resources to students, focusing on mentorship and methods to optimize residency applications for their chosen specialties.

Keywords: Medical education; Medical student anxiety; Step 1.

Figure 1.

Student-reported specialty of interest—students reported the specialty they are most interested in pursuing.

Figure 2.

Student opinions on important application factors from the perspective of students and PDs—student-reported factors of residency applications they felt would be most important and those they thought PDs would find most important. Abbreviations: LOR, letters of recommendation; AI, acting internships; AOA, Alpha Omega Alpha Honor Society.

Figure 3.

Student perceptions on likelihood of matching into desired specialty following the transition to Step 1 pass/fail scoring—student responses separated by specialty of interest, comparing those interested in “competitive” versus “other” specialties (P = .0008).

Figure 4.

Student level of agreement with USMLE Step 1 pass/fail scoring—student responses were separated by specialty of interest to compare those interested in “competitive” versus “other” specialties (P = .4417).

Figure 5.

Student-reported anxiety surrounding USMLE Step 2 scores following transition to pass/fail Step 1 scores—student responses were separated by specialty of interest to compare those interested in “competitive” versus “other” specialties (P = .2634).