We summarize and discuss a recent, big change to the USMLE Step 1 made by the FSMB and NBME

On February 12, 2020, the Federation of State Medical Boards (FSMB) and National Board of Medical Examiners® (NBME®), co-sponsors of the United States Medical Licensing Examination® (USMLE®), announced a significant change to how the USMLE Step 1 will be assessed. In short, the USMLE Step 1 will be moving from a 3-digit scored exam to a pass or fail result. *UPDATE: January 26, 2022 has been announced as the official date of the change to pass/fail.

The decision was made after almost 12 months of review and input collected at the Invitational Conference on USMLE Scoring (InCUS). InCUS (held in March 2019) was sponsored by the American Medical Association, the Association of American Medical Colleges, the Educational Commission for Foreign Medical Graduates, the Federation of State Medical Boards and the National Board of Medical Examiners.

Reasons for the Change

As part of its explanation for the shift to a USMLE Step 1 pass-fail scoring system, the FSMB and NBME (referred to after this as the USMLE program) cited concern over the way the 3-digit Step 1 score has evolved to become one of the most significant factors in evaluating students for different residency programs. They specifically cited “overemphasis on Step 1 performance” and said that they wished to refocus medical licensing authorities (and in turn, med students) more on the use of the exam for its primary purpose of medical licensure eligibility.

Put another way, the USMLE program now feels that the current use of the 3-digit Step 1 score as a means for screening applicants for residency programs deviates from how the Step 1 score was originally meant to be used. Moving to a pass-fail Step 1 test result and taking away this 3-digit score, they feel, will refocus the medical licensing authorities back to the primary intended purpose of the Step 1 exam—that is, to grant med student exam-takers a provisional license to continue in a post-graduate medical training program.

The AMA is one organization that supported the shift to a Step 1 pass-fail scoring system, stating in part, “The American Medical Association supports the decision to move to a pass/fail reporting structure for the USMLE Step 1 as a first element in improving the UME to GME transition. Our student, resident and physician members voted to endorse a pass/fail policy, in part, because we know our current residency selection system is causing significant distress for our students.”

USMLE.org published this chart of their view of the pros and cons of changing Step 1 to a pass/fail exam:

Image courtesy of USMLE.org

Timing of the Change

The USMLE program plans to make this change to Step 1 scoring effective as of 2022.

*UPDATE: Following this announcement in February 2020, the USMLE published an announcement about requests they were receiving to either delay or accelerate the change; to which they responded they would not change the timeline as they still feel this date will have the best outcome. Additionally, as a result of COVID-19, they delayed their routine review of the minimum passing score from December 2020 to December 2021, and the effects of this change (although usually minor) will be implemented on the same January 2022 timeline.

Other USMLE Program Changes

Notably, the Step 2 CK and the Step 3 exams will retain their 3-digit scoring system. As well, the USMLE program reduced the number of allowed attempts at any Step exam to 4, from 6. This change will be taking place January 1, 2021. Finally, the program will be requiring all med students to pass the Step 1 before they can take Step 2. This requirement will take effect on March 1, 2021.

Implications for Med Students and Test Prep Companies

Medical students in forums such as Reddit have had mixed reactions to the coming change. Many students feel that a scored Step 1 exam was one way they could set themselves apart when applying to residency programs. They argue that a high Step 1 score gives students an edge when competing with other students, who may be coming from more prestigious medical schools. Other students took the position that the change isn’t necessarily a bad thing, since students will still have to pass all their school exams in the first two years of medical school, PLUS pass Step 1, so they will still be learning.

*UPDATE: Since announcing the decision in February 2020, this study showed the majority of orthopaedic and internal medicine program directors that responded felt the decision lacked transparency and will negatively impact allopathic students from less prestigious medical schools, osteopathic students, and international medical graduates, for example. 

We discuss in this blog post how this change may affect Step 2 CK, but the table below also shares some helpful information to keep in mind. As you can see, the national mean score has risen steadily and now far surpasses the minimum passing score of 209. What this means: although it’s not completely clear how the change to pass/fail will affect Step 2 CK, we know for sure the USMLE is overdue to raise the minimum passing score.

As for test prep companies, including Cram Fighter, it is hard to predict how the change will affect their businesses. It could be that med schools don’t change their curriculum significantly to prepare students for Step 1, so there will still be a need for these outside companies to provide content for med students to get students ready for Step 1. It’s also possible that since Step 2 CK will still be a scored exam, that exam might be more closely evaluated by residency programs to determine which applicants to accept, so med students may still want external test preparation resources outside of their clinical experiences and coursework.

Below are some excellent articles and blog posts that illustrate the medical school industry’s as well as med students’ perspectives on both sides of the coming change:

• NBME Just Made the USMLE Step 1 Pass/Fail! What Does this Mean for Medical Students? – ProspectiveDoctor.com
• Cheers and jeers as med school’s Step 1 test becomes pass/fail – Statnews.com
• Why Pass/Fail Step 1 is Really Only Step 1 – Harvard Crimson
• USMLE Step 1 pass/fail winners and losers – KevinMD.com

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