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Your USMLE Step 1 Score in a Pass/Fail World: What Does It All Mean Anymore?

  • by Dr. Brian Radvansky
  • Apr 13, 2022
“January 26, 2022, a date which will live in infamy.”
–unattributed. Or maybe FDR. Cannot recall.
If you are anywhere in the medical education realm, you know this date as the moment when the USMLE transformed Step 1 from a numerically scored hurdle to a mere pass/fail test. It was a bombshell that rocked the medical education community, students and educators alike. Is your whole residency admissions plan derailed? Will things never be the same? Why are they doing this to you?
Take a breath. While it some ways it seems everything is different, in reality, the paradigm of selecting excellent medical students for residency hasn’t changed too much. Let’s take a look from the perspective of admissions committees, who were formerly criticized for placing too much important on a single number. Students probably fall into one of these four groups.
  1. If you were an excellent test taker who excelled all-around, you will pass the test and still excel all around. Nothing much has changed. You were marvelous before and after this news.
  1. If you were an excellent test taker whose non-testing ability left something to be desired, this might be sad news indeed. You can no longer ride a high score into residency interviews, and must depend on the rest of your application to shine.
  1. If you were a poorer test taker who excelled all-around, this news has come from the heavens. Finally, you won’t be labeled as a number, and the totality of who you are can float to the surface of your application. You’ll have a chance to shine without hiding behind a number. As long as you pass.
  1. And if you were a poorer test taker who is just scraping by, you’ll need more than just a passing score. You might want to re-evaluate how you can improve your candidacy overall.
As you can see, no matter where you came from, unless you were from camp B, your approach to things will be pretty similar. If you were in camp B, it’s time to get the rest of your application up to the level of your test taking ability!
Now, what can one do to make the rest of their application shine?
For the physician-scientist in you, let us look at the data. Throughout my articles, you’ll notice the NRMP Program Director Survey is a document that I frequently reference. And there’s a reason. It’s the only source of objective data we have regarding what is important to the attendings reading your applications. In the mysterious world of medical education and admissions, there are so many urban legends and backroom stories that float around…forget all of that, and look at the data! From the 2021 edition, we find this:
Figure 1. NRMP Program Director Survey, 2021
What are PD’s looking at when deciding who gets an interview? Let’s look at some of the most important aspects of your application, and talk about what you can do to build the best application, and nail that residency spot you so desire.
#1: Step 1 score – Gone. out the window. Naturally, you must pass the test. A failure is going to be a large red flag on your application, so while you don’t need to aim for a 260+, you DO need to pass. Do what you need to get that P.
#2: Your MSPE (Medical Student Performance Evaluation) – Colloquially known as your “Dean’s letter, this part of the application was exceedingly important in the past. With Step 1 scores vanishing, your MSPE will only be more important going forward. You need a great one. How do you get a great one? By being a great medical student of course. Hopefully you already know how to do this, and have been doing it throughout medical school. 
The big picture shift that comes with the cancelling of Step 1 scores is a move away from being defined by quantified metrics, and a move toward a being defined by your character. Program directors want well-rounded, humanistic physicians who do the best possible for their patients, and who will be joys to work with.
The quality of your MSPE letter is defined by the quality of your character. Did you go the extra mile throughout medical school, or just skirt by? Did you aim to improve the experiences of everyone around you? Did you devote what precious little free time you had to community outreach? Volunteerism? Were you a joy to be around on rounds? Did you lift up your fellow medical students in collaborative way instead of being a cutthroat competitor? All of these answers are facets of your character, and character is the new centerpoint of everyone’s applications.
Luckily, you’ve probably been building character all of your life; you don’t need to make any changes to achieve good character. After all, it’s how you made it this far. But your MSPE gives deans (as well as the writers of your evaluations) the explicit examples of what makes you a great person. Ergo, you must use every opportunity in medical school to be a mensch, do great work, and show everyone why you’ll be a great physician through the actions that you take throughout medical school.
#3: USMLE Step 2 CK Score – We didn’t make it far before finding that oft-dreaded word “score” once more. There has been no formal guidance as to how Step 2 CK scores should and will be interpreted in this new scoreless Step 1 world. Will Step 2 CK score supplant Step 1 score as the most important part of the application? There is certainly a chance; admissions committees will need some way to screen the incredibly large amount of applications they receive. Step 2 score is an easy way to divide students into piles of yeas and nays. While this is counter to the goal of getting rid of Step 1 scores, it’s hard to imagine things any other way. This scenario is made more likely by the fact that more and more program directors want to see a Step 2 score on your initial application. Gone are the days where students would strategically schedule Step 2 so that they would have the option to disclose (or withhold) the score on their application. The new teaching is to do outstanding on Step 2 and report this score.
Even if it stays behind MSPE, Step 2 CK score is the only numerical score you’ll be sporting on your application, so you need to do incredibly well on it. The better you do, the better your chances of getting an interview. Period. We will see how things shake out during future admission cycles (as well as with the new Program Directors Survey from 2022).
Remember, the admissions process is dynamic. Perhaps the USMLE will do away with Step 2 CK scores. Or a new metric will get invented that scores students on humanism. It’s senseless to speculate when you can channel that energy into Step 2 studying.
We will break down the rest of the Program Director’s Survey, and tell you just how you can compile the best application possible in this ever changing residency admissions world. After all, that’s why we are here.
Further reading: