I. Background

-Step 1 is the first in a series of medical licensing exams for student physicians in the United States

-2019, Journal of Academic Medicine, group of medical students talked about the toxic Step 1 environment that develops during the preclinical years of medicine (https://journals.lww.com/academicmedicine/Fulltext/2019/03000/Student_Perspectives_on_the__Step_1_Climate__in.9.aspx)

-A few days ago, NBME decided to make Step 1 pass fail to help with student wellness and reduce this toxic culture

II. Pros and Cons

Pros

-Everything in this post by Dr. Brian Carmody MD (https://thehealthcareblog.com/blog/2019/03/20/usmle-step-1-leveling-the-playing-field-or-perpetuating-disadvantage/)

• A pass/fail USMLE is a means to an end. The exam wasn’t designed to be a metric of evaluating candidates, but rather a competency test. Other metrics are better to evaluate students.

Cons

-More difficult for non-top tier MD students, DO students, and foreign students to stand out in clerkship and residency applications.

• NBME made a statement about this in Academic Medicine journal (https://www.ncbi.nlm.nih.gov/pubmed/30570495):
  • “Students and U.S. medical graduates (USMGs) from elite medical schools may feel that their school’s reputation assures their successful competition in the residency application process, and thus may perceive no benefit from USMLE scores. However, USMGs from the newest medical schools or schools that do not rank highly across various indices may feel that they cannot rely upon their school’s reputation, and have expressed concern in various settings that they could be disadvantaged if forced to compete without a quantitative Step 1 score. This concern may apply even more for graduates of international medical schools (IMGs) that are lesser known, regardless of any quality indicator.”
• Rebuttal: There’s more to the score. Specifically regarding IMGs: “We’re still going to have the same number of spots – and U.S. allopathic graduates can’t fill all of them. Sure, programs who currently match IMGs / DOs could certainly choose to stop interviewing them. In my opinion, programs who find value in training IMGs / DOs (or who need IMGs / DOs to fill their positions) will still choose to interview and rank IMGs, regardless of the evaluation methods available. In fact, if we had more meaningful metrics – metrics that actually predicted residency success, unlike the USMLE – more programs might be willing to consider IMGs. So why not choose methods that are more meaningful?

-This will shift the focus to USMLE Step 2 CK and clerkship grades; just shifting the stress forward more.

-Look at what happened to dental schools and dental residencies (thanks to /u/ivy-ch on reddit):

• “Part 1 dental boards went P/F about 5-10 years ago. It didn’t last long. 

Eventually, residency programs needed something. We have too many schools which are P/F, not to mention that grading in dental school in the clinical years is messy, boarding on unethical. Eventually, specialties found other exams.

Maxillofacial surgery started making applicants take the CBSE. Orthodontics starting making applicants take the GRE. Eventually, some genius decided to make a new exam called the ADAT (imagine the AMCAT – the advanced medical college admission test). Once that exam came out, general residencies, endodontics, periodontics, everyone wanted applicants taking that.

Only difference is that our part II dental boards also went pass/fail. So as some posters have said, my guess would be medical part II becomes the important exam now.”

-Program Directors, anonymous online, not fans of the change. See here:

“In a climate of everything being pass/fail for the first 2 years, you want as much information that will differentiate you as an individual as possible. I am not looking forward to MS4 students who will forgo learning opportunities to study for step 2 which will be the test that differentiates you the most. Also, i have had residents who did very well on step 1 but not as well on step 2. This decision will decrease that student’s ability to get into a residency.

If step 2 CK is made pass/fail…..then you will be judged solely on your medical school…period. Any bumps in the road that could have been smoothed over with outstanding scores (ex: failed a course as an MS1 but came back with 240s) are now more glaring. IMGs and Caribbean schools will be hosed. I trained some carrribean school grads with great scores that waaaay outperformed their US grad counterparts. That possibility will not happen if STEP 1 and 2 are pass/fail.”

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