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All physicians practicing medicine in the United States are required to pass a series of standardized board exams known as the United States Medical Licensing Exams (USMLE), which consists of the Step 1, Step 2 Clinical Knowledge (CK), and Step 3 exams. Prior to January 26 of this year, all three exam grades were reported as a numeric score in addition to the designation pass or fail. Since January 26th, the USMLE and its sponsors, the National Board of Medical Examiners (NBME) and the Federation of State Medical Boards (FSMB), have decided to forego a numeric grade for the Step 1 exam, making the score designated only as pass or fail.
The reason for the change? According to Dr. Kevin Jubbal, a plastic surgeon and founder of Med School Insiders, the change occurred to improve the well-being of medical students and decrease the stress and anxiety of students surrounding the exam. According to the 2018 National Resident Matching Program’s Program Director Survey, the USMLE Step 1 score was the number one factor used when deciding which candidate to offer an interview for residency training (post-graduate training that occurs for each medical specialty immediately after graduating medical school). This test, often taken between the second and third years of medical school, aims to confirm minimal competency for licensure by testing fundamentals of the basic clinical sciences that are taught in the pre-clinical years of medical school. It is of no surprise that many medical students would often obsess over getting the highest score possible in order to join the career of their choice after medical school graduation.
Has the change to pass/fail of the USMLE Step 1 done what it was intended to do- namely decrease stress and anxiety in medical students? According to the 2021 National Resident Matching Program’s Program Director Survey, 94% of residency programs require a numeric score on the USMLE Step 2 CK exam before offering interviews to candidates. According to another study, many residency programs now consider the USMLE Step 2 CK as the primary factor when considering which medical students to offer interviews for residency training. The stress and anxiety many medical students feel has simply shifted from the Step 1 exam to the Step 2 CK exam. In other words, the USMLE Step 2 CK exam is the new Step 1, when considering medical student well-being and mental health.
According to a study in JAMA Network Open, 50% of medical students are experiencing burnout. Although there has been much attention given to the crisis surrounding the dramatic rise of physician burnout since the Covid-19 pandemic, much less focus has been given to burnout in medical students, the future caregivers and first responders that will care for you and your loved ones. How can we expect future physicians to master clinical medicine and care for the ill when they cannot even care for themselves?
Equally troubling to the detrimental effects of well-being are the racial and ethnic disparities the USMLE brings to underrepresented medical student candidates for residency. According to data from an article in Academic Medicine, Black and Latino medical students are more likely to score lower and/or fail all three USMLE exams when compared to White students. The reason- downstream effect of decades of systemic racism whereby they are provided fewer resources and opportunities to succeed and excel in academics. Consequently, it is much more difficult for underrepresented minorities to receive interview offers in the specialty of their choice when graduating medical school when compared to White students.
The USMLE, NBME, and FSMB have a real opportunity to promote medical student and physician well-being as well as racial equity by addressing scoring on physician licensing exams. Just as they made the Step 1 pass/fail, they must make all USMLE exams pass/fail. This would undoubtedly reduce the enormous stress and anxiety medical students face during their arduous years in school. Furthermore, underrepresented students will perhaps have a fairer shot at pursuing their dream specialties after graduating. Standardized tests are merely one metric and measure for success. Eliminating numeric scores on the USMLE will force residency programs to make a more holistic review of prospective candidates.
Some medical schools are already doing this for medical school admissions. At the University of Maryland School of Medicine, the admissions committee performs holistic screening deemphasizing standardized tests scores, offers unconscious bias training for interviewers, and blinds interviewers to standardized scores; to name a few initiatives. Residency programs throughout the country should follow suit when considering future trainees in their programs. The USMLE, NBME, and FSMB as well as the hundreds of medical training programs throughout the country must start taking care of medical students, who we will all rely upon to take care of us.
