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March 6, 2020

The USMLE Step 1 Decision: An Opportunity for Medical Education and Training

Author Affiliations
  • 1Federation of State Medical Boards, Euless, Texas
  • 2National Board of Medical Examiners, Philadelphia, Pennsylvania
  • 3Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
JAMA. Published online March 6, 2020. doi:10.1001/jama.2020.3198

The announcement by the Federation of State Medical Boards (FSMB) and the National Board of Medical Examiners (NBME), on February 12, 2020, to change score reporting of Step 1 of the United States Medical Licensing Examination (USMLE) from a 3-digit numerical score to pass/fail followed years of debate; more than 2 years of active discussion; comprehensive input from various groups including medical students, international medical graduates (IMGs), residents, medical school faculty and administrators, residency program directors, state medical boards, and members of the public; and review of many direct and indirect suggestions.

Even though the change will not take effect before 2022, the decision should encourage residency applicants, medical school faculty, and those involved in selecting candidates to review processes and identify opportunities by which medical students and IMGs transition into graduate medical education (GME) training positions. The decision has already enlivened nascent discussions at the Coalition for Physician Accountability,1 whose participating organizations that oversee the assessment, accreditation, licensure, and certification of physicians are considering processes that meaningfully recognize and prioritize desirable factors among residency candidates and also provide candidates with better information to guide their residency search and selection.

This Viewpoint discusses the rationale for the Step 1 decision, including some of the advantages, challenges, and opportunities that may lie ahead for USMLE examinees and those who use examination results.

The USMLE was created by the FSMB and NBME in 1991 on behalf of state medical boards as a multistep assessment to determine a physician’s licensure eligibility. As physicians, regulators, and educators have focused on improvements in medical education and the licensure process, concerns have gradually grown about the deleterious effects of high-stakes examinations like Step 1 on medical student well-being and the potential adverse effects of such an environment on medical school learning. Secondary uses of the Step 1 examination (eg, for residency screening and selection) have gained in importance as significant changes have occurred in both undergraduate medical education (UME) and GME. Many medical schools now only report pass/fail grades on their transcripts for the first 2 years of instruction. The Balanced Budget Act of 1997, meanwhile, instituted caps on funded GME residency positions, intensifying competition for residency training positions as the number of qualified medical students and medical schools has increased.

Score reporting on the USMLE was identified as a potential area of concern several years ago when the cosponsors of the examination undertook an analysis called the Comprehensive Review of the USMLE.2 Focused on advancing innovations in various aspects of the program, they agreed to defer action to better understand secondary use practices and their unintended effects, such as heightened anxiety among examinees who were making career decisions about specialty training based on Step 1 examination performance.

In 2018, the FSMB adopted a policy on physician wellness that called on organizations involved in medical education and training to “[improve] the culture of medicine and [facilitate] open conversations about illness and wellness in order to promote positive change.”3 To explore examinee wellness, the NBME created a task force called Re-Examining Exams: NBME Effort on Wellness (RENEW).4 Both organizations began substantive conversations to explore what was happening around them, guided by the shared commitment of the USMLE program to provide state medical boards with important measures of the competencies of a physician while trying to improve the overall climate of stress and anxiety among medical students.

In 2019, both organizations partnered with the American Medical Association, the Association of American Medical Colleges, and the Educational Commission for Foreign Medical Graduates to convene a summit in Philadelphia called InCUS (Invitational Conference on USMLE Scoring), which included examinees, medical school faculty, residency directors, and sponsor representatives.5 The meeting generated a broad range of opinions and fostered rich information exchange. In addition to student wellness, other issues raised included the disproportionate attention students paid to Step 1 preparation to the detriment of other curricular elements, and the influence of Step 1 scores on applicants from groups historically underrepresented in medicine. On a website created to solicit feedback and suggestions, more than 21 500 comments were received from individuals and organizations across the country and around the world.

While there was no unanimity among the various groups about the best path forward, following an internal review of possible Step 1 score reporting options, including the possibility of no changes or the adoption of other types of scoring, the staff and governance of the FSMB and NBME aligned around one decision—reporting Step 1 results as pass/fail. The decision does not substantively change the way state medical boards make their licensure eligibility decisions (passing Step 1 remains a requirement and first step, literally, for medical licensing) and it is balanced with the concerns and input received from many groups, especially examinees. In making this decision, the FMSB and NBME are suggesting there should be less reliance on a single point-in-time licensing assessment like Step 1, which is focused on foundational sciences, to inform the transition from medical school to residency.

In the short term, it is likely that all examinees will continue their current practices in preparing for these assessments. Some have postulated that after the Step 1 score reporting change goes into effect, the Step 2 Clinical Knowledge examination may gain more importance for residency selection. The Step 2 Clinical Knowledge, in contrast to Step 1, is focused on clinical sciences, and there is evidence that correlates scores with clinical and other outcomes.6,7 It is hoped that organizations involved with medical education and training will use the period between the announcement and implementation of the change as an opportunity to create a better transition from UME to GME so that the stress associated with Step 1 is not simply transferred to Step 2 Clinical Knowledge. Many medical students already take Step 2 Clinical Knowledge before the residency application process and others may elect to take it sooner than they do now.

Many osteopathic medical students take Step 1 and Step 2 Clinical Knowledge to compete for residency positions and, given this change, more students may be prompted to take Step 2 Clinical Knowledge. The National Board of Osteopathic Medical Examiners, which produces the 3-part Comprehensive Osteopathic Medical Licensure Examination for osteopathic physician licensure, is exploring score reporting changes to its examination. With a single accreditation system for GME nearing completion this year, there may be opportunities for collaboration to ease the transition from UME to GME for all medical students.

Because many IMGs interested in GME positions in the United States have already graduated from a medical school by the time they apply for residency positions, some have examination results available for all 3 steps of the USMLE. While the USMLE program does not require taking and passing Step 1 before being able to take Step 2 Clinical Knowledge, IMGs are required to pass Step 1, Step 2 Clinical Knowledge, and the Step 2 Clinical Skills examination (which is also pass/fail) for certification by the Educational Commission for Foreign Medical Graduates. That designation enables them to enter residency or fellowship programs accredited by the Accreditation Council for Graduate Medical Education, to take Step 3 (which has a 3-digit numerical score), and to ultimately become eligible to obtain an unrestricted license to practice medicine from a state medical board. Residency programs will likely continue to look at numerical scores on Step 2 Clinical Knowledge and Step 3 for residency screening and selection. It is uncertain whether residency program directors will also value seeing passing performance on Step 1 as part of their screening and selection process.

The USMLE program will continue to work with UME and GME communities and others as they explore a process that supports a career journey for physicians that the public can trust. Thaler and Sunstein8 have described “nudge” as an effort by which positive reinforcement and indirect suggestions can influence behavior and decision-making. Although primarily focused on behavioral economics, their work highlights how the right types of nudges can improve health and happiness. It remains to be determined how the change to Step 1 score reporting will be perceived. The change should certainly stimulate needed conversations about what other transformations may be required.

(This Viewpoint is available for online commenting.)

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Article Information

Corresponding Author: Humayun J. Chaudhry, DO, MS, Federation of State Medical Boards, 400 Fuller Wiser Rd, Ste 300, Euless, TX 76039 (hchaudhry@fsmb.org).

Published Online: March 6, 2020. doi:10.1001/jama.2020.3198

Conflict of Interest Disclosures: Dr Chaudhry reported employment with the FSMB, a co-owner and cosponsor with the NBME of the USMLE. Dr Katsufrakis reported employment with the NBME. Dr Tallia reported being chair of the NBME.

Additional Contributions: We thank Scott Steingard, DO, FSMB chair, for providing valuable input to the manuscript, for which no compensation was received.

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