Is the USMLE Step 1 scoring system going to a pass/fail model and eliminating the 3 digit score?
A few months ago, major medical organizations in the United States (US), including the Association of American Medical Colleges (AAMC), American Medical Association (AMA), Educational Commission of Foreign Medical Graduated (ECFMG), The Federation of State Medical Boards (FSMB) and the National Board of Medical Examiners (NBME), convened at the Invitational Conference on USMLE Scoring (InCUS) to discuss United States Medical Licensing Exam (USMLE) reform. One of the main focuses of this gathering was to determine whether or not the USMLE should be scored as a pass/fail test. The InCUS meeting did not end with a conclusion on this matter and discussions are still ongoing. It is imperative that all those in the medical field participate in this conversation because the decision may have severe consequences for students, current physicians and potentially the US health care system.
The USMLE was created in the 1990s as the latest version of a board exam that was previously known as the National Board of Medical Examiners (NBME). Initially developed as a pass/fail test, the result also came attached with a 3-digit score. Nowadays the USMLE score, fortunately or unfortunately however you want to look at it, sits next to your name until you complete medical training. The score determines where and what type of residency/fellowship a medical trainee will ultimately obtain.
There are many who advocate for the USMLE to become a pass/fail test in hopes of reducing the “Step 1 Climate.” If you are a current student or have already gone through the USMLE studying process you can relate to this term. Students usually take 6-8 weeks off for the test, hibernating to study for 8-12 hours a day. Even during medical school many students have stopped going to class and solely study for the USMLE disregarding their school’s curriculum. So much focus on one test and the result also creates a difficult and unstable mental environment for some, which can lead to depression and burn out. The reason the “Step 1 Climate” exists is because in recent years the USMLE Step 1 score has become the major determining factor in medical students receiving interviews for residency positions. Students who have dreamed of a career in a specific specialty may even have to reconsider their interest in a field based solely on a test score.
In 2018 the National Resident Matching Program (NRMP) sent out a survey to different residency programs and their directors in various medical fields. (https://www.nrmp.org/wp-content/uploads/2018/07/NRMP-2018-Program-Director-Survey-for-WWW.pdf). The primary purpose as stated in the survey was to “shed light on the factors that program directors use to select applicants to interview and rank for the Match.” USMLE Step 1 score was the most important factor that was considered when selecting applicants to interview. Meaning that the 3-digit score is heavily weighted as the main screening tool programs use when determining who to invite for an interview, which was never the test’s intent.
Since the score does matter so much, there is much to consider before changing the scoring system to pass/fail. As an international medical graduate (IMG), I know firsthand the degree to which the IMG community depends on this 3-digit score to remain competitive with our US medical student counterparts. US graduates will always have an edge in obtaining highly sought competitive residencies over IMGs, but this advantage can be leveled to some degree if an IMG scores well on their USMLE Step 1. This is very important because as seen in the NRMP survey many specialties interviewed and ranked far less IMGs than US graduates. On the flip side, a low score can be detrimental to an IMG’s career. If you score low your chances in obtaining a residency position become difficult. There are horror stories of IMG students who take out hundreds of thousands of dollars in loans, pass medical school classes, but score low on the USMLE Step 1 and subsequently are unable to obtain a residency position.
Now that we can see two sides of the story, where a high score can help some greatly, but a low score can be damaging, is there a proper solution for USMLE scoring reform? The answer remains unclear, but for those leading the InCUS meeting there should be inclusion of IMG schools and the students they represent. Saint George’s University (SGU), my alma mater, placed 940 students into residency last year in a pool of 32,194 total positions available. When making decisions that will affect such a large number of future physicians, representation is key. The attendees of the meeting are listed here: https://www.usmle.org/pdfs/incus/InCUS_Conference_Attendees.pdf. Outside of folks from the ECFMG and the Medical Council of Canada there were no major international medical schools present. IMGs account for 25% of the US medical force, working mostly in underserved and rural areas (where physician need is greatest). If so many physicians suddenly become negatively impacted by USMLE reform our already fragile health care system will suffer further.
I think most people will agree that some type of reform should be considered given that the 3-digit score was never intended to be used as a screening tool to weed out applicants. Additionally, a number on a test does not translate to an empathetic, knowledgeable, competent physician. Before we consider USMLE score reform we need to change the way residency programs and their program directors view applicants. For far too long the stigma of the IMG has been apparent and it is time that residency programs view the IMG and all applicants with a more holistic approach while not weeding out applicants solely by a 3-digit score or the school they graduate from. One bad test score should not determine the rest of a future doctor’s life. Let’s start this change with the above accredited associations and commissions coming together to let our voice be heard.
The groups who set up InCUS are open to dialogue and anyone can leave comments on this topic at https://www.surveymonkey.com/r/incuscomments . The survey will end on July 26th, 2019 at 11:59pm. I urge everyone reading to click the link and leave their constructive criticism on USMLE reform and the applicant screening process.
“Education is the most powerful weapon which you can use to change the world.” – Nelson Mandela
-Doctor P