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  • Viewpoints

    The Step 1 exam is going pass-fail. Now what?

    For years, medical residency programs used the first part of the United States Medical Licensing Examination to help choose among reams of applicants. An advisor offers insights on how medical students might deal with the upcoming change.

    Katherine Chretien, MD, advises a student through videoconferencing software on her computer
    Katherine Chretien, MD, has been advising students who are concerned about what the upcoming change to Step 1 means.
    Courtesy: Katherine Chretien, MD

    Editor’s note: Step 1 of the United States Medical Licensing Examination is the first of three exams required for medical licensing in the United States. The daylong exam — usually taken at the end of second year of medical school or the start of the third — assesses the ability to understand and apply foundational concepts related to health, disease, and treatment options. On Jan. 26, Step 1 will become a pass-fail exam. The opinions expressed by the author do not necessarily reflect the opinions of the AAMC or its members. 

    Emma* and I were talking one day a couple of months into her third-year clerkships. She wanted to work through what she was experiencing with me, her career advisory dean at the George Washington University School of Medicine and Health Sciences. She hadn’t done as well as she’d hoped on Step 1 of the United States Medical Licensing Examination — that high-stakes test covering key components of medical knowledge — despite spending more than 10 weeks preparing.

    “I was testing higher,” she confided quietly about her many practice exams. “I don’t think I’ll be able to match in OB-GYN, which I’ve been loving.” Emma’s sadness and defeat were palpable.

    I talked about how her Step 1 score did not define her. I noted that she was more than a number and that the test by itself was a poor predictor of later clinical performance and the physician she'd become. I wanted her to see the gifts that I saw in her: her passion for social justice, her empathic communication skills, her clear potential for becoming a doctor whom her patients would adore and trust. Yet, it was hard for her to shake the feelings of incompetence, and they were even impacting her clinical performance.

    For so long, medical students have worried about the impending hurdle of Step 1 — a full-day exam that has loomed from the beginning of medical school because it has carried so much weight in residency programs' assessments of the many applications they receive.

    On Jan. 26, Step 1 scoring will change from a numeric grade to pass-fail, so the big question is, “Now what?” How should students shift their thinking and preparation for the residency program applications that determine where they’ll spend the next several years of their medical training?

    I see an opportunity to get back to what matters: helping students reach their individual personal and professional goals in medicine, engage in the preclinical curricula that lead up to Step 1, effectively tell their stories to residency programs, and stay focused on their overall well-being.

    No one knows exactly how residency programs will change their selection processes based on the new pass-fail grading of the Step 1 exam. All programs are different, and several pilot initiatives are underway nationwide to alleviate the pain points of the broken transition from medical school to residency. Will there be new forms of assessment to measure the skills that our current knowledge-focused metrics don't capture? Will there be new ways for programs to conduct holistic review that looks at candidates’ arrays of traits and experiences?

    One thing the pandemic has taught us is to be OK with uncertainty and to move forward in ways that make the most sense despite not knowing how the landscape may evolve.

    I see an opportunity to get back to what matters: helping students reach their individual personal and professional goals in medicine, engage in the preclinical curricula that lead up to Step 1, effectively tell their stories to residency programs, and stay focused on their overall well-being.

    Advice for students in a post-Step 1 score world

    Authentically develop your interests

    You may have come to medical school with certain interests and passions — whether in research, teaching, health policy, community engagement, or something else — or you may be still exploring which areas you want to focus on in the future. Take the time. Find what excites you and gives your medical education meaning. Sample and explore if you need to, then center your extracurricular pursuits along this thread.

    Always be intentional with your time, and fight any urge to do a little of everything. Concentrating on a smaller number of interests can help you develop your professional goals while also allowing you to differentiate yourself from other candidates when applying to residency programs.

    As Lisa Willett, MD, program director in internal medicine and professor of medicine at the University of Alabama at Birmingham Marnix E. Heersink School of Medicine, advises, “Focus on being the best doctor you can be, prioritizing your clinical studies to provide great patient care. Then, involve yourself with extracurricular activities that truly interest you. It is better to spend meaningful time in a few select activities — perhaps even serving in a leadership or organizational role — than to volunteer in hundreds of smaller activities.”

    Engage in the preclinical curriculum

    Many medical educators believe that the focus on Step 1 has led some schools to devalue a number of vital competencies not covered on the exam — clinical skills, communication, and professional identity, among others.

    Now, you can more fully engage in your school’s preclinical curriculum and focus more on the other essential domains of developing as a physician that residencies (and patients) seek. Yes, programs want students who have the necessary medical knowledge and the ability to apply it — yet they also are looking for students who exhibit teamwork, can be both leaders and followers, have strong professional identities, and can communicate effectively with patients, family members, and colleagues.

    Craft your story

    One of the things I cherish most about being a student affairs dean is getting to know my students’ unique paths to and through medical school. As we lose the Step 1 score, and as some schools have also moved to pass-fail grading in preclinical courses and even the clinical curriculum, effectively communicating your story to residency programs is even more important.

    How can you capture your interests and trajectory effectively?

    One way is to take an inventory of your activities and interests and reflect on the underlying themes. What are your personal strengths? What are the main things you would want a residency program director to know about you? Many times, meeting with an advisor or mentor can help you craft your story or even help you identify themes you may not have noticed.

    When I met with Chris*, another medical student, to go over his residency application strategy, he said, “Well, I’ve done a lot of different things and I can’t find a way to link them together.”

    We reviewed his various extracurricular activities, and he was right: He had done a lot in different domains. Together, we ultimately were able to detect a recurrent pattern of his identifying needs — whether in health care systems, patient care, or society — and then creating an innovative way to address those needs. He was an innovator.

    Attend to your well-being

    One of the principal reasons Step 1 was moved to pass-fail scoring was for medical student wellness. Some students have described their Step 1 study period as the worst time of medical school for them — and sometimes of their lives! With the high levels of burnout, stress, and anxiety among medical students, removing the undue burden of the exam is a welcome change.

    Celebrate the transition by starting regular self-care, spending time connecting with loved ones, or making your primary care and mental health care appointments. Self-care is a critical skill you’ll carry forward into the rest of your career. We can’t care for others if we don’t take care of ourselves.

    But what about Step 2 CK? Is it the new Step 1?

    Over time, Step 2 Clinical Knowledge (CK) has become more important to many programs, as evidenced by the increasing number that require CK scores when deciding which applicants to interview. In 2018, 60% of respondents to the National Residency Matching Program®’s biannual Program Directors Survey reported requiring a Step 2 CK score when considering whom to interview. In the 2021 survey, 94% reported using the scores in making that decision.

    We don’t know exactly how programs will use Step 2 CK scores differently for screening or ranking applicants now. Still, it seems likely the exam’s importance will rise from its current rank of #3 in academic factors programs consider in selecting interviewees, only behind Step 1 and the Medical Student Performance Evaluation that schools provide.

    While Step 2 CK will now be the one standardized examination with a numerical score, resist the temptation to place excessive weight on your performance to the detriment of learning the clinical curriculum. Remember that Step 2 CK is a more manageable exam in terms of the amount of content and that the National Board of Medical Examiners subject exams that many schools include as part of third-year core clerkship assessments are good preparation. In fact, Step 2 CK has been described as a long version of these exams.

    Based on prior examinees’ experiences with optimal study times, you likely won’t need more than four to five weeks to prepare for Step 2 CK after taking your core clerkships. Of course, it will be important to take the exam so you have a score by the time programs receive applications (mid- to late September for the main Match®, the week in March when applicants learn where they’ll spend their residency training).

    What lies ahead?

    The shift in Step 1 scoring will likely result in some immediate changes. Schools may decrease their Step 1 study period or change the suggested timing of when to take it. Specialties that heavily relied on the scores will be recalibrating their selection processes to adapt to a post-Step 1 score world, likely using Step 2 CK.

    But I hope we will also see an expansion of assessment of other domains important to being a physician. After all, medical knowledge is only one of six competencies required by the Accreditation Council for Graduate Medical Education. There’s also patient care, interpersonal communication skills, professionalism, practice-based learning and improvement, and systems-based practice.

    In addition, I hope the national conversation generated around the Step 1 pass-fail decision will lessen the value residency programs have placed on standardized exam scores — scores that are known to be impacted by students’ access to resources and other structural factors.

    Ultimately, I doubt anyone is going to say, “I miss the days when Step 1 was scored because that was such a valuable experience.” Let’s remember this win as we face any uncertainty with the residency application and Match® cycles that lie ahead.

    *Names have been changed.