Would USMLE Step 1 becoming pass/fail be a good or bad thing?

What are the pros and cons of each side of the argument?

Stay tuned to find out.

Dr. Jubbal, MedSchoolInsiders.com

The United States Medical Licensing Examination or USMLE is a three-part test

designed to assess one's medical knowledge and application of said knowledge to patient care.

Step 1 as it currently stands is arguably the most important test a future physician will ever take.

Even more important than the MCAT.

It is typically taken at the end of the second year in medical school,

and is followed by Step 2 in the third or fourth year.

If you'd like to know more about the USMLE Step exams and their timelines,

check out my Four Years of Medical School Explained video.

The USMLE was officially designed

to assist state authorities in granting medical licenses

but it has grown in significance far beyond the intended pass/fail indication of competence.

USMLE scores are now heavily weighted during residency applications to assess a candidate's strength

and low scores often prohibit students from pursuing highly competitive specialties

such as dermatology or plastic surgery.

Before we dive in,

I hope that this video serves as a lesson in how to approach controversial topics.

When people asked me where I stand on the issue, I said "I don't have a strong opinion yet!"

I need to first do my research, think through the subject,

and follow up with questions that I have.

Too many people first choose a side based on limited information

and then seek out data to bolster their argument.

That's the Confirmation Bias.

Learn to think for yourself and not just echo what people around you are saying.

Also a disclaimer, I am the founder of Med School Insiders

which offers pre-med and medical student admissions consulting and tutoring services,

and we do offer tutoring for Step 1 amongst other pre-med and medical student exams.

That being said, it will not influence my argument as you will soon see.

One of the biggest reasons I left plastic surgery was

to have a positive impact on the Medical Education Process

as I described in my video explaining my decision to leave the hyper competitive and highly lucrative field.

My priority is helping medical trainees.

I am a firm believer in Objective and Rational Discourse not clouded by biases.

Seek facts first then develop an argument, not the other way around.

The bubbling conversation boiled over and blew up after the CEOs of the NBME and FSMB released this:

"If students reduce time and effort devoted to preparing for Step 1, they may indeed devote attention to other activities

that will prepare them to be good physicians.

However,

if students were to devote more time to activities that make them less prepared to provide quality care

such as binge watching the most recent Netflix or compulsively updating their Instagram account,

this could negatively impact residency performance and ultimately patient safety."

How Doctors Katsufrakis and Chaudhry could release such a tactless statement as CEOs

to alienate their audience is beyond me.

The ensuing conversation blew up in their face

with large criticism over the rapidly increasing annual compensation of the NBME executives.

In short, given the current importance of USMLE Step 1,

medical students and medical schools have been strongly incentivized

to purchase more and more prep materials such as practice tests from the NBME.

Drastically increasing the organization's revenue year after year.

As it stands, there are now two camps:

those in favor of transitioning the USMLE to pass/fail

and those wishing to maintain the status quo with continuous scoring

We've already touched on the outrageous profiteering of the not-for-profit NBME

but beyond that there are several other reasons for a pass/fail test.

First, the current Step 1 climate is highly stressful and creates a rift in medical education.

A recent article in academic medicine states "many students opt to disengage from institutional curricula

in favor of intensive exam preparation and are rewarded with a high Step 1 score."

Second, the importance of Step 1 scores is argued to reduce diversity for a few reasons.

It contributes to a destructive culture of hierarchy among specialties

where you're perceived as scoring higher on step and therefore being "Smarter"

if you chose a surgical subspecialty rather than primary care.

Additionally, some claim that to perform well on Step 1 requires spending a thousand dollars

on test prep materials and not all students are able to afford that.

Lastly, underrepresented minorities and those coming from low-income families, on average,

score lower on Step 1.

Third, and in my opinion most importantly, Step 1 may be contributing to a harmful learning environment.

Some say the Step 1 climate contributes to the mental health crisis affecting the medical community.

As you all probably know, I'm incredibly passionate about addressing

the epidemic of burnout, depression and suicide

amongst medical trainees and it's why I started the #SaveOurDoctors movement,

and lastly,

despite Step 1 being a heavily weighted factor in residency admissions,

it's not a reliable indicator of one's abilities as a Physician.

Rather than a USMLE Step 1 score, other important qualities

such as clinical reasoning,

professionalism,

and the ability to work in a team should be prioritized.

Those in favor of maintaining the status quo with a continuous scoring system raised several counter points.

Status quo proponents admit that USMLE Step 1 is far from perfect

but moving to a pass/fail system doesn't address the underlying issue

and could actually make the residency selection process worse.

To be an effective physician,

we would need to reliably measure communication skills, empathy, professionalism, and other qualities

but we currently do not have any tests to adequately assess these.

Pass/fail proponents point to emphasizing heavier weighting on clinical grades for evaluation,

which brings us to the second point.

In residency admissions, your Step 1 score is heavily weighted, likely weighted more than it should be.

However, status quo proponents argue that Step 1 is the only objective measurement that we have.

With pass/fail during pre clinical courses and highly subjective clinical evaluations

that may be heavily influenced by chance,

there is no other reliable objective measurement to replace it.

There is also a complete lack of standardization amongst clinical clerkships

with some schools practicing hard quotas but others handing out honors and high pass to almost every student

making the clerkship grade close to meaningless and a terribly inaccurate indicator of true performance.

Those in favor of continuous grading argue that moving to a pass/fail grading system would lead to nepotism,

making residency selection more about who you know or what school you came from.

With continuous grading, students from less prestigious schools are able to get noticed

should they excel on the exam.

Under a pass/fail system, school prestige, your personal connections

and other far less equitable factors would be prioritized.

Some argue that with a pass/fail system, students would lose the motivation to study hard first Step

and ultimately lack medical knowledge.

While I understand where this line of reasoning comes from, it's purely speculation,

and I'd argue we don't actually know how medical knowledge would be influenced one way or another.

After considering both sides of the argument and upon closer examination,

It's apparent that the truth is somewhere in the middle and I'm glad that we're having this conversation.

It points to a larger issue.

Medicine and medical education is broken and we need to do something about it.

Proponents of moving Step 1 to a pass/fail system are fed up and we all should be

but that frustration is misguided.

Moving Step 1 to a pass/fail system would only make the issues within medical education worse, not better.

If you're confused, allow me to explain.

First, my most important consideration is the well-being of medical students and residents.

Some would argue that patient care and safety is the first priority

but I say if you don't have healthy doctors, then you don't get healthy patients.

You must first take care of yourself before you're able to take care of others.

The fact that suicide rates are the highest amongst physicians is appalling.

Again, I'd point you to the #SaveOurDoctors movement. More information in the description below.

But while step one is highly stressful, it's not the cause of the burnout, depression and suicide epidemic.

It's one element of a larger cultural issue

But pointing to a single standardized exam as the root cause is not only a naive

and misguided interpretation of the facts

but could ultimately prove harmful as well.

There are countless stories of students being devastated by a suboptimal performance on Step 1.

Rather than blaming the test, take responsibility for your life.

Figure out what went wrong and act on it.

Sometimes its factors outside of your control and life is not fair.

I get it.

That doesn't preclude you from taking responsibility.

Learn how to learn more effectively.

Learn how to be a better test taker and then go crush your shelf exams, honor your clerkships and a Step 2 CK.

The 100% free advice on this YouTube channel

has helped thousands of students radically improve their performance.

Why wouldn't it help you?

The victim mentality is becoming more and more prevalent.

Trust me.

Making Step 1 pass/fail won't solve your issues.

Residency will still be competitive under a different set of metrics

and you'll blame those new metrics for your problems as well.

I recommend you start with my Stoicism for Students video

which many of you have commented on and told me was my best ever video.

Check out Jocko Willink's Extreme Ownership while you're at it too, links in the description below.

Several other arguments from the pass/fail proponents don't hold any water.

They say Step 1 implements a destructive hierarchy of specialties and a negative stigma.

News flash, self-victimizing Victor, competitive things are competitive because of supply and demand.

More competitive specialties will always be more competitive, regardless of Step 1.

Making step one pass/fail does not change competitiveness

It just makes it so that other metrics will replace Step 1.

Even more importantly, why does it matter that someone assumes your step score is lower because you went into primary care?

Your self-worth shouldn't be tied to your Step score. Let alone what someone assumes your step score to be.

Don't blame the test, that's on you.

Pass/fail proponents quote that to perform well on Step 1,

You need to spend a thousand dollars and this is a significant barrier

to those from less financially privileged backgrounds.

This doesn't make sense for two reasons.

First, the average medical student graduates with $200,000 in debt.

There are many students who graduate without debt, further skewing the average,

meaning the average debt for students that need to take out loans is actually much higher than $200,000.

At that point, a thousand dollars is just a drop in the bucket.

Plus these costs are taken into account in your medical school budget and student loan offerings

Second, who says you even need to spend a thousand dollars?

Between six months of you UWorld, Pathoma, First Aid, and Sketchy,

I spent less than $500 and you could spend even less if you're frugal and purchase second hand.

I do not come from a financially privileged background by any means,

I had to pay for my own college, my own medical school

I did a work-study and I had to take out loans.

I was financially strapped yet I still performed quite well on my USMLE.

Possibly the most frustrating aspect of this entire debate is how short-sighted it is.

The problem isn't Step 1, but rather the medical education and training system.

Why do residencies place such emphasis and screen with Step 1?

They have so many applicants to sift through and meet an objective measurement to cut the pile down.

Even with pass/fail grading, program directors will face the same issue

and they will find other metrics to pare down the list.

You don't solve the problem with pass/fail, you simply shift that problem to somewhere else.

Pass/fail would place much more weight on clerkships which are far more subjective and biased.

Which preceptor did you get? Were they easy or the hard one?

Were you the type of personality that usually meshes well?

Or did you get unlucky?

With pass/fail, you place more importance on the number of publications, who you know,

and what school you come from.

Brown Nosing would be even worse than it already is.

would you rather have a meritocracy or nepotism?

I've even heard some pass/fail proponents say that we should place higher emphasis

on Step 2 CK or the shelf exams.

The exact same problems would simply transfer over.

It doesn't take a rocket surgeon to know that.

Proponents also point to the fact that many medical schools have

transitioned the preclinical classes from graded to pass/fail

without any negative effect on academic achievement.

I shouldn't have to explain why that's comparing apples to oranges.

And lastly, while Step 1 used to be a pass/fail exam,

that doesn't mean it should be again.

The residency selection process is an entirely different beast now,

and no, Step 1 was not the cause of those changes.

Now, I agree that the system is far from perfect and we need change.

Here are my three suggestions:

First, keep Step 1 as it currently stands.