Home MedEducation & Residency USMLE Step 1 Pass/Fail – The Pros, Cons and How to Adapt

USMLE Step 1 Pass/Fail – The Pros, Cons and How to Adapt

USMLE Step 1 has changed from its well-known numerical grading system to a pass/fail system. These changes took effect in January 2022. This post highlights the pros and cons of the new grading system and how to better adapt to this new change. This change was made into effect by the USMLE co-sponsors, the Federation of State Medical Boards, and the National Board of Medical Examiners (NBME).

Step 1

The Changes Made To USMLE

The well-known numerical grading system has been changed to a pass/fail system. However, this is only for Step 1 and not Step 2 CK.

The maximum number of attempts that anyone can take on USMLE is now four instead of six now. Looking at the USMLE data reports, 96% of people have passed on the first attempt in 2017 and 2018.

Looking at the USMLE website, they say that the co-sponsors recognized that an ideal system for evaluating candidates for residency is holistic. Now this means a lot of things, the Step 1 score has been the most determining factor to evaluate a candidate for residency by residency program directors. But there are many more qualities that should be considered when assessing an applicant for residency.

This is why the USMLE believes that changing the system into a pass/fail system can reduce the overemphasis on USMLE performance whereas it will retain its purpose to obtain medical licensing eligibility. It is said that they changed this into a pass/fail system to reduce the anxiety of medical students, which may be true. However, this anxiety is a symptom of a whole different problem.

It is agreed that the exponential weight placed on this marginally clinically relevant exam has resulted in another hyper-competitive nature amongst medical students but this anxiety and the hyper-competitive nature stems from the limited amount of residency spots compared to the number of applicants. Also without the score in the picture, there are fewer objective measures to assess a candidate.

Now when submitting a residency application, your experience is divided into three components, your work experience, volunteer experience, and research experience. One must focus on all these different aspects to fortify the resume and be the perfect applicant for residency.

Pros and Cons of the USMLE Step 1 Pass/Fail


Improved Student Wellness

This will definitely affect student wellness. The epidemic of medical school burnout is largely centered around USMLE Step 1. Students tend to opt out of the institutional curriculum in favor of intensive exam preparation and this is largely due to the stress and anxiety of the exam. With Step 1 being pass/fail, it provides the students a chance to relax a little bit more in their first and second years of medical school and focus more on their institutional curriculum.

Better Evaluation

This is the most important. Step 1 isn’t a perfect depiction of how smart a candidate is. It is an eight-hour exam that focuses more on basic science principles instead of clinical knowledge. Many doctors are good at what they do but didn’t do well in Step 1 largely because the determinant of the score is multifactorial. It depends on so many different factors like whether you’re a good test taker or not, whether you slept well the night before, or whether you’re anxious.

Step 2 Will Be More Relevant Than Step 1

With Step 2 retaining its numerical grading system, it provides some objective measures for residency program directors to assess candidates. Step 2 will definitely provide a better assessment tool just because this exam is more clinically relevant and it’s easier to prepare for than Step 1.

The scores are likely to be less inflated because there will be a harder grading curve and people will take Step 2 a little bit more serious. Step 2 being the baseline objective measure to assess a candidate will be much better than Step 1.


Networking Will Outweigh Hardwork

Knowing the right people will heavily outweigh hard work. Students will spend more time networking and getting to know the right people instead of studying.

Heavily Affects IMGs

This change has the biggest effect on IMGs, DOs, and Carribeans. According to program directors, American medical graduates are subconsciously preferred just because they have been more exposed to the American system and because they can better communicate with patients. But IMGs and DOs use the Step 1 score as a chance to stand out amongst their American peers.

Less Focus on Basic Principles

The fear and anxiety that Step 1 puts into medical students force them into learning their basic principles so well that they become better doctors ultimately. This focus will be shifted to Step 2 which is more clinically relevant but a good doctor needs to have a good grasp of these basic sciences.

Subjective Evaluation

With the pass/fail change, letters of recommendation (LORS) clerkship grades become a lot more relevant than they should be. Because this is highly subjective, some institutions or rotations make it a lot easier to get honors whereas others make it a lot more difficult. Therefore this traps medical students in their own system and makes these grades not comparable.

More Preference To Top Tier Medical Schools

The medical school that an applicant attends will definitely affect their chances of getting into a residency. Medical students from top tier schools like Harvard, Johns Hopkins, and Yale will definitely be given a higher priority than an applicant from a lower-tier medical school

How To Adapt To The Pass/Fail Scoring System


Make the most of your away rotations. Try to meet people, create opportunities, open doors for yourself, make good impressions, and talk to more doctors. It is a competitive world up there and you need to be on the top to thrive

Research Opportunities

Try your best to participate in research. Every medical student needs to be more proactive and ask the residents, fellows, and attendings if they need any help on research. There is always some work to be done but physicians don’t have the time to do it this includes literature search, data collection, and writing. Don’t worry about your ability to do research because it’s a learning process, the more you do it the better you get.

IMGs should focus on observerships or whatever little volunteer experience. If you have the opportunity to go to America during your summer break to do a rotation or an observership, you should definitely do it. Look into different hospitals in America, do some research on different professors and what research they are doing, and then send hundreds of emails to know if they need any help.



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