Unintended Consequences of USMLE Pass Fail Scoring with Dr. Hans Wolf

January 12, 2022


USMLE

Since its inception in 1992, the United States Medical Licensing Examination (USMLE) has been the requisite for medical students wishing to practice in the United States. Sponsored by the Federation of State Medical Boards (FSMB) and the National Board of Examiners (NBME), aspiring doctors must sit for a multi-part examination as a rite of passage. Passing the USMLE Step 1, Step 2 and Step 3 is the national standard for all practicing physicians. 

Colloquially known as the Step 1, the USMLE Step 1 grading system will transition to a Pass/Fail reporting starting January 26, 2022. The eight-hour exam consists of up to 280 questions and is designed to test basic science fundamentals, such as biochemistry and genetics. Stateside, it is generally taken after the second year of medical school. Step 2 CK and Step 3 exams will still be graded using a three-digit numerical score. 

Dr. Hans Wolf is the founder of the Physician Achievement Concept Course and director of WOLFPACC. As both an M.D. and medical educator, we asked Dr. Wolf for his comments on how the changes to the Step 1 exam might impact medical students going forward. Listed below are snippets of that conversation as well as some of the unintended consequences he felt the changes could have on students, educators, and the rest of us.

Here’s what Dr. Wolf had to say:

Is the USMLE Step 1 medical exam going to be easier to pass?

“Since the numeric score is no longer reported,” says Hans Wolf, M.D., CEO and Founder of WOLFPACC, “many medical students are looking at this as a big plus. But this could have unintended consequences for some students as the level of difficulty of the exam has not changed.”

Although the USMLE Step 1 exam was not originally intended to have a significant influence on a student’s selection of competitive specialties, residency directors who are responsible for reviewing applications have often placed significant weight on the student’s three-digit score. While the switch to Pass/Fail scoring may reduce pressure on undergraduate medical school students, most educators and administrators feel there is still a lot of work to be done to ensure the change results in real improvements.

Consequences: “Unfortunately, many students with a preconceived notion that the pass/fail exam must be easier… might fail,” remarked Dr. Wolf. 

How many times can a student retake the USMLE Step 1 board exam?

“The number of attempts for taking the exam has been decreased from six to four,” Dr. Wolf continued, “that’s a third fewer opportunities for a borderline student to pass the Step 1.”

Reducing emphasis on Step 1 may reduce test-taking apprehension that undergraduate medical students may have felt in years past, but proponents of equitable evaluations suggest test administrators should focus on increasing the number of objective measures available for a student’s assessment for residency rather than reduce them.

Consequences: “Each time the student challenges the Step 1 exam, they will risk depleting the number of attempts they have to pass their first Board Exam,” cautioned Dr. Wolf.  

Isn’t Pass/Fail scoring intended to reduce the academic stress that undergraduate students face when they start medical school?

“In theory,” Dr. Wolf remarked, “this is viewed as a change to improve the transition for undergraduate to graduate medical education, which is supposed to limit the stress students feel when preparing for the Board exam.”

The de-emphasis on the Step 1 score might result in reducing some of the undergraduate medical student’s apprehension over taking the initial exam, but it also makes sense that a student’s anxiety will likely shift to the three-digit grade used for Step 2 CK.

Consequences: “According the USMLE website, if you receive a pass on the exam, you will not receive content-based feedback,” Dr. Wolf added. “One could easily misinterpret as Pass on the exam as having a strong baseline, but the student may not have the foundation necessary to pass Step 2, which could also result in a higher failure rate.”

What impact will this have on students who are International Medical Graduate?

“IMGs often relied on getting a higher grade on the Step 1 for leveling the playing field when applying for residency,” explained Dr. Wolf. “Certainly, the three-digit-score had its place in allowing them to show their ability to compete against students who attended more competitive universities.”

Students at so-called low-tier medical schools and osteopathic medicine programs often used the Step 1’s three-digit score to boost their applications for more competitive residency programs. There is already concerns that a Pass/Fail grade favors students who attend subjectively higher ranker medical schools. In the future, a change like this could impact the number of students who are willing to incur debt when their options for medical school are limited to acceptance to international or DO medical institutions.

Consequences: “Scoring well on the Step 1 was a big plus for IMGs and DO students who were attempting to enter residency programs in more competitive specialties, such as dermatology or plastic surgery,” concluded Dr. Wolf.

How does the change to a Pass/Fail impact medical students in general?

“In the past, students who passed Step 1 with a low score could argue they simply had a bad day,” explained Dr. Wolf. “By scoring higher on the Step 2 exam, the student had a second chance to post a more competitive numeric score for comparison.”

Whether it was supposed to be used as a screening tool for residency programs, many specialties and surgical residency programs have set target scores for the Step 1 when selecting candidates. Three-digit scores were correlated with the expected academic performance for residences across both surgical and nonsurgical fields. 

Consequences: “Now residency programs have no option other than placing more emphasis on the Step 2 scores, as it is still a numeric grade. Students also need to evaluate ways to improve their CVs to stand out from others. Some will choose more competitive clerkship, while others will likely focus on research.” Dr. Wolf surmised. 

What does all this mean for medical students in the end?

“Prepare for the exams as though your patient’s life depends on it,” Dr. Wolf said, “some say, Step 1 material is not that important to be a good doctor, as its just basic sciences. The sad part of this statement is that it could not be farther from the truth.”

Although the three-digit score was useful in many ways, it was also criticized as a catalyst for student burnout and depression. While the change to Pass/Fail scoring is aimed at mitigating the stress of high-pressure testing, most expect the test-taking anxiety to shift to the Step 2 exam. In a positive light, Pass/Fail scoring may encourage more students to apply for traditionally competitive residency positions. Students who fear that they do not test well will need to find other opportunities to build a well-rounded application

Consequences: “As doctors, they are the ones who are going to be in a position to make decisions that will alter a patient’s life as well as (the lives of) their loved ones,” Dr. Wolf explained.

Do you think the change in Pass/Fail scoring could impact a student’s abilities as a doctor?

“In some cases, I’m afraid so,” remarked Dr. Wolf. “In order to derive a set of differentials based off a history and focused physical, requires application of basic sciences. It is these basics that will help them order the correct test to support their differential and properly manage their patients. Individuals who cannot apply the basics are the ones who play shotgun medicine and order every test, hoping one comes back abnormal to help them derive the correct differential.”

Whereas program directors in residency programs are under external pressures that have pushed them to rely heavily on Step 1 scores when selecting and evaluating candidates, administrators do acknowledge that a system, which correlates to clinical performance with a more holistic review, may still be needed to avoid selective inclusion based on the wrong student achievements. 

Consequences: “Not being efficient at applying the basic sciences could expose the patient to unnecessary tests, medical expenses, and a delay in proper care,” concluded Dr. Wolf.

In closing, what advice do you have for a medical student who might be reading this article?

“You are smart and can achieve your goal, as you would not be at this point in your training if you were not,” Dr. Wolf remarked, “so don’t be fooled by the Pass/Fail reporting!”

U.S. medical students as well as International Medical Graduates and DO medical students who want to practice medicine unattended in the United States should remain fully dedicated to his or her studies from Day One of medical school through the completion of the USMLE 3 exam. 

Consequences: “The stress you feel as a medical student,” remarked Dr. Wolf, “is probably the best preparation for managing the stress you will deal with every day as a doctor.”

Correctly identifying the problems that exist with the current medical licensing system and recommending progressive steps toward creating a more equitable system for the Board Exams will determine the future practice of medicine. Furthermore, it will take time and advocacy to make that happen. Those responsible for changes to parent boards and governance should look forward to ongoing discussions over the role of scoring practices to keep medical regulators and educators best informed. Nonetheless, neither undergraduate nor graduate medical education communities should expect the answer to come over night. In the meantime, students should dedicate time to learning the relevant basic sciences that support clinical medicine to enhance their skills as a physician.

Are You Ready for Success?

WOLFPACC was founded a decade ago and medical students as well as doctors from the United States, Caribbean and Europe have participated in the program with overwhelming success. Dr. Wolf’s USMLE preparation courses provide a structured experience that include face-to-face interactions with both instructors and fellow students. During the program, students learn to understand medicine through high yield concepts rather than just memorizing details to pass an exam. 

In helping students launch their medical careers, Dr. Wolf saw a need for a prep course that focused on the common links between organ systems. His innovative approach for preparing to sit for the USMLE or COMLEX medical licensing exam integrates the five main organ systems through physiology (called the Power 5). As physicians, WOLFPACC students have found they have a better understanding of the patient as a total unit rather than just focusing on a single presenting sign or symptom. 

We believe passing the USMLE or COMLEX should not rely on a student’s short-term memory, which can obviously fade with time. Instead, we will teach medical students how to think their way through each question and identify the correct answer. Power 5 utilizes proven concepts that help each student integrate the pertinent materials they have learned by applying the basics through a clinical understanding of the task at hand. At WOLFPACC, we teach students more than just how to pass an exam; we empower doctors with the information, tools, and skills to achieve exceptional results.