Study Tips

NBME® Announces Pass/Fail for USMLE® Step 1

Osmosis Team
Published on Feb 13, 2020. Updated on Sep 25, 2020.

After many months of research and contentious public discussion about changes coming to USMLE® Step 1 scoring, yesterday the National Board of Medical Examiners (NBME®) made it official: Step 1 is moving from a numerical scoring system to pass/fail. These changes will not take effect immediately: the NBME’s current plan is to implement pass/fail “no earlier than January, 2022.”

So, what prompted this historic decision—and what does it mean for students and institutions?

Why is the NBME changing USMLE Step 1 to pass/fail?

Until now, Step 1 has been the definition of a high-stakes exam. For many, it’s regarded as the number one factor that determines whether you’ll successfully land your first-choice residency. Because of this, Step 1 has been a source of incredible stress for medical students, with many obsessing over an exam they see as having the potential to make or break their careers. 

The NBME seems to have taken note of this, stating: "The FSMB and NBME believe that changing Step 1 score reporting to pass/fail can help reduce some of the current overemphasis on USMLE performance, while also retaining the ability of medical licensing authorities to use the exam for its primary purpose of medical licensure eligibility."

While this sounds like news that will have students sighing in relief, it’s actually more complicated than that—particularly if you’re an international student or international medical graduate (IMG).

How pass/fail USMLE scoring may impact students

If you’re a US student taking USMLE Step 1 in 2020 or 2021, the impacts of these changes will be minimal, and you should continue studying for Step 1 as normal. Similarly, if you’re a DO student studying for COMLEX®-USA Level 1, the National Board of Osteopathic Medical Examiners (NBOME®) has stated that this exam will continue to be scored on a numerical basis for now, but that the scoring system requires further evaluation. DO students should look out for potential updates on COMLEX Level 1 scoring as early as July 2020.

For students planning to take Step 1 in 2022 or beyond, these changes (if they happen on schedule) could significantly impact your medical school journey, whether you’re a US student or an international medical student (including Canadian students and US students studying abroad) who plans to practice in the US.

Greater emphasis on USMLE® Step 2 CK

According to the NBME’s announcement, Step 2 CK will retain a numerical scoring system. In general, Step 2 CK scores could possibly carry more weight than they did previously—which could mean that students simply transfer their overemphasis from Step 1 to Step 2 CK. On the other hand, a shift in focus to Step 2 CK scores could be something of a relief for US students. 

Many US medical students only take Step 2 CK after residency program decisions have been made, unless they performed sub-optimally on Step 1 and want to boost their score. In theory, this means residency programs won’t be able to include Step 2 scores as part of their requirements (at least not in the near term) for US students. 

For international students and IMGs, it’s a different story. 

Potential challenges for international medical students & IMGs

For IMGs, obtaining a high Step 1 score is crucial as their Step 1 scores play a significant role in medical residency applications. When scores move to pass/fail, IMGs will lose out on an opportunity to stand out against domestic applicants in the US.

The shift in focus to Step 2 CK also has the potential to create issues for international medical students. Many international medical students have to take Step 2 CK in the midst of clinical rotations and electives in order to become Educational Commission for Foreign Medical Graduates (ECFMG®) certified. ECFMG certification is a requirement for many residency application programs.

Dr. Maddison Caterine, Director of Curriculum at Osmosis, is a former international medical student, having studied medicine at the Royal College of Surgeons in Ireland (RCSI). Dr. Caterine had this to say about her experiences taking Step 2 CK in her third year:

As an international medical student, you have to be ECFMG-certified before applying to most residency programs. This means you need your Step 1, 2 CK, and 2 CS scores completed around mid-July (generally) if you’re planning to apply for residency in September, during your final year. Because of this, most of us complete our boards during third year, even though many students may not have completed their core rotations. For example, I hadn't done ANY surgery but was expected to know everything. This made studying for an already-difficult exam even more stressful.

Increased focus on Step 2 has a compounded effect for international medical students. Because you’re studying more intensively for Step 2 and don’t necessarily have all the required knowledge yet, you may end up spending more time preparing for that, and less time on Step 1. However, intensive Step 1 studying lays a lot of the groundwork that gets you ready for Step 2 CK—meaning preparing for this exam is much more difficult.

It remains to be seen how the ECFMG will address these potential challenges, but Dr. William W. Pinsky, President & CEO of ECFMG/FAIMER, expressed support for the NBME’s decision, and for international medical students: "The ECFMG supports the informed decision making of the NBME and FSMB Boards on these policy changes. We are looking forward to continually advocating for international graduates as well as participating in the important future conversations on residency selection and transition."

How students can prepare

Your USMLE Step 1 score is not the only factor residency programs look at when choosing candidates. Other factors include: 

  • Writing a compelling cover letter

  • Securing strong letters of recommendation from clerkships and clinical electives

  • Performing well on your residency interviews

  • Research and publications

  • Overall academic performance

  • Work and volunteer experience

  • Having a graduate degree

For more information, check out the Osmosis Ultimate Guide to the USMLE Step 1


How pass/fail USMLE Step 1 scoring impacts faculty

While it’s still early to tell all of the ways this change to USMLE Step 1 will impact faculty and institutions, some of the potential ramifications are clear.

First, this change will make it more important than ever for faculty to emphasize learning over test prep when teaching their students. While preparing for USMLE Step 1 will still matter to students—so they pass the exam—this move will force many students to reassess how they spend their time in class vs. out-of-class.

For example, student attendance at pre-clerkship lectures has decreased in a significant way as more students stream lecture-captures from home and look to high-yield, out-of-class resources to prepare them for Step 1. Why? For two reasons:

  1. Up to this point, and until the NBME implements this plan in 2020, Step 1 scores have had a significant impact on specialty selection and NRMP Match.

  2. Many medical students have felt that “low-yield” live lectures don’t prepare them with the right information they need to succeed on Step 1 in an efficient way.

With this development, lecture attendance and engagement in the pre-clinical years may increase. Ultimately, it will be up to deans and faculty to continue refining their curriculum to make it engaging and relevant for students.

Today’s announcement from NBME will create turbulence for medical school deans, administrators, and faculty for the foreseeable future. But, several facts and priorities will remain the same for medical educators.

Students (and faculty) will still rely on and expect curricular support

Despite this update to USMLE Step 1, students will still expect deans and faculty to provide them with external curricular support tools. For what reason? Because these resources will continue to serve as efficient, high-yield test prep materials and they will still allow students to reinforce their understanding of key concepts learned during class.

At the same time, faculty who’ve already incorporated curricular support resources into their curriculums—for the purpose of bringing text-heavy lectures to life or supporting flipped classrooms and problem-based learning projects—will continue to expect and rely on them.


LCME® standards for active, lifelong learning continue to exist and matter

The Liaison Committee on Medical Education (LCME®) is the accrediting body for medical schools in the United States. As a part of its accreditation standards, it states:

ED-5-A. A medical education program must include instructional opportunities for active learning and independent study to foster the skills necessary for lifelong learning. 

Further guidelines from the LCME® in this section offer more information to medical schools who want to maintain their accreditation:

It is expected that the methods of instruction and assessment used in courses and clerkships (or, in Canada, clerkship rotations) will provide medical students with opportunities to develop lifelong learning skills. These skills include self-assessment on learning needs; the independent identification, analysis, and synthesis of relevant information; and the appraisal of the credibility of information sources. Medical students should receive explicit experiences in using these skills, and they should be assessed and receive feedback on their performance.

Supplemental learning resources, such as Osmosis, give institutions an opportunity to meet this accreditation requirement by providing their students with a tool they can use for independent study. More importantly, a platform like Osmosis allows medical schools to track what material students study, and when they study it—giving them evidence that shows they fulfilled this standard.

The NBME’s decision to make Step 1 a pass/fail exam will continue to cause ripple effects in the field in the months ahead. But, this fact won’t change: medical schools must continue to develop skills that their students can use for lifelong learning. Otherwise, they will lose their accreditation. And, supplemental learning tools like Osmosis will continue to help them achieve this objective.

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