USMLE Step 1 is BECOMING PASS/FAIL!?


Per an official statement, the USMLE Step 1 may in the future be moving to a pass/fail scoring system. 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. To change Step 1 to pass/fail would be short-sighted and harmful to future medical trainees Second, put the NBME in their place. It is appalling that the NBME, a not-for-profit organization, is making Scrooge Mcduck look charitable. The fact the CEO tripled his salary in 15 years and is making over 1.2 million dollars is absurd. NBME resources, such as practice tests, should be offered for free or highly subsidized as should the cost of exams. Their monopoly on medical education is being blatantly abused. And number 3, investigate other objective assessments. Step 1 is far from perfect. While making it pass/fail is obviously not the answer, we should seek to find other objective metrics to more accurately assess a medical students aptitude. Only then can we even consider making Step 1 pass/fail. Now what are your thoughts? Are you for or against Step 1 being pass/fail? Let’s have a mature and rational discourse in the comments. Congrats that you got a 204 and are still a great physician. No one said that you aren’t. Thank you all so much for watching! If you liked the video, give me a thumbs up. And if you want to tell me to go screw myself, let me know with a thumbs down. Much love to you all, even the haters. And I will see you guys in that next one.

100 thoughts on “USMLE Step 1 is BECOMING PASS/FAIL!?

  • So you only spent $500 on test prep and "if i can do it so can you!" but then offer a $250/hour tutoring service to profiteer off students desperation to get a better test score? Like i appreciate the hustle but c'mon even with your disclaimer you need to take your opinion with a huuuge grain of salt.

  • Step 1 is a terrible exam, majority of the content is useless for future practice and could appropriately be pass/fail with more emphasis on step 2ck (a much more relevant exam) or transition to a script concordance format. Additionally, having more data points by using NBME scores to give a better overall picture of the applicant is even better. IF you want to study hard on all these exams and match in plastics, go for it, that way if you slip up on the psychiatry nbme, you got 5/6 others to shine.
    All of the points you bring up are true, but I think you focused a little to much on “this is the best we have” argument instead of agreeing that it’s a terrible exam whose performance on one day (think about the variability of that data point) has a huge influence and has an unbelievable influence on an individual’s future career (big deal). You’re a smart man but I think your conclusion was extremely short sighted in the grand scheme of things. We need to do better and we have the options. Regardless, appreciate you helping to push the conversation.

  • I'd love if the mcat was pass fail as well. Make it so a 509-511 was a passing score, that way there is very little point to dedicate an entire summer to just reading through books and taking practice exams. Instead you could volunteer in a hospital or do more research. The execs are so condescending in assuming that med students will just watch netflix. These are highly motivated and intelligent individuals not high school students.

  • This is triggering 😂😂😂.
    Thankfully I passed Step 1 with a ‘decent’ score, but I would have not studied nearly as hard if it was only P/F.

  • just increase the number of residency spots and it will reduce the crazy competitiveness and pressure on scores , thats it. if funding of residency is a bottleneck then let self finance be an option for new spots.

  • This amazing video needs more awareness, this guy is too intelligent.👏👏. I'm highly against changing the USMLE step 1 to a pass/fail system.

  • At the University of New Mexico's medical school, they actually have a course dedicated to the medical students to study for STEP 1. I believe that provides the advantage to atleast, close the gap between people of different income groups. That's a step in the right direction to provide support for those students rather than those who have the money. It also partially solves the issue of students prioritizing step one over their first two years of classes at medical school. If anyone could respond on their take of what I said, that would be great for. Cheers!

  • Making videos about controversial topics like these is not always easy, but I think it's so important. What do you think about USMLE Step 1 being Pass/Fail? I think this is a very important conversation to be had.

  • What are your thoughts on allowing retaking step 1? Why is the current policy that people are unable to retake if they pass?

  • With all due respect, but wouldn't it ultimately be in the best interest of patients, if instead of a test which is on the somewhat preclinical side compared to Step2CK/CS/3 and clerkships those more clinical and patient-centred scores would determine the chances of a med student when it comes to residency? After all, a physician has got to be as mentioned mainly a team-player from a scientific background who treats patients well.

  • I nearly went into a panic attack when I heard that it was going to change to pass/fail. I am a black immigrant IMG. There is no way I could have gotten into the US without a scoring system. The system is already biased how it is because people are biased. There needs to be some level of objectively and that is why I like exams

  • Watching this the day it got passed….. good thing I'm an incoming med student who will be the first year to deal with the pass-fail :–)

  • How will this impact current first years at medical schools (class of 2023)? There are some schools who take step during 3rd year and there are some who take it 2nd year…so with the change class of 2023 will have applicants with both p/f and scores? So how would they report numerical scores then?

  • I completely disagree! Why should one take ownership of a low step 1 score? Most students who do not score well started studying for the exam a lot later than they should have or started to study only during their school's dedicated period. They chose to focus on the school curriculum and lectures and it back fired. Everyone knows that getting a high score on step 1 increases linearly with time and the exam is heavily reliant on memorization of discrete details rather than clinical reasoning. You say, "learn from the experience and do step 2 better" but its not applicable for step 2 as you are already studying earlier for step 2 when your taking your shelf exams. Shelf exams and thorough content review over 1.5 years is needed for step 2 but beyond that more time does not equal a higher score because it is dependent on clinical reasoning rather than memorization and anki drilling.

  • I agree that if Step 2 CK became the new step 1, yes, you would have the same issues..EXCEPT step 1 is so focused on minutia and bullshit (example – what chromosome is tuberous sclerosis type 2 located on? Is the cystic fibrosis channel ion gated or ATP gated? Which cast in your urine is associated with the "Maltese cross" sign? or Tamm-Horsfall mucoproteins?) – can anyone truly say these answering these questions make you a better doctor? Whereas step 2 is MUCH more clinically focused and a better exam to differentiate students in my opinion

  • i totally agree with some comments below with making the step 1 "retakeable" the main reason for my anxiety around the exam was not the stress of trying to get the highest score possible otherwise i'll be shunned for life (which is a stress in itself), but also the fact that i have only one chance. either I slay it or I bomb it and there goes my entire future down the drain.

    instead they've reduced the number of attempts you can give. but even with the 6 attempt policy that was there earlier, culture is that if you retake the step 1, you'll be shunned, programs won't even look at your application because omg god forbid you had one bad day which caused a problem in your performance so that makes you a terrible future doctor. it's ridiculous.

    we should have the chance to do the exam as many times as we want. and trust me if we fail the exam 3 or 4 times we ourselves will make the judgement that medicine make just not be for us… we're smart enough to understand our strengths and weaknesses.

    they can also change the content of the exam.. let's be real, knowing the mechanism of mutation for this particular code on this particular gene is irrelevant when clinically examining a patient

  • Can’t agree with you more Dr. Juppal! As a current 4th year who just underwent the stress of residency interviews, I was shocked when I heard the news. I don’t believe students who come from a second tier school like me will have the same chances for good programs under this new policy. Having high step1 score is the only way to prove that you are as smart as the ones from famous schools. Without it will make the whole residency application more not less stressful.

  • i would like to know what this means for those of us planning to take it when it will still be scored. by the time we apply the pass/fail will be implemented… what does this mean for those of us in the unknown?

  • As an IMG i was so motivated to one day do this a was carving a 280 or more I'm doing everything along with my courses, kaplans, every textbook and every resource for usmle for all subjects. This is so devastating.

  • its simple. Step 2 will become the new step 1. Over time people will complain and eventually step 2 will become pass/fail too lmaoo

  • Like you said high step score= smart. It doesn’t show how compassionate, charismatic or team player you are. You can be a book smart but still be a bad doctor. The point of making it p/f is that it shows you’re competent. You wouldn’t say a dermatologist is more knowledgeable or competent that a family medicine doctor right??? Once you’re done with residency and employed NO ONE cares for your step score, all they care is that you have your license and are board certified. I think that by making step p/f it goes back to its roots of providing physicians with licensing, regardless of grade. Idk how it will play out. We’ll just have to wait and see.

  • I have a speculation that with this change to a pass/ fail system one of the objectives is to further lessen the number of applicants to specialties.
    I am not sure how much truth would be in such speculation, but with news of shortage of doctors in primary care specialities in recent years, I would not be surprised that this is a move to make things harder for students to specialize and thus have no other option but to remain in primary health care.

  • For IMG it's better this way cz we don't have to pay more than 1000$ just for an exam because compared to our currency, the US $ is off the roof

    So instead of shouting "it's short sighted" be inclusive of us too and see the bigger picture next time

  • Great take Kevin, education needs more investment to figure out solutions to these real problems you outlined, which we now face. Relevant stakeholders – PDs, chairs, and students- need to be involved in these decision-making processes. Seems we now have to figure out the fall-out in the next match and pick up the pieces to see where they fit.

  • As someone who excels in classes but has always struggled with standardized exams since I was a child, I can say that standardized exams can eliminate very good students from being noticed as the exam score overshadows all your grades, volunteering, research and basically makes all of that amount to nothing in comparison to your standardized exam score. I support their recent decision to go to Pass/Fail as I start medical school this Fall because I'm tired of having to laser focus on standardized tests instead of more important factors. I'd say there is an argument that there is nothing truly objective about the score. It's just a lazy way to access a person's aptitude.
    With this, I hope they make better ways to access an individual so it is not meritocracy either, but who knows how it will really go.

  • I destroyed my self in medical school … I know of people who committed suicide, I know others who had to be placed in psych. Institutions … Made many question this profession , but 200,000 and others up to 300,000 and others 1 million in debt, further feeds more into this freak show medical system ….

  • Everything other than standardized exams is completely subjective. I’m not a fan of subjective measures determining career options

  • Do the people who implement these changes actually look into the pros and cons of these decisions and attempt to investigate whether a change is actually going to work better than the status quo, or what people in the field think will work better because they’ve seen how the system can advantage and disadvantage people. Sometimes it feels like these choices to change things have a good intention but miss the mark.

  • With all this ridiculous requirements, dont help the graduates medical professionals, to complete the career. Then they are with a big loans, that cant pay.

  • I start med school this July and I would love to hear your updated thoughts and suggestions on this now that it will be official. I will be in the first class to take Step 1 as pass/fail. It’s a big topic amongst my peers, but we don’t know how to prep for residency now. Would love some advice for my class and beyond.

  • I really like the points you make in this video. I wonder how this is now going to play out. Many DO students, like me, are taking both COMLEX and USMLE (step 1 and 2] because not all residency programs accept COMLEX scores. Even though the COMLEX has been declared as an equitable examination in comparison, who is to say that program directors will adopt this same mentality? Superficially, it seems like this will be more of a detriment than a benefit when trying to compare residency candidates, unless they can really do a good job in categorizing effective measurements.

  • As someone who came from a public medical school and got into a top residency program with good scores and an overall good cv, I would never have gotten into my residency WITHOUT my scores, the spot would have gone to someone who went to more private prestigious $$$ Med schools that are unaffordable for many. This policy will greatly benefit the for-profit private medical schools!!! I wouldn’t be surprised if that’s how this policy changed! Follow the money !

  • Everyone who is against this change in step 1 grading:
    PLEASE sign and share this petition to have this change reversed!!

    https://www.change.org/p/national-board-of-medical-examiners-reverse-the-usmle-step-1-scoring-system-5d75f21a-2a9a-4815-b2b8-e0f6b19a8650

  • I like P/F. How you interact in the world around you matters more than your ability to sit down and take an exam. Now more than ever, MCAT/Step 1/Step2 scores keep increasing. Most schools won't even consider an applicant with an average MCAT or step 1 score. Becoming a physician is about team work, and networking among your peers. Knowing particular specialist as a general physician to recommend you patients to is as important as a diagnoses. Diagnoses come from clinical experience. Simply ask nurses, they are by far the most knowledgeable in the entire hospital when It comes to diagnosing. They didn't need to take the mcat or step 1 to differentiate themselves. This was all learned on the job. Why should an exam have to be the way you "prove yourself?" What about experiences, who you interact with, and the way you communicate with those around you. After all, this was always the role of a physician. The ability to diagnose (gained through experience), communicate effectively, and knowing others to come to a proper diagnoses will always be more beneficial than what you got on your Step 1 or MCAT score. Life isn't an exam you can prepare for.

  • Wow….The CEO's really do have to use an irritatingly condescending tone to address us don't they? This makes things so much worse. Especially for IMG's. I don't think the CEO's are qualified to give a statement for the bs that they've pulled with this one. Bravo. Excellent video as always Dr. Jubbal.

  • I totally agree. I would go further. Step 1 is an easy exam that tests fundamental knowledge. Changing the test to a pass/fail grading system will have a lot of unintended consequences in a climate where medicine has become protocol based. I think it will degrade the overall quality of physicians who enter residency.

  • Why are the competitive residencies competitive? Because they won't open anymore residencies or spots in them. They will of course blame money, supply/demand, knowledge base, wanting competent doctors, etc. but honestly ask yourself how hard is dermatology really? Why has it gotten so competitive? Do you have to be the top of your class to diagnose relatively simple skin conditions? Why does it take 3 months to see a dermatologist?

  • I like how you try and diagnose the broader cultural problem of medical education in this country but I can see how you are slowly shifting the blame back on the student. It is very true that people should only focus on what they can change as it is not helpful to think otherwise but it still does not address the overarching reasons and gives the institutions a pass on how they work and what they do to preserve their power and prestige.

  • I have to point out that you are being a tiny bit disingenuous. You said in this video that you had to take out loans for med school but you have stated else where that you didn't have to worry as much about student loans when you dropped out of your plastic surgery residency because you got a scholarship or grant for medical school because of your high MCAT score.

  • They should have made it possible to retake the test at least once if you weren't happy with your score. Think about it, you have a bad test day or couldn't prepare as hard or as long because of health, and yes that includes mental health, and don't do very well. BUT, someone who failed it but then did incredible on the retake is somehow in better shape, very odd. Still keeps the exclusivity of the high first time score and people who aren't interested in super competitive residencies, shocking I know, can just get on with things.

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