USMLE Step 1 Pass Fail – Meaning and Impact on IMGs

In February of 2020, the USMLE parent organizations (FSMB and NBME) approved the change of USMLE Step 1 scoring outcomes from a 3 digit score to Pass/Fail. This post aims to provide a better perspective on this change and how the USMLE Step 1 Pass Fail will affect IMGs.

Major changes made:

• USMLE Step 1 Scoring from 3 digit score to Pass/Fail
• You must take Step 1 and Pass prior to taking Step 2 CS
• The number of attempts on any USMLE exam is reduced from 6 to 4

As you can see the major change is the shift from a 3 digit score on the USMLE Step 1 to Pass Fail.

The USMLE Step 1 Pass Fail will not be implemented before January 2022

Why the change to a Pass/Fail reporting?

The idea was debated several times before it was passed. The main reasons to change from a 3 digit score on the USMLE Step 1 to Pass Fail were:

• The content tested on USMLE step 1 does not correlate well with how good a clinician you will be. Although you need to have a good understanding of the basic sciences to have solid clinical concepts, knowing them does not necessarily mean that you are a good clinician.
• Student well being and burnout prevention.

Here are some of the pros and cons of USMLE Step 1 Pass Fail that were discussed and are available on the website.

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PROS	CONS
USMLE offers highly reliable, objective assessment of relevant competencies. A national standard.	A passing score on USMLE demonstrates minimum competency. Pass/Fail reporting suffices for this.
Mitigates the reliability challenges of some medical school assessments	Licensure requires only a Pass/Fail outcome
May stimulate student preparation more than a Pass/Fail outcome	Focus on numeric scores negatively impacts student well-being
Incremental numeric USMLE performance correlates with other valued measures e.g., specialty board certification, state board disciplinary actions, improved practice	Standardized test scores best predict other standardized test scores (vs. clinical performance)
Offers a “level playing field” for all examinees, including those from international and new or lesser known schools	Maintaining 3-digit score reporting may limit diversity within various specialty programs
If no USMLE numeric score exists, and the demand for a national assessment remains, what fills the gap?	Maintaining 3-digit score reporting has an opportunity cost due to students’ heavy focus on maximizing USMLE scores (e.g., less time for research, volunteerism)

USMLE Step 1 Pass Fail – Overall Impact

Since its inception, the USMLE Step 1 three digit score was used as one of the main factors in screening residency applicants. With that factor now gone, here are a few things that will become more important.

• Step 2 CK score. There has been no change in the 3 digit score reporting for Step 2 CK. Step 2 CK is a much better reflector of a good clinician and residency program directors will place more emphasis on the Step 2 CK score.
• Medical School and Letters of Recommendation. Prestigious medical schools and the quality of letters of recommendations from renowned faculty members will become much more important in differentiating applicants.
• Research. Although research is currently cited lower on the list of factors that program directors consider while chosing applicants, with the introduction of USMLE Step 1 Pass Fail system, research publications will be considered more strongly.

Basically, you application as a medical student will be looked at in a holistic fashion considering a lot of variables that were originally masked by good Step scores.

How does the USMLE Step 1 Pass Fail affect IMGs?

The short answer is – USMLE Step 1 being Pass/ Fail affects competitive IMGs negatively. (Notice the word competitive.)

If you see the trends of matches in different specialties and compare American Medical Graduates (AMGs) to International Medical Graduates (IMGs) you will notice that for the same spot, an IMG has a higher step 1 score as compared to an AMG.

This Step 1 score was one of the important factors that helped IMGs stand out when it came to competitive residency applications. By removing that factor, the game is now tougher for IMGs.

So what can IMGs do to improve their chances?

Firstly, these changes will come into effect no earlier than January 2022, so if you will be applying prior to 2022, you have no reason to worry.

For the IMGs who will be taking the USMLE Step 1 post 2022, here are some things to keep in mind.

• If you are reading this and haven’t yet entered medical school, work hard. Try to get into the best medical school that is recognized widely.
• If you are already in medical school, be awesome. Work hard on your grades to get great transcripts and deans letter.
• Take Step 1 early. Many IMGs used to take Step 2 CS as their first exam. With the new rules, this will not be possible unless you first finish Step 1. It is best to take your USMLE Step 1 immediately after you have finished you basic science years in medical school. Remember, you only need to pass now, no stress 😛
• Focus on your clinical subjects and score really well on USMLE Step 2 CK. Check out my book on How to Crack the USMLE Step 2 CK for guidance on how to study for this beast.
• Keep electives in mind and apply early. You can do hands on electives as a final year student. Apply atleast 6-8 months before you plan to do the elective. Read my posts about electives here.
• Approach your application holistically. Remember to do research during medical school and publish. Get involved in volunteering and other leadership opportunities.
• Try to take USMLE Step 3 before you submit your rank order list. This has 2 advantages. One, you have something that distinguishes you. Two, you qualify for an H1B visa if the program offers it.

Although this may seem like a lot and may seem unfair, remember that IMGs have always been a part of the US healthcare system and if you are good, you will find a residency spot.

If you have any questions, use the comments section below. For personalized consultation fill out the consult request form and I will get back to you.

This article has been written by Dr. Rohit Nathani who is a medical graduate from Seth GS Medical College. Ask your questions in the comments section below.

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