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No More Numerical Scores for USMLE Step 1 Exam

— New pass/fail policy aims to reduce overemphasis on test performance

by Judy George, Senior Staff Writer, MedPage Today February 14, 2020

Scores for Step 1 of the United States Medical Licensing Examination (USMLE) will be reported as pass/fail, not as numeric scores, the two organizations that sponsor the test announced Wednesday.

The change, which will happen no sooner than January 2022, aims to reduce overemphasis on Step 1 performance while allowing licensing authorities to continue to use the test to determine medical license eligibility, the Federation of State Medical Boards (FSMB) and the National Board of Medical Examiners (NBME) said.

“I am stunned,” said Bryan Carmody, MD, of Eastern Virginia Medical School in Norfolk, who has advocated for more meaningful evaluations to select medical students for residency programs. “By itself, making Step 1 pass/fail doesn’t fix much, but it does give us the opportunity to make changes,” he said in an interview with MedPage Today.

“If we do nothing, Step 2 mania will be the natural result of a pass/fail Step 1,” he added. “Unless we give residency program directors more useful information and the time to thoughtfully review all the applications they receive, they’ll gravitate to another convenience metric out of necessity.”

The USMLE consists of three “step” tests:

  • Step 1, typically taken midway through medical school
  • Step 2, which has both clinical knowledge (CK) and clinical skills (CS) components and is taken before matching into a residency program
  • Step 3, taken during residency

Candidates who pass all USMLE step tests may apply for a license to practice medicine in the U.S.

In addition to the change in Step 1 score reporting, the policy changes announced Wednesday will reduce the allowable number of exam attempts on each step component from six to four and require success on Step 1 before taking the Step 2 CS component.

Step 1 was implemented in the 1990s. For state licensing purposes, the exam always has been pass/fail, but over the years, its three-digit numeric score has become a key part of screening and selecting residents.

Last year, a group of medical students wrote an invited commentary for Academic Medicine, pointing out unintended consequences of Step 1’s numeric scoring process on education, diversity, and student well-being.

Step 1 had created a rift in medical education, those authors argued, encouraging students to disengage from medical school curricula to study for what would be on the Step 1 exam. In this climate, courses about medical ethics and social determinants of health were considered “low yield” for Step 1. Students could spend $1,000 in commercial resources to prepare for Step 1, and not all students can afford that, the commentary pointed out.

In a response that ran alongside it, Peter Katsufrakis, MD, CEO of the NBME, and Humayun Chaudhry, DO, CEO of the FSMB, argued that numerical scores can help residency programs differentiate among thousands of applicants for a limited number of slots.

In an early version of the essay, they noted that if students spent less time preparing for Step 1 and “more time to activities that make them less prepared to provide quality care, such as binge-watching the most recent Netflix series or compulsively updating their Instagram account, this could negatively impact residency performance and ultimately patient safety.” Within a few days, Katsufrakis and Chaudhry issued an apology and removed the phrase, but the comment fueled a Twitter storm, bringing Step 1 scoring to the forefront.

Step 1 scoring was addressed later that year at the Invitational Conference on USMLE Scoring (InCUS), hosted by the FSMB, NBME, American Medical Association, Association of American Medical Colleges, and Educational Commission for Foreign Medical Graduates, which invited representatives from education, state medical boards, and others to participate.

“If there’s one thing I took away from my experience at InCUS, it was that changing Step 1 to pass/fail will not solve every problem,” said Christle Nwora, a fourth-year medical student in Houston.

“The process of transitioning to residency is complicated and everyone is trying to figure out how to identify which residents are the best fit for their program,” Nwora told MedPage Today. “Every program has a different flavor and every applicant is unique, and it’s difficult to determine what metrics are best to use.”

The new policy change has generated mixed responses from medical students, which an informal Twitter poll this week by Leo Brueggeman, a University of Iowa MD, PhD student, highlighted.

“After 24 hours, 551 votes had been cast, with 19% supporting the change, 54% not supporting the change, and 27% undecided,” Brueggeman told MedPage Today. “Given that studying for Step 1 is generally considered the low-point of medical school, the results surprised me.”

“I think a large part of the negative response may be centered on drawbacks of other possible metrics for residency applications,” Brueggeman added. “I’m in the undecided camp, but am hopeful that this will serve as an opportunity to refocus on quality medical education and making further changes to improve the residency selection process.”

But for others, the policy is a step in the right direction. “As far as I’m concerned, it’s the single biggest shift to occur in medical education since the introduction of the first version of the exam,” noted David Chen, a fourth-year medical student at the University of Washington in Seattle. “It shows that advocacy makes a difference, and change is possible in medical education.”

New pass/fail policy aims to reduce overemphasis on test performance

Scores & Transcripts

Examination Performance Data

Every year, the NBME publishes performance data for each of the exams. You can view excerpts of performance data here.

Score Interpretation Guidelines

The USMLE Score Interpretation Guidelines provide score interpretation information for Step 1, Step 2 CK and Step 3 examinations.

Understanding Your USMLE Score Report

Please note: The interactive score report below is a sample Step 3 report, but can be used to understand Step 1, Step 2 Clinical Knowledge (CK), and Step 3 score reports. Samples of the content areas that appear in Step 1 and Step 2 CK score reports are also provided.

Scores

With the exception of Step 2 CS (which is reported as Pass/Fail), USMLE results are reported on a 3-digit scale.

The current minimum passing scores are as follows:

Step 1 : 194
Step 2 CK : 209
Step 3 : 198

Examination data (including performance information and recorded patient encounters) from USMLE examinations may be used by the USMLE program or made available to third parties for research and other purposes that are disclosed to or authorized by you, as appropriate, at the time any data is collected. In such instances, the data will be confidential, and individual examinees will not be identifiable in any publication. If you do not wish your examination data to be made available for such purposes, you must advise the USMLE Secretariat in writing no later than 30 days before your administration.

What’s Included on Your Transcript?

Your USMLE transcript includes the following:

  • your name and other personal identification information, including your date of birth;
  • your complete examination history of all Steps and Step Components that you took;
  • your history of any examinations for which no results were reported;
  • indication of whether you have previously taken the former NBME Parts I, II, or III, Federation Licensing Examination (FLEX), or ECFMG Clinical Skills Assessment (CSA);
  • annotation(s) and information documenting classification of any scores as indeterminate (see Score Validity and Irregular Behavior);
  • annotation(s) and information documenting any irregular behavior (see Score Validity and Irregular Behavior); and
  • annotation(s) of any actions taken against you by medical licensing authorities or other credentialing entities that have been reported to the FSMB Board Action Databank.

Note: Graphical performance profiles, which are included on your original score reports, are not included in your USMLE transcript.

To obtain your USMLE transcript or have it sent to a third party, you must contact the ECFMG, FSMB, or NBME depending on which examinations you have taken and where you want your transcript sent.

Contact the FSMB if you want your transcript sent to a medical licensing authority at any time. If you have not registered for or taken Step 3 and want your transcript sent to anyone other than a medical licensing authority, submit the request to the last entity that registered you.

Requesting a Transcript of USMLE Scores

To obtain your USMLE transcript or have it sent to a third party, you must contact the ECFMG, FSMB, or NBME and pay the associated fee. Which entity you contact depends on which Steps you have taken and where you want your transcript sent. Use the table below to determine which entity you should contact based on your specific details and needs.

Contact Information for Transcripts

Step(s)/Component(s) Taken Recipient of Transcript Contact
One or more USMLE Steps Medical licensing authority FSMB
All three USMLE Steps; or Step 1 and Step 2 CK and CS (if required), only when registered for or after taking Step 3 Any recipient FSMB
Step 1 and/or Step 2 CK and/or CS only, registered by ECFMG Any recipient other than a medical licensing authority ECFMG
Step 1 and/or Step 2 CK and/or CS only, registered by NBME Any recipient other than a medical licensing authority NLES
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The United States Medical Licensing Examination® (USMLE® ) is a joint program of the FSMB and the NBME.

The United States Medical Licensing Examination (USMLE) assesses a physician’s ability to apply knowledge, concepts, and principles, and to demonstrate fundamental patient-centered skills, that are important in health and disease.