The Case for Pass/Fail Step 2 

On February 12, 2020, the USMLE program announced that the USMLE Step 1 would effectively become pass/fail graded beginning with exam dates on or after January 22, 2022. While controversial, the move was partially welcomed for helping alleviate much of the stress that stems from having to perform so well academically in one’s preclinical medical education. The pressure of graded Step 1 created what was perceived as a “do or die” environment for many medical students who aimed for more competitive specialties such as neurosurgery, dermatology, or plastic surgery, necessitating doing well on Step 1 to even have a chance at applying for these specialties. Instead, students could have more opportunities to branch out beyond test prep in their first two years as they pursued various extracurriculars, research, and simple everyday hobbies. Moreover, a strong body of evidence suggests that graded Step 1 is potentially unfair to underrepresented groups in medicine, highlighting both racial and gender disparities.  

Amidst all these benefits, however, vague concerns have arisen that the switch to pass/fail Step 1 would reinforce a “hierarchy” in competitive specialties among students from the top-ranked medical schools versus those from lower-ranked allopathic, osteopathic, and foreign medical schools. This concern, that the switch to pass/fail Step 1 would somehow benefit those students from the upper echelon of medical schools, pales in comparison to the real drawback of switching to pass/fail Step 1. Despite all the benefits of the move, the change in grading has begged the question as to what exactly would supplant the importance of Step 1 in weighing residency applications. Consequently, many students have begun to hypothesize that much of that weight would instead shift to their Step 2 exam, which is presently still graded. Therein lies the real controversy of switching the grading of the Step 1 exam: the fact that it did not go far enough to alleviate the pressures that would remain with a graded Step 2 exam.  

In the present system, a graded Step 2 score would still present a major disadvantage to students who would have otherwise excelled in other areas of their application even with Step 1 being pass/fail. “I’m really worried about what Step 2 might mean for my career prospects if I were to do poorly,” said an anonymous medical student from a top 10 ranked medical school. “I mean, I’ve put in a lot of work to really get to know some of these program directors. Is it not enough that I’ve been playing squash with them on the weekends? Why should a test score be a barrier for me when I’ve excelled so much elsewhere?” Cupping their hands around an imaginary racket, they began stretching and waving their arm out to demonstrate the impressive work they had put into their backhand. 

In questioning another anonymous medical student, this one from a top 5 medical school, they worried further about how all of that Step 2 preparation would interfere with extracurriculars and work on their residency application. “Look, I’m applying derm, and I’d really like to use the summer of my third year to prepare my application and maybe even go vacation in Prague.” They gave a yearning look at a pair of plane tickets and continued, “I can’t exactly do that if I have a major exam to prepare for. That’s a lot of time that I’m losing out on. And coming from the school I attend, that could mean all the difference between matching my first- or second-choice derm program with my third.”  

Clearly, the stresses of Step 1 would invariably shift to Step 2 so long as it is still graded. In the best interests of students like these who simply wish to pursue their medical education without having to constantly worry about test scores and grades, the USMLE ought to further extend pass/fail grading to Step 2. By doing so, they can further eliminate the clear divide that exists between test takers from advantaged and disadvantaged groups in medicine, such as students from the higher-ranked medical schools.  

Given the importance of this matter, please do what you can to further pressure the USMLE program by writing them urging a change to pass/fail for Step 2 as well.   

Also please consider donating to sponsor one of these students on their trip to Prague.