USMLE (Step 1)- Grading changed to pass/fail

In the push for equity, excellence is being brushed aside

It is hard to believe it has been ten years since I wrote the essay below. My daughter had come home from medical school at the University of Miami, my alma mater, to study for the first part of the three part United States Medical Licensing Examination (USMLE), usually referred to simply as Step 1. This is a comprehensive all-day written examination that covers the first two years of medical school. It is considered the most difficult of the three exams, all three of which must be passed for a medical student to obtain a license to practice medicine. Failure is a non-starter for a medical career.

Until 2022, Step 1 was a graded exam. A high grade was considered essential to be competitive when applying for residency training in highly desirable specialties, e.g. plastic surgery, dermatology, and in elite institutions, nearly all of which used Step 1 scores to screen applicants. In 2022, the exam was changed to a pass/fail format, ostensibly to reduce stress on students, but also because the grading was said to disfavor minority students, who often did not perform as well. To say the result was simultaneously surprising and predictable sounds contradictory but is not. Nearly 1,600 first-time MD test-takers failed in 2022, compared to about 900 in 2021, a roughly 75% increase in one year. While the change to pass/fail possibly reduced stress there was another predictable, but unanticipated consequence- students did not take the exam as seriously and did not study as hard for it. Given that the US faces a critical shortage of physicians, especially in the primary care specialties- family practice, internal medicine, pediatrics, and ob-gyn- these figures do not bode well.

Without standardized, objective metrics, how do you distinguish between students? With so many applicants for the more popular specialties and elite programs, there has to be some sort of preliminary screening. Testing allows a blinded focus on academic excellence. Whether this directly translates to better doctors is a more complex question because more than book knowledge is required. That is more difficult to measure.

Medicine is a difficult and demanding profession. Hard work is expected of medical students and a part of this is learning to work under pressure and assimilate large amounts of information, and recall this for later use. Admittedly, some of it, perhaps even most, will never be useful in a medical career, but how is one to know in advance what will be useful and what will not? I have often found myself dredging up information from medical school when dealing with patients. You cannot practice medicine by relying on having reference books or a computer at your side at all times to look up information.   

As to my daughter, ten years later she is now a board-certified dermatologist in private practice.

Here is my essay:

August 6, 2014- There’s a Medical Student in my House

For 5 weeks this summer we had the rare pleasure of observing, up close, a unique species, Medicis studiensis. the common medical student. These creatures, identified by their pale complexion, bleary eyes, and tendency to yawn repeatedly, are usually confined to the vicinity of their natural habitat around academic medical centers. However, at certain times of the year, they scatter from their enclaves and follow well-established migratory routes across the country to private residences, where they establish themselves in a symbiotic relationship with Homo sapiens parentis.

Although fully formed adults, M. Studiensis, regress to an earlier stage of development during this period. They become dependent on the H. parentis for nearly all necessities, concentrating on a relentless pursuit of medical knowledge to the exclusion of basic life support functions. The single-minded focus of M. Studiensis can be easily seen as he or she will ignore meals, basic grooming activities, baths, and, in general, all activities not directly related to the task at hand.

M. Studiensis is territorial, staking out an entire residence as their turf and are very protective of that territory. Within the confines of that territory, M. Studiensis will move from place to place, establishing a temporary nest for a day or portion of a day. One never knows where M. studiensis will be found at any given time and so observers and visitors in the residence must tread lightly and quietly so as not to disturb them and prompt a rapid flight to another location while uttering their signature call “C-a-n’t t-a-l-k n-o-w. G-o-t-t-a s-t-u-d-dee!”

M. studiensis exhibits classic nesting behavior even though no courtship rituals have been observed. Nests are composed of materials readily at hand and tend to be of simple construction, with little attention to appearance or durability- typically a blanket and pillow.

Care and feeding of M. studiensis can be challenging. They are picky eaters and not subject to any schedule for mealtimes. Grazing behavior is universal and favors a variety of easy-to-consume snacks, most of which are largely devoid of significant nutritional value. To truly sustain your specimen, some effort must be made to providing an occasional healthy, tasty meal. M. studiensis can sometimes be coaxed from their nest of the moment by a combination of cooking odors and visual cues that emanate from LED screens found in most homes. Like moths, they are drawn to light. Each specimen has unique cues he or she will respond to. Our M. Studiensis was particularly fond of Pride and Prejudice on DVD or reruns of Big Bang Theory combined with the smell of a vegetable stir fry. This seemed to guarantee at least a 30 minute break from the frenzied studying. During this time, limited communication can be re-established albeit between bites of food.

Fortunately, or unfortunately, as the case might be, the time in residence of M. Studiensis must draw to a close after a few weeks as they prepare to return to their academic home. This is when it is most critical to insure the care and husbandry of your specimen. Their nervous systems are very fragile and they can be severely disturbed by any disruption in their established study patterns, or simply by asking, “How’s it going?” at the wrong time. This can throw M. studiensis over the edge emotionally like a lemming going over a cliff.

The culmination of this period is a return to their academic enclaves where they will spew all of the accumulated knowledge of the past few weeks in an incredible explosion of information under pressure. In the aftermath of this brief, intense expenditure of energy, M. studiensis will go into a brief period of relative inactivity in sharp contrast to its prior frenzied study. At this time they are more approachable without being spooked and can be found at water holes in large and small groups consuming variable amounts of fermented hops and assorted foods. Ground beef patties on bread accompanied by strips of potatoes fried in oil are especially popular. Their cries “Yeah, baby, we did it!” accompanied by the sharp slaps of ‘high fives’ can be heard above the din of other denizens of the watering hole.

Another year has passed in the life cycle of M. studiensis.

Richard T. Bosshardt, MD, FACS is a retired plastic surgeon, Senior Fellow at Do No Harm, and Founding Fellow at FAIR in Medicine

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