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Improving Residency Selection Requires Close Study and Better Understanding of Stakeholder Needs

Katsufrakis, Peter J., MD, MBA; Chaudhry, Humayun J., DO, MS

doi: 10.1097/ACM.0000000000002559
Invited Commentary: PDF Only

The United States Medical Licensing Examination (USMLE) has long been valued by state medical boards as an evidence-based, objective assessment of an individual’s progressive readiness for the unsupervised practice of medicine. As a secondary use, it is also valued by residency program directors in resident selection. In response to Chen and colleagues’ consideration of changing Step 1 scoring to pass/fail, contextual and germane information is offered in this Invited Commentary, including a discussion of potential consequences, risks, and benefits of such a change. A review of stakeholders involved in the residency application process and their possible reactions to a scoring change precedes a discussion of possible changes to the process, changes that may better address expressed concerns. In addition to pass/fail scoring these include limiting score releases only to examinees, changing the timing of score releases, increasing the amount and improving the quality of information about residency programs available to applicants, developing additional quantitative measures of applicant characteristics important to residency programs, and developing a rating system for medical school student evaluations. Thoughtful and broad consideration of stakeholders and their concerns, informed by the best evidence available, will be necessary to maximize the potential for improvement and minimize the risk of unintended adverse consequences resulting from any changes to the status quo. An upcoming invitational conference in 2019 that is being organized by several stakeholder organizations is expected to further explore underlying issues and concerns related to these options.

P.J. Katsufrakis is president and CEO, National Board of Medical Examiners, Philadelphia, Pennsylvania. ORCID:

H.J. Chaudhry is president and CEO, Federation of State Medical Boards, Euless, Texas.

* A complex system is defined as a system composed of a large number of interacting components, without central control, whose emergent “global” behavior—described in terms of dynamics, information processing, and/or adaptation—is more complex than can be explained or predicted from understanding the sum of the behavior of the individual components. Source: Santa Fe Institute (

Editor’s note: This is an Invited Commentary on Chen DR, Priest KC, Batten JN, Fragoso LE, Reinfield BI, Laitman BM. Student Perspectives on the “Step 1 Climate” in Preclinical Medical Education. Acad Med. 2019;94:XXX–XXX.

Funding/Support: None reported.

Other disclosures: The authors are the CEOs of the two organizations that sponsor the United States Medical Licensing Examination program.

Ethical approval: Reported as not applicable.

Correspondence should be addressed to Peter J. Katsufrakis, National Board of Medical Examiners, 3750 Market St, Philadelphia, PA 19104-3102; email:

© 2019 by the Association of American Medical Colleges