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Student Perspectives on the “Step 1 Climate” in Preclinical Medical Education

Chen, David R.; Priest, Kelsey C., MPH; Batten, Jason N., MA; Fragoso, Ligia E., MA; Reinfield, Bradley I.; Laitman, Benjamin M., MD, PhD

doi: 10.1097/ACM.0000000000002565
Invited Commentary: PDF Only

The United States Medical Licensing Examination (USMLE) Step 1 was implemented in the 1990s as the most recent version of the National Board of Medical Examiners’ preclinical licensing examination originally created in the late 1960s. For the purposes of state licensure, the exam is pass/fail, but the Step 1 numeric score has in recent years become central to the residency application and selection process. Consequently, a medical student’s Step 1 score is increasingly viewed as a key outcome of preclinical medical education.

In this Invited Commentary, students from various institutions across the country draw on their shared experiences to argue that the emphasis on Step 1 for residency selection has fundamentally altered the preclinical learning environment, creating a “Step 1 climate.” The authors aim to increase awareness of the harms and unintended consequences of this phenomenon in medical education. They outline how the Step 1 climate negatively impacts education, diversity, and student well-being, and they urge a national conversation on the elimination of reporting Step 1 numeric scores.

D.R. Chen is a third-year medical student, University of Washington School of Medicine, Seattle, Washington. ORCID:

K.C. Priest is a fifth-year MD/PhD candidate, Oregon Health & Science University and OHSU-Portland State University School of Public Health, Portland, Oregon. ORCID:

J.N. Batten is a fifth-year medical student, Stanford University School of Medicine, Palo Alto, California.

L.E. Fragoso is a third-year medical student, The Warren Alpert Medical School of Brown University, Providence, Rhode Island.

B.I. Reinfield is a fourth-year MD/PhD candidate, Vanderbilt University School of Medicine, Nashville, Tennessee.

B.M. Laitman is a first-year otolaryngology resident, Icahn School of Medicine at Mount Sinai, New York, New York.

Editor’s note: Invited Commentaries from P.J. Katsufrakis and H.J. Chaudhry, and from K.M. Andolsek will appear in the March 2019 issue with this article.

Acknowledgments: The authors thank their mentors for sharing their wisdom, their peers for sharing their experiences, and, specifically, Molly Jackson, MD, whose passion for medical education and unyielding support made this work a possibility.

Funding/Support: Reported as not applicable.

Other disclosures: None reported.

Ethical approval: Reported as not applicable.

Correspondence should be addressed to David R. Chen, 1959 NE Pacific St., Seattle, WA 98195; email:; Twitter: @kelseycpriest.

© 2019 by the Association of American Medical Colleges