More on the Role of USMLE Step 1 in Resident Selection : Academic Medicine

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More on the Role of USMLE Step 1 in Resident Selection

Carmody, J. Bryan MD, MPH; Rajasekaran, Senthil K. MD

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Academic Medicine 94(7):p 921, July 2019. | DOI: 10.1097/ACM.0000000000002744
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To the Editor:

As educators, the concerns expressed by Chen and colleagues1 regarding the adverse effects of the United States Medical Licensing Examination (USMLE) “Step 1 Climate” on undergraduate education resonated strongly. Frankly, we were disappointed by Drs. Katsufrakis and Chaudhry’s2 response.

Though the USMLE was designed to provide a binary determination regarding fitness for licensure, secondary use of Step 1 scores in resident selection is commonplace. Although Drs. Katsufrakis and Chaudhry acknowledge that no convincing data exist demonstrating that USMLE scores predict residency success, the structure and content of their Commentary read as a justification for a scored Step 1. Should the presidents of the National Board of Medical Examiners (NBME) and Federation of State Medical Boards (FSMB) be leading the defense of the status quo?

We find a compelling analogy in the policies of the U.S. Food and Drug Administration (FDA). After receiving proof that a drug is safe and efficacious, the FDA approves the drug to treat a specific condition. While physicians are permitted to prescribe drugs “off-label,” pharmaceutical companies are expressly forbidden from marketing their products for purposes for which they have not proven beneficial.

While both the NBME and the FSMB are nonprofit corporations, review of these organizations’ publicly available tax documents demonstrates that their executives are highly compensated and that their corporations derive substantial returns from programs whose revenues might be impacted by a pass/fail USMLE. Given that residency selection policy is not a core mission of either organization, their defense of the status quo is curious and leads to the appearance of a conflict of interest.

On one point, we agree entirely with Drs. Katsufrakis and Chaudhry—the need for a thorough and transparent consideration of the Step 1 scoring policy. However, in the absence of proven benefit, and amidst the harms outlined elsewhere, we urge the NBME and FSMB to avoid the appearance of “marketing” Step 1 for secondary, off-label uses such as resident selection.

J. Bryan Carmody, MD, MPH
Assistant professor, Department of Pediatrics, Division of Nephrology, Eastern Virginia Medical School, Norfolk, Virginia; [email protected]

Senthil K. Rajasekaran, MD
Associate dean for academic affairs, Eastern Virginia Medical School, Norfolk, Virginia.


1. Chen DR, Priest KC, Batten JN, Fragoso LE, Reinfeld BI, Laitman BM. Student perspectives on the “Step 1 climate” in preclinical medical education. Acad Med. 2019;94:302–304.
2. Katsufrakis PJ, Chaudhry HJ. Improving residency selection requires close study and better understanding of stakeholder needs. Acad Med. 2019;94:305–308.
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