Letters to the Editor
To the Editor:
Several medical students and a resident wrote a thoughtful and convincing argument to purge the United States Medical Licensing Examination (USMLE) Step 1 score in favor of a pass/fail designation.1 We applaud their challenge to reconsider how a 3-digit Step 1 score figures into a holistic residency application process. Medical educators are familiar with how high-stakes examinations impact the education environment and student wellness. Our position on releasing the Step 1 score begins where the authors’ conclusions end. If we have the courage to withhold students’ standardized scores, then perhaps we should consider withholding other application data—especially when such data may have little or nothing to do with future performance in residency education programs. If we dispense with standardized scores, then we must be willing to take another step and have an honest conversation about existing biases and assumptions that may come to the forefront as a result.
For example, in the absence of standardized data, it is possible that some program directors may lean on familiar assumptions about applicants and medical schools. Although a pass/fail designation may be the answer to enhancing student wellness and untethering the medical school curriculum from Step 1, it fails to reflect that there is likely more score variability within medical schools than between medical schools. Some students from smaller and perhaps less well-known medical schools earn exceptionally high Step 1 scores. With a pass/fail scoring system, such students lose an opportunity to stand apart from the crowd. It is possible for students from, say, Brown University and Stanford University (the authors’ schools) to be judged more favorably than students from less well-known schools for limited interview spots at competitive residency programs. In an ironic twist, abandoning the Step 1 score may actually serve to exacerbate what the authors characterize as a “tiered system of ‘worthiness’ among students.”1
If the answer to the Step 1 problem is removing the score, we may want to pause and reflect on where this discussion is leading us. All applicant data (e.g., access to research experiences, options for leadership experiences) may be reduced to a potential advantage or disadvantage. If we continue down the path of removing applicant data, then perhaps we will become more and more removed from our goal of reviewing applicants through a broad and holistic lens.
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.