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Aiming High on USMLE Step 1: Why It Still Matters in a Pass/Fail World

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Is the pass/fail USMLE Step 1 really that difficult? How much time should you study for Step 1 now that it’s pass/fail? Are more students passing now that Step 1 is pass/fail?

The United States Medical Licensing Examination (USMLE) Step 1 has long been considered a pivotal moment in a medical student’s journey. However, with the recent shift to pass/fail scoring, many students are left wondering how much effort they should invest in preparing for this exam. While it may be tempting to aim for a mere passing score, there are compelling reasons why you should still strive to do your best on Step 1.

The Switch to Pass/Fail Scoring

The decision to change Step 1 scoring to pass/fail was made by the American Medical Association (AMA) and the National Board of Medical Examiners (NBME) in an effort to reduce the excessive stress placed on medical students and to promote a more holistic residency selection process.

Historically, Step 1 scores were often used as a primary factor in determining a student’s “competitiveness” for various specialties and residency programs. This practice led to an overemphasis on Step 1 performance, often at the expense of other important aspects of a student’s application, such as clinical grades, research experience, and extracurricular activities. The hope is that the new scoring system will encourage a more well-rounded evaluation of applicants, taking into account their overall strengths and potential as future physicians.

Impact on Exam Performance and Residency Selection

While the full effects of the pass/fail scoring system are still being studied, early data provides some valuable insights into how the change has influenced exam performance and residency selection:

Step 1 pass rates for US MD test takers ranged from 95-97% between 2019-2021, with a passing score of 194. In 2022, the passing score increased to 196, and pass rates decreased to 91% in 2022 and 90% in 2023. This change can likely be attributed, at least in part, to the shift to pass/fail scoring, as some students may have felt less pressure to achieve a high score and thus prepared less intensively. See the table below from our article on USMLE pass rates for MDs, DOs, and IMGs.

Step 1 Passing Rates2017201820192020202120222023
MD Degree Examinations21,38221,61122,14620,34323,07824,25125,146
MD Degree Passing %94%95%96%97%95%91%90%
MD Fails*1,2831,0818866101,1542,1832,515
DO Degree Examinations3,8354,1364,8375,2745,3654,7224,913
DO Degree Passing %95%96%96%95%94%89%86%
DO Fails*192165193264322519688
IMGs Examinations17,20316,44316,06513,11719,21024,95626,141
IMGs Passing %73%75%78%83%77%71%68%
IMG Fails*4,6454,1113,5342,2304,4187,2378,366
Total Step 1 Exams42,42042,19043,04838,73447,65353,92956,200
Overall Step 1 Pass Rate86%87%89%92%88%82%79%
Total Step 1 Fails6,1195,3574,6143,1045,8949,93911,569

Average Step 2 CK scores and pass rates (97-99%) have remained relatively stable from 2020-2023, approximately one year after Step 1 transitioned to pass/fail. This suggests that students are still motivated to perform well on Step 2 CK, which remains a scored exam and is increasingly important in the residency selection process.

The 2024 residency match will be the first cycle in which a significant number of applicants will not have a Step 1 score. More data will be needed to fully assess the impact of this change on the selection process, but it is likely that other factors, such as Step 2 CK scores, clinical grades, research experience, and letters of recommendation, will play a larger role in determining an applicant’s competitiveness.

Reasons to Aim High on Step 1

Despite the shift to pass/fail scoring, there are several compelling reasons to do your best on Step 1:

  1. Maximize your chances of passing: Step 1 is a challenging exam that covers a vast amount of material. Even students who perform well in their pre-clinical coursework can struggle with the exam’s format and content. Failing Step 1 can result in significant financial costs, logistical difficulties with clinical rotations, and added stress when applying to residency. By aiming high and thoroughly preparing for the exam, you can minimize the risk of failure and its associated consequences.
  2. Build a strong foundation for Step 2 CK and beyond: While Step 1 is now pass/fail, Step 2 CK remains a scored exam that is increasingly important in the residency selection process. The content tested on Step 2 CK builds upon the foundational knowledge assessed in Step 1, including anatomy, physiology, pathology, and pharmacology. By mastering the material for Step 1, you will be better prepared to excel on Step 2 CK and in your clinical rotations, where you will be expected to apply this knowledge to patient care.
  3. Develop effective study habits and time management skills: Preparing for Step 1 requires discipline, dedication, and the ability to manage large volumes of information. By developing effective study strategies and time management skills during your Step 1 preparation, you will be better equipped to handle the demands of clinical rotations, future exams, and ultimately, your career as a physician. Learning how to prioritize information, use active recall techniques, and balance studying with self-care are valuable skills that will serve you well throughout your medical training and beyond.

Strategies for Success on Step 1

  1. Target scores on practice exams: While the passing score for Step 1 is 196, the USMLE does not release an official percentage correct required to pass. However, it is generally agreed upon that answering approximately 60% of questions correctly is sufficient to achieve a passing score. Aiming for a score of >70% correct on practice exams before sitting for the actual exam to ensure a high likelihood of success. This buffer allows for the natural variability in exam performance and helps to account for the heightened stress and pressure that many students experience on test day.
  2. Benefits of timed practice exams: Regularly taking practice exams under timed conditions can also help you build endurance and develop effective test-taking strategies, such as managing your time wisely and identifying key information in question stems.
  3. Use spaced repetition for retention: Spaced repetition is a powerful learning technique that involves reviewing material at increasing intervals to promote long-term retention. By revisiting concepts and facts periodically, you can solidify your understanding and minimize forgetting. Incorporate spaced repetition into your Step 1 study plan by using flashcards, such as Anki. If you have never used Anki or find it difficult to use consistently, consider booking a consultation with a USMLE Success Specialist to help get you on track.

Concluding Thoughts

In summary, despite the change to pass/fail scoring, it is still in your best interest to put forth your best effort on the USMLE Step 1 exam. By aiming high, you can maximize your chances of passing, build a strong foundation for future exams and clinical rotations, develop valuable study and time management skills, and prepare yourself for a successful career in medicine.

Remember, your journey to becoming a physician is not defined by a single exam. Approach Step 1 with dedication and resilience, and maintain a growth mindset throughout your medical training. By doing so, you will be well-equipped to face the challenges ahead and make a positive impact on the lives of your future patients.

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Want FREE Cardiology Flashcards?

Cardiology is key for impressive USMLE scores. Master cardiology from a Harvard-trained anesthesiologist who scored USMLE 270 with these 130+ high-yield flash cards. You’ll be begging for cardio questions - even if vitals make you queasy.