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Does Step 1 Matter Now That It’s Pass-Fail?

Step 1 is Now the Most Reliable Single Practice Test for Your Step 2 CK Score – Treat It As Such

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by Alec Palmerton, MD in Uncategorized

Now that Step 1 is pass-fail, does it matter? Should you care about it at all? How do you approach a test where the only thing a program director sees is whether you passed (or didn’t); where program directors won’t see your specific score? And if you’re an IMG, DO, or MD student not at a prestigious medical school, what should you do?

In this article, we’ll discuss:

  • The impact of this change on the importance of Step 2 CK
  • How well you can predict your Step 2 CK score from your Step 1 performance
  • How to prepare for Step 1 and Step 2 CK simultaneously,
  • What you should do now that Step 1 is pass-fail

Table of Contents

Step 2 CK Scores Matter More: What Does That Mean for Step 1?

Step 2 CK will gain significance, with Step 1 becoming pass-fail. This prediction is mirrored by residency program directors, arguably the most critical cohort:

  • In a survey of dermatology PDs, 86.0% (49/57) indicated they would increase their emphasis on Step 2 CK.
  • 78.2% (43/55) of these PDs also reported they would begin requiring Step 2 CK for all applicants.
  • In one survey of internal medicine PDs, 87.8% said Step 2 CK scores would be more important
  • 96.9% of these orthopedic surgery PDs said Step 2 CK would become more important

If Step 2 CK is pass-fail, where does that leave Step 1? Does it still matter? Here are some reasons why Step 1 matters more than you might think.

Step 1 Is One of the Best Predictors of Step 2 CK Scores

Does it worry you that Step 2 CK is now so important? Is it even more worrisome that Step 2 CK is the culmination of 3+ years of intense studying?

At university, you may have had classes where the entire class grade came down to the final exam at the end. You would go to class for months, never getting any feedback on how you were doing. Until the last day of the course, your grade was the same as everyone else’s: an incomplete. Quizzes, midterms, and discussions didn’t explicitly factor into your transcript.

Or did they? The quizzes and midterms offered an essential glimpse into your progress in those cases. If you did poorly on the midterms, even if they didn’t have a grade, it was a wake-up call that something had to change. On the other hand, you probably felt very reassured if you had a series of high quiz grades.

In the same way, Step 1 will now become like a pass-fail mid-term. It is an important milestone on the path to you taking Step 2 CK.

This intuition is backed up by the fact that Step 1 performance is one of the strongest predictors of Step 2 CK scores. It is the single best indicator of how well students do on Step 2 CK.

The Best Predictors of Step 2 CK Scores

Here is data from research on the best predictors on Step 2 CK:

PredictorStep 2 CK
correlation r
When is
Average subject exam score with three subject exam scores (Combination A)0.81***Year 3
Average subject exam score with three subject exam scores (Combination B)0.80***Year 3
Step 1 score0.75***Year 2 – end
Preclinical mean exam score0.54***Year 2 – end

***p<0.001. Combination A = internal medicine, surgery, and pediatrics subject exam scores; Combination B = internal medicine, surgery, and obstetrics and gynecology subject exam scores

Source: Monteiro KA, George P, Dollase R, Dumenco L. Predicting United States Medical Licensure Examination Step 2 clinical knowledge scores from previous academic indicators. Adv Med Educ Pract. 2017;8:385-391. Published 2017 Jun 19. doi:10.2147/AMEP.S138557

What do you notice? Step 1 is the best single test that will predict Step 2 CK scores. The best overall indicators combine your IM + Surgery + Peds/Ob-Gyn shelf scores.

Does it scare you that your residency application may hinge on a single score with 3+ years of preparation? Remember:  the best way to achieve one big, overarching goal is to break it into manageable steps. Step 1 is a valuable milestone on your path to a high Step 2 CK score.

Step 1 is a Great Predictor of Shelf Scores (Which Predict Step 2 CK Scores Even Better)

An interesting observation from Step 2 CK research is that the combinations of shelf scores are slightly better predictors of your final score. That shouldn’t be a surprise. Step 2 CK is essentially a combination of the shelf exams from the core rotations: pediatrics, internal medicine, surgery, ob-gyn, etc.

In the above table, you’ll notice that the shelf score combinations, including internal medicine and surgery, were the best predictors. This squares with other research on Step 2 CK score prediction.

It makes sense that internal medicine and surgery would be among the best predictors of Step 2 CK. These clerkships comprise a considerable part of Step 2 CK.

But where does that leave Step 1? If there is any rotation or shelf exam that approximates the material on Step 1, it would be internal medicine. I have yet to see any research on predicting shelf scores. However, in my experience, high Step 1 scores are great predictors of high shelf scores, particularly for internal medicine and surgery.

How Much Time Should You Spend Preparing for Step 1?

You may be wondering, now that Step 1 is pass-fail, how much time should we prepare for it? Previously, students would spend much more time on Step 1 preparations than Step 2 CK. That will likely reverse now. But how much time is enough for Step 1?

The Best Approach for Step 1 is to Prepare for Step 2 CK Simultaneously

Wouldn’t it be great if you could prepare for BOTH Step 1 and Step 2 CK simultaneously? You can. The overlap between Step 1 and Step 2 CK is high. There are very few things on Step 1 that do not show up on Step 2 CK. Genetics, biochemistry, immunology, and microbiology show up on Step 2 CK, particularly pediatrics.

To prepare for Step 1 now, we recommend learning Step 2 CK material, but with a deeper focus on pathophysiology, mechanisms, and concepts. Pathophysiology and mechanisms are the subjects of more questions on Step 1. However, Step 2 CK still tests the application and mastery of concepts – the focus is more on clinical vignettes. The deeper your understanding of concepts – rather than details – the better your Step 2 CK performance will likely be.

The better you build your foundation during your Step 2 CK studying, the more your Step 1 scores should improve. I’d wager that if you are preparing well for Step 2 CK, you should be able to pass Step 1 comfortably.

To read Should You Take Step 2 CK Before Step 1 (or Can You Study for Both)? click here.

Concluding Thoughts: Overnight Success Takes Years

Sometimes it seems like other people’s success comes from out of nowhere. Your friend says that she scored high on Step 2 CK – all she did was buckle down for a couple of months with UWorld questions every day.

It’s tempting to think that your friend’s success was due to the few months of intense preparation before her exam. However, it would be a mistake to assume that the final leg of a marathon is the primary determinant of the final result.

Instead, it’s the years of preparation before Step 2 CK that will matter.

There is, however, one major problem with the fact that Step 2 CK is the culmination of 3+ years of work. People are reactive – not proactive – especially when overwhelmed and overworked. How often have we left an essential deadline until the last minute, only to be scrambling the night before? For such an important test like Step 2 CK, waiting until the proverbial last minute could lead to disappointment.

What to Do Now That Step 1 Is Pass-Fail

So you know that you need to be preparing well, but you may be struggling with knowing what to do now? Maybe you are trying to master concepts – but still get stuck memorizing things at the last minute? Do you get overwhelmed by the immensity of the task of preparing for a test you might not take for years?

If so, break your task down into measurable goals with specific milestones. The best predictors of Step 2 CK scores have been Step 1 scores and shelf scores. Because IMGs don’t have shelf scores to guide performance, Step 1 becomes even more important as a milestone and an indicator for how well they will be doing.

Step 1 – like Step 2 CK – tests your mastery and application of concepts. The USMLEs are not tests of memorization. As such, a pass-fail Step 1 is still an important milestone on the way to a high Step 2 CK score.

What do you think? How important will Step 1 be in your preparations, now that it is pass-fail? Will you try and study for Step 2 CK and Step 1 simultaneously? Let us know in the comments.

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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.