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Why is Step 1 So Hard to Pass?

Did Step 1 Mania mask deep problems with the medical education system?

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by Alec Palmerton, MD in Step 1 Pass-Fail

Step 1 is pass-fail. But why is it so hard to pass? Previously, Step 1 had an overall pass rate of 85+%. The pass rate was 95+% for most years at US MD schools. So why does it seem like so many students struggle to pass?

If passing Step 1 was more challenging than you imagined, you’re not alone. I’d bet that many students are (often silently) struggling with an exam many have underestimated.

In this article, we will discuss:

  • Why so many people are struggling to pass Step 1 despite sky-high pass rates previously,
  • Whether students are lazy or just incentivized to work on other things,
  • A hypothetical nightmare school (and why it may hit close to home for many),
  • The most prominent reason schools do a poor job of preparing students for the USMLEs, and
  • Much, much more

Table of Contents

Lots of Students Struggle to Pass Step 1

I know no official statistics on how many students struggle to pass Step 1. However, the number is high judging by conversations with students and the large volume of emails/(free) consultation requests we receive.

How high? No one knows. However, I spoke with a student recently from a highly-regarded med school who told me that roughly 25% of the class had delayed their Step 1 exam date. This postponement meant either pushing their test to the last possible pre-clerkship date or even taking an entire research year to give them more time. But, of course, that doesn’t include the number of students who weren’t ready to take their exam and failed.

I’ve had similar conversations with students from other schools across the country. It seems as if passing Step 1 wasn’t as easy as some may have expected.

Why Do So Many Students Struggle to Pass Step 1?

So why do so many students struggle to pass Step 1 now? Before, when Step 1 had a score, passing wasn’t even on many people’s radar. Instead, the goal was to score as high as possible. Step 1 scores weighed heavily in residency applications; scoring high was paramount.

Are Students Who Struggle to Pass Step 1 Lazy?

The first thing many people will claim is that students are simply less motivated. Peter J Katsufrakis, MD, MBA, and Humayun J Chaudhry, DO, MS – the respective CEOs of the NBME and FSMB at the time – infamously raised this prospect. They raised the possibility that students would essentially become lazy. Here is the quote:

“If students reduce time and effort devoted to preparing for Step 1, they may indeed devote attention to other activities that will prepare them to be good physicians. This would arguably be an ideal outcome of such a change. However, if students were to devote more time to activities that make them less prepared to provide quality care, such as binge-watching the most recent Netflix series or compulsively updating their Instagram account, this could negatively impact residency performance and ultimately patient safety. We know that assessment drives learning, so another concern resulting from a shift to pass/fail scoring may be a less knowledgeable physician population.”

Katsufrakis PJ, Chaudhry HJ. Improving Residency Selection Requires Close Study and Better Understanding of Stakeholder Needs. Acad Med. 2019;94(3):305-308. doi:10.1097/ACM.0000000000002559

It is natural to speculate whether struggling to pass Step 1 is the fault of med student escapism or laziness. And there is certainly something to be said for a high-stakes examination focusing our energies and attention. However, there are several other more likely explanations.

Med Students Respond to Incentives

Med students are (usually) rational actors. Many have responded to the lack of a graded Step 1 to increase their participation in other extracurriculars, including research. Students focused on research even before a pass-fail Step 1. However, at least anecdotally, it seems that has increased.

However, less focus on Step 1 increases the chances of being unprepared. And if you spend all your time in the lab, in clubs, or other activities, you’ll have less time to get ready to pass Step 1. So rather than an issue of laziness or lack of motivation, it may well be a product of a shift of priorities. The result, however, is being less prepared for Step 1.

Why Med Schools Do Such a Bad Job of Preparing Students for the USMLEs

However, focusing on med students’ actions ignores the elephant in the room. Specifically, med schools do a generally atrocious job of teaching students, particularly when it comes to the Board exams.

Before my inbox explodes with hate-mail from med schools, let me explain. I have spoken with multiple deans and other administrators at schools. I’m always impressed with how talented, thoughtful, and dedicated the educators are. In addition, the intellectual firepower among the faculty is remarkable.

So how do schools generally do such a poor job of preparing students to be doctors and the USMLEs specifically? Two things: incentives and the system.

You Get What You Pay For: We Don’t Pay (Most) Med School Professors

Incentives are simple enough to understand. Most people who teach med students don’t get paid to educate. Yes, med schools pay all/part of the salaries of many deans and course directors. And yes, the DEPARTMENTS of the lecturers receive a lot of money from schools. However, the scientists, physicians, and others who provide the lectures are usually not paid or promoted based on the quality of their teaching.

Instead, most professors/physicians’ research and/or patient care determine their salary/promotions. Just like med students respond to incentives, so do professors. If we don’t pay them to prepare high-quality lectures, how can we expect to get anything other than recitation of facts from a PowerPoint slide? Yes, some exceptional professors devote hours to try and make great lectures. However, sadly, they are the exception that proves the rule.

We Expect Too Much of Disconnected Experts

Imagine there is a new charter high school that is trying a new method of educating students in science. In it, they want to source professors with “real-world experience” and get as many people on board as possible.

For example, in chemistry, for the 30-week academic year, each lecture will be taught by a different member of the community. Thus, they will need to recruit roughly 150 lecturers, each who will give an hour lecture. These lecturers will have minimal training in teaching. In addition, they’ll have regular jobs – some may be chemical engineers or work at pharmaceutical companies. The teachers will also:

  • Not talk to each other or be able to coordinate,
  • Be unaware of what students have already learned, and
  • Not even know what grade the students are in,

On top of that, teachers won’t receive a salary. Instead, teaching is simply an expectation of their “real” job—community service to support the organization’s reputation.

Now imagine that we’re well into the school year. The students have already gotten through 60% of the chemistry lectures. What do you think has happened?

It doesn’t take a crystal ball to realize that this system is doomed to fail. No matter how brilliant the professors, having a gigantic uncoordinated group of “teachers” without actual training in education is bound to fail.

It would also be easy to blame the teachers in this doomed system. “Oh, they are so bad – that is why the students are all burned out, confused, and hate chemistry.”

However, blaming the teachers misses the mark. Instead, it’s the system that is the problem.

Our Current Med School System Is No Different

If you replace “chemistry” with “cardiology,” this hypothetical system is what we expect from med school. But unfortunately, inertia and tradition have substituted for the hard work of improving classroom education.

Interestingly, many within med schools (privately) acknowledge the problems with the system. For example, I’ve spoken with deans at two of the top five med schools, each of whom has independently recounted the difficulties with educating med students.

The upshot, however, is still the same. Professors lack the training, incentives, and structure to teach effectively. As a result, med students memorize to pass their med school exams, only to be blind-sided by the USMLEs.

The USMLEs Are What Med School Tests Should Be Like, But Aren’t

Med school exams often have the reputation of being mindless regurgitation of professors’ pet facts. The USMLEs, in contrast, endeavor to test the application of essential concepts. The NBME – writers of the USMLEs – explicitly state that they are trying NOT to test the recall of facts.

While some argue that there are still minutiae tested on the USMLEs – particularly Step 1 – most questions test concepts. And therein lies the problem.

In essence, med schools make passing Step 1 harder by testing the regurgitation of facts. Why? Because students – long rewarded for memorizing facts – are suddenly faced with a test that requires them to apply actual concepts. Rather than being able to cram and brute-force their way through the content, many students flounder.

The Same Happened Before Pass-Fail Step 1, But Less

Note that this same dynamic existed before Step 1 moved to pass-fail. Specifically, many students who had diligently studied their class material but little else found the transition to Step 1 challenging.

These struggles were less common, however. Why? Because most students had been preparing for Step 1 long before they reached their dedicated study. I’d often have at least a student or two begin tutoring with me during their first term of med school – even their first week. Having seen UWorld or other QBank questions – and even taken an NBME or two – prior students were much more prepared for the USMLE format and expectations.

Now, it’s much less common to see students prepare much, if at all, before their dedicated study. And as a result, passing Step 1 becomes that much harder.

I’m Struggling to Pass Step 1. What Should I Do?

What should you do if you’re in the unfortunate situation of struggling to pass Step 1? First, remember that you aren’t alone. Second, recognize that while rushing is the most natural desire in the world, it is also the least likely to lead to your goals. Finally, remember that the USMLEs test the application of concepts, which requires you to master the foundations of medicine – not memorize it as many details.

See this article for more on what to do if you struggle to pass Step 1.

Concluding Thoughts

Step 1 pass-fail is an extended experiment with high stakes for all involved. Students, in particular, now must navigate a world where the measures used by residency application committees will shift.

Many predicted “unforeseen consequences.” Some even evoked a sort of Heisenberg uncertainty principle – by changing what we were measuring, we can’t help but change students’ behaviors.

While the entire story is still incomplete, it appears more students struggle to pass Step 1 than in prior years. But why?

My personal opinion is that the system of medical education is fundamentally flawed. What reasonable person could expect a disconnected group of experts to teach students an integrated, applied view of medicine? Even worse, how could we expect such a system to succeed when we don’t train or compensate those teachers adequately?

Did Step 1 Mania Mask a Broken Med School Education System?

But why such a struggle with Step 1 now? Prior to Step 1 going pass-fail, students often would learn much of their preclinical curriculum through Boards-prep resources. Some students would go so far as to skip their classes and learn entirely from Step 1 resources.

Schools would decry this Step 1 focus; “teaching to the test,” was anathema. However, in retrospect, it may turn out that this “Step 1 mania” actually masked the deeper systemic problems with medical education.

Is it any surprise so many trainees and doctors are depressed, anxious, and burned out? In a US study, roughly 50% of medical students reported burnout within 12 months. Depression/suicidal thoughts among med students worldwide are almost three times higher than the general population.

We started Yousmle because we wanted to heal a broken medical education system. Given the systemic struggles within medical education, here’s to hoping that the voices of innovation and change within med schools win out. In the meantime, if you find yourself wanting help to find the best way to prepare for the USMLEs – even if you haven’t even started studying for Step 1 – sign up for a free consultation. We help students “make thick textbooks thin” – to distill what appears to be a collection of random facts into a small set of timeless principles. To start mastering more – and memorizing less – sign up for a free consultation here.

What do you think? Are more people struggling to pass Step 1 than in prior years? What sorts of trends have you been seeing? Let us know in the comments!

2 Comments
  1. Ameera Khan says:

    A great article, spot on!

    1. Yousmle says:

      Thank so much for your kind words! What have you been noticing on your end?

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