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Will Pass-Fail Step 1 Be Terrible for IMGs? I’m Not So Sure.

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by Alec Palmerton, MD in Uncategorized

Step 1 will become pass-fail for tests administered on or after January 26, 2022. It marks a huge change for those seeking residency in the US, as Step 1 had become a de facto cut-off for applications. Many are predicting moving Step 1 to pass-fail will:

  1. Shift the goal-posts from Step 1 to a much heavier emphasis on Step 2 CK,
  2. Help students from brand-name schools like Harvard and Stanford, and
  3. Be bad for IMGs

We’re previously discussed whether Step 2 CK will become the new Step 1, and the effect of a pass-fail Step 1 on students from lower-ranking med schools. Today, I’ll specifically discuss the argument (and counterargument) that Step 1 pass-fail will be bad for IMGs.

Table of Contents

Will Step 1 Pass-Fail Hurt IMGs?

Residency programs are high stakes for all involved. The stakes are high for applicants and programs because they are committing to each other for (many) years. Unlike a normal job, where you can more easily quit and move to a different job, residencies are long-term commitments on both ends.

Residency programs must sort through thousands of applicants to identify a more manageable number of applicants to interview. For example:

  • Mean applications received per program: 789
  • Mean interview invitations: 107
  • Interview rate: 14% (107 interviews/789 applications)

That’s too many applications for many programs to review carefully. Programs rely on objective data to make the vetting process more tractable, like USMLE scores and applicant background (MD vs. DO vs. IMG).

USMLE Screens Make Reviewing Applications More Manageable

The use of screens is widespread. Program director surveys suggest that more applications are rejected via screens like USMLE scores than get rejected after a careful reading.

  • Applications rejected via screens: 45%
  • Applications rejected after more careful reading: 41%

In other words, the use of objective data is a big deal, especially if it can be used as a screen. There are only so many objective pieces of data that programs can use as screens. If you take away one, the other factors become more important.

Based on the previous logic – taking away objective data puts greater emphasis on the remaining factors – meaning that IMGs will be hurt by Step 1 pass-fail. Why? The thinking is that if there is less emphasis on Step 1, then there will be more emphasis on their med school. However, I’m not so sure this is true.

Before we discuss my skepticism, let’s acknowledge that IMGs face an uphill battle already when it comes to residency applications. Since IMGs that have already graduated from med school are limited in what they can do clinically, their letters of recommendation may be less helpful. The interview and match rates for these two groups are significantly lower. Program directors openly admit that they consider IMGs at a lower rate than other applicants.

In a vacuum, by making Step 1 pass-fail, IMGs will have fewer opportunities to stand out. However, if you believe logic and early feedback from program directors that Step 2 CK will become more important, all is not lost. In fact, I’m not sure IMGs as a group will suffer as much as people expect.

How Do IMGs Do on Step 1 vs. Step 2 CK?

The first question I had when digging into this question was how well IMGs do on Step 1 vs. Step 2 CK. We’ll start by looking at some raw numbers for the USMLE passing rate for IMGs.

Step 1 vs. Step 2 CK Pass Rates for IMGs

Here is the passing rate for IMGs for Step 1:

Step 1 Passing Rates2017201820192020
IMGs Examinations17,20316,44316,06513,117
IMGs Passing %73%75%78%83%
IMG Fails*4,6454,1113,5342,230
Here is the passing rate for IMGs for Step 2 CK:
Step 2 CK Passing Rates:2016-20172017-20182018-20192019-2020
IMGs Examinations14,29113,61312,94110,295
IMGs Passing %76%78%82%87%
IMG Fails*2,3422,1441,8591,172

You’ll notice that the passing rate is higher for Step 2 CK, but that the number of IMGs taking Step 2 CK is generally lower. That is likely not a coincidence – someone that doesn’t pass Step 1 is less likely to continue on and take Step 2 CK. As such, there is likely some attrition bias at play for the higher Step 2 CK pass rate.

Verdict: IMGs pass Step 2 CK at a higher rate than they do Step 1. This, combined with the fact that Step 2 CK content favors IMGs, pass-fail Step 1 may not be as bad for IMGs as initially assumed.

Average Step 1 vs. Step 2 CK Scores for IMGs: Non-US IMGs Are Closer to US MDs on Step 1 than on Step 2 CK

It was very difficult to find good data on the actual average Step 1 vs. Step 2 CK scores for IMGs. I could find not the data for IMG test-takers. Instead, the only data I could find was Step 1 and Step 2 CK scores of matched vs. unmatched APPLICANTS.

 US IMGsNon-US IMGsDOUS MD
Weighted Step 1 Mean (ALL Applicants)219229227233
Weighted Step 2 CK Mean (ALL Applicants)229236239246

What do you notice?

On the surface, it seems that non-US IMGs have weighted Step 1 scores essentially at the average for Step 1.

Notice, too, that the average Step 2 CK scores for non-US IMGs are lower than the US MDs. (They are similar to the scores of DOs). Since the Step 1 scores between non-US IMG applicants and US MDs were more similar, does this mean Step 1 moving to pass-fail will hurt non-US IMGs more than expected? Possibly.

If Non-US IMGs Emphasize Step 2 CK Studying, Could They Do Even Better?

However, I’m not convinced Step 1 pass-fail will hurt IMGs disproportionately – or even much at all. In my work with IMGs, I find that they put disproportionate emphasis on Step 1. That is logical; because Step 1 has up until this point been so important for matching, it makes sense to spend more time on it. Now that Step 1 will be pass-fail, inevitably more of the emphasis will shift to Step 2 CK.

With considerable effort, non-US IMGs appear to have gained Step 1 parity with US MDs. However, with the same amount of effort now towards Step 2 CK, I wonder if they might do as well if not better. Only time will tell. However, given that their background/training favors Step 2 CK studying, I wouldn’t be surprised to see IMGs do even better on Step 2 CK than they did on Step 1.

US IMGs Score Lower on Both Step 1 and Step 2 CK

Another observation is that US IMGs Step 1 and Step 2 CK scores lag those of non-US IMGs, DOs, and US MDs. There are a variety of possible explanations for this. One is that the average US citizen/green card holder who trains outside the US has more difficulties with standardized tests. Low MCAT scores, for example, are one reason that someone may choose to pursue med school outside the US. Another possibility is that the schools’/learning environments aren’t as conducive to scoring well on the USMLEs.

It’s impossible to know why based on these data. However, it is interesting to note that while non-US IMGs seem to have similar Step 1 scores to US MDs and DOs, the scores of US IMGs lag for both Step 1 and Step 2 CK.

What do we make of the fact that USMLE scores for matched US IMGs be lower than their non-US IMG counterparts? It may reflect the added difficulty that non-US IMGs have in obtaining residency, given the added complexity of securing a visa. It may also reflect attrition bias. Given how difficult it is for non-US IMGs, in particular, to obtain residency in the US, potential applicants with lower scores may decide applying isn’t worth it.

What Does This Mean for IMGs?

So, what do all these data mean for IMGs? The available data suggest that there isn’t a clear advantage for IMGs (US or non-US) to have Step 1 or Step 2 CK emphasized in residency applications. The pass rate for Step 2 CK for all IMGs is slightly higher than it is for Step 1. However, the relative performance for non-US IMGs on Step 1 is slightly better. (US IMGs, again, have lower average USMLE scores on both Step 1 and Step 2 CK than US MDs). Both, however, come with huge caveats.

In my work with IMGs, I’ve noticed that both US IMGs and non-US IMGs have a harder time standing out on Step 1 than on Step 2 CK. Why? Because Step 1 focuses on skills/knowledge where they are often disadvantaged. This disadvantage is most pronounced for non-US IMGs.

Non-US IMGs, in Particular, Don’t Learn As Much Step 1 Material

For example, many international schools are 6+ year programs. These IMG schools combine what would be 4 years of undergraduate and 4 years of graduate medical education in the US. Because of this, the basic science curriculum that is emphasized on Step 1 tends to be a lot shorter. Consequently, non-US IMGs in particular struggle to learn things like biochemistry, immunology, microbiology, genetics, and other subjects needed to score well.

In addition, non-US IMGs have often grown up in environments that emphasize rote learning over conceptual understanding. Memorization of facts makes both Step 1 and Step 2 CK more difficult, but it is especially true for Step 1. By Step 2 CK, as well, these students will have had more time to practice applying concepts. Additionally, because Step 2 CK focuses more on clinical applications of ideas – and less on preclinical subjects – it plays more to the strengths of those who trained abroad with a greater clinical focus.

IMGs who have had more clinical experience and/or have greater time since their basic science learning are especially likely to benefit from Step 1 moving to pass-fail. Why? Because their clinical experience is more advantageous with Step 2 CK than it will with Step 1.

IMGs assume Step 1 pass-fail will hurt them. However, I’m not so sure.

Concluding Thoughts

If you’re an IMG, you may be in a panic about pass-fail Step 1. However, I’m not quite so sure the testing changes will be as bad as IMGs fear. Yes, program directors (PDs) say the pass-fail Step 1 change will negatively impact IMGs. But PDs also say that pass-fail Step 1 will hurt DOs and anyone else that doesn’t attend a highly ranked med school. In other words, everyone that doesn’t go to a top school is in the same boat from the PD perspective.

Are IMGs hurt MORE than others? Perhaps. However, because the curriculum for IMGs shares much more overlap with Step 2 CK material, they may still benefit relatively. My personal hunch is that non-US IMGs may not be hurt much by Step 1 pass-fail and may even come out a little bit ahead.

Of course, time will tell. It will also be critical for IMGs and others to focus on Step 2 CK, as PDs appear to be coalescing around that as the new screen for applications.

What do you think? Will Step 1 pass-fail be bad for IMGs? Terrible? Or might there be a silver lining or even net benefit? Let us know in the comments!

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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.

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