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Step 1 Pass-Fail: Bad for Students from Lower Ranking Medical Schools?

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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. As discussed previously, this is a considerable shift since Step 1 had become a de facto screen for residency application. The natural inclination following such a huge announcement is to ask yourself some questions:

  • “How will Step 1 pass-fail affect me if I go to a lower-ranked med school?”
  • “Will Step 1 pass-fail help make applications more holistic? (And would this even be beneficial for me?)”
  • “Will this help students that go to ‘top’ schools like Harvard or Stanford?” And
  • “How should I be studying now that Step 1 will be pass-fail?”

In this article, we will discuss the likely impact on students from higher and lower-ranking med schools. The framework and points, however, will apply to all students with implications for how to prepare.

Table of Contents

Program Director View: Are You Screwed If You Don’t Attend a Prestigious Medical School?

Program directors have arguably the most important perspectives on the upcoming Step 1 pass-fail transition. If you don’t go to a higher-ranked US medical school, the news from surveys of program directors isn’t good. Numerous surveys have been coming in from many specialties, all of which show very similar results. For example, in one survey of internal medicine (IM) program directors (PDs):

  • 63% thought that MD students NOT attending a highly regarded medical school would be disadvantaged
  • 52% of thought that DOs would be disadvantaged
  • 83% believed that IMGs would be disadvantaged

Other surveys show similar expectations that students who don’t attend the top schools will be disadvantaged:

The early results are sobering. But might there be an upside? Will applications become more holistic? If so, will that help students who don’t come from prestigious schools?

How Will Pass-Fail Step 1 Affect Residency Applications?

As discussed previously, Step 1 became the de facto first hurdle to getting a desirable residency. The desire for high Step 1 scores is even more poignant for students from lower-ranking med schools. These students already feel the need to stand out, especially if they are interested in more competitive specialties.

The question: will Step 1 pass-fail make residency applications more holistic? And if the applications are more holistic, would that help or hurt you?

Will Step 1 Pass-Fail Make Applications More Holistic?

There is a romantic (some say naïve) hope that making Step 1 pass-fail will render the residency application evaluation more holistic. Take away a highly weighted numeric factor, and other less numeric factors will take its place. Simple, right?

We’ve discussed previously that residency program directors crave objective data when evaluating applicants. The average residency program receives 700+ applications and has 100-some odd interview slots. In addition, med schools have a vested interest in making their students look as good as possible.

The large pool of applicants and skewed incentives create a massive need for a simple, efficient screen to whittle down the number of applicants. Nearly 50% of applications are rejected via a screen in these programs, with the remainder getting a closer look.

Making Step 1 pass-fail addresses a symptom of this underlying numbers/incentive problem. However, I’m skeptical of how much it will change the reliance on USMLE scores. Instead, many program directors appear to be ready to shift the emphasis towards Step 2 CK. So, the idea that this change will realistically result in a more holistic evaluation is questionable.

Would a More “Holistic” Application Process Help Students from Lower-Ranked Schools

Even if this change will result in a more holistic assessment, “holistic” is a loaded term. On the one hand, it evokes positive connotations that trainees will be seen as humans, not numbers. But, on the other hand, it also means that other harder-to-quantify things may get more weight.

An interviewer for a residency program said, “the only things I look at before the interview are their Board scores and what school they go to.” So, take away the Board scores, and what’s left? Their school.

Everyone in medicine is busy, including those involved in residency admissions. There is an unspoken hope that by making applications more “holistic,” programs will spend EXTRA time digging through applications to try and uncover a hidden gem. Take away a scored Step 1, and maybe your application reader will scrutinize the letter from your research advisor more? Sounds good to me!

But what if that assumption is false? What if residency programs don’t have tons of extra time to spend looking through applications? In that case, attempting to make the admission process more “holistic” means that they’ll likely just look for other short-cuts. Things like med school prestige and quality/number of publications will get more emphasis.

Research certainly feels like it might level the playing field. However, remember that school prestige correlates strongly with that school’s strength as a research institute. There is nothing that makes Harvard’s curriculum intrinsically better at preparing its students for Step 1. However, Harvard has a much larger share of top researchers who are publishing in leading journals. Harvard students have an advantage in research due to this. In other words, having more “holistic” applications could favor top schools even more.

What Going to Stanford Makes Me Think Re: “Holistic” Applications

As we discussed, I’m skeptical that making Step 1 pass-fail will drastically change the overall reliance on USMLE scores for residency applications. Schools that used cut-offs before will still use cut-offs, and those that didn’t will continue not to.

However, let’s consider that there may be SOME shift away from the quantifiable to the more subjective factors. What does this mean? My experience as a medical student at Stanford is both illustrative and sobering.

While at Stanford, the curriculum went from pass-fail to graded. This transition was the opposite of Step 1 pass-fail. For decades Stanford had only reported a “P” or “F” for every class during the entire four years – preclinical and clinical.

In many ways, pass-fail grading at Stanford was a bet on the brand of the institution. “Grades at Stanford are artificial,” one of my interviewers had claimed. A “below average Stanford student may have been near the top of their class at a different medical school.”

The hubris of that statement aside, Stanford students continued to match at top programs around the country. So why did this privileged pass-fail environment change while I was in medical school? Reportedly the dean thought that residency program directors would want more objective information on our performance and that having grades would help. (Remember, PDs crave hard numbers – hence the shift in emphasis to Step 2 CK).

Less Easily Quantifiable Data Benefits “Softer” Qualifications

The fascinating part of the story was when the Medical Student Performance Evaluation (MSPE) format came up for debate. The MSPE – formerly the “Dean’s Letter” – is a narrative summary written by your school. In it, the school summarizes your performance in medical school in a format determined by the school. For example, some schools may include a ranking, histograms of your grades, or other summaries. The goal is to make comparing students easier for residency admissions committees.

Other schools make it harder to compare students with others from the same school. Whether this is intentional or not, the result is still the same: it becomes more difficult to compare students from top schools against each other.

For example, Rafael H. Llinas, MD, FAAN is the program director of the Johns Hopkins Bayview Medical Center. He points out that many top schools make it difficult to compare students from that school objectively against each other. “So, you get a lot of applicants from Stanford or Yale and it’s all pass, pass, pass, and they all have some generic dean’s letter and then [with pass-fail Step 1] you take away an objective measure we could use,” he said. As a result, the MSPEs from these schools are colloquially known as “garbage” among some PDs. (More on this later).

How Do Top Schools Make It Harder to Compare Students Against Each Other?

Given the new grading system put in place at Stanford, there was massive interest in how the MSPE would present data. For example, will there be class rankings? Summary tables with a tally of our grades of “Pass with Distinction” (essentially Honors)?

There were a lot of meetings, surveys, and proposals. One common theme, though, was this (quoted from a summary written after one meeting):

“5) At the end of each summative evaluation, there will be a sentence written in longhand listing the domains in which the student achieved pass with distinction. This sentence should not be visually distinguished from the remainder of the summative evaluation…

6) There will be no quantitative data presented in the MSPE. This includes but is not limited to, a table or chart, comparison with other students (histograms, percentiles, etc.), exam scores.”

In other words, there would be no easy way to compare Stanford students against each other. More to the point, there would be no way that a busy program director could skim your MSPE and tally which clerkships you’d honored.

Residency Program Directors Have a Hard Time Knowing Where at Stanford or Harvard Student Ranks Against His/Her Peers

Interestingly, I’ve found that Stanford is not alone in trying to make the MSPE less objective. For example, a program director from one of Harvard’s most competitive surgical specialties told me the Harvard Med School’s MSPEs were “garbage.” I’ve heard similar statements about MSPEs from other brand-name schools.

My take-home from attending Stanford, and hearing the views of program directors? When the name of your school is prestigious, it benefits you to limit the other objective data. In other words, taking away something like a Step 1 score increases the focus on the remaining things, including the prestige of your med school.

Verdict: Step 1 pass-fail may not make applications more holistic. However, insofar as residencies will de-emphasize USMLE scores, it’s hard to imagine how this wouldn’t help students from top schools. On the other hand, it will likely hurt students from lower-ranking schools, IMGs, and DOs.

Concluding Thoughts: How to Prepare Now that Step 1 Will Be Pass-Fail?

I get it. The likely effects of Step 1 becoming pass-fail don’t make me feel warm and fuzzy for students that don’t already have an advantage. As someone who’s been to both Harvard and schools no one has ever heard of, I can say that those with “pedigree” don’t need the extra help.

So how should you prepare now that Step 1 will be pass-fail? We’ll discuss this much more in a future article. But for now, let’s discuss some broad principles that will help you regardless of your residency goals and background.

The key? Study so that you can peak on Step 2 CK.

Even if you’re still studying for Step 1, learn so that it will benefit you for Step 2 CK. Like Luis, who doesn’t go to one of the “brand name” med schools. Regardless, he scored 250+ on Step 1 and then used that to peak on Step 2 CK: 260+.

How to Peak on Step 2 CK

So how do you study, so you’re at peak performance for Step 2 CK? How do you learn today for that distant goal, even if you haven’t taken Step 1 yet?

First, you must learn for the long term. Step 2 CK will become disproportionally important among the USMLEs. Step 1 essentially tests two years’ knowledge. In contrast, Step 2 CK covers virtually all medical school. Thus, do NOT cram your way through biochemistry and genetics. You may think you’ll never see them again but remember that pediatrics contains a lot of first-year med school-type questions.

Second, focus on question interpretation. Question interpretation is the process of understanding the exact meaning of each sentence in a vignette. It is the opposite of the buzzword-seeking approach many people desperately use to try and improve their USMLE scores. Step 1 has many more conceptual-type questions, and the interpretations are comparatively more straightforward. Step 2 CK, however, puts a premium on question interpretation.

Finally, focus on mastery rather than details. If you want to learn for the long-term – and if you’re going to improve your interpretations – you need to understand the material. Memorizing FEELS faster. You get to check things off your list and cover more questions.  You may even get a few questions right just because you can spot a pattern. However, if you genuinely want a Step 2 CK score that stands out, you need to fully comprehend and understand the material.

Step 2 CK Can Help You Stand Out…Even If You’ve Been Below-Average So Far

Don’t believe me? Hear from Minali, who scored 260+ and who is a resident at Harvard. She went from a below-average Step 1 score to her dream USMLE score/residency, all by mastering and applying what she is learning.

If you want to learn how to study now so you can peak on Step 2 CK – even if you haven’t taken Step 1 – sign up for a FREE consultation today. You will discuss how you can master things now so you can be at your best during clerkships and Step 2 CK.


What do you think? Will Step 1 pass-fail make it easier for applicants from lower-ranking schools to stand out? Or will it favor top schools even more? Do you have ideas for how to stand out? 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.