“The words ‘bad timing' came to be ghosts haunting our every move in Birmingham. Yet people who used this argument were ignorant of the background of our planning . . . they did not realize that it was ridiculous to speak of timing when the clock of history showed that the Negro had already suffered one hundred years of delay.”1— Martin Luther King Jr, Why We Can't Wait
In January 2020, the Federation of State Medical Boards (FSMB) announced its intention to report the United States Medical Licensing Examination (USMLE) Step 1 score result as pass/fail, rather than its previous numeric score. In doing so, the FSMB acknowledged that the USMLE was never intended to help rank physicians in training, nor has the score been shown to correlate with clinical performance. The new pass/fail reporting process is not scheduled to take effect until at least January 2022, 2 years after the initial announcement.2
Since then, our country has faced a reckoning with racialized violence, a pandemic that has laid bare the health disparities faced by racial and ethnic minorities, and governmental rhetoric that has failed to denounce white supremacy. In late spring, Chicago medical student Jasmine Solola wrote a compelling letter laying out the disproportionate burden being shouldered by Black medical students who were preparing for and taking the examination in the wake of civil protests ignited after the murder of George Floyd by Minnesota police. She wrote:
“I am a Black student taking the USMLE Step 1 exam on Thursday, June 11. I have not had time to grieve, I have not had time to feel, and I have not had time to hurt—because in order for me to pass this exam I am required to be hyper focused and undistracted. A luxury, that I do not have.”
Her letter—the full text of which is provided as online supplementary data—calls for an earlier enactment of the FSMB's decision to report USMLE Step 1 as pass/fail. As program directors at the University of Chicago Medicine, we support this call, and we pledge to enact the spirit of this call even without an FSMB timeline adjustment. This pledge acknowledges the inordinate burden of sorrow and its impact on cognitive load, and the mental and physical health of our Black students especially.3
While this burden would be sufficient reason to enact an earlier change to the utilization of USMLE scores, there are many other reasons to proceed more quickly: restitution for the discriminatory practices of the American Medical Association,4 for the profession's complicity in the forced sterilization of black and brown bodies, for experimentation without consent, and for our profession's role in pathologizing non-conforming genders and sexualities. Compelling, as well, is the crucial role played by diversity in successful management of pressing complex medical issues,5 like the current COVID-19 pandemic, widespread health inequities, and the understandable mistrust we face from any number of marginalized communities. Our patients suffer from these long-standing injustices on a daily basis. Further delay is not acceptable.
We acknowledge that there is value in medical licensing examinations; students should be able to demonstrate sufficient medical knowledge prior to licensing. However, performance below an arbitrarily selected scoring threshold should not automatically disqualify students from consideration in the specialty of their choice. As argued in a recent New England Journal of Medicine article by Drs Youmans, Essien, and Capers,6 reducing our reliance on this examination in selecting and ranking residency applicants not only acknowledges its poor predictive quality, it also reinforces our commitment to building a diverse workforce of physicians. Rather than pretending that each standard deviation above the mean USMLE score predicts a more competent resident, we should review applicants holistically. Beyond passing licensing examinations, we should also look for the skills that truly make exceptional residents—evidence of service, leadership, tenacity, advocacy, and a dedication to advancing the field of medicine.
We should all seek to “serve as allies during this racial crisis,”7 and we call on all our colleagues to adopt an accelerated timeline to justice. Beginning with the 2020 recruitment season, we pledge to consider only pass/fail status for USMLE Step 1, and our pediatrics program pledges the same for Step 2 as well. We will mask these scores in our decisions to interview and rank applicants. We urge our fellow program directors to join us in this effort. Our patients and our nation's health care workforce cannot afford to wait. Justice cannot wait.
Jasmine Solola, MA, Alisa McQueen, MD, Rochelle Naylor, MD, Victoria Okuneye, PhD, Monica Vela, MD
Endorsed by Program Directors: Chrissy Babcock, MD (Emergency Medicine); Adrianne Dade, MD (OB/GYN); Yasmin Hasan, MD (Radiation Oncology); Kammi Henriksen, MD (Pathology); John McConville, MD (Internal Medicine); Edwin Ramos, MD (Neurological Surgery); Kevin Roggin, MD (General Surgery); Adena Rosenblatt, MD (Dermatology); Rita Rossi-Foulkes, MD (Medicine-Pediatrics); and Deborah Spitz, MD (Psychiatry).
Editor's Note: The online version of this article contains the full letter written by Jasmine Solola.