Reporting of USMLE Step 1 as Pass/Fail: A Benefit for Residency Programs and Those Underrepresented in Medicine?

First aid: the immediate assistance given to a person with an injury or illness. Ironically, for medical school students, it is their most coveted book used to pass a licensing examination. For some students who are underrepresented in medicine (URiM), this licensing examination will determine their fate. Physicians are considered URiM if, as defined by the Association of American Medical Colleges, they represent “those racial and ethnic populations that are underrepresented in the medical profession relative to their numbers in the general population.”¹  Studies have shown that racial and ethnic minority patients, who historically suffer from greater health care disparities, are more likely to seek care from physicians URiM.^2,3  Physicians URiM may feel obligated to cater to their racial and ethnic populations and choose a specialty or practice location based on the needs of these groups. In fact, compared to white physicians, physicians URiM are more likely to practice in underserved areas, which typically comprise a high population of racial and ethnic minorities.⁴  Because of the lack of numbers and the increased demand placed on physicians from populations URiM, there is more need for these physicians than can be met.³ 

The medical workforce does not reflect the diversity in the general population.^4,5  Each year, the residency match allots medical departments an opportunity to further diversify their physician workforce; however, navigating the recruitment of persons URiM can be difficult in a setting with an inadequate pipeline from medical school into residency.

On February 12, 2020, the National Board of Medical Examiners (NBME) announced that the United States Medical Licensing Examination (USMLE) Step 1 will transition to being reported as pass/fail rather than a 3-digit score. The long-term implications of this change on medical education and residency selection have yet to be determined but could be advantageous to both residency programs and those URiM.

According to the NBME, the purpose of the USMLE is to provide an objective measure of the minimal level of knowledge and competency required to obtain medical licensure. However, the USMLE Step 1 examination has been reported as the most important factor in ranking applicants by program directors.⁶  Performance on multiple-choice examinations, such as the USMLE Step 1, have been correlated with future performance on multiple-choice examinations, which is not the ultimate goal of our medical training.^7–9  Furthermore, non-white examinees historically score lower on the USMLE Step 1 than white test takers. Therefore, applicants URiM represent a disproportionately smaller percentage of applicants selected for interview, and are consistently the least represented among competitive specialties.^8,10  Standardized examinations like the USMLE Step 1 place those URiM at a disadvantage when applying to residency.¹¹  Given this inequity, it seems fitting that this examination will now be reported as pass/fail rather than a numeric score.

As the USMLE Step 2 examination will continue to be reported with a 3-digit score, there is concern that program directors will now place more importance on this score as it was already ranked the fourth most important factor in selecting applicants to interview.⁶  While it provides objective measures for comparison, neither USMLE Step 1 nor Step 2 account for other qualities equally as important to being a well-rounded physician such as empathy, research capabilities, communication skills, leadership, teamwork, or diverse perspectives. Although there is recognition in the importance of these other qualities outside of board scores, they appear less prioritized among program directors. Per the NRMP Program Director Survey 2018, leadership qualities were ranked 13th, volunteer and extracurricular experiences were ranked 19th, and fluency in languages spoken by your patient population was ranked 31st out of 33 criteria.⁶  This mindset was further demonstrated among a review of orthopedic candidates, which saw that white applicants were more likely to get accepted despite URiM applicants having more publications and volunteer experiences.¹²  Until a shift in mindset is seen among program leadership, internal reviews for potential unconscious biases in the residency selection process are performed, and changes are enacted to review applicants holistically, we will continue to encounter problems with bias in the residency selection process and therefore an inequitable workforce.

Diversity initiatives that can be readily implemented by residency programs for the 2020–2021 recruitment season are discussed here and delineated in the Box. Residency programs can create a diversity task force designed to recruit applicants URiM. Working with local undergraduate institutions and medical schools to establish mentorship and provide opportunities for students URiM is crucial to helping supply the pipeline. One way to accomplish this is by reaching out to minority organizations or starting specialty interest groups in order to develop longitudinal relationships and communication with students URiM. In addition, updating the residency program website to reflect a commitment to a diverse and inclusive culture is a simple first step that can capture interest of applicants who are URiM.