Students who aim to become practicing physicians in the United States are required to demonstrate their competence with a variety of assessments during medical school, including those required to obtain a license to practice medicine. The specific challenges and stressors associated with the preparation for successful completion of licensure assessments is not well understood. To better understand students’ experiences in preparation for United States Medical Licensing Examination (USMLE) Step 1, as part of the Re-examining Exams: NBME Effort on Wellness (RENEW) research initiative, a series of eight focus groups were conducted with 33 medical school students who took the exam and received their score. The results provide a retrospective understanding of the lived experiences of aspiring medical professionals and their perceptions of the impact of a high-stakes licensure examination.
Becoming a physician in the United States (US) requires that students and trainees demonstrate competence through multiple assessments, including the high-stakes United States Medical Licensing Examination® (USMLE®) licensing exams. It is well known that three-digit USMLE Step 1 scores are traditionally used by medical schools for progression and graduation requirements and residency programs to screen or select residency applicants1 . How students view and cope with the challenges associated with high-stakes exams, such as USMLE Step 1, is not well described. While Step 1 scoring recently transitioned to pass/fail reporting1 , it is important to understand the impact of stressors and mitigating strategies related to high-stakes exams in general, as students and medical practitioners encounter high-stakes exams at various points throughout their training and careers.
While data suggest that students’ mental health declines during the second year of medical school2 , a common time of preparation for the USMLE® Step 1 exam, little empiric research has been conducted to identify the cause of this decline from students’ perspectives. For women and underrepresented minorities in medicine (URMM) students, there may be additional stressors during medical training related to impostor syndrome3 and stereotype perception4 , although no data exists assessing the impact of these on wellbeing related to Step 1. To gain insight into students’ experiences related to Step 1, we conducted a qualitative focus group study of medical students who had completed Step 1 and had received their scores. The aims of this study were to determine what factors contributed to stress related to preparation for and receiving USMLE Step 1 results and what techniques and strategies students used to mitigate stress. The objective for this project was to understand the role high-stakes exams such as those comprising the USMLE series (particularly Step 1) play in student wellbeing.
Design: This qualitative study utilized content analysis of responses from focus groups of medical students6 . Listening to the opinions of others in a small, safe group setting encourages individuals to form thoughts and opinions7,8 . Focus groups can reveal a wealth of detailed information and deep insight by creating an accepting environment that puts participants at ease, allowing them to thoughtfully answer questions in their own words and add meaning to their answers7 . Ideally a focus group of five to 10 people led through an open discussion by a skilled moderator who ensures that all voices are heard8 . This approach gives voice to people in their own context, relying on verbatim quotations and “thick, rich” description of experiences9 .
Research Team: This study was part of the collaborative work of the Re-examining Exams: NBME Effort on Wellness (RENEW)10 Task Force. The research team was comprised of NBME research staff (UD, MD, MP) as well as researchers and content experts in the field of wellness and medical education (KT, PV, KEH, LD).
Participants. A convenience sample of students located in the northeastern United States who had previously taken and passed the USMLE Step 1 examination were recruited via email and from two listservs whose members comprise URMM students (The Latino Medical Student Association and the Student National Medical Association). Participants completed a demographic questionnaire prior to study participation. The study received human subjects-exempt IRB approval from American Institutes for Research (AIR), Washington, D.C.
Using the results of the demographic questionnaire, participants were divided into one of three focus group types. Separate focus groups were organized for women and URMM students to foster dialogue and to identify any themes unique to those groups. Eight one-hour focus group sessions included participants from the general medical school population (three sessions), women-only (three sessions), and URMM students (two sessions) (Table 1). Two trained facilitators (UD, PV) conducted each session.
Data collection. Focus group discussions were guided by questions developed by the authors based on review of literature regarding wellbeing of medical students and through discussion with RENEW task force members ( Appendix). For the women and URMM groups, there were specific questions asked to gauge if they faced additional or different challenges.
All sessions were audio-recorded and transcribed. Transcripts from each focus group were analyzed using an inductive approach to content analysis. First, two authors (UD, KT) independently reviewed two transcripts and identified common themes and topics that arose from these. A separate pair of authors (LD, PV) discussed these topics and connected the commonalities to draft an initial code-book. Authors then met to discuss, refine, and reconcile the codebook which was then used to code all transcripts. Remaining transcripts were coded individually by two authors and differences in codes were identified by a separate author. These discrepancies were discussed and reconciled in pairs until agreement in coding was reached.
Participants comprised 33 current second- or third-year medical students. The sessions ranged from 2–7 participants each, totaling 15 in the general group, 6 in the URMM group and 12 in the all-female group. Participants’ average age was 27.1 (SD = 3.5). Participant demographics are shown in Table 1.
Four major themes with associated sub-themes were identified through content analysis of the focus group transcripts: high-stakes nature of the exam (career implications, perceived impact on medical education), emotional impact (financial burden, impact of scores), social support, and behaviors engaged in while studying for Step 1 and after receiving their scores (Table 2). Additionally, comments reflecting gender-based differences and underrepresented minorities were separately considered.
High-stakes nature of the exam
Most students expressed that performance on USMLE Step 1 influenced their future career options in terms of specialty and/or location of residency training program: “Step 1 is the only test you’ll ever take in your entire life where you can totally eliminate future career options if you don’t perform well on test day.”; “…there are programs…that will not give me an interview based on my score…that makes me sad because there’s one program…that I would love to go to [that] probably won’t give me an interview.” One female participant, in reflecting on her score stated, “I didn’t feel I wasn’t good enough to be a neurosurgeon, but…my application is now not good enough. Even if I am perfectly qualified… I won’t get that opportunity because of this.”
Because of the perceived implications of their scores on future career options, students experienced significant stress while preparing for the exam: “the amount of anxiety and…stress and pressure… take the joy out of learning.” This stress led some students to feel resentful about the exam’s role in the process of becoming a physician: “I was angry at the whole system and the way the system was designed and the fact that I had…so much riding on this one particular test.” Students also noted that their scores impacted how they viewed their future careers: “I actually altered my intended specialty during studying”; another student questioned whether their disinterest in surgery as a career after receiving their score was because of loss of interest in the field or “because of score stuff…”
A small minority of students noted that the exam was not stressful for them because they were planning to apply for specialties they viewed as less competitive. Some saw the process as empowering: “studying…was definitely a bit anxiety inducing…having a plan and at least knowing that I did everything I could…is probably the most empowering part.”
Perceived Impact on Medical Education
Some students described anxiety in attempting to find balance between focusing on classwork and studying for Step 1: “you’re worried about doing well in class, but…it’s only worth a little percent of my grade, obviously it’s not as important (as Step 1)”. Another student explained this disconnect as “studying two sets of material…there was pressure to…study for Step and keep up with class material” and “people spend time studying for this test and miss out on cases in the hospital and actually learning how to be a good doctor.” Some students noted that evaluation of their performance was necessary but described a disconnect between the exam and practicing medicine: “…this exam… wants you to figure out this perfect answer, which is not the reality of how we practice medicine.”
Almost all participants described feeling emotional responses while preparing for Step 1. Many viewed the exam preparation as all-encompassing: “taking over their lives” and leading to feelings of stress, anxiety, and depression. One participant noted, “the test… brought my wellbeing down…I just felt pretty helpless.” Another indicated, “I kind of…reached a breaking point…I considered just not taking the test (and) I considered…not doing medicine, because I burned myself out so much…” “this exam (is) a significant piece of the wellness deficit among med students.”
Some students indicated that the financial impact of preparing for the exam added to their level of stress: “...there’s a multitude of things that goes into preparing (for) it and the financial stress of the situation. My parents are not wealthy at all, so trying to make sure you had all the resources to really be prepared for the exam and get the score that you want and managing time was just—it was a lot.” Another student noted, “if your parents can’t help you, if you’re relying solely on loans, it can be very financially stressful just preparing for this exam, on top of everything else.” The financial burden most often cited related to the purchase of numerous study aids.
Impact of Scores
Stress related to the exam did not necessarily resolve once students took the exam: after receiving their scores, one participant noted that they “took the number really personally” and that she was “now defined by this score, whether or not I want to be or think that it…accurately reflects me”, and another student noted that when she received her score, she “felt like my life was over” and that “it (the score) is still not good enough,…even if it’s fine.” In addition, “even after getting the score back, there’s still anxiety. How does my score relate to other people’s scores and applying to the field I want to apply into? I think the anxiety will remain until we match into a residency program.”
Social interactions with peers, friends, or family members, both positive and negative, were important during Step 1 preparation. Interactions with medical school peers were complex and frequently described as leading to more stress and conflicting feelings due to comparisons of studying behaviors or scores on practice exams: “…it was hard…worrying about my friends’ feelings and how they’re doing but also not really wanting to talk about the test with them and feeling competitive and feeling like they were doing better than me but still wanting to be there to support them.” The stress of studying with peers often resulted in students studying alone, as “it was just much calmer and more relaxed being away from everyone.” However, some students found that studying alone led to feelings of loneliness or isolation: “it’s a very isolating process”; “I did just feel very alone.”
While peer interactions caused additional stress for some, a few said these relationships were supportive and positive: “it’s good to have a buddy… someone in your class who you can rely on and who you can trust, someone you can study with, but also who you can vent to or cry to.”
Relationships with family and friends often suffered from the students’ constant focus on exam preparation. Some students said family or friends were typically supportive: “this is probably the most important exam in med school and can determine what specialties you can apply into, so they kind of understood the gravity of it.” However, students also noted that they frequently had to miss important events with their families or were unable to maintain regular contact since it would take time away from studying. One student described a family emergency that arose just prior to the exam and reflected that it felt “kind of weird because…things are happening in real life, meanwhile I’m here stressing over an exam” and that “I know it’s important for medical school and in medicine, but in the grand scheme of things, this isn’t important in terms of life and death situations.”
Behaviors while studying for Step 1 and after receiving their scores
Students employed several behaviors to work through the Step 1 preparation process and related stress. Positive behaviors included scheduled wellness breaks to work out or prepare healthy food. Other students used relaxation strategies and spiritual practices, while a few sought help, including psychotherapy: “my mental health was not doing well at all. I started seeing a clinical psychologist just to deal with the stress of how to get through it.”
For most students, study schedules left little time for healthy behaviors which were perceived as time-consuming, and many felt guilty if they took time away from studying for these activities: “I was really structured. I studied between eight and ten hours…six days a week.” For many, these regimens led to negative coping behaviors, the most common of which was reduced physical activity, with students noting that they spent hours sitting while studying: “I would just eat lunch, watch a TV show and then continue studying” and discontinued exercise, “every hour counted and even taking time to regularly exercise…I didn’t even find myself doing that.” Some students also noted poor nutrition and isolating from peers, family, and friends. Although many students realized these strategies negatively impacted their physical and mental wellbeing and their relationships, they felt the sacrifice was necessary.
Minimal differences were noted amongst the focus group participants based on gender identity. However, some comments reflected the impact of societal gendered expectations. Women noted additional stress while studying: “I think I had… self-expectations of things that I have managed for our relationship and our family, like our home…it was…the things that I was giving up taking care of while also studying for Step 1.” Participants felt they did not consistently receive support in attempting to fulfill the dual roles of caretaker and student: “I would clean on Wednesday afternoon, and I saw that…going away and I didn’t get that kind of support from him because he’s working.” One female student noted that “I think if I had a significant other or some of the other constraints that people have, like families…while taking Step 1, I think that as a woman, it would be much more difficult.” Some women were impacted by the personal meaning attached to the score, with one noting that she experienced “huge impostor syndrome.”
Some participants commented about additional stressors related to their minority status: “if you’re of this minority, you need to have a higher score because you’re going to be judged differently” and “that made me feel more stressed out because I didn’t want to walk around, everyone looking at me like I’m a token…I felt like I really needed to do well on this exam to prove myself.” Another stated that, “no matter what I scored, I would still feel like people look at me and might think that I don’t belong here.” Some of the URMM students also raised concerns about race-based differences overall in exam performance: “I don’t know the statistics, but I would be willing to say the average for Blacks and Latinos is probably way lower than people who are White,” also citing differences in financial resources for the exam and study materials, because “that financial layer just knocks minorities down to the bottom.” Conversely, a few URMM participants saw the exam as a way to level the playing field, stating, “if there’s anything I’ve done in medical school…this is the one thing that I know is separate from any potential bias,” with another noting that this experience is “the one thing in med school that I’d have virtually complete control over. That was pretty empowering.”
This qualitative study of medical students is the first to take an in-depth look at how students from several institutions experienced the USMLE Step 1 exam and how the three-digit score and its use in residency selection impacted their wellbeing. Many participants reported experiencing stress and anxiety during their preparation for USMLE Step 1. Much of this stress was related to the perceived impact of their scores on matching in their intended specialty and/or residency program. Students described both positive and negative coping strategies during this period, the latter exemplified by decreasing or eliminating healthy behaviors such as exercise or interactions with friends and families due to time constraints. Students also described studying in isolation to decrease the stress from feelings of competition with their classmates.
A frequently cited source of stress by students in this study is the perception that their Step 1 score contributes to the determination of their future career options. The students in this study were interviewed at a point in time after they had received their USMLE Step 1 score. This time was selected to determine the impact, if any, of their Step 1 three-digit scores on their views of their future careers and their perception of their place in medicine. Some students indicated that they changed or were considering changing plans for future specialties based on their Step 1 three-digit scores, and a few students expressed the idea that they were defined by their score. Step 1 is the initial part of the USMLE examination series which is intended to determine minimum competency for licensure10 . While the number of medical school student graduates continues to increase, U.S. residency slots remain largely stagnant11 . Many factors (e.g., transitioning to pass/fail grades in medical school, deans letters and letters of recommendations that may not accurately reflect students’ true abilities and performance with an objective lens12 , students considering specialties with a more controllable lifestyle and higher salary over primary care13 , lack of resources within Graduate Medical Education devoted to holistic admissions decisions) have contributed to the perceived need of using of USMLE Step 1 scores in residency selection because these scores have been viewed as objective and reliable. Thus, USMLE Step 1 scores have been increasingly used to select students for residency interviews14 and students matching into more competitive programs are more likely to have higher scores than those in less competitive programs12,13 . Some of this emphasis is understandable, as USMLE scores have shown some utility in predicting the likelihood of passing specialty board certification exams in some specialties16–21 . The drive for ever-higher scores, however, has increased stress on medical students. Notably, students attending medical schools that have transitioned to pass-fail grading systems have been found to have improved levels of wellbeing22 , with unclear impacts of this change on residency placement23 . The effect of the upcoming USMLE Step 1 exam transition from three-digit score reporting to a pass/fail system on student wellbeing and residency selection warrants further study.
Another factor impacting wellbeing noted by students in this study was comparison and competition with peers. This finding echoes results from the study by Hill et al.24 that found competition with peers was the greatest stressor among second year students at a single medical school. In the current study, stress related to interactions with peers at times resulted in students choosing to study alone. This strategy of studying alone also had negative repercussions, with students noting significant feelings of loneliness and isolation. While solitary studying may be of benefit, as endorsed by some of the participants in our study, when this leads to feelings of loneliness there can be secondary mental and physical health impacts. Shapiro et al.22 noted among a group of internal medicine residents that those who considered themselves lonely were more likely to suffer from emotional exhaustion and depersonalization. Ideally, deemphasizing the USMLE Step 1 three-digit score as a critical factor in the transition to residency will decrease the pressure on students to study in isolation, and foster better long-term wellbeing25 .
Several participants noted the impact of the cost of study preparation materials as an additional source of strain. Previous studies have noted the negative impact of student debt on wellness and academic performance26 . The impact of the change to USMLE Step 1 pass/fail score-reporting27 on cost to students should be investigated, as students in this study noted that study aids for test preparation were a significant expense. The perceived need to obtain various study aids may be lessened with a reduced focus on attaining a specific Step 1 three-digit score.
Chronic stress can have a significant impact on medical students’ wellbeing, including burnout, mental health conditions, and attrition from medicine28 , and several students in this study noted issues with anxiety and depression. However, it is unknown if the stress noted among participants in this study is short-lived or if it could continue to contribute to long-term mental health issues during residency and practice. The prevalence of burnout among medical students has been cited as between 45% and 71%,29 , which is significantly higher than similarly aged college graduates in other fields or professions30 . Rotenstein et al.31 reported almost one-third of medical students are depressed even though that at the start of medical school, medical students are similar or healthier when compared to their peers32 . While there are many stressors during medical school, the current qualitative study describes the sometimes-negative relationship between the student USMLE Step 1 experience and medical student wellbeing. While the short-term impact on wellbeing needs to be addressed, future studies should also examine whether the stressors and related emotional responses to high-stakes exams such as USMLE Step 1 are time-limited or if they make students more likely to experience burnout and mental health issues later in their careers. Additionally, future work should explore whether the changes such as the change to score-reporting of Step 1 will have a positive impact in this area.
The students in the current study reported a variety of lifestyle responses to cope with the stress of preparing for the USMLE Step 1 exam. Positive behaviors included taking time away from studying to exercise or engage in other activities and having a trusted companion. Hill et al.21 found that medical students with lower stress reported more frequently exercising, playing sports, participating in extracurricular activities, socializing without alcohol, and participating in hobbies. As noted in the Results, some participants did not find their preparation period to be stressful and viewed their autonomy during their preparation process for USMLE Step 1 as empowering. Consideration should continue to be given to fostering self-care and supporting learners at all levels of the continuum, including but not limited to, periods of increased stress, such as the preparation period leading up to a high-stakes assessment.
Despite the higher prevalence of impostor syndrome reported among women33 , no consistent gender-based differences were found in responses related to scores in the present study. Women participants in our study, however, referenced impostor syndrome more often than participants in the general groups, and identified the stressors that they faced in continuing in their gendered roles with friends and at home during the period of preparation for the exam.
A few of the URMM students in our study felt pressure to obtain a high score in order to justify their place in medicine—a phenomenon that has been previously described34 and may reflect issues with stereotype perception. Some URMM participants viewed the USMLE Step 1 as an equal opportunity to demonstrate their ability. The impact of stressors related to race and wellbeing among medical students has been demonstrated in previous studies35,36 . Hardeman et al.37 found that African American students started medical school with higher levels of depression and anxiety than their white peers, and Peteet et al.38 noted that African American college students demonstrated higher levels of impostor syndrome. Additional research is needed to better understand the stressors faced by women and URMM students, including those related to high-stakes exams, and how these may impact their wellbeing and perception of their place in medicine.
There are several limitations in this study. Participants’ sentiments may not be representative of the experiences of other students in their respective schools, or of students from different schools in other regions of the United States. While we intended to provide opportunities for women and underrepresented minority students to participate in separate groups to facilitate more directed conversation, these groups were not large enough to glean generalizable differences from the group of participants as a whole. When collecting demographics, we did not query participants for the timing of their Step 1 examination, and whether they were required to pass it before starting clerkship rotations, if it was taken after clerkship rotations, or whether it was a graduation requirement. In addition, the focus groups in this study were conducted prior to the change in score reporting for USMLE Step 1, which may limit the implications and impact of the findings hereafter. Further study is warranted to elucidate the high-stakes exam-associated stressors experienced by other groups of students, including but not limited to differing gender identities, and other diverse racial, ethnic, and socioeconomic groups of medical students.
The impact of the change in USMLE Step 1 score reporting on student wellbeing also warrants ongoing consideration and study in multiple areas. The Invitational Conference on USMLE Scoring (InCUS), which recommended the pass/fail score reporting change, acknowledged that the health and well-being of students and physicians in training is at risk in the current system of UME-GME transition, of which the USMLE series plays a part39 . Additional research will be needed to determine what impact the change in USMLE Step 1 scoring will have on the short- and long-term emotional and physical wellbeing of medical students, and if the stressors experienced during the preparation period will be apparent in other high stakes examinations, the results of which could be used for unintended purposes. In addition to reframing residency selection criteria, institutions should not only continue supporting self-care interventions at the student level40 but also participate and encourage system-level changes to assure that the next generation of physicians feel supported, have optimal wellbeing, and remain in the physician workforce41 .
The role of regulatory authorities such as state medical boards is to protect the public. One of the critical ways to accomplish that is to assure the wellbeing of physicians. Given the reported rates of burnout among medical students and residents, it is of concern that physicians may start their professional lives even prior to commencing medical practice with some degree of burnout or mental health distress. The FSMB Report and Recommendations of the Workgroup on Physician Wellness and Burnout, published in 201843 , described a variety of approaches to physician wellbeing, including interventions at the state medical board, hospital, and professional association levels. However, additional targeted emphasis on improving the wellbeing of medical students, with attention to stressors such as high-stakes exams during their journey, may ultimately result in a healthier physician workforce.
APPENDIX: Focus Group Guide
Describe your thoughts/feelings/experiences when you think of the USMLE, particularly in the months leading up to you taking USMLE Step 1?
Please describe any factors or aspects of your life that may have impacted the USMLE Step 1 preparation time.
Were there any challenges that you experienced related to your personal life that you wish to elaborate on? (e.g. - children, spouse, job, other responsibilities outside of medical school, financial impact, etc.)
How did these challenges affect you in the months leading up to your USMLE Step 1 examination?
FEMALE/URMM groups only
Was your experience at the time of preparation for USMLE Step 1 different than that of the majority of your peers? If so, how?
Preparation process/resources for USMLE Step 1
How did you learn about the preparation process for USMLE?
Where did you learn about the significance of the USMLE Step 1 score?
What sources did you use to learn about Step 1 and how it was portrayed (ex.–Peers, Faculty, Websites, Other)?
How did you know what score was viewed as “desirable” for certain residencies?
Impact of getting score
How did you feel during the time between taking USMLE Step 1 and waiting to receive your USMLE Step 1 score?
Describe how you felt when you first received your Step 1 score?
What did the score mean for you when you first received it?
What impact did the score have on your overall wellbeing and your self-concept?
What impact did the score have on your view of your place in medicine?
Without divulging your actual score, did you alter your intended specialty choice after receiving your USMLE Step 1 score? Please describe.
If so, where did you get the information that your career path needed to change based on a particular USMLE Step 1 score?
FEMALE/URMM groups only
How did receiving your Step 1 score and being a female or URM medical school student influence your career path (e.g. do you now look at your career differently, change in intended/desired specialty areas)?
Now that the exam is behind you, and you have received your score, how do you look back on the experience of preparing for USMLE Step 1?
Looking back on the period of time you were preparing for USMLE Step 1, is there anything that would have helped you better manage your experience as it related to this exam?
What advice would you give to yourself if you could go back in time?
What tools/resources supported your wellbeing during the preparation period?
What tools/resources were not useful in supported your wellbeing during the preparation period?
What advice would you give to future students?
What advice would you give to your school?
What advice would you give to the USMLE program?
Is there anything you wish you had done differently improve your experience during the time you were waiting for your USMLE Step 1 score or after you received your score?
Author contributions: study concept and design (all); acquisition of data (UD, PV); analysis and interpretation of data (all); drafting of the manuscript (UD, KT, PV, MP); and critical revision of the manuscript for important intellectual content (all).
Funding/support: This work was supported by the NBME’s RENEW program (Re-examining Exams: The NBME Effort on Wellness).
Other disclosures: None
Ethical approval: Exempted from IRB approval by American Institutes for Research (AIR), Washington, DC.