Physician Licensing Exams: Failure Or Success?

All physicians practicing medicine in the United States must pass a series of standardized exams known as the United States Medical Licensing Examinations (USMLE), which consist of a Step 1 exam, a Step 2 Clinical Knowledge (CK) exam, and a Step 3 exam. On January 26 of this year, all three exam grades were reported as a numerical grade with a pass or fail mark. From January 26thThe USMLE and its sponsors, the National Board of Medical Examiners (NBME) and the Federation of State Medical Boards (FSMB), have decided to forego a numerical grade for the Step 1 exam, making the score only marked as pass or fail.

The reason for the change? According to Dr. Kevin Jubbal, plastic surgeon and founder of Med School Insiders, the change was made to improve the well-being of medical students and reduce student stress and anxiety around exams. According to the 2018 National Residency Alignment Program Directors Survey, the USMLE Step 1 score was the number one factor used in deciding which candidate to interview for residency training (the post-graduate training that takes place in each medical specialty immediately following medical graduation schools). This test, often taken between the second and third years of medical school, aims to confirm minimum competency for licensure by testing the fundamentals of basic clinical science taught in the preclinical years of medical school. Not surprisingly, many medical students would often obsess over getting the highest grade possible in order to join the career of their choice after medical school.

Did the pass/fail change in USMLE Step 1 do what it was supposed to do – that is, reduce stress and anxiety in medical students? According to the 2021 National Alignment Residency Program Director Survey, 94% of residency programs require a numerical score on the USMLE Step 2 CK exam before offering applicants interviews. According to another study, many residency programs now consider the USMLE Step 2 CK as the primary factor when considering which medical students to offer residency training interviews. The stress and anxiety that many medical students feel has simply shifted from the Step 1 exam to the Step 2 CK exam. In other words, the USMLE Step 2 CK exam is the new Step 1 when considering the well-being and mental health of medical students.

According to a JAMA Network Open study, 50% of medical students experience burnout. While much attention has been paid to the crisis surrounding the dramatic increase in physician burnout since the Covid-19 pandemic, much less attention has been paid to burnout in medical students, future caregivers, and the first responders who will be caring for you and your loved ones. Oh no. How can we expect future doctors to master clinical medicine and take care of the sick when they can’t even take care of themselves?

Of equal concern to the adverse welfare effects are the racial and ethnic disparities that the USMLE brings to underrepresented medical student residency applicants. According to data from an article in Academic Medicine, black and Latino medical students are more likely to score lower and/or fail all three USMLE exams compared to white students. The reason is the downstream effect of decades of systemic racism, whereby they are provided with fewer resources and opportunities to succeed and excel in academia. Consequently, it is much more difficult for underrepresented minorities to receive interview offers in their specialty of choice once they graduate from medical school compared to white students.

The USMLE, NBME, and FSMB have a real opportunity to promote the well-being of medical students and physicians, as well as racial equity, by addressing the scoring of medical licensing examinations. Just like pass/fail step 1, they must make all USMLE exams pass/fail. This would undoubtedly reduce the tremendous stress and anxiety faced by medical students during their busy school years. Furthermore, underrepresented students may have a fairer chance of pursuing their dream specialties after graduation. Standardized tests are only one metric and measure of success. Eliminating numerical scores on the USMLE will force residency programs to make a more holistic review of potential applicants.

Some medical schools already do this for medical school admissions. At the University of Maryland School of Medicine, the admissions committee conducts holistic screening by de-emphasizing standardized test scores, offers unconscious bias training for interviewers, and blinds interviewers to standardized scores; to name a few initiatives. Residency programs across the country should follow suit when considering future interns for their programs. The USMLE, NBME, and FSMB, as well as the hundreds of medical training programs across the country must start taking care of the medical students we will all rely on to take care of us.


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