In Response to Pass/No Pass Step 1: Navigating the Changing Path to Medical Education

Benjamin Schneider, MD

Fam Med. 2022;54(6):486-486.

DOI: 10.22454/FamMed.2022.934021

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To the Editor:

In "Pass/No-Pass Step 1: Navigating the Changing Path to Medical Education,"1 Mr Higgins and Dr Flanagan state that the ultimate goal for medical schools is, “Cultivating competent, patient-centered, humanistic physicians.” This goal resonates deeply with me as a medical educator. The authors state that the move to pass/no-pass Step one (S1) grading is unlikely to substantially change self-directed learning behavior and the pervasive use of external resources should be accepted and not fought against. They describe a curricular innovation that incorporates longitudinal clinical experiences early in the educational process and push S1 back until after clinical rotations. I look forward to seeing a future manuscript presenting the outcomes of this curricular innovation.

My concern is that students supplementing their undergraduate medical education (UME) curricula with external,2 costly3 commercial resources is not occurring simply because these students don’t trust the medical school curricula to prepare them. Students are highly motivated by a successful match and program directors (PDs) have been clear that S1 score was the single most important item used to select who to interview in 2021.4

Time in undergraduate medical education is a precious resource. S1 emphasis in residency selection has grown over the last two decades,5 and with it so have scores and time spent preparing for the exam. In 2000 the national mean score was 2155 and students reported an average of 319 hours of preparation6 during their dedicated study period. By 2020 the mean score rose to 234 (NBME)7 and students reported an average of 490 hours of dedicated study.8 Passing S1 is by no means easy, but the move to pass/no-pass scoring should free up at least the 171 extra hours that students are now spending, as 215 is still well above the national passing level of 196. I applaud the authors for filling that time with meaningful, early, patient-centered care. How else can we leverage this time to best prepare learners for graduate medical education and future practice?

Unfortunately, Step 2 Clinical Knowledge is already the third most commonly cited factor by PDs in selecting candidates for interviews.4 I remain concerned that if we as a community of educators cannot identify other meaningful metrics for selecting who to interview, we will simply see that time shifted from S1 study to S2 study. I continue to encourage us as a community of medical educators to define what we care about and how we can objectively assess and communicate those data to partners across the UME-GME divide. Longitudinal patient-centered education may be an excellent way to train the next generation of physicians, but I fear that as long as our interview selection process favors multiple-choice question examinations, that is what our students will dedicate their efforts to mastering.


  1. Higgins R, Flanagan M. Pass/No Pass Step 1: Navigating the Changing Path to Medical Education. Fam Med. 2022;54(6):XXXX.
  2. Burk-Rafel J, Santen SA, Purkiss J. Study behaviors and USMLE Step 1 performance: implications of a student self-directed parallel curriculum. Acad Med. 2017;92(null):S67-S74. doi:10.1097/ACM.0000000000001916
  3. Bhatnagar V, Diaz SR, Bucur PA. The cost of board examination and preparation: an overlooked factor in medical student debt. Cureus. 2019;11(3):e4168. doi:10.7759/cureus.4168
  4. National Resident Matching Program, Data Release and Research Committee: Results of the 2021 NRMP Program Director Survey. National Resident Matching Program. August 2021.
  5. Carmody JB, Rajasekaran SK. On Step 1 Mania, USMLE score reporting, and financial conflict of interest at the National Board of Medical Examiners. Acad Med. 2020;95(9):1332-1337. doi:10.1097/ACM.0000000000003126
  6. Thadani RA, Swanson DB, Galbraith RM. A preliminary analysis of different approaches to preparing for the USMLE step 1. Acad Med. 2000;75(10)(suppl):S40-S42. doi:10.1097/00001888-200010001-00013 
  7. Tackett S, Jeyaraju M, Moore J, et al. Student well-being during dedicated preparation for USMLE Step 1 and COMLEX Level 1 exams. BMC Med Educ. 2022;22(1):16. doi:10.1186/s12909-021-03055-2

Lead Author

Benjamin Schneider, MD

Affiliations: Department of Family Medicine, Oregon Health and Science University, Portland, OR

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