The Optimal Timing of Step 1 in Medical Education Following the Transition to Pass/Fail: A Unique Perspective from Post-clerkship Step 1 Schools

The National Boardof Medical Examiners’ decision to change Step 1 of the United States MedicalLicensing Examination (USMLE) from a three-digit score to Pass/Fail (P/F)represents a disruptive change for students, faculty, and leaders in theacademic community. In the context of this change, some schools may re-considerthe optimal timing of Step 1 as they strive to align their assessment practiceswith sound educational principles. Currently, over 20 schools administer USMLEStep 1 after the core clerkships. In this commentary, we review the educationalrationale for a post-clerkship Step 1, highlighting how adult learning theoriessupport this placement. We discuss some short-term challenges post-clerkshipStep 1 schools may encounter due to the proposed timing of the change inscoring, which creates three unique scenarios for learners that can introduceinequity in the system and provoke anxiety. We review outcomes of potentiallyheightened importance when Step 1 is P/F, including lower clinical subject examscores in some clerkships, lower failure rates on Step 1 and stable Step 2Clinical Knowledge scores with implications for the residency match. We outlinethe future potential for performance-based time-variable Step 1 study periodsthat are facilitated by post-clerkship placement of the exam. Finally, wediscuss opportunities to achieve the goal of enhancing student well-being,which was a major rationale for eliminating the three-digit score.