Assessing a Paradigm Shift: Perceptions of the USMLE Step 1 Scoring Change to Pass/Fail

June 2020 | Volume 19 | Issue 6 | Features | 669 | Copyright © June 2020

Published online May 20, 2020

Chapman Wei , Misty G. Eleryan , Alex Gu , Adam J. Friedman

aDepartment of Dermatology, The George Washington School of Medicine and Health Sciences, Washington, DC bThe George Washington School of Medicine and Health Sciences, Washington, DC



The United States Medical Licensing Exam (USMLE) Step 1 scores are heavily factored for dermatology interview selection.1 Recently, the Step 1 scoring system changed from a three-digit score to Pass/Fail on February 2020, to take effect in January 2022 at the earliest.2 As Step 1 has historically served as a screening tool for application review, we distributed an IRB-approved non-incentivized survey among dermatology program directors (PD) to assess the potential impact on dermatology interview selection.

This survey was disseminated by e-mail using SurveyMonkey. Of 127 PDs who received the e-mail, 76 opened the invitation, 45 clicked through the survey, and 37 completed the survey after 10 days of collection. Most responders were from university- based residencies (70.27) represented from the regions in Question 3 (Table 1).

A majority perceived that Step 1 will not be or will only be slightly important (69.44%) for interview selection. Most perceived that Step 2 Clinical Knowledge (CK) scores should be required for interviews (71.98%). More than half of PDs perceived that their program will require Step 2 CK scores in the future (64.87%).

A majority perceived that this change will not affect their recruitment ability for competitive applicants (44.44%). More than half of respondents (56.76%) collectively perceived that this change will negatively impact applicants from ‘lower-ranked’ medical schools, which is defined by the National Resident Matching Program (NRMP) survey as non-highly regarded by program directors.1 Almost half of respondents collectively answered that applicants will need to obtain additional extracurricular/ extramural resources for interview consideration (43.24%). A majority were unsure whether future resident quality will be affected. In response to a follow-up survey sent to the PD's, 42.86% did not support the change from numerical score to Pass/Fail; however, 33.33% felt it would positively impact interview selection of those from underrepresented minority groups.

Our survey showed that the Step 1 scoring change may not be well received among dermatology PDs. Applicants will likely need to take Step 2 CK earlier than the Electronic Residency Application Service (ERAS) application deadline, attend audition rotations, and have additional extramural experiences to be granted interviews; especially if they attend ‘lower-ranked’ medical schools. This may severely limit options for financiallydisadvantaged applicants. Interestingly, over one-third believed there could be some positive impact on applicant diversity.3

Unfortunately, the assumption that removing the numerical score for Step 1 would result in an increase in diversity highlights a bigger issue. The belief that these applicants do worse on Step 1 further adds to the instances of bias and microaggression that they regularly encounter; and furthermore, continues to perpetuate the stereotype that “diverse” applicants regularly underperform on USMLE Step exams without taking into account the barriers faced by this subgroup of applicants when compared to their counterparts.4

Additional methods are being considered to complement Step 2 CK, such as institution-based examination, but these options will vary by institution. Our study’s limitation is its response rate, likely from response fatigue of other similar surveys, which is consistent with response rates from dermatologists to other non-incentivized surveys.5


Dr. Friedman is the residency program director at the George Washington University School of Medicine and Health Sciences for the Department of Dermatology.


1. National Resident Matching Program. Results of the 2018 NRMP Program Director Survey. https://mk0nrmp3oyqui6wqfm.kinstacdn.com/wp-content/uploads/ 2018/07/NRMP-2018-Program-Director-Survey-for-WWW.pdf. Accessed March 17, 2020
2. United States Medical Licensing Examination. Change to pass/fail score reporting for Step 1. https://www.usmle.org/incus/#decision. Accessed March 17, 2020
3. Isaq NA, Bowers S, Chen ST. Taking a “step” toward diversity in dermatology: deemphasizing USMLE Step 1 scores in residency application. Int J Womens Dermatol. 2020 Mar 5. https://doi.org/10.1016/j.ijwd.2020.02.008.
4. Osseo-Asare, A. Minority resident physicians’ views on the role of race/ethnicity in their training experiences in the workplace. JAMA Netw Open. 2018 Sep 7;1(5):e182723.
5. Wan J. Abuabara, K. Shin DB, et al. Dermatologist response rates to a mailed questionnaire: A randomized trial of monetary incentives. J Am Acad Dermatol. 2012 Jan;66(1):e18-e20.


Adam J. Friedman MD FAAD ajfriedman@mfa.gwu.edu