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

To the Editor,

We commend Wei et al¹ for highlighting the fundamental shift that dermatology program directors (PDs) and students alike will experience following the change of the USMLE Step 1 to pass/fail. Historically, Step 1 scores were pivotal in applicant selection.^2,3 PDs utilized the three-digit score objectively to evaluate a student’s competitiveness and determine residency interview invitations.² This selection criteria undoubtedly placed tremendous stress on medical students to meet the criteria/demands of residency programs.

The USMLE website reasoned that this change to Step 1 will eliminate the overemphasis on USMLE performance and decrease student distress.⁵ Wei et al reports 71.98% of dermatology PDs indicated that given this change, Step 2 CK scores should be required prior to residency application submission. Currently, 79.49% of PD’s do not require Step 2 scores prior to application submission. While this change appears to ameliorate the uncertainty, PDs have regarding how they will assess applicants moving forward, it does, however, contradict the basis for changing Step 1 to pass/fail. Now, a greater emphasis will be placed on only one score, rather than two scores, and inherently disallow “redemption” for applicants who may have had subpar step 1 scores.

56.7% of PDs believe applicants from ‘lower ranked’ medical schools will be negatively impacted by this change. We must consider the impact upon applicants from osteopathic and international medical schools, who annually fill a small portion of dermatology residency positions. Of the 529 (PGY-1, PGY- 2 and Physician) dermatology positions filled in the 2020 Main Residency Match Data, only 74 (13.99%) were filled by osteopathic and international medical school graduates.⁶ Step 1 scores enable students from these schools to be competitive among US allopathic applicants. The removal of Step 1 scores makes the future of osteopathic and international students nebulous.

Applicants often narrow their specialty choice after receiving Step 1 scores, after evaluating their “competitiveness.” Step 2 CK is traditionally taken after the 3rd year of medical school, this shift now provides students with increased uncertainty about their desired specialty and applications for dermatology away rotations. An unconsidered effect is that students may prematurely take Step 2 CK, prior to completing core clinical rotations and subject exams. Without an objective score to characterize applicants, students from higher ranking medical schools may be favorably selected for dermatology away rotations. Additionally, shifting emphasis to Step 2 CK may reduce time for extracurricular activities such as research, volunteerism, and elective dermatology rotations (opportunity for Letter of Recommendation) that make applicants well-rounded.

Wei et al. illuminated the new narrative required of the residency selection process given USMLE Step 1 score changes. Without changes to the Step 2 CK scoring system, it is possible that the distress will shift from one exam to another, further complicating the application process for medical students and residencies. It should be noted that competitive residencies such as dermatology may become solely available to students at highly regarded medical schools, eliminating chances for students from low tier allopathic, osteopathic, and international medical schools. This change needs to be examined further by USMLE and program directors to ensure fair opportunities in the dermatology residency selection process.

Robert P. Dellavalle MD PhD MSPH robert.dellavalle@cuanschutz.edu