Converting USMLE Step 1 to Pass or Fail: The Potential Impact on Applicants Who Are Female or From Underrepresented Groups

Background

In January 2022, the United States Medical Licensing Examination (USMLE) Step 1 exam became pass/fail and the transition to using USMLE Step 2 scores for residency interview screening appeared imminent. While this change was intended to result in holistic reviews of residency applicants, the impact remains unclear. In this study, we aimed to determine how USMLE scoring changes might affect female candidates and applicants from underrepresented groups (URM).

Methods

We performed a retrospective cross-sectional study of all applicants to a single institution. Data for applicants were extracted from their 2021-2022 residency applications and included age, race, sex, medical school, region, USMLE Step 1 score, and USMLE Step 2 scores. All applicants who graduated from a US medical school with both USMLE Step 1 and Step 2 scores were eligible for inclusion. Our primary outcome was the difference between USMLE Step 1 versus Step 2 scores. Two comparisons were made; female candidates were compared to male candidates and URM compared to non-URM.

Results

On regression analysis, we noted that female candidates (coefficient = 4.007; 95% CI, 2.64-5.37, P < .001) had greater improvements between USMLE Step I and Step II scores compared to male applicants, while URM (coefficient = -5.056; 95% CI, -7.6 to -2.5, P < .005) demonstrated smaller differences between USMLE scores compared to the reference group (non-URM).

Conclusion

Making USMLE Step 1 pass/fail may benefit female candidates during the interview process, while adversely impacting URM. As the application process evolves, the impacts on female and URM need to be carefully evaluated to achieve equitable representation in residency programs.