On February 12, 2020, and after a yearlong discussion, the National Board of Medical
Examiners (NBME) announced that the reporting of the U.S. Medical Licensing Examination
(USMLE) step one exam will transition from a three-digit numeric score to a pass/fail
reporting system and is expected to take effect as early as 2022.[1] This was based on input received by the Federation of State Medical Boards (FSMB)
and the National Board of Medical Examiners (NBME) during the Invitational Conference
on USMLE Scoring (InCUS). This decision was further supported by the Education Commission
for Foreign Medical Graduates (ECFMG), a body responsible for certification of international
medical graduates (IMGs). Of note however, only 5 of 65 attendees of InCUS were IMGs.[1],[2] The goal of this paper was to discuss this change, and its effect on trainees (especially
IMGs), and their selection process.
The NBME argued that this change will help reduce the over-emphasis on USMLE performance.
It will also become the first step towards facilitating a broader system-wide approach
that will improve the transition from medical school to graduate medical education.
They further emphasized that the decision on the application review process should
be holistic, and that the USMLE exam should be one of many other objective measures
to aid in the selection process.[1] Furthermore, the NBME argued that the preparation for such a high-stakes exam may
create a negative impact on the student’s well-being.[3],[4] In addition, they stated that the current system may negatively impact diversity
in the graduate medical education based on known group differences in performance
and devalue the preclinical curriculum.[1] Conversely, they acknowledged that the step one exam has a value of providing a
level of comparison across various applicants from various backgrounds (US graduate
or IMG), and across different schools and curricula.[1] They further suggested that the selection criteria for postgraduate training should
include other measures including Medical Student Performance Evaluation (MSPE), letters
of recommendation (LOR), research, medical school reputation, visiting rotations,
community service experience, personal statement, and demographic characteristics.
The change in the reporting system was met with a spectrum of responses and attitudes
amongst medical students, and current physicians across the US and those interested
in coming to the US from IMGs. While the argument for pass/fail reporting system may
hold for US graduates, it tilts the scale when it comes to IMGs, especially with lack
of a current objective system to compare US graduates and IMGs. While all residency
applicants may apply for residency without completing all USMLE step examinations,
IMGs are required to have passed Step 1, Step 2 Clinical Skills (CS), and Step 2 Clinical
Knowledge (CK) to obtain ECFMG certification. Therefore, at the time of application,
most IMGs apply with all examination scores, while US graduates have an option of
applying with step 1 exam only.[5] And while having step 1 scores allowed for aiding programs in the screening process
and creating a comparison factor between US graduates and IMGs, this factor will now
be gone after the transition. In addition, it may create a more stressful system for
IMGs, as step 2 CK will now be the only standardized exam to help differentiate amongst
IMGs. Therefore, an IMG who fails their step 2 CK exam and/or has a lower performance
will not have a chance to redeem their application with a better step 1 exam. Furthermore,
other measures mentioned by the NBME such as medical school reputation, MSPE, LOR
apply less to IMGs given the lack of MSPE system in some medical schools, and due
to the fact that international medical schools are less likely to be known compared
to American medical schools. In addition, with the instate of the visa ban, it has
been difficult for IMGs to secure an elective rotation.[6],[7]
The implications of this do not only impact residency applicants, but they will eventually
impact fellowship applicants, and finally the IMG contribution to the US workforce.
First, the selection and success of fellows are known to be correlated with USMLE
step 1 score.[8] Second, the downstream effect of selecting fewer IMG residents will result in fewer
IMG fellow candidates. Over the past several decades, IMGs continued to contribute
to the US physician workforce, starting with 10% in the 1960s, and increasing to nearly
20% in the 1990s.[9] While the immigration ban has created an obstacle for IMGs to secure residency and
fellowship in the US,[9] the elimination of the scoring system is likely to add another obstacle to IMGs,
and hence limiting their availability and long-living contribution to the US physician
task force.
While removal of step one score reporting may create a positive impact in the short-term,
the implications on IMG trainee selection and long-term consequences on the US health
system remain unanswered. Without a current systematic trainee selection process,
the implications on the health system may be sorrow.
