Getting in Step

How a new pass/fail option will change the way medical students prepare for residency.

Published in Hopkins Medicine - Fall 2022

Emma* and I were talking one day a couple of months into her third-year clerkships. She wanted to work through what she was experiencing with me, then a career advisory dean at the George Washington University School of Medicine and Health Sciences. She hadn’t done as well as she’d hoped on Step 1 of the United States Medical Licensing Examination — that high-stakes test covering key components of medical knowledge — despite spending more than 10 weeks preparing.

“I was testing higher,” she confided quietly about her many practice exams. “I don’t think I’ll be able to match in Ob-Gyn, which I’ve been loving.” Emma’s sadness and defeat were palpable to me.

I talked about how her Step 1 score did not define her, noting that she was more than a number and that the test by itself was a poor predictor of later clinical performance and the physician she’d become. I wanted her to see the gifts that I saw in her: her passion for social justice, her empathic communication skills, her clear potential for becoming a doctor whom her patients would adore and trust. Yet, it was hard for her to shake the feelings of incompetence, and they were even impacting her clinical performance.

For so long, medical students have worried about the impending hurdle of Step 1 — a full-day exam that has loomed from the beginning of medical school because it has carried so much weight in residency programs’ assessments of the many applications they receive.

Last Jan. 26, Step 1 scoring was changed from a numeric grade to pass/fail, so the big question is, “Now what?” How should students shift their thinking and preparation for the residency program applications that determine where they’ll spend the next several years of their medical training? I see an opportunity to get back to what matters. My advice for students in a post-Step 1 score world:

Authentically develop your interests: You may have come to medical school with certain interests and passions, or you may be still exploring which areas you want to focus on. Find what excites you and gives your medical education meaning. Concentrating on a smaller number of interests can help you develop your professional goals while also allowing you to differentiate yourself from other [residency] candidates.

Engage in the preclinical curriculum: Many medical educators believe that the focus on Step 1 has led some schools to devalue a number of vital competencies not covered on the exam — clinical skills, communication and professional identity, among others. Now, you can more fully engage in your school’s preclinical curriculum and focus more on the other essential domains of developing as a physician that residencies (and patients) seek.

Craft your story: One of the things I cherish most about being a student affairs dean is getting to know my students’ unique paths to and through medical school. As we lose the Step 1 score, and as some schools have also moved to pass/fail grading in preclinical courses and even the clinical curriculum, effectively communicating your story to residency programs is even more important.

Attend to your well-being: Some students have described their Step 1 study period as the worst time of medical school for them — and sometimes of their lives! With the high levels of burnout, stress and anxiety among medical students, removing the undue burden of the exam is a welcome change. Celebrate the transition by starting regular self-care, spending time connecting with loved ones, or making your primary care and mental health care appointments. Self-care is a critical skill you’ll carry forward into the rest of your career. We can’t care for others if we don’t take care of ourselves.

Katherine Chretien is associate dean for medical student affairs and director of medical student wellness at the Johns Hopkins University School of Medicine. A longer version of this article appeared in AAMC News on Jan. 11, 2022. It is reprinted with permission of the Association of American Medical Colleges.

*Name has been changed.