As of January 1, 2022, USMLE Step 1 officially became pass/fail. Historically, the Step 1 score served as a metric for competency of basic medical foundational knowledge and most importantly, was used by residency programs to determine an applicant’s competitiveness. One of the reasons for the change to pass/fail was because of the emphasis that evolved over time on scoring well on the Step 1 exam. This was not the intended original purpose of this exam. You can read more about the pros and cons of this change here. In this post, we will discuss whether clerkships are likely to replace Step 1 as a means to filter applicants for residency, specifically, the surgery and medicine shelf exam scores.

With the new Step 1 scoring system, many students are wondering how it would affect their overall application and what it means for them moving forward. It is important to understand that while Step 1 has become pass/fail, there are still other score-based assessments that residency programs can use to screen their applicants. Based on the results of the 2021 NRMP Program Director Survey, the top 6 most important academic performance characteristics were the USMLE Step 1 score, MSPE, USMLE Step 2 CK score, grades in required clerkships, and any failed attempt at USMLE, and class ranking/quartile. We predict that the USMLE Step 2 CK score and grades in required clerkships will become increasingly important.

With the USMLE Step 1 Pass/Fail, Will the Surgery and Medicine Shelf Exam Scores Serve as a Replacement?

By taking away one objective measure available for student assessment, there will only be a shift toward others. While scoring well on the USMLE Step 2 CK will become important for landing competitive residency spots, so is doing well on shelf exams. Both place emphasis on mastering clinical diagnosis and management. Grades in required clerkships often depend on shelf exam scores, so this means that students now have the increased stress of balancing the rigors of their clinical rotations with carving time out to perform their best on shelf exams. 

Out of all the clinical shelf exams, the surgery and medicine shelf exam scores will most likely be the most important.

If you take a look at the USMLE Step 2 CK content outline, you will see that medicine makes up 50-60% of the exam while surgery makes up 25-30%. Together, these two disciplines are the most high-yield topics and are major predictors of Step 2 CK performance. However, it is important to consider the fact that shelf exam scores in other disciplines (pediatrics, obstetrics and gynecology, and psychiatry) will be a factor that program directors may consider as well.

Every medical school computes final clerkship grades differently, by using a combination of clinical performance and shelf exam scores.

Depending on your medical school, your shelf exam score may make or break your final clerkship grade. For example, your preceptor may give you an Honors grade for your clinical performance, but scoring a Pass on your shelf exam means that you only receive a Pass on your final clerkship grade. For students in other medical schools, it may mean that they will receive a High Pass on their final clerkship grade. This discrepancy highlights the reliability challenges of using final clerkship grades to assess an applicant’s competitiveness. Furthermore, if you are a student at an osteopathic medical school, you may need to take the osteopathic version of shelf exams, the COMAT exams. Interpreting COMAT exams creates a new level of challenge since the scoring scale is different from shelf exams. Moving forward, programs will need to adjust how they use this information to evaluate applicants.

As a result of these changes, there will be additional stress for medical students in their clinical years, especially for the surgery and medicine shelf exams.

Notably, Internal Medicine and Surgery rotations are known to be time intensive, with many requiring medical students to dedicate up to 12 hours of their day learning from their preceptors in person. After returning home from a long day at their clinical clerkships, students are expected to return home and study for their shelf exams. This requires great time management and the establishment of good study habits from the very start. 

In order to successfully balance clinical rotations and shelf exams, I have some tips that I would like to share.

1. At the beginning of every clinical rotation, create a study schedule that works for you. By planning ahead, you have a clear idea of what your goals are and you are less likely to slack off. Make sure to set aside time for your personal interests and craft a plan that works for you.
2. Next, make sure that you choose effective and high-yield materials to study for shelf exams. You will have limited time to prepare, so invest in resources that allow you to absorb the most information. Be realistic with your study style! Focusing on 2 effective resources is always better than spreading yourself thin with multiple resources.
3. Lastly, and I cannot emphasize this enough, is to do practice questions! Use question banks, like UWorld, to do daily practice question sets. It is equally important to implement the use of practice NBME assessment exams because they offer insight into high-yield content on the actual shelf exams and will give you a feel of the actual test day. 

If you have further questions about how the change of USMLE Step 1 to pass/fail may affect you or how to excel on shelf exams, please do not hesitate to contact us here. Our expert tutors here at Elite Medical Prep are available to help you reach your goals!