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How USMLE Step 1 Going Pass/Fail Will Affect IMGs

A group of IMGs in their US residency.


How the USMLE Step 1 Going Pass/Fail Will Affect IMG Medical Students


After being considered the most important exam for residency matching for year, the USMLE Step 1 has transitioned to Pass/Fail scoring in 2022. We’ve been following along this change and how it has changed the residency applications landscape for all US residency applicants. In this post, we will cover how this change has, and will likely continue to affect IMGs.


While this may sound like great news, as there has been less stress associated with Step 1, it is clear that this change will have significant secondary effects, particularly on international medical graduates (IMG’s). The most likely change is that the conversion of USMLE  Step 1 to a pass/fail scoring system will likely cause USMLE Step 2 CK to become the standard by which residency programs measure and compare applicants for interviews and for the residency match. 


Students who completed medical school outside of the United States typically have a harder time obtaining a residency match compared to US medical graduates. However, this news, unfortunately, isn’t new. To compensate, most IMGs have learned (or been told) that they need to have a higher USMLE Step 1 score compared to their American medical graduate counterparts in order to successfully match. In addition, most IMGs also try to obtain a higher Step 2 CK score than US medical graduates that typically match successfully in the field or program that they are aiming for. Take the following Step 2CK graph for example:


Unfortunately, the fundamental idea is that an IMG is considered a more risky residency applicant compared to a US medical graduate. Therefore a higher score on Step 1 and Step 2 CK suggests (to the residency program) that they are properly prepared for the program.


If we start with this premise, then we can dive a little bit deeper into the secondary effects of the USMLE Step 1 pass/fail decision for IMGs. Using a little bit of logic, we can make the following predictions about what to expect in the future:


  • It will be more difficult for IMGs to distinguish themselves in their residency applications as compared to USMGs.
  • IMGs may want to consider taking Step 2 CK and Step 3, prior to applying to residency. 
  • IMGs should try to take Step 1 before taking Step 2 CK
  • IMGs may have increased difficulty finding time to prepare for Step 2 CK, especially if they are at a school that is not oriented to the US Medical System
  • IMGs should increase efforts to connect with clinicians at academic training programs before they apply for residency.

Let’s take a closer look at why each of the hypotheses may become a reality.



Difficulty Distinguish Themselves in Residency Applications:


It is very likely that the residency application process will become more difficult for IMGs.  This is because the absence of a numerical score for Step 1 removes another objective measure with which to compare themselves to other candidates. Currently, IMGs typically have a Step 1 score and a Step 2 CK score (and Step 2 CS) on their transcript. Many IMGs recognize that having both, especially if they are strong scores, helps them demonstrate that they are a strong residency applicant. Residencies like higher scores not just because it may correlate with a stronger or smarter resident, but because it suggests the resident will have less difficulty with future standardized exams. 


If you weren’t already aware, there are lots of exams during residency and even afterward. All medical students or residents will need to take the USMLE Step 3 in order to obtain a medical license. This is the bare minimum. Internship and residency programs are required to give their trainee two days off to complete Step 3, but it’s not something they are happy about. They lose a worker–I mean a trainee–for 2 days then that person needs to be covered by another resident. If the resident fails Step 3, then they need to retake it and miss more days of service. 


Additionally, a prior failure may require the program to provide dedicated time off from service. In almost every field, there are also yearly In-training or In-service exams, usually called by some acronym involving I-T-E.  If you are a surgery resident, you will take the ABSITE every year of your residency training. Poor performance on the ABSITE can in certain cases lead to dismissal from a surgery training program. So, as you can see, a record of strong test performance helps a residency program reduce the risk of losing their resident to exam prep, or in the case of surgery, lose their resident altogether.



Considering Taking Step 2 CK and Step 3


In response to the change in Step 1 to pass/fail, IMGs may want to consider taking Step 2 CK and Step 3 prior to applying to residency. 


As mentioned above, many IMGs try to take Step 1 and Step 2 CK so that they will have both scores available for their transcript when applying to residency. In an ideal world, both scores are strong and their application is fortified by this history of success on high stakes standardized exams. In less optimal cases, one of the scores is low but the other one is strong(er).  


Classically, IMGs and USMGs have used Step 2 CK as a chance to redeem a weaker Step 1 score. Now that Step 1 will be pass/fail, most IMGs will only have the Step 2 CK with which to show off their strength as an applicant. However, unlike USMGs, many IMGs can take the USMLE Step 3 exam before applying to residency.  The reason is that Step 3 can only be taken after graduation from medical school. Per the FSMB, verification of medical school graduation can take up to 12 weeks. Therefore, most USMGs will already be matched and enrolled in their residency program. While many IMGs may find themselves in a similar position, there are also many IMGs who have completed their medical degree prior to starting their residency application. For those students, taking and performing well on Step 3 would offer an opportunity to strengthen their application.  


Furthermore, some IMGs may want to delay applying for residency until after graduation so that they can take Step 3 and include it in their application packet. One could even see a situation where USMGs with weak applications and weak Step 2 CK scores or prior failures (on Step 1 or Step 2CK) decide to graduate and take Step 3 prior to applying to the residency match.



Take Step 1 Before Taking Step 2 CK


IMGs should try to take Step 1 before taking Step 2 CK. While this statement may be obvious to some, there are many IMGs who consider taking Step 2 CK prior to Step 1. Largely, this is because the material is more clinical and they are rusty on the basic medical science. 


However, with the change to pass/fail for Step 1, the risk of performing less than your best is largely removed. This means that while taking Step 2 CK can seem like an easier test to begin with, the reality is that Step 1 and Step 2 CK have significant overlap in material and taking Step 1 first should give some IMGs a chance to get more comfortable with USMLE exam conditions in a lower stakes environment. Many IMGs come from schools that have curricula oriented towards different testing styles. In Italy, for example, extensive oral examinations are used to determine whether a student has passed their national licensing exam. This means that taking USMLE Step 1 as pass/fail before USMLE Step 2 CK can provide somewhat of a “test run” and an opportunity to feel confident with the style of the test before taking high-stakes Step 2 CK.



Difficulty Finding Time to Prepare for Step 2 CK


For many IMGs, their medical education has not been oriented towards the USMLE and US style standardized exams. Their medical school curriculum calendars are set up to match the training system in that country, and are not aligned to the needs of taking the USMLE series of exams.


In the current system, IMGs often have to carve out specific time where they can do dedicated study for Step 1, and then again for Step 2 CK. Because Step 1 is typically taken earlier in medical school, it may be easier for the IMG to plan specific time (e.g. during a research block) for their Step 1 dedicated prep. However, with the emphasis now shifting to Step 2 CK, it may be harder to find the dedicated time because it will naturally occur after clinical rotations are completed. 


Additionally, IMGs may be even more likely to bundle Step 1 and Step 2 CK together, and then find it even harder to have enough time to prepare for both. An additional consideration regarding preparation time is that the US educational system is heavily based on multiple choice question (MCQ) exams. This means that IMGs who did not attend high school or college in the US may be naturally uncomfortable with lengthy MCQ exams and may need more time to acclimate to the exam style. The bottom line is that early preparation and planning for these exams will be key moving forward– especially for Step 2 CK.



Connect with Clinicians at Academic Training Programs 


Without a Step 1 score IMGs (and students from lower-ranked medical schools in the US) will need to find additional ways to strengthen their application.


Currently, a strong Step 1 and Step 2 CK score creates a great platform on which to build a strong residency application. With only Step 2 CK providing a numerical score, applicants and the residency programs they apply to will look for other ways to distinguish applicants. Like Hollywood, a lot of decisions in medicine are based on personal connections.


If the residency director considering an applicant knows the applicant well that is best. If they know the person recommending the applicant that’s also excellent. If the residency program director doesn’t know the person referring the applicant but does know their institution then by proxy, there is an additional level trust in the quality of the applicant. Thus, the more an IMG can make connections with clinicians, researchers, and senior trainees (upper level residents and fellows) at a medical center, the better they will position themselves later on in the residency application cycle.  If an IMG can develop strong ties at one institution that is great. If they can do that at more than one institution even better. The key though is to create ‘strong’ connections, and that usually requires more than just doing a single rotation at a particular site.


If you have further questions about what the USMLE Step 1 score change from numeric to pass/fail means for you, please do not hesitate to contact us here. In addition, if you have a USMLE Step 1 test date before January 1st, 2022 and would like help preparing, please take a look at our USMLE Step 1 tutoring page if 1-on-1 tutoring could be right for you.

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