Select header/footer to go to
Table of Contents



 Patient: Autonomy

 Practitioner: Beneficence & Nonmaleficence

 Public Policy: Justice


Appendix 1 - Step Exams & Interviews

Step 1, Step 2, Step 3, & Interviews

[S:1] Step 1 scores are now pass/fail. In 1994, when the Step 1 exam was created, it had an average score of 200 out of 300 and was designed to be the first step towards medical licensure eligibility. Residency directors then started using the Step 1 scores as their primary criteria for granting residency interviews, as it was thought to be an “objective” and fair way to select students from a large applicant pool. The problem was that no empirical data showed a correlation between higher Step scores and a practitioner’s competency, skills, and patient outcomes after residency completion. The medical licensure exams were being used for purposes that the exams were never designed to be used for, resulting in enormous unanticipated consequences.

[S:2] Residency directors’ use of Step 1 scores for screening purposes resulted in the creation of a parallel medical school curriculum using third-party materials for improving Step scores. As a result, since 1994, the average Step 1 score has increased from 200 to 230.

[S:3] Medical school course directors and deans have supported changing Step 1 to pass/fail, thinking that medical students will now focus on the institutional medical school curriculum rather than third-party study programs.

[S:4] Residency directors and US medical students have been opposed to the change of Step 1 to pass/fail because then the residency directors would need to find something else to differentiate resident applicants such as subjective criteria like medical school prestige or extracurricular activities, in addition to new objective criteria like Step 2 CK scores and the number of Step 1 failures before passing the exam. As of July 1, 2021, examinees are limited to four attempts, instead of six, per Step exam, and the USMLE transcripts will provide a complete exam history. Some believe that this change will only increase student stress because residency directors will now use not passing Step 1 on the first attempt as a negative selection criterion. In addition, if residency directors start to use the Step 2 CK scores, which are not pass/fail, then the examinee will need to take Step 2 CK early enough to get the exam score back before applying for residency. Since Step 2 CK is taken early in the fourth year and can only be taken once every six months, this will leave no time to retake a failed exam before residency match, increasing student performance stress.

[S:5] In other words, changing Step 1 to pass/fail will not decrease student stress, will not result in a fairer way for selecting students for residency from large applicant pools, and will not result in less emphasis on the Step 1 exam. When Step 1 was graded, at least the students had up to six tries to pass without penalty, as what was important was the score, not what school a student went to or other subjective criteria that seem to be even less relevant as to measuring a practitioner’s competency, skills, and patient outcomes after residency completion.

[S:6] The medical profession recognizes that exams for medical licensure eligibility are essential for assuring a minimum standard of medical competency. However, what might surprise some medical students is that there are more than twice as many ethics case studies questions on these Step exams as there are questions for any individual organ system, such as GI, Cardiovascular, Musculoskeletal, Immune System, Respiratory, or Renal, and the number of ethics questions are only increasing in number each year. Since most problems in medicine result from lapses in ethical judgment rather than lapses in medical knowledge, it behooves the medical licensure board to increase the number of ethics-related board questions for addressing those problems.

[S:7] The Step 1 exam consists of seven 60-minute blocks of 40 questions. On average, there are around four ethics questions per block. This means 280 questions, with approximately 10%, or 28 questions being ethics questions (7x4=28).

[S:8] Step 2 CK consists of eight 60-minute blocks of 40 questions for a total of 320 questions. 10-15% of the questions will be ethics/legal/professional or approximately 10% or 32 ethics questions (8x4=32).

[S:9] Step 3 consists of six 60-minute blocks of 38-39 questions on day 1. Day 2 consists of six 45-minute blocks of 30 questions for a total of 180 questions, followed by 13 case simulations. Again, approximately 10% of the questions will be ethics/legal/professional or about 18 ethics questions.

[S:10] Because of the number of ethics questions that will be asked, the test taker must be at least as knowledgeable in ethics as they are in any other specialty area of medicine to ensure the passing of the Step 1 exam and excelling on Step 2 CK and Step 3 exams.