The Impact on Medical Student Stress in Relation to a Change in USMLE Step 1 Examination Score Reporting to Pass/Fail

Abstract

The United States Medical Licensing Examination (USMLE) Step 1 was designed to be a benchmark measure of knowledge and has been used heavily in the residency application process. Step 1 has moved from 3-digit scoring to a pass/fail scoring system, in part to decrease the stress associated with the exam. Emerging literature suggests that this transition has led to other stresses for students. Our study compared student stress levels, both overall and in relation to Step 1, leading up to the exam between a scored cohort and pass/fail cohort. We administered to each cohort a 14-item survey that included demographics, the PSS-4 stress scale, and 6 other potential stressors. Data was analyzed using two-tailed t test for independent means and analysis of variance. We found that while there was no difference in general overall stress between the students who took Step 1 for a score and students who took Step 1 pass/fail, we did see differences in stress related to the Step 1 exam. Step 1 stress was significantly lower for the pass/fail cohort than the score cohort during the second year of medical education leading up to the exam. However, this difference in Step 1 stress between the cohorts disappeared by the dedicated study period immediately before the exam. The change in scoring appears to have decreased stress specifically related to Step 1, but this reduction was not sustained as students entered their study period to prepare for Step 1.

How Student and Faculty Perceptions Differ on the Stressors that Medical Students Face

“…Because preclinical students no longer needed to aim for a very high score on USMLE Step 1, it is possible that they shifted their stress toward research and extracurriculars as discussed above. 23,28 There were numerous limitations to this study, including possible self-selection bias because the survey was open and students and faculty were able to choose to complete it or not. In future studies, participant recruitment could occur through a random selection of the medical school faculty and students.…”

“…At the time of this study, most of the preclinical students were in the cohort to take the USMLE Step 1 pass/fail, whereas most clinical students took it graded. Because preclinical students no longer needed to aim for a very high score on USMLE Step 1, it is possible that they shifted their stress toward research and extracurriculars as discussed above 23,28 …”