Medical School - Preclinical

USMLE Step 1 Pass/Fail Scoring: Impact on Medical Students

All USMLE Step 1 scores are reported as either a “pass” or “fail” result for tests administered after January 26, 2022. Students must achieve a score of 196 on the three-digit system to pass the exam. 

However, the USMLE no longer provides exact score measurements (although you can see how close you were to passing if your score does not meet the minimum threshold for a passing grade).

I first shared my thoughts on the announcement from the NBME on the transition to a pass/fail scoring system in early 2020. Years later, with 2+ years of USMLE test results using this current system, let’s take a look at how this scoring change has impacted medical students (and future implications).

Want to get a jump start on studying for Step 1? Our experienced tutors help students study more effectively for the best chance at a Pass.

More Students Failed During the First Pass/Fail Year

On average, over 90% of students pass the USMLE Step 1 in any given year. However, the first year after the USMLE’s scoring change, pass rates dropped across the board:

 MD StudentsDO StudentsInternational Medical Graduates (IMGs)
Pass rate (2021)96%94%82%
Pass rate (2022)93%89%74%

It’s important to note here that the pass/fail change took place at the same time as a 3-point increase in the “pass” score. Some variation is to be expected, especially as the score required was slightly higher.

However, students have also reported a significant reduction in the ongoing study time they devote to Step 1. This is the other reason for the potential drop in pass rates for first-time test takers.

Many students I talk to stress out significantly about this exam partly because a failure is generally considered a “black mark” when applying to residency programs. Yes, students may retake Step 1 — but the failure is reported in any future residency applications.

The most significant change here was a stark 8% drop in IMG pass rates. This lends some credibility to the idea that the pass/fail outcome is a net negative for graduates from international institutions. When it comes to diversifying health care, this is not necessarily a good thing.

The Stress Isn’t Gone — It’s Just Delayed

The primary reason the United States Medical Licensing Examination changed its scoring policies was, as they stated, “to help reduce the overemphasis on USMLE Step 1 numeric scores (among both examinees and secondary users of exam scores, such as residency program directors).”

But although the well-being of medical students is paramount to this decision, there is significant concern that transitioning from a three-digit score to a pass/fail outcome simply delays the stress.

For instance, there is now only a single standardized metric to use for residency selection (the Step 2 CK score), rather than two standardized test scores. Research suggests that both of these granular metrics were useful in predicting success during residency, but now, only the Step 2 CK score will differentiate students in the Match.

This not only pushes test anxiety to a time in a student’s medical education when they’re busy with clinical rotations but also delays that single objective metric to just before residency match applications are submitted.

We’re in the early stages of understanding how this will impact the Match — so far, most students who have taken the USMLE Step 1 exam as pass/fail haven’t gone through the residency application process. It will be easier to draw data-driven conclusions after the 2024 Match is complete.

Maya Guhan, a current MD/MBA student at the Baylor College of Medicine, took USMLE Step 1 after this pass/fail change. Here’s what she had to say:

“I feel that the stress has shifted to a different period of time. Students now feel that they have to do something to “stand out.” Some competitive residency applicants have even felt increased pressure to take a research year. 

“To be honest, as a student, I am not sure how the Step 1 being P/F will affect residency match rates and overall student education in the long run and I’m not sure if faculty or program directors know either. At this point, I feel that my peers and I are worried about our future and doing whatever we can to differentiate ourselves, without knowing exactly what it is that program directors are looking for.”

Students Now Focus More on Subjective Metrics

For better or worse, students in medical school must now emphasize application features such as research, letters of recommendation, extracurricular activities, and clerkship grades. This sounds like a positive move in the medical community, but as these expectations aren’t consistent or yet understood, some residents (like Maya) aren’t sure if what they’re doing is enough.

Extracurriculars, in particular, should be approached with more intentionality than ever before. You’ll need to plan in advance for research, service, and leadership opportunities during medical school. Ensure these are relevant to your preferred specialty, as they will likely be weighed heavily in the residency selection process.

And don’t just take on every extracurricular activity you stumble across. In 2023, ERAS limited residency applicants to a maximum of 10 extracurriculars.

My hope is that students view this as an opportunity during med school to focus more heavily on activities likely to encourage personal growth, rather than on getting a high score on a single standardized test in their second year. Time will tell if this is actually the case.

WEBINAR: Preparing for the USMLE Step 1 and COMLEX Level 1 

This Could Negatively Impact Under-Represented Communities

Many people in the medical community have expressed concern that the push to non-standardized metrics will have a negative effect on students typically underrepresented in medicine (UiM). Here’s what Physician Advisor Amar Mandalia, MD (also a former ADCOM) thinks:

“Interestingly, survey results on the perception of scoring change to P/F for Step 1 published in October 2021 demonstrated students/residents who identified themselves as Underrepresented in Medicine (UiM) welcomed the change. They felt that it would decrease inequities between UiM and non-UiM. 

“It remains to be seen what type of impact this change will have on UiM applicants, as there is not enough data available. I do foresee that the increased emphasis on Step 2 will further highlight inequities seen in medical education and extracurricular opportunities between lower- and higher-tier programs. 

“For example, given that there is a larger emphasis on a holistic approach to an applicant, higher-tier medical schools may encourage students to pursue research and extracurricular activities that they have to offer. Lower-tier programs, where resources could be sparse or lacking, may not be able to afford the same opportunities to their students.”

Student Well-Being May Take a Hit

Yes, USMLE Step 1 moved to pass/fail scoring due, in part, to concerns about student health and wellness during the first two years of medical school. However, shifting the stress may have yet-unknown negative impacts on the mental and physical health of medical students, especially as the first rounds of students who were scored in this way enter the Match process.

Now clerkships and studying for Step 2 feel more high-stakes than ever. Dr. Mandalia expressed his concern to me that this will result in more students than ever feeling pressure to take a gap year if they are unhappy with their scores after taking Step 2.

However, not everyone sees this change negatively. Emily Zitkovsky, a medical student at Brown University, sees it as a little more stressful, but better for medical students in general:

“Overall, I think this is a net positive change. Medical school and applying to residency are stressful regardless. Removing the emphasis on perfection and the need to memorize small details that aren’t super clinically relevant is a good thing for most people.

“My best advice to medical students is to focus on learning at whatever stage you are at. You can’t control changes to the NBME exams or the residency application process, but developing a strong foundation in preclinical and clinical medicine will benefit your patients and your future success. 

“Lastly, I think we need more research on the institutional level to understand the impact of removing objective measures in the application process on student well-being and diversity in the workforce because, at this time, it is not clear.”

Osteopathic and IMG Students Are Among the Most Concerned

The survey referenced by Dr. Mandalia revealed that DO and IMG students felt that a high Step 1 score previously aided their residency prospects by demonstrating their competency in key medical knowledge. They now worry about being disadvantaged in the Match compared to MD applicants without it.

We’ll need to watch the data — after the Match in 2024, the medical community will be able to understand how this change correlates with residency acceptance rates for DOs and IMGs.

Read Next: COMLEX vs USMLE 

Here’s What to Do If You’re Concerned

A career in medicine has always been a competitive one. With changes to scoring on USMLE Step 1 and, as of January 2024, a new passing score for Step 3, students must adapt to ensure they are ready for licensure.

Here are the steps my team recommends to our medical students:

  • Plan ahead: Create a 4-year plan for the timing of major extracurriculars and standardized testing. Review this plan on a short-term and long-term basis regularly (at least twice per year, preferably once per quarter).
  • Study hard for Step 1: Make an effort to understand the exam and how questions are asked. It will provide a foundation to help prepare for Step 2 in the future, and a failure will remain in your records through the remainder of your medical education.
  • Create a Step 2 study plan: Plan to take Step 2 according to your school’s dedicated time for studying. If you are planning to do aways and sub-internships, complete Step 2 prior to these rotations. It is important to have Step 2 on your ERAS application, as residencies will place additional emphasis on Step 2 scores.
  • Take a gap year, but only if you need to: A gap year should really be for those more competitive specialties that emphasize research experience.


Can you fail Step 1 and still match?

It’s possible to fail USMLE Step 1 and still match into a residency program, but it will probably be more challenging. A failure on Step 1 will remain on your USMLE transcript, and you’ll need to retake the exam and pass it to be eligible for most residency programs.

Once you pass Step 1 on your second attempt, you’ll need to improve your attractiveness as a candidate by:

  • Showing a strong performance on USMLE Step 2 CK
  • Gaining clinical experience and excellent letters of recommendation
  • Strengthening other aspects of your application, like research experience, volunteer work, or other relevant extracurricular activities
  • Applying to programs that may be more forgiving of a Step 1 failure or that take a more holistic approach to their review of applicants
  • Networking effectively within the medical community to establish professional relationships that can aid in securing interviews

Some very competitive residency specialties may choose not to consider applicants who have a Step 1 failure in their transcript.

How many times can you retake USMLE Step 1 if you fail?

Technically, the NBME allows students to take any of the USMLE exams up to 6 times. However, if you have to take the USMLE more than twice, your chances of matching into a competitive specialty drop dramatically.

What is the minimum passing score for USMLE Step 1?

Currently, the minimum passing score for Step 1 is 196. However, your exact numerical score for this exam will not be included in your score report.

According to the NBME:

“The USMLE Management Committee establishes the minimum passing score. The USMLE Management Committee reviews data for each component in the USMLE sequence approximately once every four years and decides whether to change the recommended minimum passing score.”

How long does it take to get your USMLE Step 1 pass/fail result back?

All USMLE test scores are delivered within 2-8 weeks after your test date. The NBME claims that while most results are delivered within 4 weeks, you should allow up to 8 weeks in case of unforeseen circumstances.

Your score will remain available for free for approximately one year after your test date.

How can I get my USMLE scores back faster?

According to the National Board of Medical Examiners (NBME), no individual or group may have USMLE test results accelerated for any reason. You’ll need to wait in line for your scores, regardless of extenuating circumstances.

Work with MedSchoolCoach & Face the USMLE with Confidence

If you’re concerned about your USMLE exam scores, let our experienced tutors help you craft a personalized study plan that makes sense for your schedule and unique needs.

Our tutors have an average of 10 years of teaching experience. Our USMLE/COMLEX expertise will help you work smarter, not harder.

Sahil Mehta

Sahil Mehta M.D. is an attending physician in the Department of Radiology at Beth Israel Deaconess Medical Center and the Founder of MedSchoolCoach. Dr Mehta is one of the world’s experts on medical school admissions having founded MedSchoolCoach in 2007. MedSchoolCoach provides admissions consulting to premedical students in the form of interview preparation, essay editing and general advising. In the past 10 years, he has had a hand in over a thousand acceptances to medical school.

Related Articles

Back to top button