In January 2022, the influential Step 1 of the United States Medical Licensing Examination (USMLE) changed from numerical to pass-fail scoring. Faculty members on the medical school and physician residency sides of training touted the move for deemphasizing numeric scores while preserving the exam’s utility for determining physician-licensure eligibility.
The AMA had long advocated moving away from the previously used three-digit numeric score, saying that it was detrimental to student well-being because it created a parallel curriculum to prepare for the exam and distracted medical students from developing teamwork and communication skills.
Still, even years later, in the wake of the Step 1 switch to pass-fail scoring, many medical students are left wondering how the change is reshaping the criteria programs use to select residency applicants. Data from the National Resident Matching Program (NRMP) and insight from a residency program director offer fresh perspective on that question.
Passing is paramount
While a Step 1 numerical score will not be a differentiator for physician residency applicants, a failed Step 1 or Step 2—still scored numerically—attempt can be, for the wrong reasons.
According to the 2024 NRMP survey of program directors, 77% of respondents considered failed attempts on either USMLE Step exam when deciding whom to interview. That makes passing both Step exams on the first try a baseline requirement for keeping more doors open in the Match.
Passing Step 1, however, is a little more difficult in the pass-fail era.
In 2021—the year prior to Step 1’s moving to pass-fail scoring—95% of first-time test takers from MD-granting medical schools and 94% from DO-granting schools passed Step 1. In the years since, that number has ranged from 91–93% for MD students and 86–89% for DO students.
What’s behind the decline? One simple answer is that the threshold for passing increased. When the exam went pass-fail in January 2022, the score required to pass moved from 194 to 196.
Pass rates on Step 2 are higher across the board. In 2024, 98% of medical students from MD-granting medical schools and 96% of DO medical students passed the exam on their first attempt.
The AMA offers essential tools and resources to support medical students in their preparation for the USMLE series of exams. To help you with your studies, AMA members receive a discount on test prep materials for the USMLE and the Comprehensive Osteopathic Medical Licensing Exams (COMLEX-USA).
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Using Step 2 to stand out
The change in Step 1 scoring has put new emphasis on Step 2 performance.
Daniel Dent, MD, is the residency program director and a professor of surgery at the University of Texas Health San Antonio. He opined that scores on the Step 2 exam are taking on new importance in assessing residency applicants. Additional academic metrics, though they differ by how schools assess students, also can offer key data points.
“Ultimately, I guess you can distinguish yourself via Step 2. Many schools have class rank. Many don't,” Dr. Dent, an AMA member, said during an episode of “AMA Update.” “And schools that are not just pass-fail but have honors, high pass, pass, or A, B, C type grading—you can distinguish yourself with those grades.”
In the 2024 NRMP survey of residency program directors, 30% of programs required applicants from MD-granting medical schools to meet a target Step 2 CK score to secure an interview. For international medical graduates (IMGs), that figure was slightly higher, with 36% of programs requiring a specific Step 2 score.
Among applicants from DO-granting medical schools, the percentage was lower, at 22%. All DO students take Level 2 of the COMLEX-USA, which is often considered equivalent to Step 2 CK. Still, it’s worth noting that most DO students opt to take both exams.
The AMA Succeeding in Medical School series offers tips and other guidance on a wide range of critical topics, including preparing for the USMLE and COMLEX exams, navigating clinical rotations, publishing scientific research, and maintaining optimal health and wellness.
Clinical performance matters
The value of academic performance is evident in the program director survey—as is the significance of passing the Step 1 exam. In that survey, the five most frequently considered factors in determining whether an applicant was granted an interview were:
- Passing USMLE Step 1—considered by 86% of programs.
- The Medical Student Performance Evaluation (MSPE or dean’s letter)—85%.
- Letters of recommendation in the specialty—84%.
- The USMLE Step 2 score—83%.
- The personal statement—81%.
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In Dr. Dent’s view, doing well on exams about clinical medicine will be just as important as a Step 1 score “because you're going to be taking tests on clinical medicine for the rest of your life” such as the board exam, he said. A letter of recommendation that speaks to a person’s medical knowledge and work ethic is crucial.
Dive deeper:
- USMLE Step 2 FAQs: Methods to help maximize your score
- How to find the right people to write letters of recommendation
- What makes a GME applicant’s personal statement stand out?
- These study tips will help you ace your shelf exams
- After Step 1 shift, research experience is a watchword for Match
Applicant intangibles a factor
Beyond test scores and academic performance, programs also weigh more subjective elements of an application—factors that can vary in importance depending on the institution. Leadership experience, volunteer work, and involvement in organized medicine or health policy advocacy can all meaningfully influence whether a student is offered an interview or ranked highly.
“Any of that is viewed positively. I want to make that clear. But significant commitment to it is viewed much more positively,” Dr. Dent said. “And so, if you're the AMA rep for your school, or you've done other things within the AMA and have worked with—to do some local volunteer work for the AMA and your community and those sorts of things, whether it's AMA or your state medical association—that is definitely viewed positively as well.”
“But again, there's the people that show up so they can check a box and put it on their CV,” Dr. Dent said. “And then there's the people that show up and pay attention and commit. And that's really who we're looking for.”
For medical students looking to turn their passions into health policy, the AMA offers the chance to connect with nearly 53,000 AMA student members, get hands-on experience advocating for change at the state and federal levels through trainings, meetings and events in Washington, D.C.—and online.
