Impact of the USMLE

 

A couple of recent articles got me thinking about USMLE again.

In recent years we have seen some big changes in the role and structure of the USMLE exams. Central to this transformation was the shift to pass / fail Step 1 reporting. As residency programs have grown more used to this change, there has continued to be discussions about the impact and how programs should use medical school and licensing data for residency selection and progression.

Liu, et al. (1) in an article published in 2025 propose that decoupling the USMLE from existing curricula would significantly reduce stress and promote authentic learning. The authors argue that when licensing exams are integrated too tightly into daily teaching, they dominate both students’ time and mental energy, detracting from professional identity development.

This view echoes longstanding concerns. The intense, singular focus on mastering exam content (and specifically multiple-choice exam content) probably diverts student attention from broader curricular goals like clinical reasoning, patient communication, and reflective practice. Liu, et al. suggest that when high-stakes testing is decoupled, the curriculum can prioritize formative assessment, early patient care, and professional socialization—key components of identity development rooted in self-reflection, mentorship, and values-driven practice. I am not sure that I agree with that statement. While in theory students would agree, in practicality in my experience as a clinical clerkship director and as a basic science course director in Year 1 and 2, students complain about content that is not directed at Step 1 or their clinical shelf exams or Step 2.

So, what do students think about the changes to USMLE 1?

Cangialosi et al. (2) in Academic Medicine, provide the student‑authored narrative on the transition of Step 1 to pass/fail scoring. They identify profound ripple effects:

·                  Reduced anxiety but shifted pressure. While removing the numerical score alleviated individual stress, students voiced concerns that focus would simply shift toward Step 2 CK, clerkship grades, and institutional reputation.

·                  Unintended inequities. The loss of a standardized score may advantage students at prestigious institutions while limiting opportunities for others—especially DO students or international medical graduates (IMGs) to differentiate themselves objectively.

·                  Program director adaptation lag. Residency directors will need time to recalibrate application screening methods, placing greater emphasis on qualitative evaluations, letters of recommendation, and narrative assessments.

·                  Logistical challenges. Scheduling Step 2 CK earlier for competitive specialties while allowing sufficient clinical exposure emerged as a thorny constraint.

Students emphasized the importance of proactively addressing these challenges to preserve the positive intent of Step 1’s reform. There were also some good thoughts on the impact to medical schools. Specifically linked to Liu, et al’s concerns on teaching to the test. Maybe a pass / fail USMLE Step 1 allows the medical school to think more broadly about success in the Preclinical curriculum.

Both papers converge on a critical theme: the alignment of assessment structure with educational values. Educators can reclaim core learning space—embedding reflective practice, mentorship, interprofessional learning, communication skills, and early patient engagement.

• Students need to learn medicine as a profession, not just a test.
• Faculty and peers can engage in formative feedback, modeling professional behavior.
• Wellness becomes integral, not merely a box to check.

The curriculum should focus on what doctors actually do—work at the bedside, listen to patients, reflect on ethical dilemmas—not just what we know and how we answer a multiple-choice question.

Translating these insights into educational reform requires action on multiple fronts:

Stakeholder                           Strategy

Medical Schools                     Shift exams like Step 1 to external, remote formats; prioritize formative assessments, reflective portfolios, and structured mentorship.

Residency Programs               Expand holistic review: integrate narrative evaluations, trainee wellness, and clinical performance rather than numeric cutoffs. Provide guidelines/training for new selection criteria.

Students                                  Diversify focus—early involvement in clinical teams, scholarly projects, reflection activities—to shape a well-rounded, professional identity.

Licensing Boards                    Consider alternative evaluation models that emphasize ongoing competence review and real-world skills (e.g., tele-simulated assessments, recertification modules).

There are and will be challenges:

•   Removing high-stakes pressure should not cultivate complacency or uneven learning rigor.

•   Schools may struggle to consistently develop reliable assessments and ensure faculty development.

•   Institutions need mechanisms to support nontraditional learners and protect diversity within residency applicant pools.

•   Ongoing research is needed on outcomes: do changes in the national assessment system improve student well-being, patient care, or professional longevity?

Moreover, true reform demands culture change—deprioritizing “test scores as identity” in favor of holistic measures of compassion, resilience, and collaboration.

The considered proposals of Liu et al. and the reflective commentary of Cangialosi et al. together signal an opportunity to rethink medical assessment. We can—and should—reorient from “passing the exam” to “becoming a doctor.”  But to realize this promise requires strategic alignment: from curriculum design to residency selection, to licensing evaluation. It is time to reaffirm that the goal of medical education is not just what students know—but who they become.

 

References

(1) Liu L, Chachad N, Tadjalli A, Rajput V. Decoupling the United States Medical Licensing Examinations (USMLEs) From the Medical Curriculum to Promote Student Well-Being and Professional Identity Development. Cureus. 2025; 17 (5): e83335. doi: 10.7759/cureus.83335. PMID: 40458346; PMCID: PMC12127707

(2) Cangialosi, Peter T.; Chung, Brian C.; Thielhelm, Torin P.; Camarda, Nicholas D.; Eiger, Dylan S.. Medical Students’ Reflections on the Recent Changes to the USMLE Step Exams. Academic Medicine. 2021: 96 (3): 343-348. doi: 10.1097/ACM.0000000000003847