The present study was designed to determine the effect of USMLE’s binary pass/fail scoring system on Jordanian medical students, which became active in January 2022. This research was conducted to provide evidence of international medical students’ views, specifically Jordanians, toward this change, since IMGs constitute an essential part of the United States physician workforce. Perhaps the most striking finding in our study was that 44.4% agreed that USMLE should be a pass/fail exam, while only 26.8% were against it. Another important finding was that 82.3% agreed that greater emphasis will be on Step 2 CK score for residency application.
Historically, a variation in medical students’ perspective toward pass/fail Step 1 score has been noted; In a study conducted by NBME in 1989 showed that less than 50% favored pass/fail scores, while a survey in 1997 revealed a strong preference toward pass/fail scores(Bowles et al., 2000; Nungester et al., 1990). However, studies conducted in 2011 and 2020 revealed that only 26% and 34% of medical students, respectively, agreed with this transition(Lewis et al., 2011). Our study shows that Jordanian medical students had similar perspectives toward pass/fail score with a recent study conducted at Johns Hopkins University in Baltimore, Maryland, as the total percentage of medical students who favored this transition was 39%(Girard et al., 2022). Moreover, our findings were consistent with another study which found that 43% of medical students, especially those underrepresented in medicine, favored the transition(Ganesh Kumar et al., 2021). This could be attributed to less time and effort dedicated to step 1 exam preparation, therefore decreasing stress and improving quality of life which might also assist students with low Step 1 score, low GPA, and decrease socioeconomic disparities(Ganesh Kumar et al., 2021; McDade et al., 2020; Thompson et al., 2017). In our study having a good or a very good GPA was significantly associated with perceiving the change as a good idea compared to students with an excellent GPA. Moreover, our results found that 53.8% of respondents agreed that this transition will improve well-being, which is inconsistent with the literature as several program directors believe that medical students’ stress and anxiety will shift toward achieving a high Step 2 CK target score, which leaves the root of the problem unaddressed(Choudhary et al., 2021; Pontell et al., 2021).
Most program directors among different specialties revealed a negative perception toward USMLE transition to binary pass/fail scoring(Chisholm & Drolet, 2020; Choudhary et al., 2021; Ganesh Kumar et al., 2020; Lin et al., 2020; Mamidi et al., 2022; Mun et al., 2022; Pontell et al., 2021; Tamakuwala et al., 2021). This is not surprising considering the overreliance on Step 1 numerical score as a primary standardized tool to stratify applicants in the residency application process, thereby blunting the importance of other metrics including research experience, elective rotations, letters of recommendation, deans’ letter, and extracurricular activities(Bowles et al., 2000; Residency Data & Reports | NRMP, n.d.). Therefore, this transition aims to eliminate the use of Step 1 as a single primary metric to screen out applicants and help reestablish and adopt a holistic view in selecting applicants for residency(Rozenshtein et al., 2019; Salari & Deng, 2020; Salehi et al., 2021). However, most program directors revealed that Step 2 CK emphasis will increase after this transition becomes active (Makhoul et al., 2020; Raborn & Janis, 2022). According to our study findings, 82.3% of Jordanian medical students agreed that Step 2 CK will carry more weight in selecting applicants for residency. With respect to that, age, having parents who work as doctors, higher GPA, and having publications were factors found to be associated with increased Step 2 CK emphasis. Moreover, 86.7% of respondents, especially sixth-year medical students, believed that more students will participate in research activity and was ranked as the second most important item in residency matching. According to our study findings, respondents with a high number of publications believe that the number of interviews granted would increase. This is significant since some Orthopedic and Otolaryngology program directors are more likely to emphasize research activity, elective rotation at esteemed institutions, letters of recommendation, and extracurricular activities for selecting applicants(Goshtasbi et al., 2021; Mun et al., 2021).
Several studies have shown that this transition will put IMGs at a disadvantage(Ganesh Kumar et al., 2021; Goshtasbi et al., 2021; Lin et al., 2020; Mun et al., 2021; Pontell et al., 2021). In agreement with prior records, our study found that 53.8% of Jordanian medical students, significantly in students who had an excellent GPA, agreed that Step 1 pass/fail scoring will put IMGs at a disadvantage. This result may be explained by the fact that IMGs depend on Step scores to distinguish themselves when applying to residency programs since foreign medical schools are less well acknowledged(Mun et al., 2021; Pontell et al., 2021). Another possible explanation for this might be the increased importance of visiting international student rotations (Electives) and letters of recommendation thereby adding more burden to IMGs especially those who can’t afford it(Pontell et al., 2021).
The findings of this study have to be seen in light of some limitations that could be addressed in future research. The first limitation concerns the underrepresentation of medical students at Yarmouk and Mut’ah Universities in Jordan. Second, a low number of responses was submitted by 1st year medical students. In addition, this study only represents Jordanian medical students, therefore further research and future studies should be multi-national. Moreover, the use of convenience sampling methods may increase the risk of selection bias.