In January 2022, the medical school curriculum underwent a transformative shift when Step 1, the first of three licensing exams for U.S. medical students, switched from numerical score to a pass/fail (P/F) grading system. Now, with several years of perspective, we can assess the broader implications of this change on medical education. The primary objective of this reform was to alleviate the pressures associated with Step 1 and to promote a more holistic evaluation of residency applicants. While this shift has produced some positive outcomes, an emerging and perhaps unintended consequence is the ripple effect it has triggered in other areas.
The objective of decreasing the degree of studying appears to have fallen short. Data reveals a concerning decline in Step 1 pass rates, with U.S. MD students’ pass rates dropping from 95% in 2021, prior to the change, to 91% in 2022, and further to 90% in 2023. The trend is even more pronounced among U.S. DO students and international medical graduates (IMGs), with pass rates falling from 94% to 86% and from 82% to 72%, respectively, over the same period. Interestingly, this decline is unique to Step 1, as pass rates for Step 2 and Step 3—both of which continue to be scored quantitatively—have remained stable.
While it can be speculated that students might be taking the test less seriously under the P/F system, this does not fully account for the sustained decline over multiple years, as one would expect attitudes to adjust. A more plausible explanation is that the difficulty of the exam content has increased to counterbalance the P/F switch and ensure that pass rates do not inflate. This can be seen by the passing score for Step 1 rising from 194 to 196 in the P/F era.
The increased pressure on Step 1 has been compounded by a growing emphasis on Step 2, as the reduction in available quantitative metrics has shifted greater weight onto the remaining ones. Step 2 scores have now become more critical in maintaining competitiveness, leading to a surge in time and effort devoted to preparing for this second board exam. Indeed, the trend of rising Step 2 scores in matched applicants across specialties from 2020 to 2024 reflects this heightened focus.
The shift to a P/F system for Step 1 poses a significant challenge in residency admissions as fewer remaining quantitative metrics exist. This issue is compounded by the fact that many medical schools also employ P/F grading systems, further narrowing the pool of objective criteria. As a result, students are increasingly dedicating more time and effort to other aspects of their applications, such as research, extracurricular activities, and community service, in order to distinguish themselves. A recent survey of community-based medical schools revealed that approximately 50% of students have intensified their research efforts in response to this Step 1 shift, with around 70% believing that residency programs will place greater emphasis on research experience. Additionally, students are investing more time in extracurricular activities, such as striving to stand out through greater involvement in interest groups, the creation of new initiatives, and participation in state or national organizations. Recent research revealed that a major driver of medical student involvement in extracurriculars is the perceived advantage for residency applications. This is strengthened by data showing significantly higher volunteer rates among third-year students compared to fourth-years, 80% vs. 53.4%, respectively, as applications are submitted at the end of third year. This growing emphasis on non-academic achievements underscores the heightened pressure on students to diversify their applications and intensifies competition for residency positions.
The situation is further complicated by the ambiguity surrounding residency program requirements, as most programs do not set clear minimum standards for applicants even though students would significantly benefit from it. This uncertainty fosters a pervasive sense of anxiety, leaving students unsure of what is necessary to succeed.
Students aiming for competitive specialties now find themselves pitted against classmates for leadership roles or opportunities. The scarcity of such positions, coupled with the anxiety over unclear residency criteria, has cultivated a culture of competition rather than collaboration within medical schools. This competitive environment undermines the spirit of teamwork that is essential in practice.
This situation also introduces bias, as some medical schools offer more dedicated time within their curricula, freer from class or exam commitments, allowing students to devote additional hours to studying for Step exams or engaging more deeply in extracurricular activities. Furthermore, certain programs provide more resources and opportunities, thereby disadvantaging students from less resource-rich institutions.
Medical students face a significantly higher burden of mental health challenges compared to their non-medical peers of similar age, with elevated rates of anxiety, depression, and suicidality. The prevalence of anxiety among U.S. medical students is estimated at 24%. Recent studies also continue to highlight the persistent issue of burnout among medical students. Whether these numbers continue to rise or stabilize, they remain alarmingly high. Addressing this issue requires proactive measures aimed at mitigating the underlying causes, rather than reactive interventions.
The primary aim of transitioning Step 1 from a quantitative to a pass/fail system was to alleviate the burden on medical students, yet it appears to have had the opposite effect. Rather than reducing stress, this change has led to heightened burnout, pressure, and anxiety, as students feel compelled to expand their involvement in extracurricular activities, research, and other matters to remain competitive.
As students strive to meet these escalating expectations, the system may soon reach a breaking point, where the standards outpace available opportunities or abilities, or destabilize medical education. To prevent further exacerbation of burnout and mental health challenges, a reconsideration of Step 1’s pass/fail format may be necessary. Reintroducing a scoring component or exploring innovative alternatives—such as nationally requiring standardized exams post each clerkship—could offer a more balanced and sustainable solution for evaluating students.
Christian Tallo and Aaron Kiel are medical students.
