Coronavirus Takes A Toll On IMGs: Anxieties Over USMLE Step 1 Becoming Pass/Fail

The NBME has announced that the USMLE Step 1 exam is changing from graded on a curve to pass/fail no earlier than Jan 1, 2022. This announcement came before the coronavirus pandemic took hold and significantly disrupted pretty much everything, including medical education. Since then, given widespread Prometric center closures, study schedule disruptions, altered medical school curricula, and a whole host of other unexpected challenges, many students have wondered if the change to pass/fail may be implemented sooner.

According to Dr. Michael Barone, the vice president of the NBME, “There’s always been a perception that we could flip a switch to make [the exam] pass-fail. Changing Step 1 to pass-fail reporting is actually quite complicated and will take some time.” It is unlikely, therefore, to expect that Step 1 will go to pass/fail in 2020 or 2021. Students just starting out their medical school education should be prepared for the exam either being graded or pass/fail (because again, the NBME has said that the change will take place no earlier than Jan 1, 2022, but that doesn’t mean that the change will occur on Jan 1, 2022).

The uncertainty of the situation is difficult for all medical students, but especially for international medical graduates (IMG’s) for several reasons. IMG’s have had to score higher on Step 1 than their American medical graduate (AMG) counterparts in order to get into comparable residency programs. With Step 1 changing to pass/fail at some point in the future, IMG’s will no longer be able to “show off” with a high Step 1 score. Instead, IMG’s will have to build their resume with other things to stand out from the crowd, like research, volunteering, and leadership. While this may seem like a good exchange (less time spent memorizing biochemical pathways and genetic associations in exchange for more time spent pursuing activities of interest), the coronavirus pandemic is poised to undermine extracurricular activities for medical students, both IMG and AMG.

With schools closed, health care support groups meeting via Zoom, and hospitals limiting entry to essential staff, volunteer activities are next to impossible. Research activities have been variably suspended or re-directed, and even labs that are back in business are practicing social distancing and shift-work, thus making it challenging to learn techniques or get a new project off the ground. If anything, the coronavirus pandemic has facilitated independent study, which would be beneficial for IMG’s looking to score high on the exam. In the current milieu, standing out from the crowd of incoming medical students becomes extremely challenging.

Furthermore, the uncertainty of when the exam will officially be pass/fail makes it difficult for incoming medical students to prioritize their time – should students start studying intensively during M1 as if they are prepping for a scored exam, or should they instead use their time to prioritize extracurricular activities such as research, leadership, or volunteerism? It is challenging for any medical student to score a 260+ on Step 1, while simultaneously being the president of the medical interest group, publishing peer-reviewed papers, and mentoring at-risk youth, IMG’s have to do all these things and more: IMG’s are expected to score better on the exam, publish more papers, and generally have a better-looking CV in order to match into an equivalent specialty as their AMG counterparts.

Another unique challenge facing IMG’s in the coronavirus era with a pass/fail Step 1 is the inability to do away rotations at American institutions where they hope to match into residency. Away rotations serve two major roles: they allow the student to really get to know the program, while allowing the program to evaluate the student. Needless to say, away rotations in the United States have been suspended for the foreseeable future. This is particularly difficult for IMG’s, as often they rely on away rotations to get their foot in the door at a particular residency program.

The anonymity of IMGs without the ability to do an away rotation at an American institution may be further compounded by a pass/fail Step 1. A similar challenge can be encountered with the transition of all academic conferences to an online format. IMG’s with great research experience could often rely on presenting at conferences to meet potential contacts in their field of interest. This becomes much more difficult during Zoom conferences, where participants and potential contacts of interest for IMG’s may or may not be paying attention (or wearing their pajamas) to a presentation.

Doom and gloom aside, the coronavirus pandemic has ubiquitously upended medical education, and residency program directors are aware that unique challenges may be faced by incoming residents, both AMG and IMG. The change in USMLE Step grading also has an effect on DO students.

Given that the planned date of Step 1 changing to pass/fail is not yet set in stone, students should always plan to err on the side of caution. It’s always better to be overprepared for an exam than underprepared, particularly for an exam that takes a fair amount of advanced preparation. Furthermore, being well prepared for the Step 1 exam is also beneficial in preparation for the Step 2 exam, which will continue to be a graded exam (and may consequently increase in importance for IMGs). Hopefully in a future pandemic-free world IMGs (and all of us) will be able to reflect positively on how the coronavirus pandemic shaped their careers.

Karolina Woroniecka is a pathology resident and ad hoc reviewer for cancer medicine and a USMLE tutor, Elite Medical Prep, LLC.

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