Comparison of Medical students' preparation for the United States Medical Licensing Examination (USMLE) Step 1 before and after transition to Pass/Fail

Background The transition of the United States Medical Licensing Exam: Step 1 to Pass/Fail (P/F), from scored, caused uncertainty about students’ preparedness and wellbeing related to the exam. Comparison of study behavior and results, before and after the P/F transition can provide insights for medical curriculum and student support. The aim of this study is to evaluate students’ perceptions of their efforts in Step 1 preparation, as compared to cohort performances to determine the impact of the transition of Step 1 to P/F on medical students. Methods Data from two cohorts each of second-year medical students were collected from their dedicated Step 1 self-study block, before and after the transition to P/F Step 1 (Classes of 2022-23 scored & 2024-25 P/F, N = 204). Student study regimens, aggregate practice test results, Step 1 pass rates and post-block self-reported surveys were analyzed qualitatively to compare student effort and outcomes for scored and P/F cohorts. Results Analysis of practice exam averages across the four student cohorts demonstrates a potentially slower and less rigorous start to Step 1 self-studying during the dedicated preparation block for the cohorts that took the P/F Step 1 exam format as compared to the previous cohorts that prepared for a scored Step 1 exam. Similarly, self-reported study regimens decreased in the median number of hours/day and number of weeks of study for the cohorts with P/F Step 1 exam. A slight shift was observed in the type of study resources used, between the two groups, with the scored group using more traditional board preparation resources. Conclusions The P/F transition of the Step 1 exam may lead to reduced student preparedness and may require adjustments in the resources and support provided by institutions.