Securing Interviews as an Underrepresented Applicant Post-USMLE Pass/Fail: A National Survey of Competitive Residency Directors

doi:10.21203/rs.3.rs-3395907/v1

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Securing Interviews as an Underrepresented Applicant Post-USMLE Pass/Fail: A National Survey of Competitive Residency Directors

https://doi.org/10.21203/rs.3.rs-3395907/v1

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Background

In January 2022, the United States Medical Licensing Examination (USMLE) changed Step-1 score reporting to pass/fail.

Objective

To report selection criteria important to residency program directors (PDs) and whether they believe pass/fail scoring will impact underrepresented in medicine (URM), international (IMG), or osteopathic (OG) residency applicants.

Methods

A Qualtrics survey was sent between August, 2022 – January, 2023 to 1,141 US PDs from specialties with traditionally low match rates: dermatology, ophthalmology, otolaryngology, orthopedic surgery, neurosurgery, interventional radiology, diagnostic radiology, radiation oncology, thoracic surgery, vascular surgery, plastic surgery, and urology. Contact information was obtained from AMA, FRIEDA, or program websites.

Results

We received 433 responses (38%). When asked to anticipate the difficulty student groups will face matching into their specialty, PDs reported: for URM, 24.0% increased, 46.0% unchanged, and 30.0% decreased, OG, 49.19% increased, 44.58% unchanged, and 6.23% decreased; for IMG, 56.35% increased, 39.72% unchanged, and 3.93% decreased. When asked to rank the most important selection factors, the top two responses were Step-2 CK score and away rotation participation at their site.

Conclusion

PDs overwhelmingly believed match difficulty would either increase or remain unchanged for OG (93.77%) and IMG (96.07%). In contrast, 76.0% reported difficulty for URM students would either decrease or remain unchanged. Paradoxically, PDs ranked Step-2 CK score and away rotation participation as the most important selection factors. Although the intention may be to dismantle barriers for URM applicants, enhanced emphasis on Step 2CK and away rotations place additional socioeconomic and standardized exam barriers.

Underrepresented in Medicine (URM)

USMLE

Medicine

Graduate Medical Education (GME)

Residency

The United States Medical Licensing Examination (USMLE) recently changed their score reporting techniques for the Step-1 examination from a 3-digit number to pass/fail. This change, implemented in January 2022, has resulted in uncertainty among future medical residency candidates, especially underrepresented in medicine (URM) students, osteopathic graduates (OG), and international medical graduates (IMG) [referred to as foreign medical graduates (FMG) in several other studies]. It remains unclear which criteria will now be weighted more heavily by residency program directors (PD) when selecting candidates to interview, although some have suggested that USMLE Step-2CK (Step-2CK) and participation in away rotations may take on greater importance^1,2.

When the USMLE was formed in 1992, Step exams were created to standardize testing across state borders, thereby creating a “single pathway for licensure”³³. The Federation of State Medical Boards of the United States and the National Board of Medical Examiners describe the USMLE Step 1 as designed to ensure the student’s “master of not only the sciences that provide a foundation for the safe and competent practice of medicine in the present, but also the scientific principles required for maintenance of competence through lifeline learning”³⁴. For many years, the USMLE Step 1 score was a significant factor in determining residency candidate selection for interview, and when this change was announced, the Association of Program Directors in Surgery contributed a letter to oppose this change, demonstrating its importance to many programs when making candidate selection decisions³⁵.

To date, no study has surveyed the opinions of PDs nationwide about how the new pass/fail grading system will impact URM applicants. The AMA defines URM students as “those racial and ethnic populations that are underrepresented in the medical profession relative to their numbers in the general population”. URM students often face not only a disparity in their USMLE Step exam scores as compared to their non-URM peers, but also an overall achievement gap due to systemic inequities that have followed them throughout their education, prior to medical school matriculation⁸. This is due to a number of systemic inequities, such as reduced accessibility to resources and funding in predominantly underrepresented neighborhoods³⁶. The achievement gap has negative physical and psychological consequences on URM medical students, and after matriculating, there may be some internalization and externalization of negative stereotypes that they have encountered in the past, contributing to their lower mean standardized exam performance⁶. The recent US Supreme court ruling that higher education admissions cannot consider race elevates this concern and warrants further exploration of the beliefs of PDs to discern how the new system will impact URM applicants. The current gap in the number of URM physicians compared to the general population is one of many crucial areas that need to be addressed to improve equity in patient care and health outcomes for underrepresented populations.

While all medical students are eligible to apply for any residency program, historically some applicant groups such as URM, OG, and IMG students have lower match rates^3,4,5,6. A study by Makhoul et al (2020) reported valuable data on the perspectives of PDs from 30 specialties on the pass/fail Step-1 scoring change; overall, 77.2% of PD respondents believed that all applicants will have a more difficult time matching into their specialty. Although they discussed how this new policy may impact the overall process and specifically addressed the potential impact on IMG and, to a lesser extent, OG applicants, they did not explore the impact on URM applicants.

A few recent studies have explored how this Step-1 scoring change may impact specific residency’s application process. In one study, about 50% of dermatology PDs agreed that all medical students will have more difficulty matching into dermatology. Another study surveyed medical student deans; when asked to rank the importance of various application factors, the most frequently selected first-choice was Step-2CK score. Collectively, medical school deans reported feeling that students who apply to dermatology, neurosurgery, orthopedic surgery, ENT, and plastic surgery would be most impacted²⁵. Many stakeholders have expressed concerns about removing the standardized Step-1 score and posit additional issues that may arise from this scoring change^2,27,28,29. Some have highlighted the potential impact of structural biases on URM applicants, given the existing socioeconomic inequities that lead to reduced financial and community resources among the URM population³⁰.

In the past, URM residency applicants had lower mean Step-1 and Step-2CK scores than non-URM candidates^9,10. Studies suggest that a reduction in the reliance on Step-1 scores may mitigate racial biases¹¹. Due to the weight that PDs historically ascribed to Step-1 scores in choosing applicants for residency interviews, URM applicants may have been screened out of interview opportunities, a point that was emphasized by the Invitational Conference on USMLE Scoring when they recommended minimiz(ing) “racial demographic differences that exist in USMLE performance”⁶. While many have expressed opinions, to date, no study has explicitly surveyed PDs regarding how they believe URM applicants will be impacted by the Step-1 pass/fail policy.

Twelve competitive U.S. residency specialties were selected for this study due to their relatively low rates of admitting OG, IMG and URM applicants^16,17,18. Specifically, these specialties historically lack racial diversity due to the low admittance of URM applicants^16,17,18. We aimed to identify what selection factors PDs from these twelve specialties consider to be most important now that Step-1 is pass/fail, and if PDs believe this change will impact the match difficulty of URM, OG, and IMG applicants.

A cross-sectional study design was used to obtain data from PDs in twelve competitive specialties: dermatology, ophthalmology, otolaryngology, orthopedic surgery, neurological surgery, interventional radiology, diagnostic radiology, radiation oncology, thoracic surgery, vascular surgery, plastic surgery, and urology. Inclusion criteria for the competitive specialties were twofold: accreditation by the Accreditation Council for Graduate Medical Education (ACGME) and a published mean Step-1 score average of ≥ 239 for those who matched into their specialty in the 2020 residency match⁴. Residency programs were broken down geographically, using definitions of regions set by The National Geographic Education - United States Regions¹⁹.

A Qualtrics survey was administered to 1,141 residency PDs from the twelve listed specialties. The survey link was sent to the publicly listed email addresses available on the AMA, FRIEDA, or the institution’s website. Duplicate surveys were sent to program coordinators to encourage collaboration and responses. Data were collected from August 2022-January 2023. The survey consisted of ranking questions, such as prioritizing the most important factors in selecting interviewees and multiple-choice questions seeking perspectives on the potential impact of the Step-1 pass/fail scoring system on the difficulty of URM, IMG, and OG applicants to match into their specialty (Online Supplementary Appendix). Participation was optional and all data were de-identified and aggregated prior to analysis.

IBM SPSS version 28.0.0.0 (190) was employed for the analysis of both quantitative and qualitative data utilizing "crosstabs" and "descriptive statistics" functions. Continuous data were described using means and standard deviations, whilst categorical variables from the survey were presented as frequencies. Through the utilization of Microsoft Excel, the "Step-2CK score/COMLEX Level 2 score" and "away rotation at your site" variables were ranked, represented as percentages, and then converted into graphical illustrations.

This study was deemed exempt by the NYMC IRB Review Board (#15162).

A total of 433 responses were received (38%) out of the 1,141 accredited residency programs contacted. Within the 433 responses, each specialty was represented as follows: 11% dermatology, 18% diagnostic radiology, 4% interventional radiology, 10% neurosurgery 8% ophthalmology, 13% orthopedic surgery, 10% otolaryngology, 5% plastic surgery, 5% radiation oncology, 2% thoracic surgery, 10% urology, and 4% vascular surgery. Response rates within each specialty ranged from 24% to 48% (Table 1). A geographical breakdown of responses appears in Table 2.

PDs were asked to report whether they felt the Step-1 pass/fail policy will impact the match difficulty experienced by OG applicants (Table 3). Overall, 49.2% of all PDs reported it would be more difficult, 44.6% reported it would be the same as in past years, and 6.2% reported it would be less difficult. Specialties in which greater than 50% of PDs reported increased difficulty for OG applicants included: plastic surgery (69.6%), neurosurgery (60.5%), otolaryngology (57.1%), and vascular surgery (53%). Notably, none of the neurosurgery, plastic surgery, and thoracic surgery PDs believed the pass/fail policy would decrease match difficulty for OG applicants. Regionally, two trends in frequency of responses were observed: fewer PDs in the west selected “more difficult”, while more PDs in the midwest responded “less difficult”.

Across all twelve specialties, 56.4% of PDs reported believing that the Step-1 pass/fail policy will make it more difficult for IMG applicants to match (Table 3). 39.7% of PDs believed it would be the same as in past years and 3.9% believed it would be less difficult. Specialties in which greater than 50% of PDs reported increased difficulty for IMG included plastic surgery (78.3%), radiation oncology (75%), ophthalmology (69.4%), diagnostic radiology (61.8%), neurosurgery (58.1%), thoracic surgery (57.1%), vascular surgery (53%), and urology (51.6%). Notably, none of the orthopedic or plastic surgery PDs believed the pass/fail policy would decrease match difficulty for IMG applicants.

Across all specialties, 24% reported believing that the Step-1 pass/fail policy will make it more difficult for URM applicants to match into their specialty (Table 3). None of the twelve specialities reported greater than 40% of PDs anticipating increased match difficulty for URM applicants. However, 46% of PDs reported the difficulty would stay the same, and 30% reported it would be less difficult. Regionally, two trends were observed: PDs in the west had a higher number of those reporting “less difficult” and a lower number of those reporting “more difficult” compared to other regions.

When PDs were asked to rank specific academic criteria (1-7) in the order of importance for interview selection (Step 2 CK score, Alpha Omega Alpha Honor Medical Society membership, class rank, tier of medical school, published research, research year/fellowship, and clinical grades), 61% of PDs ranked Step-2CK score as either #1 or #2 (Figure 1).

When PDs were asked to rank personal attribute criteria (1-6) in the order of importance (away rotation at your site, strong clinical LOR, previous knowledge of applicant, leadership in clubs, volunteer hours, and personal statement), 75% of PDs ranked an away rotation at their site as #1 or #2 (Figure 2).

In the absence of a numerical Step 1 score, the majority of PDs from twelve competitive specialties anticipate the two most important residency interview selection factors will be Step-2CK score and participation in an away rotation at their site. Overall, there was a stark contrast in PDs’ beliefs regarding the difficulty of matching between URM applicants and IMG and OG applicants (collectively). The intention of changing the USMLE scoring to pass/fail was to mitigate barriers. However, data reported in this and other studies illuminate potential unintended consequences for three student subgroups: URM, OG and IMG. Our results are of particular concern to URM applicants in the aftermath of the US Supreme Court ruling disallowing admissions officers from considering race and many institutions’ DEI programs being defunded at the state level.

Makhoul et al (2020) reported that nearly half of the PDs (44.4%) from 30 specialties believed IMGs will be at a disadvantage⁷. Data from our survey, limited to twelve of the most competitive specialties, surpass these findings with 56.4% of PDs reporting they believe the Step-1 pass/fail policy will increase match difficulty for IMGs (39.7% believed it would remain the same). While the Makhoul et al study included an osteopathic residency, PDs were not specifically asked how the new policy may impact OG applicants⁷. In our study, almost half of PDs (49.9%) reported a belief that it would be more difficult for OG applicants to match, while 44.6% believed it would stay the same.

In stark contrast, for URM applicants 46.0% of PDs believed that the match difficulty will remain the same and 30.0% of PDs reported it would be less difficult. With Step-1 having been previously reported by PDs as the most important factor in ranking applicants²⁰, and non-white examinees historically scoring lower on both Step-1 and Step-2CK,^9,10 URM applicants have represented a disproportionately smaller percentage of those selected for interviews and are some of the least represented among competitive specialties^21,22. The previous Step-1 scoring system placed URM applicants at a disadvantage, and some proponents of the change feel the pass/fail system will mitigate this divide⁶.

While 76% of PDs from competitive specialties believed the score change will make it less difficult or stay the same for URM students, it should be noted that performance on Step-1 has been an indicator of Step-2CK performance, an exam that now has enhanced emphasis^2,12. Indeed, data demonstrate that URM residency applicants had a lower mean Step-1 and Step-2CK score than non-URM candidates which raises the concern that one standardized exam may simply replace another.^9,10 In addition, with Step-2CK being administered so late in training, it increases the amount of pressure on students to enhance their score⁷, while often requiring them to secure away rotations prior to knowing their score that may impact where they can match. ³² It is unclear what downstream effects may result from the recent US Supreme Court ruling; therefore, it is incumbent upon medical education stakeholders to proactively consider how to dismantle barriers to make the residency application process more inclusive.

In addition, we noted an interesting trend: a higher percentage of PDs from western programs believed it would be less difficult for URM students to match than PDs from other regions. Importantly, the western region had the lowest number of responses, so these results should be viewed with caution. Nevertheless, this trend aligns with results reported in an earlier study that surveyed vascular surgery PDs about their use of Step-1 scores to screen applicants. Those located in the western region were less likely to report using Step-1 as a screening tool than other regions²⁶, so it is possible that western regions may have less of a need to prioritize Step-2CK in the absence of Step-1 scores. Studies have demonstrated that individuals who are URM are more likely to practice in underserved areas¹⁹ and it is possible that the larger metropolitan areas in the western states are implementing more holistic admissions tools to diversify resident cohorts.

Away rotations are an essential part of the medical student experience, especially for those interested in pursuing a competitive residency. Students obtain clinical experience among different patient populations and health systems while having the opportunity to network with residency PDs. However, away rotations can be expensive and impose financial constraints on students, which may particularly impact URM students and those from lower-income backgrounds¹³. In addition, URM students often face barriers such as fewer opportunities to receive mentorship and make professional connections, which can limit opportunities to participate in away rotations³¹. Fortunately, numerous medical schools and professional organizations have recognized these disparities and developed programs to work toward providing more equitable access to away rotations¹⁴. While it is encouraging that some funded away rotations exist for URM applicants, they are not universally available and have limited enrollment¹⁵.

The current study has many limitations, including the variation in response rates across the twelve specialties, which prevented subspecialty analysis and thus limited specialty generalizations. There may have been a response bias toward PDs who feel strongly in favor of, or opposed to, the scoring change. While lower response rates were noted, it was encouraging to see that some of our results supported those of previous studies. PDs from the twelve different specialties have varying experiences and might prioritize different factors in selecting residents beyond USMLE scores, making it challenging to generalize findings.

One of the goals of changing the Step-1 exam to pass/fail was to minimize demographic differences that impact Step-1 performance⁶. However, results of this and other studies suggest that additional barriers to the residency application process need to be addressed. Our results suggest that the majority of PDs believe the score change policy may not impact, or could even lessen, barriers for URM students to match into competitive specialties. However, paradoxically the increased emphasis on the Step-2CK score coupled with the importance of financially burdensome away rotations may perpetuate socioeconomic, systemic, and other barriers facing many URM students. Collectively, these unintended consequences could further impede URM students’ pursuit of competitive residencies.

In the absence of Step-1 numerical scores, PDs from twelve competitive specialties believed that IMG and OG applicants will experience increased or unchanged difficulty matching. In stark contrast, a majority of PDs believed URM students will encounter decreased or unchanged difficulty matching. Paradoxically, PDs believed the two most important selection factors will be Step-2CK score and away rotation participation. Hence, despite the beliefs of PDs that the Step-1 pass/fail scoring will mitigate barriers for URM students, potential unintended barriers have not been adequately considered.

USMLE- United States Medical Licensing Examination

URM- underrepresented in medicine

IMG- international medical graduates

OG- osteopathic medical graduates

FMG- foreign medical graduates

PD- program directors

Step 2-CK – United States Medical Licensing Examination, Step 2 Clinical Knowledge

ACGME- Accreditation Council for Graduate Medical Education

-Ethics approval and consent to participate

This study has gone before the NYMC IRB Review Board (#15162), and was deemed exempt. A waiver of informed consent was approved by the NYMC IRB Review Board and all participants received the informed consent information.

-Consent for publication

All authors give full consent to publish all materials in this manuscript.

-Availability of data and materials

The datasets used and/or analyzed during the current study available from the corresponding author on reasonable request.

-Funding

Funding provided by NYMC Medical Student Summer Research Fellowship

-Conflict of Interest

All authors have no conflicts of interest to disclose.

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Tables 1-3 is available in the Supplementary Files section.

No competing interests reported.

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Securing Interviews as an Underrepresented Applicant Post-USMLE Pass/Fail: A National Survey of Competitive Residency Directors

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