Home Medicine Impact of the USMLE Step 1 and COMLEX Level 1 transition to Pass/Fail on osteopathic medical student stress levels and board preparation
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Impact of the USMLE Step 1 and COMLEX Level 1 transition to Pass/Fail on osteopathic medical student stress levels and board preparation

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Published/Copyright: September 5, 2023
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Journal of Osteopathic Medicine
From the journal Journal of Osteopathic Medicine Volume 123 Issue 12

Abstract

Context

The United States Medical Licensing Examination (USMLE) Step 1 and Comprehensive Osteopathic Medical Licensing Exam (COMLEX) Level 1 transitioned from a numeric scoring system to a Pass/Fail designation in 2022. This transition intended to decrease stress, improve medical student well-being, and encourage residency program directors to emphasize other aspects of residency applications. Pass/Fail score transitions in the undergraduate medical education curriculum have improved medical student psychological well-being and satisfaction; whether these same benefits translate to the board examination period is unknown.

Objectives

The objectives of this study are to assess the impact of USMLE Step 1 and COMLEX Level 1 grade scale transition on medical student stress, wellness, board preparation decisions, and future residency selection processes. Investigators hypothesized that students under the Pass/Fail designation would experience less stress during the intensive study period leading up to USMLE Step 1 and COMLEX Level 1 and devote more time to other aspects of their residency applications.

Methods

To examine the impact on osteopathic medical student (OMS) stress and approach to board preparation, two surveys were administered to Rocky Vista University College of Osteopathic Medicine (RVU-COM) students before (Class of 2023) and after (Class of 2024) the transition to a Pass/Fail designation. All students within the RVU-COM Classes of 2023 and 2024 were invited to participate. The Cohen Perceived Stress Scale (PSS-10) was administered at the beginning of the focused board study period in May 2021 and 2022 to the Class of 2023 and 2024, respectively. The investigator-designed Licensing Exam Questionnaire (LEQ), meant to capture board preparation patterns, residency application perspectives, and wellness during examination preparation, was administered immediately after the board examination deadline in July 2021 and 2022 to the Class of 2023 and 2024, respectively. Statistical analysis included the use of independent t tests (numeric variables) and chi-square tests (categorical data). This project was considered exempt from full Institutional Review Board review.

Results

Approximately one-third of the Class of 2023 (PSS-10: n=86; LEQ: n=93) and 2024 (PSS-10=89; LEQ: n=92) responded. No difference was detected in mean PSS-10 score, 20.14 (SD=7.3) compared to 19.92 (SD=6.56) for the Class of 2023 and 2024 (p=0.84), respectively. The Class of 2023 reported more weeks studying (mean 6.27 weeks, SD=0.79) vs. the Class of 2024 (mean 5.44 weeks, SD=0.007), p<0.001, more practice examinations taken X 2 (1, n=182)=13.75, p<0.001, and a greater proportion scheduled examinations after June 20 X 2 (1, n=182)=29.01, p<0.001. No difference existed in hours studying per day, sequence of Step 1/Level 1, time between examinations, money spent, or type of study resources utilized.

Conclusions

The transition of USMLE Step 1 and COMLEX Level 1 to a Pass/Fail designation did not reduce stress for OMSs at a single, multicampus COM. Respondents, however, altered board preparation practices in meaningful ways. As student behaviors and board-study patterns emerge, these insights must be connected to outcomes in the future.

Keywords: medical licensing exam preparation; osteopathic medical education; perceived stress; undergraduate medical education

In 2022, the United States Medical Licensing Examination (USMLE) Step 1 and Comprehensive Osteopathic Medical Licensing Exam (COMLEX) Level 1 announced their transition from a numerical scoring system to a Pass/Fail designation.

Responding to data collected at the Invitational Conference on USMLE Scoring (InCUS), the National Board of Medical Examiners (NBME), and the Federation of State Medical Boards (FSMB) announced the USMLE Step 1 numeric scores transition to Pass/Fail, occurring no earlier than January 2022 [1]. This decision meant to emphasize other aspects of a medical student’s residency application [1]. Given the importance that medical students place on USMLE Step 1 numeric scores, Pass/Fail outcomes prioritize student well-being [1]. During this transition, a two-point increase (194–196 on the previous three-digit score scale) in the passing standard utilized to determine a Pass/Fail outcome was applied to Step 1 examinees, effective January 26, 2022. In December 2020, the National Board of Osteopathic Medical Examiners (NBOME) released a similar statement, transitioning COMLEX Level 1 scores to Pass/Fail beginning in May 2022 [2]. The Board’s decision focused on supporting medical student wellness [2].

Residency program directors heavily weight USMLE Step 1 scores in their decision to interview and rank future residents [3]. Although higher USMLE Step 1 scores have been associated with higher first-time American Board of Surgery pass rates and comprehensive faculty evaluations, these scores do not predict rotation evaluations or dropout rates as markers of success in residency. In addition, Sutton et al. [3] demonstrated, that regardless of the USMLE Step 1 score, all surgeons achieved American Board Certification.

Evaluation of surgical program director perspectives regarding the change of USMLE Step 1 to a Pass/Fail designation is not positive [4]. The majority of program directors (78 %) disagreed with the scoring change, and only a small percentage (∼20 %) agreed that the scoring change will improve medical students’ well-being [4]. With USMLE Step 1 scores transitioning to Pass/Fail, most program directors (∼89 %) planned to prioritize the scored USMLE Step 2 [4].

Similar to licensing examinations, many medical schools have converted preclinical grading systems to Pass/Fail, intending to decrease medical student stress. In contrast to the use of traditional letter-grade scales in medical school, Pass/Fail systems improve medical student psychological well-being and satisfaction without reducing performance on USMLE Step 1 and Step 2 scores, successful residency placement, or overall academic performance [5].

During the time frame of this investigation, second-year medical students at Rocky Vista University College of Osteopathic Medicine (RVU-COM) were required to take both USMLE Step 1 and COMLEX Level 1. RVU-COM offers an applications-based systems curriculum across two campus locations, Colorado (CO) and Utah (UT). After the final systems course, students enter a preclinical capstone phase or dedicated board study time. Preparing for and completing board examinations is a stressful process. Historically, required board examination deadline dates varied but were left to the individual student and their advisor to determine timing, order, and spacing of the examinations. Students, however, must pass the COMLEX Level 1 examination before participating in clinical clerkships, with a few exceptions each year for students in unique academic circumstances.

As the national board examinations transitioned to Pass/Fail grading scales, we aimed to characterize osteopathic medical student (OMS) stress preceding the required licensing examinations. Secondary aims evaluated other factors impacting board examination preparation patterns and future residency application strategies.

Methods

Ethical approval and informed consent

The RVU Institutional Review Board (IRB) considered this project (RVU IRB# 2021-0031) exempt from full IRB oversight. All participants in this study provided written informed consent via an electronic form prior to participation.

Study population

The research occurred at RVU-COM, encompassing two campus locations, Parker, CO and Ivins, UT between May 2021 and July 2022. A convenience sample of equivalent cohorts of OMSs across two campus locations of a single institution were included. Participants were enrolled in RVU-COM and expected to graduate in 2023 and 2024. Students in each class (i.e., 2023 or 2024), were invited to participate in two voluntary surveys during the transition from OMS Year 2 to OMS Year 3. RVU-COM OMS enrolled in other cohorts (i.e., outside the Classes of 2023 and 2024), faculty, and staff were excluded.

Survey design

This nonexperimental survey-based study deployed two independent and anonymous surveys (Appendix A). These surveys were administered via student class email distribution lists and the RVU-COM Research Teams Page. Participation in both surveys was voluntary, and participants could opt out at any time. Provision of all information was at each individual student’s discretion. The first survey was the Cohen Perceived Stress Scale (PSS-10) [6], an evidence-based stress scale created by Sheldon Cohen. This 10-item Likert Scale measures an individual’s perception of stress for the prior month. Lower scores (e.g., 0–13) indicate lower stress, whereas higher scores (e.g., 27–40) signify greater perceived stress [7]. PSS-10 scores from 14 to 26 indicate moderate stress [7]. The second, investigator-designed survey, entitled the “Licensing Exam Questionnaire” (LEQ), collected additional information about board examination preparation and future residency application plans. The LEQ included 21 questions: one participant informed-consent question, five demographic questions, seven licensing examination questions, five questions assessing study materials, stress, wellness, and dedicated study time, and three questions pertaining to future residency plans.

Survey distribution for the Classes of 2023 and 2024 occurred over a similar time frame (Figure 1). The PSS-10 was administered in May, following completion of the students’ last preclinical systems course in 2021 and 2022 for the RVU-COM Classes of 2023 and 2024. Investigators selected May to characterize psychological stress at its peak, as students transitioned into dedicated board study time. Rather than assessing change in PSS-10 scores within a cohort over time, equivalent cohorts were surveyed at the same time during their course of study. The LEQ was administered in July for both classes, immediately following the board examination deadline. For the Class of 2023, the LEQ was administered before the start of the required Foundations of Clinical Medicine (FCM) course and subsequent rotation start. For the Class of 2024, the FCM course structure was dispersed to allow for an earlier rotation start date. The simulation requirement was completed in May, and the other course requirements were completed asynchronously via online modules before the start of OMS Year three rotations.

Figure 1: Study timeline. FCM, Foundations of Clinical Medicine; LEQ, Licensing Exam Questionnaire; PSS, Cohen Perceived Stress Scale.
Figure 1:

Study timeline. FCM, Foundations of Clinical Medicine; LEQ, Licensing Exam Questionnaire; PSS, Cohen Perceived Stress Scale.

For the Class of 2024, the rotation start date was offered earlier, by two weeks, in an effort to better support students in advance of the transition to Pass/Fail for USMLE Step 1/COMLEX Level 1. This change allowed earlier completion of core rotations, additional flexibility for the timing of Step 2/Level 2, and anticipated support of application for audition rotations.

Students who completed each survey were entered into a raffle to win one of several prize drawings. Each cohort had an opportunity to win one of two Amazon gift cards ($25/each) or a study resource of their choice for up to $500. Participation in one survey earned one entry, while participation in both surveys allowed two entries into the board materials drawing.

Data analysis, storage, and monitoring

Student responses were collected utilizing “Survey Monkey,” allowing anonymous responses to questionnaires. No identifying information was collected, utilized, or associated with either survey. Independent t tests were utilized to compare the classes for numeric variables. Categorical data were assessed utilizing a chi-square test. Individual PSS-10 question responses are scaled between 0 and 4 based on current perceived stress, with 0=Never to 4=Very Often [6]. Once a participant submits the PSS-10, the score is determined by “reversing responses (e.g., 0=4, 1=3, 2=2, 3=1, and 4=0) to the four positively stated items (items 4, 5, 7, and 8) and then summing across all scale items” [6]. Several categorical questions were converted to numeric numbers for analysis (e.g., 1–3 days between licensing examinations was converted to two days for comparison between groups).

Results

In the Class of 2023, 86 students participated in the PSS-10 and 93 participated in the LEQ. For the Class of 2024, 89 and 92 students participated in the PSS-10 and LEQ, respectively. Demographic information (Table 1), collected in the LEQ, revealed a campus response distribution of 105 students (56.8 %) from the Colorado campus and 80 students (43.2 %) from the Southern Utah campus.

Table 1:

Respondent demographics.

Class of 2023 Class of 2024 Cumulative
n, % n, % n, %
Campus
Colorado 54 (58.1 %) 51 (55.4 %) 105 (56.8 %)
Southern Utah 39 (41.9 %) 41 (44.6 %) 80 (43.2 %)
Gender
Female 47 (50.5 %) 42 (45.7 %) 89 (48.1 %)
Male 43 (46.2 %) 48 (52.2 %) 91 (49.2 %)
Nonbinary 2 (2.2 %) – 2 (1.1 %)
Prefer not to answer 1 (1.1 %) 2 (2.2 %) 3 (1.6 %)
Age, years
18–24 8 (8.6 %) 8 (8.7 %) 16 (8.7 %)
25–30 80 (86 %) 74 (80.4 %) 154 (83.2 %)
31–34 5 (5.4 %) 7 (7.6 %) 12 (6.5 %)
Over 35 – 3 (3.3 %) 3 (1.6 %)

PSS-10 survey

There was no significant difference in perceived stress found between the Class of 2023 (M=20.14, SD=7.3) and Class of 2024 (M=19.92, SD=6.6), p=0.8354 (Figure 2).

Figure 2: Cohen Perceived Stress Scale (PSS). Mean PSS for the Classes of 2023 and 2024 accounting for the perception of stress in the previous month.
Figure 2:

Cohen Perceived Stress Scale (PSS). Mean PSS for the Classes of 2023 and 2024 accounting for the perception of stress in the previous month.

Licensing Exam Questionnaire (LEQ)

Respondents from the Class of 2023 reported spending significantly more time (M=6.27 weeks, SD=0.79) studying during their dedicated board preparation period than those respondents from the Class of 2024 (M=5.44 weeks, SD=0.997), p<0.0001. Daily study time, however, was not significantly different, with the Class of 2023 spending a mean 11.11 h (SD=2.23 h) and the Class of 2024 spending 10.86 h (SD=2.25) per day preparing (p=0.4477). For the Class of 2023, 67.3 % (n=68) of respondents reported taking the COMLEX Level 1 after June 20 compared to only 32.7 % of the Class of 2024 (n=33) respondents, X 2 (1, n=182)=29.01, p<0.001. Similar results were found for the USMLE Step 1, with 67.1 % (n=59) of Class of 2023 respondents vs. 33 % (n=29) of Class of 2024 respondents sitting for the examination after June 20: X 2 (1, n=181)=20.56, p<0.001. The approximate time that the survey respondents scheduled between the two licensing examinations was similar between the Class of 2023 (M=5.69 days, SD=4.47) and the Class of 2024 (M=5.13 days, SD=4.15), p=0.3805. More than 72.4 % (n=134) of all respondents elected to take the USMLE first.

Students from both cohorts began board preparation around the same time, yet the other aspects of the preparation decisions varied (Figure 3). Approximately 66.7 % (n=120) of all participants chose to begin board preparation after their final preclinical systems course. In addition to the three required practice examinations provided by RVU-COM, more than 64 % (n=58) of the Class of 2023 participants reported taking >3 practice examinations, independently, in preparation for their boards, compared to only 37 % of the Class of 2024 (n=34) respondents. Approximately 85 % (n=76) of the Class of 2023 survey participants reported spending six weeks or more in dedicated board study time, in contrast to only 45.7 % (n=42) of the Class of 2024 participants.

Figure 3: Board preparation decisions.
Figure 3:

Board preparation decisions.

Compared to the academic year, students that reported experiencing significantly more stress during the dedicated study period were more likely to indicate that wellness routines were not maintained (γ=−0.51, p<0.001). These results were not significantly different between groups.

The estimated amount of money that respondents reported spending on board preparation resources was not significantly different between the Classes of 2023 and 2024, $1,145.60 (SD=$484.90) vs. $1,063.60 (SD=$447.50), respectively p=0.2373 (Figure 4).

Figure 4: Estimated cost of board preparatory resources.
Figure 4:

Estimated cost of board preparatory resources.

Combined survey results demonstrated that both groups (Class of 2023 and Class of 2024) characterized UWorld (71.1 %, n=64 and 80.4 %, n=74, respectively) as the ‘Most’ important board resource. FirstAid (24.4 %, n=22 and 28.3 %, n=26, respectively) ranked ‘Second’. The Class of 2023 selected Pathoma (24.4 %, n=22), and the Class of 2024 selected Sketchy (30.4 %, n=28) as ‘Third’.

When asked to predict the most important factors in their residency application that would influence the chance of obtaining the residency of choice, participants in the Class of 2023 selected: letters of recommendation (77.5 %, n=69), USMLE Step 1/COMLEX Level 1 scores (70.8 %, n=63), and grades in clerkship in the desired specialty (25.8 %, n=23). Respondents from the Class of 2024 selected: letters of recommendation (80.4 %, n=74), USMLE Step 2/COMLEX Level 2 scores (60.9 %, n=56), and grades in clerkship in desired specialty (40.3 %, n=38).

When asked to predict whether a numerical score vs. a Pass/Fail designation would better the applicant’s chance of obtaining residency of their choice, the Class of 2023 participants ranked the following: numerical score (44.9 %, n=40), Pass/Fail designation (39.3 %, n=35), and no impact (15.7 %, n=14). The Class of 2024 responses ranked similarly: numerical score (42.4 %, n=39), Pass/Fail designation (33.7 %, n=31), and no impact (23.9 %, n=22).

Discussion

The shift in USMLE Step 1/COMLEX Level 1 scores from a numeric to a Pass/Fail designation was intended to decrease medical student stress, increase wellness, and shift the emphasis away from a high-stakes, scored examination on residency applications.

Our investigation demonstrates that OMSs perceive moderate stress in the month leading up to their board examinations. Compared to mean PSS-10 scores in individuals between 18 and 29 years old (n=645, M=14.2, SD=6.2) [6], RVU-COM students in the Classes of 2023 and 2024 experienced greater perceived stress. Despite the transition to Pass/Fail, these self-reported student stress levels were not significantly changed.

Unfortunately, although not surprisingly, medical students have higher anxiety, higher depression, and higher perceived stress compared to others of similar age and education [8, 9]. Both student characteristics (e.g., personality, disease, coping mechanisms) and institutional factors (e.g., competitive culture, excessive workload) impact the decline in student well-being [8]. Elevated PSS-10 scores in healthcare personnel and students are correlated with sleep disturbances, substance use, and a greater prevalence of depression, anxiety, and burnout [10, 11].

Our findings are consistent with other PSS-10 investigations in medical students worldwide. In Hong Kong, final-year health professional students had PSS-10 scores of 21.77 for Chinese Medicine degree students (n=13) and 19.95 for other healthcare-related degree students (Medicine and Surgery, Nursing, Pharmacy, Biomedical Sciences) (n=267) [12]. Higher perceived stress was documented by investigators citing a mean PSS-14 score of 28.61 in first-year medical students (n=293) from the Datta Meghe Institute of Medical Sciences University [13]. Finally, a mean PSS-10 score of 18.56 was published in a study in Italian medical students (n=2,455) [14]. Although RVU-COM mean PSS-10 scores of 20.14 and 19.92 are similar to the available evidence, our findings demonstrate that modification of the grade scale for Step 1/Level 1 board examinations did not alter OMSs’ perceived stress, as anticipated.

Board preparatory decisions varied significantly between groups in this investigation. The Class of 2023 (numeric grading) respondents spent significantly more weeks studying, took their board examinations later in the dedicated study window, and attempted more practice examinations. Meanwhile, the Class of 2024 (Pass/Fail grading) respondents did not devote as much time to board preparation. From the data gathered, we were not able discern whether these significant differences were due to the grading system itself or other influences, but these board-preparation patterns are interesting and warrant further exploration.

Interestingly, both classes surveyed reported contributing similar monetary investments to board resources, elected to take the USMLE Step 1 first, and maintained consistent spacing between the board examinations. Respondents believed that the residency programs would emphasize the same aspects of a resident’s application, with one important change, the shift in priority of the USMLE Step 1/COMLEX Level 1 score to the USMLE Step 2/COMLEX Level 2 score. Thus, the change in the board examination grade scale appears to have simply shifted the importance to another numerical scored board examination. Investigators predict a continued elevation in perceived stress as students progress in their undergraduate medical education, especially in preparation for the USMLE Step 2/COMLEX Level 2.

Contrary to the hypothesized statements set forth by both medical examination agencies, this transition did not appear to benefit OMS wellness or stress levels as previously anticipated. Although the intent was clear to decrease stress, increase wellness, and emphasize other aspects of residents’ applications, these changes were not observed in the respondents surveyed.

Residency directors predicted the lack of benefit and shift in focus to another scored examination to categorize potential applicants [4]. Based on the findings reported here, the surveyed students agree, and they will most likely prioritize the USMLE Step 2/COMLEX Level 2 examinations in the future. Many in undergraduate medical education continue to speculate how residency program directors will weigh other aspects of residency applications going forward. Our results demonstrate that students rank letters of recommendation and grades in clerkships of desired specialty highly.

Limitations

During the study period, the clerkship rotation start dates shifted. Rotations began August 2, 2021 for the Class of 2023, and were earlier, July 11, 2022, for the Class of 2024. Although an approximate deadline of July 1 was communicated to both the Classes of 2023 and 2024, the earlier rotation start date for the Class of 2024 may have resulted in students opting to take their board examinations earlier, spend less time preparing, and commit to fewer practice examinations. Despite these shifting dates, the timing of both the PSS-10 and LEQ survey administration remained consistent (Figure 1). This allowed for a similar period of analysis for both cohorts, and the students had the same preparatory time window between surveys. Given the confounding schedules between the cohorts, it is difficult to conclude whether the reported differences in board preparation between the Classes of 2023 and 2024 can be directly attributed to the change Pass/Fail.

The Coronavirus Disease 2019 (COVID-19) pandemic significantly impacted medical student wellness [15]. The pandemic led to changes in preclinical curricula, clinical clerkships, and the timing of board examinations [15]. Students suffered from having to reschedule, delay, or cancel these important licensing examinations [15]. Students in the Class of 2023 experienced the dramatic impact of COVID-19 in their first year of osteopathic medical school, changing to remote work in March 2020. A mixed, hybrid curriculum with virtual and in-person learning sessions characterized their second year. The Class of 2024 began their preclinical journey in 2021, with greater in-person opportunities in their second year. It is challenging to predict how the pandemic influenced the individual results of the study, but it may have contributed to medical student stress.

Our team acknowledges that this was the first year of the new score transition and that the unknown can present a source of stress. Successful implementation of change often takes time to demonstrate the intended results. Future study, including data from outside institutions, would enhance our understanding of medical student psychological stress surrounding national board examinations.

Conclusions

Although grade-scale transitions away from numeric grades have demonstrated a positive effect on wellness in undergraduate medical education, the shift in board-examination grading practice did not significantly alter medical student stress at RVU-COM. Students changed board preparation processes in meaningful ways, spending fewer weeks studying and attempting fewer practice examinations after the shift to Pass/Fail grading. These insights into student behaviors will be invaluable for future studies to understand and compare the impact on board examination outcomes. Future directions for this work include contextualizing these findings in terms of institutional and national pass rates, as reported by NBOME and NBME, and the continued monitoring of student self-reported stress levels and board-preparation behaviors. As medical education continues to evolve, aspiring to reduce medical student stress, we hope that these efforts ultimately produce healthy, effective physicians for the future.

Corresponding author: Jacquelyn Waller, PharmD, BCPS, Rocky Vista University Montana College of Osteopathic Medicine, 4130 Rocky Vista Way, Billings, MT 59106, USA, E-mail:

Funding source: Rocky Vista University Intramural Grant Program

Acknowledgments

The authors would like to thank Matt J. Linton, PhD (Assistant Dean of Preclinical Education and Curriculum, Professor of Physiology), for his review and assistance.

  1. Research ethics: This study was considered exempt from full Rocky Vista University (RVU) Institutional Review Board (IRB) oversight (RVU IRB# 2021-0031).

  2. Informed consent: All participants in this study provided written informed consent prior to participation.

  3. Author contributions: All authors provided substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; all authors drafted the article or revised it critically for important intellectual content; all authors gave final approval of the version of the article to be published; and all authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

  4. Competing interests: None reported.

  5. Research funding: This work was supported by the Rocky Vista University Intramural Grant Program.

  6. Data availability: The data that support the findings of this study are available from the corresponding author, JW, upon reasonable request.

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Supplementary Material

This article contains supplementary material (https://doi.org/10.1515/jom-2023-0045).

Received: 2023-02-22
Accepted: 2023-07-20
Published Online: 2023-09-05

© 2023 the author(s), published by De Gruyter, Berlin/Boston

This work is licensed under the Creative Commons Attribution 4.0 International License.

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https://doi.org/10.1515/jom-2023-0045
Keywords for this article
medical licensing exam preparation; osteopathic medical education; perceived stress; undergraduate medical education
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Articles in the same Issue

  1. Frontmatter
  2. Innovations
  3. Original Article
  4. Analysis of alternate material Onyx™ for total knee arthroplasty instrumentation sets
  5. Medical Education
  6. Original Article
  7. Impact of the USMLE Step 1 and COMLEX Level 1 transition to Pass/Fail on osteopathic medical student stress levels and board preparation
  8. Musculoskeletal Medicine and Pain
  9. Original Article
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  12. Clinical Practice
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