The United States Medical Licensing Examination has long been valued by state medical boards as an evidence-based, objective assessment of an individual's progressive readiness for the unsupervised practice of medicine. As a secondary use, it is also valued by residency program directors in resident selection. In response to Chen and colleagues' consideration of changing Step 1 scoring to pass/fail, contextual and germane information is offered in this Invited Commentary, including a discussion of potential consequences, risks, and benefits of such a change. A review of stakeholders involved in the residency application process and their possible reactions to a scoring change precedes a discussion of possible changes to the process-changes that may better address expressed concerns. In addition to pass/fail scoring, these include limiting score releases only to examinees, changing the timing of score releases, increasing the amount and improving the quality of information about residency programs available to applicants, developing additional quantitative measures of applicant characteristics important to residency programs, and developing a rating system for medical school student evaluations. Thoughtful and broad consideration of stakeholders and their concerns, informed by the best evidence available, will be necessary to maximize the potential for improvement and minimize the risk of unintended adverse consequences resulting from any changes to the status quo. An upcoming invitational conference in 2019 that is being organized by several stakeholder organizations is expected to further explore underlying issues and concerns related to these options.
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