Step 1 is Pass/Fail, Now What? Can Clinical Clerkship Grades be Used as a Reliable Metric to Screen General Surgery Residency Applicants?

Introduction: For decades, the three-digit United States Medical Licensing Exam Step 1 score has been used to competitively evaluate and compare candidates during the residency application process. Starting in 2022, however, all Step 1 scores will be converted to pass/fail. A different quantitative measure will likely gain importance in its stead, one such being clerkship performance grades. This study aims to determine the consistency of class rank and distribution of clerkship grades reported by medical schools for applicants to a general surgery program.

Methods: Candidates' Medical Student Performance Evaluation letters from 141 unique US allopathic medical schools were reviewed for student overall class rank, the number of grading tiers in each clerkship, and the percent achieving honors criteria in each clerkship from the 2020 application cycle. Comparative analysis was performed by region and medical school prestige.

Results: Most medical schools rank students using a four-tier system (e.g., fail, pass, high pass, and honors). A third of schools do not provide an overall class rank of students (34.7% of schools); this was most prevalent in the Northeast and Western regions. Schools in the Central US more often rank their students in five tiers compared to the South (P < 0.01). The percent of students that achieve the highest grading tier varies across the core clerkships (mean 37.1%, range 6.5%-78%); an average of 34.5% of students meet the highest honors tier in their Surgery clerkship. Students at US News and World Report Top 20 medical schools are more likely to receive the highest honors tier, across all core clerkships and overall class rank, than students at schools outside the Top 20 (P < 0.05).

Conclusions: In the absence of the United States Medical Licensing Exam Step 1 score, the variability in clerkship grading tiers and overall class rank will likely pose a challenge to residency programs' ability to stratify desirable applicants. Further transparency and standardization may be required to compare students objectively and fairly from medical schools across the country.