What is it about?

High-stakes examinations are an integral part of medical education. To practice in the United States (U.S.), medical students must pass all three parts of the U.S. Medical Licensing Examinations (USMLE). In the past several decades, emphasis on these examinations has continued to increase to a point where many medical students view performing well on these exams as the most important part of their medical education, more so than performance on clinical rotations, working with patients, and development of communication skills. The first part of the USMLE is Step 1, which for years has been considered the most challenging of the three exams and was recently transitioned from a three-digit score to pass/fail scoring, sparking a worldwide debate on how residency program directors will filter and select applicants moving forward. The USMLE Step 2 Clinical Knowledge (CK) exam has emerged as the next logical exam that program directors will use, placing additional pressures on students as this exam is taken much later in medical students' training at a time when there are many other competing responsibilities. In this study, the authors conducted focus groups of fourth-year medical students who recently took the Step 2 CK exam to explore their decision-making and emotions approaching these high-stakes exams. They explore the role of formal, informal, and hidden curricula related to USMLE and highlight the unintended consequences these added pressures have on trainee burnout, professional identity formation, choice of specialty, and interpersonal interactions throughout training.

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Why is it important?

The transition of USMLE Step 1 to pass/fail scoring on January 26, 2022 was one of the largest changes in medical education in recent history. Residency program directors have increasingly suggested that they will now look more closely at USMLE Step 2 CK scores in residency selection, shifting the pressures previously faced by students preparing for Step 1 to those who are preparing for Step 2. With this new transition to an era of pass/fail Step 1, careful consideration must be put towards preventing a shift from the current "Step 1 mania" environment to a new "Step 2 mania" environment. This study highlights the unintended consequences that pressures driven by formal, informal, and hidden curricula can exert on medical trainees and highlights a critical need for medical educators to pay careful attention to the toll faced by trainees not just within the United States, but throughout the world.


As a medical student, I've experienced firsthand and seen countless peers go through periods of immense stress and pressure approaching licensing exams, often to the point where they put their actual clinical learning and responsibilities on the back burner. This study provides the real student voice and empiric qualitative data shedding light on how formal, informal, and hidden curricula place unintended pressures on students and shape their priorities during training. It is a lesson that educators should play close attention to in order to improve the quality of medical education and the learning environment in which we all operate.

Joseph Geraghty
University of Illinois at Chicago

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This page is a summary of: One test to rule them all: A qualitative study of formal, informal, and hidden curricula as drivers of USMLE “exam mania”, PLoS ONE, February 2023, PLOS,
DOI: 10.1371/journal.pone.0279911.
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