It’s a well-known fact that medical school has grown increasingly competitive over the past decade. While this is true that getting into medical school has become somewhat harder, what is more concerning is that for many students, admission to, and paying for, medical school does not guarantee a career as a physician. A critical part of becoming a physician is graduate medical education, or residency. It is well-known that there is an overall physician shortage issue in the United States, given the growing and aging population of the United States. While many new medical schools have opened, and most medical schools have increased their class sizes, there has not been a corresponding increase in the number of residency spots.

The National Resident Matching Program (NRMP) has recently released some of the data from the 2021 Match, which has revealed that despite 38,106 positions, an all-time high (up from 37,256 in 2020, 35185 in 2019, and ~33,000 in 2018), the number of medical students seeking positions was also at an all-time high of 48,700, including both U.S and International applicants. A quick calculation reveals that over 10,000 applicants (approximately 20 percent of all applicants) didn’t match last cycle. This trend was true across the board, regardless of whether the applicant is U.S. or foreign, MD or DO, underscoring the increasingly competitive nature of the NRMP match:

Applicant	Match Rate 2021	Change from 2020
U.S. MD Senior	92.8%	-0.9%
U.S. DO Senior	89.1%	-1.6%
Total applicants	78.5%	-2.3%
Couples match	93.4%	-2.2%
U.S. FMGs	59.5%	-0.5%
Non-U.S. IMGs	54.8%	-6.3%

Given that the match is growing increasingly competitive, medical students are scrambling to find ways to stand out from their peers. Traditionally, strong Step 1 scores were a great way for students to get interviews at programs they were interested in. Now that Step 1 is moving to pass/fail, and many medical schools are transitioning to pass/fail grading for pre-clinical years, there are becoming fewer and fewer ways to stand out.

Perhaps the easiest way for program directors to parse through an ever-increasing number of applicants, and for students to stand out, is substituting previous emphasis on USMLE Step 1 scores with USMLE Step 2 scores. Despite the many issues with standardized exams, score reports and percentiles are much easier (and faster) for program directors to evaluate compared to personal statements, letters of recommendation, and parsing through long CVs. Given the ease of score interpretation, USMLE Step 2 is likely to become the new Step 1. In the near term, Step 2 is likely to remain graded, as the NBME has released no information about changes to the Step 2 grading system.

With the new focus of residency applications likely shifting to USMLE Step 2 scores, doing well on that exam is likely to become the focus for many medical students; however, doing well on USMLE Step 2 is likely to become more challenging. This predicament is especially acute for students at international medical schools compared to students applying from U.S. medical schools. Previously, students from international medical schools relied heavily on good performances on the USMLE Step 1 exam. Correspondingly, curricula at international medical schools are often designed around Step 1 exam performance. With the upcoming change in the grading of USMLE Step 1, adjusting curricula to more heavily emphasize Step 2 content will likely take a few years. While this emphasis on exams may be more prevalent at international medical schools, U.S. medical schools have also had to focus on getting students through the USMLE exams. U.S. medical students, therefore, may also find that curricula may not reflect the increasing importance of USMLE Step 2. This may place students taking USMLE Step 2 within the next few years at a relative disadvantage, as they may not be adequately prepared for doing well on Step 2 through their medical school education alone.

Another challenge to good performance on USMLE Step 2 is the changes in standardized testing and grading on exams and coursework overall.  As USMLE Step 1 and many medical school classes in the first 1-2 years are moving to pass-fail, students may not have an accurate idea of their performance metrics. Likewise, grading during the clinical clerkships is often more subjective, based on personality, communication skills, general likeability, and clinical medical knowledge. These challenges will make it more difficult for students to know how well they are likely to do on USMLE Step 2, and correspondingly, how much effort they will need to put in to do well on USMLE Step 2. Utilizing the NBME practice exams and question banks such as UWorld early on will become increasingly important prior to the dedicated study period. In any case, being over-prepared is always better than under-prepared. In the first couple of years of their training, medical students should take the time now to plan an approach to the USMLE exams.

Karolina Woroniecka is a pathology resident and ad hoc reviewer for cancer medicine and a USMLE tutor, Elite Medical Prep, LLC.

Image credit: Shutterstock.com