Flipping Tradition on Its Head: A Single-Institution Study on United States Medical Licensing Examination Step Order

Given the recent change in Step 1 grading, medical students are faced with decisions surrounding the optimal Step examination order and timing. There is a current lack of guidance outside commonly used United States Medical Licensing Examination study blogs. The aim of this study was to characterize current practices in Step examination order and understand the factors influencing student examination preference. To gather data, we used a 24-item survey and electronically distributed it through three separate email requests to medical students. Participants included medical students (MS1-4) attending a single institution, interested in a surgical residency. In total, 56 students responded to the survey (response rate of 20%). Most students (63.6%) opted to take Step 2 before Step 1. Justifications included the perceived importance of Step 2 for residency applications (33.3%), the change to pass/fail grading (27.0%), the relevance of Step 2 after rotations (27.0%), and a desire to obtain a Step 2 score earlier (7.9%). Step examination order did not lead to differences in Step 2 score (P = 0.459), time used to prepare for Step 1 (P = 0.396), or time used to prepare for Step 2 (P = 0.078). Due to the perceived importance of Step 2, most medical students at our institution who are interested in pursuing a surgical residency are reversing the traditional Step examination order. As this may represent a national trend, additional work needs to be done to provide guidance to medical students and identify the optimal step examination testing strategy.