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Escalating Research Output After the USMLE Step 1 Pass/Fail Transition: Implications for Equity, Ethics, and the
Yzen Al-Marrawi1, James R Burmeister1, Majd Al-Marrawi2
1Department of Foundational Medical Studies, Oakland University William Beaumont School of Medicine, Auburn Hills, USA.
Background:
Orthopaedic surgery remains one of the most competitive residency specialties in the United States. Following the 2022 transition of USMLE Step 1 to pass/fail, research output (RO) has emerged as a prominent screening metric for residency selection. However, longitudinal trends in RO and the impact of this policy change on applicant behavior have not been fully characterized.
Methods:
Aggregate data from the National Resident Matching Program (NRMP) Charting Outcomes in the Match reports from 2014 to 2024 were analyzed for U.S. allopathic applicants to orthopaedic surgery. RO was defined as the self-reported number of peer-reviewed publications, abstracts, and poster presentations. Descriptive analyses were performed, and linear trend modeling compared RO growth before the Step 1 policy change (2014-2020) and after implementation (2022-2024).
Results:
Average RO among matched applicants increased by 255% over the study period, rising from 6.7 in 2014 to 23.8 in 2024. Unmatched applicants demonstrated similar upward trends but consistently reported lower RO. From 2014 to 2020, RO increased modestly at approximately 1.3 research products per year. Following the Step 1 pass/fail transition, RO growth accelerated sharply to approximately 5.2 products per year between 2022 and 2024. During this period, matched applicants experienced a 44.24% increase in RO and reported 32% higher RO than unmatched applicants by 2024.
Conclusions:
Research output among orthopaedic residency applicants has risen dramatically over the past decade, with a pronounced acceleration following the Step 1 transition to pass/fail. These findings suggest a shift toward research quantity as a dominant selection metric, raising concerns regarding sustainability, equity, burnout, and ethical authorship practices. Ongoing ERAS reforms and adoption of holistic review frameworks may be necessary to ensure fair, meaningful, and transparent residency selection in orthopaedic surgery.
