Suboptimal outcomes were observed for 11.3% of matriculants in our sample. Graduates with and without first-attempt-passing scores on Step 1 and Step 2CK were distinguished because graduates with first-attempt-passing scores are more favorably positioned for entry into and progression through GME compared with graduates without first-attempt-passing scores.
GME program directors place importance on Step 1 and Step 2CK scores in resident selection.15
In the 2008 National Resident Matching Program (NRMP) Program Director Survey results, USMLE Step 1 score was the most frequently cited factor in selecting interviewees.16
Furthermore, among program directors who required applicants to submit Step 1 and/or Step 2CK scores, 83.5% reported that they would seldom or never consider interviewing an applicant with a first-attempt Step 1 failure, and 87.7% reported that they would seldom or never consider interviewing an applicant with a first-attempt Step 2CK failure.16
Applicants with first-attempt-failing (or even lower passing) scores remain over-represented among unmatched applicants in the NRMP.17, 18
Graduates with first-attempt Step 1 and/or Step 2CK failures also face challenges during GME. Many GME programs require USMLE sequence completion for contract renewal beyond the initial GME year(s).19–21
To do so, graduates must pass USMLE Step 3.22
Step 1 and Step 2CK passing scores are prerequisites for Step 3 eligibility, and Step 3 scores correlate with MCAT, Step 1, and Step 2CK scores.22–24
Thus, graduates without first-attempt-passing scores on Step 1 and/or Step 2CK are at risk for difficulty in timely USMLE sequence completion and are vulnerable to program dismissal. Many state-licensing boards limit the number of attempts to pass each licensing examination and/or the time for USMLE sequence completion.25
For these reasons, the optimal medical-school outcome is graduation with first-attempt-passing scores on Step 1 and Step 2CK.
That lower MCAT scores were associated with an increased likelihood of suboptimal outcomes is consistent with other multi-institutional studies and a meta-analysis that documented positive associations between MCAT scores and each of Step 1 scores, third-year-clerkships’ grade-point average, and Step 2CK scores.14, 24, 26, 27
The observations that each of underrepresented minority and Asian/Pacific Islander race/ethnicity was associated with a greater likelihood of academic withdrawal/dismissal and of graduation without first-attempt- passing scores on Step 1 and Step 2CK in a model that controlled for MCAT score is consistent with a report that non-white students performed more poorly in medical school compared with white students with the same MCAT scores.26
Because these observations are from a model that also controlled for other variables including premedical debt, further research seems warranted to identify additional variables amenable to intervention that may contribute to the disparate outcomes observed on the basis of race/ethnicity.
Lower MCAT scores did not preclude an optimal outcome for many matriculants. Because medical schools accept applicants with a wide range of MCAT scores, these findings may be of value in identifying matriculants who may benefit from additional support to maximize their likelihood of an optimal outcome.14, 28
The outcomes observed among matriculants without MCAT scores, and among the race-by-MCAT-interaction group of underrepresented minority matriculants without MCAT scores, may be of interest to medical schools with special admissions programs that waive MCAT-score requirements.
That women were at lower risk of academic withdrawal/dismissal differs from findings of an earlier study, which reported that women were at greater risk for academic difficulty.29
As matriculation of women in medical school has reached parity with that of men, the physician workforce gender gap may continue to narrow.
Consistent with previous reports, older age at matriculation was associated with a greater likelihood of suboptimal outcomes.27, 29
These matriculants might have had additional responsibilities (e.g., family) during medical school or might have had difficulty gaining medical-school acceptance and devoted additional years to study or research.
Almost 50% of matriculants in the sample received undergraduate degrees from “Research Universities – Very High Research Activity” institutions; graduates from other undergraduate-institution categories were more likely to have a suboptimal outcome. These findings suggest that student experiences in very high research-activity university settings may be associated with success in the medical school environment.
College research-apprenticeship-program participation was associated with a lower likelihood of suboptimal outcomes, but summer-academic-enrichment-program participation during college was associated with a higher likelihood of suboptimal outcomes. Many summer-academic-enrichment programs are specifically intended for students interested in health professions careers who seek to strengthen their performance in premedical courses and on the MCAT, and so may be at greater risk for performance difficulties in medical school.
Because higher premedical debt was associated with greater likelihood of suboptimal outcomes, the low levels of socioeconomic diversity that exist among medical school matriculants may be even more pronounced among graduates.31
The findings regarding premedical debt and participation in college programs to prepare for a career in medicine, both of which are amenable to intervention, may be of particular interest to medical schools as they seek to meet the revised LCME accreditation standards on diversity.32
More than 40% of matriculants who graduated without first-attempt-passing scores on Step 1 and/or Step 2CK were enrolled in medical school for more than 4 years. This likely reflects, at least in part, delays in advancement or graduation among matriculants enrolled at schools with Step 1 and/or Step 2CK passing score requirements for advancement/graduation. In 1994–1995, 87 schools had such Step 1 requirements and 53 schools had such Step 2CK requirements for advancement/graduation;7
in 2000–2001, 103 schools had Step 1 requirements and 72 schools had Step 2CK requirements.8
In 2008–2009, 112 schools had Step 1 requirements and 93 had Step 2CK requirements.9
Therefore, most contemporary matriculants who initially fail Step 1 and/or Step 2CK are subject to delayed advancement or graduation if they eventually pass the examination(s), or to withdrawal/dismissal if they do not.
Despite trends towards increasing MCAT, Step 1, and Step 2CK scores, the proportion of matriculants in the optimal outcome group did not increase over time, which was likely due at least in part to changes in minimum passing scores on Step 1 and Step 2CK. The initial Step 1 passing score of 176 in 199410
was revised to 179 in 1998,33
182 in 2001,34
185 in 200735
and 188 in 2010.36
Similarly, the initial Step 2CK passing score of 167 in 199410
was revised to 170 in 1996,37
174 in 2000,34
182 in 200338
and 184 in 2007.39
Many matriculants in this study who withdrew or were dismissed from medical school had no USMLE records. School-specific curricula that facilitate identification and counseling of matriculants with difficulties before they attempt the USMLE sequence might be among the contributory factors.40
This study of a nationally representative sample of medical school matriculants should be interpreted within the context of its limitations. Since we excluded matriculants who entered other types of medical degree programs, the findings can be generalized only to MD-degree program enrollees. MSQ variables in the study were by self-report, which may be prone to self-protection bias. Inclusion of only MSQ respondents may have introduced some selection bias, since MSQ respondents had higher MCAT scores than nonrespondents. Matriculants’ experiences during medical school and medical-school-specific variables, such as cultural climate for demographically diverse student populations, curriculum, USMLE sequence policies, and quality of student support services would be expected to contribute substantially to attrition and graduation outcomes.40–43
Furthermore, because most matriculants with nonacademic withdrawal/dismissal were not dismissed, but had withdrawn from medical school for unspecified reasons, other unmeasured variables likely contributed particularly to this outcome. Because this is an observational study, causation cannot be inferred.
US LCME-accredited medical schools are currently in a period of concerted efforts to increase enrollment and diversity of enrollees. These results regarding prematriculation variables associated with suboptimal medical school outcomes may help inform these endeavors.6