Medical Student Non-Modifiable Risk Factors and USMLE Step 1 Exam Scores


Jenna Davison, MPH (1, 2); Malynda Taylor, MBA, MPH (2) 1. Oregon Health and Science University School of Medicine 2. Oregon Health and Science University - Portland State University School of Public Health


Females, people of Color, and nontraditional students have been shown to score significantly lower than their Caucasian, male counterparts on Step 1 (1,2). A passing score is required, however, residencies have been utilizing Step 1 scores to screen out applicants. A study of Internal Medicine residencies found that African Americans were 3 times less likely to be interviewed when Step 1 was used to screen applicants (3). These disparities remain a barrier in light of Step 1 becoming pass/fail in 2019. Our aim is to assess how multiple non-modifiable risk factors may relate to Step 1 score and the diversity of the medical graduate workforce.


The Oregon Health and Science University class of 2021 completed a 14-question voluntary survey (n=81). Many non-modifiable risk factors were examined: Adverse Childhood Experience score (ACEs), sex, gender, race, ethnicity, family income, highest degree of 1-2 guardians, discrimination experience, federal/state assistance use, and rural versus urban primary home. Descriptive and linear regression analysis of the association between Step 1 as a continuous variable and non-modifiable risk factors were performed. The association between Step 1 as a categorical variable (<220 or =220) and non-modifiable risk factors, to mimic cutoff scores for residency interviews, and the relation between ACEs and student race and sex were reported as OR (95%CI).


Of participants, 28.3% identified as students of Color, 65.4% as female, and 23.5% having an Adverse Childhood Experience score (ACEs) =3. Students of Color and female students had >4.00 times increased odds of ACEs =3 (p<0.05). Students with ACEs =3 had 6.67 (2.22, 20.01) times decreased odds of meeting a 220 cutoff score (p<0.05). ACEs and highest guardian degree were associated with Step 1 score through linear regression (p<0.05).


These are the first results to demonstrate a relationship between Step 1 score and ACEs. Students of Color and females had higher odds of ACEs =3. The relationship may put the students at higher risk of not meeting residency cutoff scores for interviews, and may contribute to the inadequate and insufficient diversity observed in the medical graduate workforce (4). Notably, the relationship between Step 1 score and ACEs lose significance if Step 1 is made categorical with the passing threshold of 194. Limitations included the number of students of Color and the categories of non-modifiable risk factors analyzed. These findings contribute to a foundation of research that can inform decisions about the diversity and equity of the residency interview process.


  1. Gauer JL, Jackson JB. Relationships of demographic variables to USMLE physician licensing exam scores: a statistical analysis on five years of medical student data. Adv Med Educ Pract. 2018;9:39-44. [PMID: 29391841] doi:10.2147/AMEP.S152684
  2. Spector AR, Railey KM. Reducing reliance on test scores reduces racial bias in neurology residency recruitment. J Natl Med Assoc. 2019;111:471-474. [PMID: 30935681] doi:10.1016/j.jnma.2019.03.004
  3. Edmond MB, Deschenes JL, Eckler M, et al. Racial bias in using USMLE step 1 scores to grant internal medicine residency interviews. Acad Med. 2001;76:1253-6. [PMID: 11739053] doi:10.1097/00001888-200112000-00021
  4. Silver JK, Bean AC, Slocum C, et al. Physician workforce disparities and patient care: a narrative review. Health Equity. 2019;3:360-377. [PMID: 31312783] doi:10.1089/heq.2019.0040

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