Impact of delaying the USMLE Step 1 exam on subsequent academic performance in medical school: a retrospective study at UConn School of Medicine

Purpose The United States Medical Licensing Examination (USMLE) Step 1 is the first of three board examinations that medical trainees must pass for licensure. The impact of delaying Step 1 on subsequent academic performance is of growing concern. To evaluate the effects of delaying the USMLE Step 1 exam on performance in Step 1, Step 2 clinical knowledge (CK), and clinical clerkships among students at one US medical school. Method The researchers conducted a retrospective analysis of medical students matriculating in 2016, 2017, and 2019 at the University of Connecticut (UConn) School of Medicine. Students who delayed taking the Step 1 exam were compared with those who did not delay. Data on Step 1 scores, Step 2 CK scores, and clerkship performance (exams and final grades) were analyzed using two-sample t-tests, rank-sum tests, and chi-square test, based on the properties of the data. Results Of the 294 students analyzed, 80 (27%) delayed taking the Step 1 exam. Delayers had significantly lower Step 1 scores (mean [SD], 222.83 [16.76]) versus non-delayers (234.72 [15.56]; P < .001). Delayers also performed worse on home-grown clerkship exams and NBME shelf exams and had lower rates of honors in key clerkships. Furthermore, delayers had lower Step 2 CK scores (median [IQR]: 244 [236-251]) versus non-delayers (254 [245-261]; P < .001). Conclusions Delaying USMLE Step 1 is associated with poorer performance in subsequent assessments, including clerkship exams and Step 2 CK scores. These findings suggest that delay may serve as a midstream indicator associated with broader academic challenges. Early identification of students at risk of delay and the provision of targeted academic support may improve educational outcomes and ensure timely progression through medical training.