Discussion: Matching Into Integrated Plastic Surgery: The Impact of USMLE Step 1 Transition to Pass/Fail: Did the 2019 Predictions Come True in 2024?

We had the pleasure of reading the article entitled “Matching into Integrated Plastic Surgery: The Impact of United States Medical Licensing Exam (USMLE) Step 1 Transition to Pass/Fail: Did the 2019 Predictions Come True in 2024?” When medical students ask, “How do I match into plastic surgery?” the answer formerly had 2 major checkboxes: score well on Step 1, then score well on Step 2; numerical testing had traditionally been a large factor in a successful plastic surgery application. Since USMLE Step 1 transitioned from a 3-digit score to pass/fail (P/F) grading in 2022, the answer has been less clear-cut. Before the policy change, program directors (PDs) anticipated a heightened focus on Step 2 scores, research experience, and subjective measures, such as medical school reputation.1 Students similarly anticipated shifting time spent studying for Step 1 to research and Step 2.2 Although the change may have reduced student stress, it eliminated 1 of only 2 standardized objective metrics that programs relied upon to differentiate applicants during the Match. Boyd et al3 offered timely insights into how plastic and reconstructive surgery (PRS) PDs have adjusted. In their national survey of 37 integrated PRS PDs following the 2023–2024 Match, the authors identified the 3 most important criteria for interview invitations: away rotation participation, letters of recommendation (LORs), and research involvement. A total of 68.1% of PDs reported difficulty distinguishing applicants without numeric Step 1 scores, with 1 noting that the change favors applicants “from academic legacy.” The results substantiate concerns that the move to P/F heightened reliance on less standardized—and potentially more biased—selection tools. Indeed, the movement toward less available numerical data may, by its nature, bring more subjective factors into the equation. The response rate may suggest a specific pool of respondents, as PDs with strong opinions may have been more inclined to participate.3 Nonetheless, the results from Boyd et al3 are not anomalous. Asghari et al4 similarly surveyed 44 PDs and associate PDs in PRS on their updated selection criteria. Their findings indicated that LOR content had the most significant increase in weight.4 In agreement with Boyd et al,3 Asghari et al4 also observed that school prestige, subinternship performance, and interview performance are increasingly important determinants of a Step 1 P/F applicant’s competitiveness. Challenges remain, as existing studies substantiate the importance of research and academic networking on match outcomes. Elemosho et al5 demonstrated that 15 or more publications were associated with increased match probability in integrated PRS applicants from 2016 to 2022. Godbe et al6 reiterated that PRS applicant competitiveness is strongly correlated with first-author publications, research years, and attendance at a top 40 medical school. Accordingly, PRS residents from 2017 to 2022 experienced a significant increase in the proportion who completed dedicated research years.7 Subinternships, LORs, and research are important selection criteria. However, their weight redistribution underscores major setbacks for 2 groups: students without home residency programs (HPs) and international medical graduates (IMGs). Akhter et al8 suggested that applicants without HPs are more than 3 times more likely to go unmatched than those with HPs. Zeng et al9 found that students without HPs feel most disadvantaged in finding research and identifying mentors. Such opportunities are not equitably distributed; top-tier institutions often have easier access to funded research, high-impact journals, and experienced mentors.7 Students without HPs are significantly more likely to match if they seek research and mentorship outside their home institutions, which may present insurmountable barriers to entry.10 Away rotations are costly and time-intensive, and research years can cost between $35,000 and $73,000.11 Nearly one-third of PRS applicants from 2019 to 2022 cited a lack of monetary support as the reason they did not participate in an extended research experience.12 The results from Boyd et al3 validate the heavy weight placed on research and personal engagement, underscoring how this pressure disproportionately affects a structurally vulnerable group. IMGs face similar challenges. From 2010 to 2020, IMGs filled less than 10% of integrated plastic surgery positions, and 52% of programs did not match any IMGs during this period.13 Prereform, 96% of PDs across competitive specialties believed the Step 1 P/F would either worsen or not affect IMGs’ chances.14 Step 1 was a rare objective benchmark to demonstrate academic parity. Now, IMGs must rely on fulfilling subjective criteria that are largely inaccessible to them. Lujan-Hernandez et al15 surveyed PRS PDs to identify factors contributing to IMG competitiveness. Their findings revealed that prior experience working with the candidate and strong LORs from well-known letter writers were key determinants of an applicant’s success. Unfortunately, only 18% of US-based host institutions on Visiting Student Learning Opportunities accept international medical students for clinical rotations, and only 96 international medical schools have agreements with Visiting Student Learning Opportunities to send students to US programs.16 These policies severely limit IMG exposure to invaluable clinical experience and mentorship that would benefit their match outcomes. One potentially equitable innovation—preference signaling—is relatively new for plastic surgery and remains perhaps underused in plastic surgery, though it is evolving. Only 4 PDs in the survey by Boyd et al3 listed it among their top 3 criteria, despite evidence from other fields showing its effectiveness. In the Step 1 P/F era, urology PDs rank signaling as their second-most important selection criterion, after LORs.17 In orthopedic surgery, which offers 30 signals, nearly 80% of programs in the 2023–2024 Match only interviewed applicants who signaled their institutions.18 Although PRS will expand signaling from 5 to 20 signals for the 2025–2026 cycle, the impact will depend on programs’ prioritization of signals as a selection criterion. In conclusion, Boyd et al3 yielded timely and important early evidence on how PRS programs are adapting to the Step 1 reform. Their findings demonstrate a shift toward subjective selection metrics, such as away rotations, LORs, and research productivity—criteria that may disproportionately disadvantage applicants without home programs and IMGs. Although the study does not link selection metrics to match outcomes, it highlights critical areas where current practices may reinforce rather than reduce inequity. As one factor (Step 1) has been taken away, it makes intuitive sense that all the other factors that go into an application are more important. As a field, we should continue striving to be cognizant of those groups who may be even more challenged during this competitive application process to continue providing opportunities for all. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article.