Medical school ranking and orthopaedic match outcomes in the USMLE Step 1 pass/fail era: a PGY-stratified analysis

In 2022, the USMLE Step 1 transitioned from numeric scoring to pass/fail. Previously, Step 1 scores screened applicants; with fewer metrics, programs may emphasize alternative applicant characteristics. Limited data exist on this transition’s impact. This study examines whether associations between medical school characteristics and orthopaedic residency program ranking outcomes differ between cohorts spanning the transition from numeric to pass/fail Step 1 scoring. We performed a cross-sectional analysis of all orthopaedic surgery residents in ACGME-accredited programs using publicly accessible rosters, directories, social media, and school websites. Medical school rankings were derived from U.S. News & World Report and categorized by allopathic vs. osteopathic, public vs. private, and “orphan” status (no affiliated orthopaedic residency). Chi-square tests, univariate and multivariate ordinal logistic regression, and Spearman correlation coefficients assessed associations. A total of 3,844 residents across 215 programs were included. Medical school rank correlated with residency program rank among PGY-1 through PGY-3 residents, representing more recent Match-era cohorts after the transition period surrounding pass/fail Step 1 scoring, whereas no significant association was observed among PGY-4 and PGY-5 residents from earlier Match-era cohorts. Because individual Step 1 examination dates were unavailable, PGY level was used as a temporal proxy rather than a direct measure of Step 1 scoring format. Tier 1 medical school students had the highest median residency rank (47). MD students had approximately 10-fold higher odds of training in a higher-ranked residency program compared with DO students. Orphan status was associated with 40% lower odds of training in a higher-ranked residency program. More recent Match-era cohorts demonstrated stronger observed associations between institutional characteristics and residency program ranking during the transition period surrounding pass/fail Step 1 scoring. These findings represent temporal associations and should be interpreted in the context of the observational study design.