Proposed and Recent Changes in USMLE Step 1 and Step 2 CK: A Narrative Review of Scoring, Administrative, and Test Delivery Reform

The United States Medical Licensing Examination (USMLE) has undergone substantial changes since 2022, with additional reforms continuing through 2026. This narrative review examines the key modifications to USMLE Step 1 and Step 2 Clinical Knowledge (CK), including the transition of Step 1 to pass/fail scoring, the increase in the Step 2 CK passing standard from 214 to 218, the administrative consolidation of exam services under the Federation of State Medical Boards (FSMB) and the National Board of Medical Examiners (NBME), and the introduction of new test delivery software. A literature search of published studies, official USMLE program announcements, and national survey data was conducted. Results indicate that the Step 1 pass/fail transition has been associated with declining pass rates across all examinee groups, a shift in emphasis toward Step 2 CK scores in residency selection, and mixed evidence regarding the intended reduction in student stress. The increase in the Step 2 CK passing score disproportionately affects international medical graduates. These findings suggest that while the reforms aim to create a more holistic and equitable medical licensure process, unintended consequences warrant continued monitoring and evaluation.