Evolving determinants of neurosurgery match outcomes after USMLE Step 1 pass/fail transition

Background The 2022 transition of United States Medical Licensing Examination (USMLE) Step 1 from numeric to pass/fail scoring represents a fundamental shift in neurosurgery residency applicant selection. Historically, Step 1 scores served as a key objective metric. With numeric scores no longer available, programs may place greater emphasis on alternative metrics. To the authors’ knowledge, this study is the first that aimed to evaluate how predictors of neurosurgery match outcomes have shifted before and after Step 1 became pass/fail. Methods We conducted a retrospective cohort analysis of neurosurgery residency applicant data from pre-pass/fail (Step 1 numeric) and post-pass/fail eras. Data were used from the 2023 and 2024 application cycles. Variables included demographics, USMLE Step 2 clinical knowledge (CK) scores, Step 1 pass status, research output variables, dedicated research years, postgraduate training after medical school graduation, Alpha Omega Alpha (AOA) membership, home institution status, and other academic metrics. Descriptive statistics were compared for matched and unmatched applicants within each era. Independent predictors of match success were identified through multivariable logistic regression analysis. Results In the pre-pass/fail era, matched applicants had higher Step 2 CK scores and more review article, neurosurgery-specific, neurosurgery-specific first-author, and total publications than unmatched applicants (p < 0.001 for all). Independent predictors of match success included Step 2 CK score and review article productivity. Research year and postgraduate training were negative predictors. In the post-pass/fail era, Step 2 CK, home institution, AOA membership, research year, neurosurgery-specific publications, and basic science publications were significant positive predictors. Review articles no longer predicted match success. Conclusion The transition to pass/fail Step 1 has shifted the emphasis of neurosurgery residency applicant selection from general research productivity and review articles toward specialty-specific scholarship, home institution affiliation, AOA membership, and dedicated research experience. Step 2 CK has remained a consistent predictor across eras.