{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,13]],"date-time":"2026-10-13T23:04:06Z","timestamp":1791932646343,"version":"4.3.4"},"reference-count":54,"publisher":"Public Library of Science (PLoS)","issue":"2","license":[{"start":{"date-parts":[[2023,2,3]],"date-time":"2023-02-03T00:00:00Z","timestamp":1675382400000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"Association of American Medical Colleges Central Group on Educational Affairs"}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS ONE"],"abstract":"<jats:p>High-stakes examinations are an integral part of medical education. To practice in the United States (U.S.), students must pass the U.S. Medical Licensing Examinations (USMLE). With the transition of USMLE Step 1 to pass\/fail scoring on January 26, 2022, a worldwide debate regarding how residency program directors will view the Step 2 Clinical Knowledge (CK) exam emerged. Here, the authors explore the role of formal, informal, and hidden curricula related to USMLE, with broader implications for high-stakes examinations. Six focus groups of fourth-year students who recently took Step 2 CK and a supplemental curricular content analysis were conducted to explore students\u2019 decision-making and emotions regarding the exam, including how the formal, informal, and hidden curricula influence their perspectives. Participants highlighted how informal and hidden curricula drive the belief that high-stakes examinations are the single most important factor in medical school. Prior experience with Step 1 drives behaviors and attitudes when preparing for Step 2 CK. Pressures from these examinations have unintended consequences on burnout, professional identity, specialty choice, and interpersonal interactions. Both interpersonal interactions within medical education as well as subconscious, unintended messaging can influence medical student approaches to and perspectives about high-stakes examinations. Within the context of U.S. medical training, with the transition to a new era of a pass\/fail Step 1 examination, careful consideration to prevent shifting the current \u201cStep 1 mania\u201d to a \u201cStep 2 CK mania\u201d is warranted. More broadly, medical educators must examine the unintended yet potentially damaging pressures institutions generate in their medical trainees in relation to high-stakes examinations.<\/jats:p>","DOI":"10.1371\/journal.pone.0279911","type":"journal-article","created":{"date-parts":[[2023,2,3]],"date-time":"2023-02-03T18:25:18Z","timestamp":1675448718000},"page":"e0279911","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":18,"title":["One test to rule them all: A qualitative study of formal, informal, and hidden curricula as drivers of USMLE \u201cexam mania\u201d"],"prefix":"10.1371","volume":"18","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-6828-4893","authenticated-orcid":true,"given":"Joseph R.","family":"Geraghty","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sarah M.","family":"Russel","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hilary","family":"Renaldy","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Trevonne M.","family":"Thompson","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0894-2994","authenticated-orcid":true,"given":"Laura E.","family":"Hirshfield","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2023,2,3]]},"reference":[{"key":"pone.0279911.ref001","volume-title":"Teaching and Learning in Medical School. 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