Though intended to inform a binary decision on initial medical licensure, the United States Medical Licensing Examination (USMLE) is frequently used for screening candidates for residency positions. Some have argued that reporting results as pass/fail would honor the test’s purpose while preventing inappropriate use. To date, the USMLE’s sponsor organizations have declined to make such a change. In this Perspective, the authors examine the history and mission of the National Board of Medical Examiners (NBME), trace the rise of “Step 1 mania,” and consider the current financial incentives for the NBME in implementing a pass/fail score-reporting policy.