To investigate how the shift of the United States Medical Licensing Examination (USMLE) Step 1 to a Pass/Fail (P/F) scoring system impacts the perceptions of Urology Program Directors (PDs) on evaluating urology residency applicants.

A cross-sectional survey was sent to 117 PDs, including questions about program characteristics, perceptions of shelf scores and medical school rank post-transition, beliefs about the predictive value of Step 1 and Step 2 Clinical Knowledge (CK) scores for board success and residency performance, and changes in applicant parameter ranking.

Forty-five PDs (38% response rate) participated. Notably, 49% favored releasing quantitative clerkship grades, and 71% valued medical school rank more. Opinions on Step 1 scores' correlation with board success were split (49% agreed), and 44% endorsed Step 2 CK scores' connection to board performance. As predictors of good residents, only 9% and 22% considered Step 1 and Step 2 CK scores, respectively, indicative. Clerkship grades and Urology rotation recommendation letters maintained significance, while research experience gained importance. Step 2 CK scores' importance rose but did not match Step 1 scores' previous significance.

The transition to P/F for USMLE Step 1 adds intricacies to urology residency selection, exposing PDs' uncertainties regarding clerkship grades and the relevance of medical school rank. This research underscores the dynamic nature of urology residency admissions, emphasizing the increasing importance of research in evaluating applicants and a diminishing emphasis on volunteering and leadership.