To License or not to License?

All students can learn and succeed, but not in the same way on the same day.

~ William Spady

I am sure you heard the news. "The USMLE program will change score reporting for Step 1 from a three-digit numeric score to reporting only a pass/fail outcome. A numeric score will continue to be reported for Step 2 Clinical Knowledge (CK) and Step 3. Step 2 Clinical Skills (CS) will continue to be reported as Pass/Fail."

I have seen a plethora of mixed reactions from peers, colleagues, mentors, physicians, social media, and people not even involved/knowledgeable in medicine (*eye roll*). I know not everyone will agree with what I am about to say, but I wanted to share my thoughts on the matter because hopefully this will help someone of you who are angry about this see the potential benefits. My brief outline is as follows:

1. It is a licensure exam

2. We are clinicians, not scientists

3. We are human

Here is a quick review of the USMLE if you do not know about it. It is a 3 step licensure examination that medical students are required to take during their undergraduate medical education (i.e. before residency). Step 1 is a written test usually taken after the second year, and focus primarily on basic science, molecular biology, genetics, pathology, physiology and pharmacology. Step 2 is taken after the third year, and has 2 parts: clinical skills (practical) and clinical knowledge (written). Step 2 aims to test clinical knowledge acquired during clerkships, to determine if the student is adequately able to solve clinical problems, treat conditions, and interact with patients (hence the practical portion). Step 3 is taken after graduation before residency, and assess overall competency as a practicing physician.

Here is a little extra information about Step 1 for those not in medicine:

Test

7 40-question blocks

60 minutes for each block - totaling 7 hours of test time

45 minutes of break time disbursed throughout the 7 hours for drinking, eating, restroom etc.

Passing score - 194

Highest score ever recorded - 276

In 2000, number of topics tested - 900

In 2019, number of topics tested - over 3,000

Cost

Step 1 Registration - $630

UWorld (question bank) - $480

1 NBME practice test - $60 (recommended to take at least 4 in preparation)

First Aid Review Book - $70

That is over $1,000 all at once for one exam (and there is 3 of these). Not only is there incredible mental stress about score, content and studying, there also is stress financially!

1. It is a licensure exam

The USMLE stands for the United States Medical Licensing Exam. It does not stand for the "residency program choosing score" or the "how good of a doctor you will be test" or the "you can only go into IM now test". It was created to be a licensing exam, to see if medical students learned what they were supposed to, and could provide exceptional care upon graduation. If we look at other licensing exams, such as the Bar (law), the NCLEX (RN), and PANCE (PA), they are all pass fail. They may report scores, but the scores do not mean anything as long as you pass. It is a competency exam to make sure you are prepared for your career. It is not an assessment test to determine future performance, not a way to decide specialties, and not a way to rank future doctors against each other; yet that is exactly what it has become.

The USMLE cites the following as the main reason for changing USMLE Step 1 to pass/fail:

"...address exam security and unintended consequences of secondary score uses. The secondary uses of Step 1 scores for residency screening, in particular, have been the focus of extensive discussion... changing Step 1 score reporting to pass/fail can help reduce some of the current overemphasis on USMLE performance, while also retaining the ability of medical licensing authorities to use the exam for its primary purpose of medical licensure eligibility."

2. We are clinicians, not scientists

First, a large amount of the content on Step 1 is memorization of facts, many facts which will not be pertinent to future careers as physicians. Do not misunderstand me, learning the pathology and physiology of disease is incredibly important, but changing the Step 1 exam from 3-digit scores to pass/fail does not mean we are not learning that material, it simply means that we are judged on whether we know it enough to pass, not given a numerical score to be used in comparison to others.

Second, much of this information is available on the plethora of resources physicians now have. And if we teach physicians how to use resources like Up-To-Date, they will not need to memorize the kinetic pathway of the metabolism of "insert drug name here" because they know reliable ways to find that information. No, I am not talking about Dr. Google, but because of incredible technological advances we have had recently, we have access to so much more reliable and updated information, let's use it!

Third, numerous studies have looked at the statistical significance of differences in score. They have all agreed on one thing: over a certain score, there is no longer a statistically significant difference in performance on the exam, even if the score differs. I have read in numerous studies and been told by our Dean of Students that no significant difference exists between a score of a 240 and a score of a 270. On exams, this can be the difference of anywhere from 0-2 questions, yet residency programs will look at a 270 compared to a 240, and think "wow, the 270 is WAY smarter". But, there is actually no difference. The test was not designed to prove differences that high, because a passing score is 194. Obtaining a 194 means you have gotten enough questions right to demonstrate exceptional knowledge of basic science and clinical/pathological medicine. Yet, that person who gets a 270 will still be looked at as way better than your 240, even though you could have gotten the exact same number of questions correct. *mind blown*

Finally, and perhaps the most important reason I agree with this change, is that we are clinicians. Step 2 CK (the clinical knowledge exam) is still scored. This means that instead of residency programs looking at Step 1 as an indicator to separate candidates, they will look at Step 2. The clinical exam. You know, what we will actually be doing in our careers. This is HUGE.

"... The USMLE co-sponsors also believe that moving to pass/fail reporting of Step 1 while retaining a scored Step 2 CK represents a positive step toward system-wide change, while limiting large-scale disruption to the overall educational and licensing environment."

This means that medicine will finally be heading in a direction away from book smart, photographic memories (nothing against these people, but us normal folk need something), to real humans who are scored and judged on clinical practice instead of their memorization ability. Step 2 CK looks at clinical scenarios, treatments, ethics, diagnostic testing, patient and family interaction, medication interactions, problem solving, emergency reactions, and it has a practical portion with standardized patient actors!

3. We are human

I have been worried about Step 1 since I began medical school. They gave us a countdown at the beginning of M2 year. Every course is tailored to it, every resource references it, and everyone talks about it. It is a huge factor in medical student burnout.

"It decides your future"

"(insert specialty here) requires a Step 1 score over 250"

"If you don't get a 260, don't even think about applying to (specialty)"

Why is this one test, on one day, deciding my entire life? We all take a different test with different questions, at different places, at different times, and yet we are all compared and that 3-digit numbers decides what kind of doctor we get to be?

I had a mandatory meeting with our academic support team (every student does) to make a study schedule. The schedule goes as follows:

7AM: wake up, breakfast

8AM: question block, analysis, content review

12PM: lunch, exercise

1PM: question block, analysis, content review

5PM: dinner

6PM: question block, analysis, content review

10PM: end studying

11PM: bed

12 hours of studying per day.

4 hours "off" per day for cooking, eating, showering, driving, getting gas, brushing teeth, calling mom, petting cat, grocery shopping, stretching, exercise

8 hours of sleep (at least that's a blessing)

Every day. For 6 weeks.

Do you know many human beings who would enjoy that? Who can do that without burning out? Who can do that and not lose a part of themselves? (see last post for burnout)

No, because we are human. I am human. I am not a machine. I have feelings, thoughts, emotions. I can't sit in one place for 12 hours. I get distracted. I need to move around. I can stare at a screen or book for hours. I need social time. I need time to decompress. And for 6 weeks from mid-March to May, I won't have that.

While changing Step 1 to pass/fail will not eliminate that by any means, it will take some of the stress off. Both a 194 and a 270 are passing, and finally, that will be all that matters. Unfortunately, it will not affect me, as it does not go into effect until 2022. However, for those future doctors starting next year, go you!

To me, this is an incredible step in the right direction. Thank you Federation of State Medical Boards (FSMB) and the National Board of Medical Examiners (NBME).