The United States Medical Licensing Examination (USMLE) is a three-step exam (Step 1-3) required for medical licensure. The exam is designed to assess a “physician's ability to apply knowledge and fundamental skills required for the safe and effective practice of Medicine” (USMLE, 2019). However, in recent years, students’ USMLE scores have been interpreted and used in various ways that often do not align with the primary intention of the test (Lewis, 2011; Gauer & Jackson, 2017; Andolsek, 2019). This has been generating many concerns in the medical education community. A critical view of this important issue through a historical and a sociological lens can be helpful to better understand the problem and develop potential solutions.
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Historically, the USMLE was first introduced in 1992, replacing the National Board of Medical Examiners (NBME) Examination and the Federation of State Medical Boards (FSMB) Licensing Examination programs (NBME, 2019; FSMB, 2019). Traditionally, a medical school’s curriculum consists of a two-year pre-clinical phase with foundational sciences instruction, followed by a two-year clinical phase when students complete clinical rotations (i.e. “2+2”) (National Resident Matching Program, 2014 & 2019; Gauer & Jackson, 2017). Students have generally taken USMLE Step 1 (i.e. Step 1) at the end of their second year before starting their third year clinical rotations (Alcamo, 2010). Every year, a number of students fail the exam, which leads to a delay of their third year, and often graduation. Data from the Association of American Medical Colleges (AAMC) show that 82% of schools “require their students to take Step 1 before starting the third year, and 4% of students in a given class delay the start of third year due to Step 1 failures” (AAMC, 2014). This setback negatively affects student academic advancement and residency training.
At the same time, the practice of medicine has been continuously evolving with the rapid advances in technology and changes in patient care models necessitating a broader set of competencies for practicing and future physicians (Boulet & Durning, 2019; Laiteerapong & Huang, 2015). These trends have led to a curricular reform in medical schools with the adoption of the competencies endorsed by the Accreditation Council for Graduate Medical Education (ACGME) (Hawkins, 2015; ACGME, 2019). Assessment has become competency-based to follow these curricular trends. Moreover, majority of medical schools have changed their grading policies transitioning to a pass/fail system from the traditional numerical system (AAMC, 2014). Responding to this reform, the NBME, that sponsors the USMLE, modified the content of Step 1 exam for better alignment with current standards, and raised the minimum passing score (Haist, 2013 & 2017).
Looking at USMLE through a sociological lens, it is clear that it has had a significant impact on students and other stakeholders since its early implementation. There has always been a lot of angst among the students about taking a high-stakes that is difficult (Sutton, 2014; Weissbart, 2015). Furthermore, the recent transition to a pass/fail grading system in most schools has prohibited the stratification of students according to their level of achievement (AAMC, 2014 & 2019). Residency program directors place a disproportionate amount of weight on Step 1 scores as they screen applications. As a results, Step 1 has become the most critical factor in determining a student’s career choice, residency training, and overall trajectory (Kim, 2018; Carmody, 2019). Data from the AAMC show that mean Step 1 scores for each medical specialty positively correlate with compensation, including salary and estimated net worth at retirement (Eltorai, 2013). Generally, students are advised to consider their own USMLE scores when deciding which specialties and programs to rank (Gauer & Jackson, 2017). Moreover, a failure in Step 1 delaying third year has a significant financial impact considering the expensive medical school tuition and accumulated debt. Retaking the exam is also costly and not covered by the medical school (NBME, 2019).
In the midst of these changes, medical educators are under pressure to align their curriculum and teaching with the USMLE new blueprint to better prepare students for the exam. In fact, many medical educators worry that they “now only teach students to the test” (Karan, 2014). An increasing number of medical schools are shifting to a shorter pre-clinical phase, and integrating basic, clinical, and health systems sciences in all their courses (Pock, 2019). Some schools have moved Step 1 to the end of the third year (Daniel, 2017). In addition to the medical school community at large, other stakeholders are also affected, including residency program directors, medical licensure bodies, the AAMC, the National Resident Matching Program, patients and communities as this issue affects graduation rates, specialty choices, location of practice, and patient care (Gauer & Jackson, 2017).
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Looking at USMLE Step 1 exam through both a historical and a sociological lens confirms the complexity of the issue and help better understand the underpinnings of this problem. The two perspectives are complementary and highlight the various dimensions and broad impact of this issue on the medical community at large. An important next step would be to get all the actors and stakeholders together and learn from the schools that have implemented changes to make the most appropriate decision about the USMLE exam at a national level that will work best toward students’ academic success.
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