Among the endless metrics for assessing the quality of health care, one that is exceedingly important for measuring physician quality is on the chopping block.
I’m talking about turning the U.S. Medical Licensing Exam Step 1, which all medical students take at the end of their second year of studies, into a pass/fail test. This proposed change was quietly announced by the owners of the test and has received almost no media coverage. Such a pivotal change, which I find troubling, merits greater attention and debate. If you, too, think it is an unwise move, make your voice heard before comments on the proposal are closed on July 26.
Over the past 20 years, medical schools have mimicked larger trends in higher education to become more diverse by deemphasizing standardized testing for admissions. Once medical students are in the door, administrators have attempted to address disparate levels of achievement by embracing pass/fail grading systems that emphasize experiential learning over foundational concepts.
The lack of objective metrics has led to a greater reliance on numerical scores from the Step 1 exam. For the directors of residency and fellowship programs, these scores serve as easily quantifiable proxies of ability. A change to pass/fail would represent the culmination of years of watering down medical education in ways that have significant repercussions for medical training and patient care.
In theory, these well-intended efforts aim to reduce pressure on medical students and increase diversity. Yet they are likely to have the opposite effect.
Without objective standards like standardized testing or grades, residency directors will have to focus on who you know and what you are. Using the who-you-know standard will place even more pressure on students to secure entrance into prestigious colleges and medical schools because the proxy of academic pedigree and network of elite institutions will carry more weight when it comes to placement in residency and fellowship programs. This will increase the medical school rat race by forcing students to focus on accumulating secondary laurels such as pursuing myriad leadership activities or pledging indentured servitude to research professors who will have outsized influence on shaping their residency prospects due to the absence of other objective standards.
Without objective ways like grades and Step 1 scores to measure ability, the what-you-are standard will make it easier to justify race-based quotas in residencies and fellowships. Marginalizing the importance of standardized testing may make it easier to expand opportunities for individuals who can check the right gender and race boxes. But it comes at a cost for people who do not have the “right” networks and fall outside of the “right” categories.
Admission to residency programs based on networks and categories is, by definition, arbitrary. In a world without standards, people may simply assume that medical trainees got into their programs because of their elite connections, race, or gender. This would delegitimize medical students’ efforts and the process itself. Standardized testing, for all of its alleged flaws, is the key to genuine equal opportunity. By having objective metrics, medical students can focus their energies on mastering the material and demonstrating they have the ability to succeed as physicians even if they do not come from the most prestigious institutions or well-connected families.
If elite networks and pedigree had been the key a generation ago, Asian-American students like me would have had limited access to medical school or residency slots and would have been on the outside looking in — just as Jewish students were a generation earlier when elite universities and hospitals had quotas to limit the number of accepted applicants who were Jewish. In a profession where highly refined skills, impeccable judgement, and swiftness of mind can make a difference between life and death, standards that rely on networks and categories of race and gender undercut the point of medical training.
Medicine and merit should go hand in hand. When you face significant illness, you want to see physicians whose decades of rigorous training in medical school, residency, and fellowship serve as proxies for their competence. The recommendation for pass/fail reporting of Step 1 scores represents an unvarnished attempt to abolish the last merit check in medicine. While this approach may open the door for greater diversity in residency and fellowship placements, it perpetuates a pattern of evisceration in quality and standards.
No one wants to see a physician who gets diagnoses right only half of the time. Watering down the system by eliminating numeric scores on Step 1 equates to root rot that will gradually undermine the medical profession.
Kim-Lien Nguyen, M.D., is a cardiologist and assistant professor of medicine at the David Geffen School of Medicine at UCLA. The views expressed are those of the author’s.