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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.

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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.

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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.

  • I read this editorial after learning about the changes to USMLE Step 1. I wholeheartedly agree with Dr. Nguyen and I am scared for our future patients and our profession.

    The questions on the exam may not always be clinically relevant, but the test is a reasonable gauge of success in medical school but perhaps more importantly an assessment of one’s intellectual ability to succeed in postgraduate education.

    • Step 2 still exists… does it not make more sense as a gauge for future resident understanding of the practice of medicine? The POINT the commenters are making is that Step 1 is not going to gauge whether someone can perform an orthopedic surgery or see some derm path on a histo slide. It’s gate keeping at its finest.

      Sorry gate keeping is falling out of favor. You’ll have to find new ways to exclude groups from medicine.

    • You’re completely missing the point. I won’t argue that Step 1 is not a great test. But why not just fix the test? Or eliminate it altogether? For example, why not just replace Step 1 with Step 2 and Step 3 with Step 2?

      The bottom line is that we NEED a test at the end of your pre-clinical years.

      Why?

      1) There MUST be a standardized test that can be used by residencies that can help compare students from different schools.

      2) This test MUST be universally completed by the end of the M3 year so that students can submit the results to residency programs.

      3) Taking the test during the M3 year is not feasible because everyone rotates through different clerkships in different order.

      3a) Now, if you wanted to make a Step 1 a standardized test at the end of M3 year to make it more “clinical” and less basic science I can see the merit. But it’s going to be equally stressful to the Step 1 test that exists now at the end of M2, and you’d just end up postponing it during the time that you should be focused on clinical experience rather than studying.

      4) You can call it “gatekeeping” all you want, but Step 1 is what gives a student from State University Med School an equal chance compared to Harvard Med. By eliminating Step 1, you’re just making the admissions committee at the ivory towers the gatekeepers.

      4b) Students will be incentivized to take on loans in order to attend a higher ranked school. Currently, I have no qualms recommending someone attending their state med school over an ivy league med school because I know if they do well on their board exams they will be given every opportunity the ivy league student has.

      4c) You are hurting DO students and FMGs who both use Step 1 as a way to match into residencies “above” their med school status. So this new policy is less inclusive than the current system.

    • As both a residency program director and an admissions committee member at a top 15 medical school, I am not aware any other top tier schools that have their students take Step 1 after M3 year.

      I would challenge you to name any schools that do, and also provide links to websites or journal articles to support your claim.

  • The commenters below are wrong. There is literature out there that denotes how better board scores leads to better completion of residency. Fully agree with the post and the other commenters are ignorant

  • Step 1 is part of a licensing exam and designed as such. It’s fundamental purpose is for licensure. The importance placed on it by residency programs is a sad byproduct of an outdated Match system. The “best objective measure we have right now” argument doesn’t mean it’s a good objective measure or a good argument. Physicians are smart people. Find new objective measures.

    Step 1 is also taken in year 2 of med school. A low score can effectively eliminate a student from most specialties before the student has had their first clinical rotation. What does that say about the growth that happens during clerkships?

    In no way does is a step 1 score (high or low) “measure ability” as a physician. Strong Basic science knowledge is a component of a good student but it shouldn’t be worn like a badge.

    Residency is part real world job and part continuing medical education. In the real world people develop networks and social skills to compliment their merits when obtaining employment. Why should medical students be treated differently?

  • For someone thats in an evidence based profession its sad to see you cite the need for a standardized test that has no evidence behind it. Infact evidence shows its a useless exam. Just get ppl that are good at taking tests and probably dont give a shit about patients getting their specialty choice. It doesnt test getting to differential or actual medical knowledge. Sad to see doctors voice their opinion off something that lacks credible evidence.

  • It is a shame to make stuents go through so much stress with the scoring system here!!! Every year I here stories students killing themselves because of this and I am disgusted by it!!! An action needs to take place now!!! It is not worth losing a life over a crazy system like this!

    • I’m an untraditional oms1 coming from a law background. Making step 1 pass fail mimics the bar exam. The legal profession almost exclusively goes by grades almost during the first semester only. Legal hiring is also heavily influenced by looks and prestige of the law school. DO schools in particular should be up in arms to prevent this.

      Anything that emulates the legal profession should be looked at with extreme skepticism. Where I practiced at least I found the level of legal knowledge retained extremely low. (personally I think they should require everyone to retake the bar every 10 years). Part of this is not testing for long term retention in a meaningful fashion.

      If the usmle tests stuff that isn’t helpful for a practicing doctor by all means change that.

  • Well, many people do not realize that programs apply filters in software in order to filter out applicants with low score or with a score below their desired value.This means that there are thousands of applicants who send their applications via ERAS without realizing that their applications will never be seen by anyone but ERAS staff.This is a money making machine.Once you break the circle, the revenue will drop.I doubt this proposition will ever take place,so please, continue studying receptors, molecular biology and biochemistry in order to score high on Step 1.

  • There are medical students committing suicide from failing step 1 because of not able to score competitively no matter how hard they try to pass the exam. A change needs to a pass/fail needs to take place to improve this system!!!

  • Or you could take a page out of the EM selection, and select individuals based on assessment letters by unbiased 3rd parties during the 4th year. Assess what you want directly. Presentations, notes, patient interactions, ability to work with team, ability to learn and take feedback, effort, and energy. Stop using indirect metric which continue to fail at being predictive for residency success. Maybe instead of interviews – you could invite students for ghost shifts to watch them work rather than care about exam grades, worthless research, or other time wasting resume padding.

    • Exactly.Why not choose an applicant with a high score,who is bright like a sun,an applicant who knows that Step 3 wants examinees to use Aspirin to manage Rheumatoid arthritis?

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