Following nearly two years of collecting and considering input from hundreds of medical education, regulatory and clinical stakeholders, administrators of the USMLE (United States Medical Licensing Examination) are making a significant change to the first in the series of tests required for securing a medical license. As soon as January 2022, USMLE Step 1 score reporting will switch from the current three-digit numeric scoring to only a pass/fail outcome. Numeric scores will continue to be reported for Step 2 Clinical Knowledge (CK) and Step 3, while Step 2 Clinical Skills (CS) will continue to be reported as pass/fail.
The move comes after careful consideration, and undoubtedly lengthy deliberation, among participants in the Invitational Conference on USMLE Scoring, dubbed InCUS. Held in March 2019 and sponsored by the American Medical Association, the Association of American Medical Colleges, the Educational Commission for Foreign Medical Graduates, the Federation of State Medical Boards and the National Board of Medical Examiners, the conference launched a full-scale review of the exam’s efficacy and its effect on students’ wellbeing.
It’s no secret that Step 1 weighs heavily on the minds of students in the months leading up to the exam, usually taken at the end of the second year of med school. It emphasizes knowledge of basic sciences, including anatomy, biochemistry, behavioral sciences, microbiology, immunology, pathology, pharmacology and physiology and is designed to measure a students’ minimum competency as a prospective medical practitioner. Further, it traditionally has been a primary factor in whether a student lands a prime choice residency.
Therein lies a top supporting reason for the switch, says Max Jordan Nguemeni Tiako, a fourth-year student at Yale School of Medicine.
“The reality is that Step 1 is neither precise nor does it predict students’ performance as residents beyond a certain threshold,” he told STAT, an online publication focused on health, medicine, and scientific discovery. “With a standard error of eight points, two applicants with scores as far as 15 points apart may not be meaningfully different and yet several programs use singular cutoff points as screening tools.”
Tiako lauds the decision, suggesting that it’s in line with medical educational systems that place less emphasis on test scores, focusing instead on overall competency – something of critical import for certain student demographics (including international students studying in the US and working double to overcome language barriers) who tend to score lower despite being equally if not more competent than their American-born fellow students.
“I studied because I wanted to become the best doctor for my future patients, not because I was preparing for a test,” he said.
“Our student, resident and physician members voted to endorse a pass/fail policy, in part, because we know our current residency selection system is causing significant distress for our students,” said Susan Skochelak, MD MPH, Chief Academic Officer for the AMA. “The AMA is currently supporting new ideas in the transition from medical school to residency through our funding of the Reimagining Residency Initiative and our Accelerating Change in Medical Education Consortium. We look forward to working with our colleagues across the continuum of medical education in developing improvements in physician education transitions.”
“The transition from medical school to residency training is a matter of great concern throughout academic medicine,” added Alison Whelan MD, Chief Medical Education Officer AAMC. “The decision by the NBME and FSMB to change USMLE Step 1 score reporting to pass/fail was very carefully considered to balance student learning and student well being. The medical education community must now work together to identify and implement additional changes to improve the overall UME-GME transition system for all stakeholders and the AAMC is committed to helping lead this work.”
In the formal joint announcement of the change, the FSMB and NBME stated that changing Step 1 score reporting to pass/fail will 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. Further, 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.” The announcement also referenced continuing work toward “advances in reliable and holistic assessment of the training of physicians.”
No word yet on what those coming changes might entail or when they can be expected.
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