When you change your medical school curriculum as we did a couple years ago, there is always a little angst over the potential of these changes having a negative impact.
One of the concerns was the potential impact of student performance on the United States Medical Licensure Exam (USMLE) Step 1 exam. The exam, commonly called "the Boards," is a one-day, multiple-choice test that assesses students’ basic science medical knowledge and their ability to apply it to clinical situations.
Before students can obtain their medical license, they must pass a total of three USMLE exams.
Step 1 is described above. Step 2 is a two-day test, usually taken in the fourth year of med school. It has two components:
- The first (called Clinical Knowledge, or CK), is a multiple-choice test on clinical sciences like surgery, internal medicine, pediatrics, and obstetrics and gynecology.
- The second (called Clinical Skills, or CS) requires students to examine and diagnose actors posing as patients. Students must travel to one of five testing centers around the country for this exam.
Step 3 is a two-day test, usually taken after the first year of residency. This is the final assessment of whether someone is prepared to practice general medicine in an unsupervised setting. It focuses on the diagnosis and treatment of patients. It includes both multiple-choice questions and computer simulations of patient care.
Our current second-year medical students – the first class that has been under the new curriculum – recently took the USMLE Step 1 exam. They did so about 3-4 months earlier than they would have under the old curriculum because of the condensed basic science blocks in the new curriculum.
We were pleased to see that the overall results for our "new curriculum" students were almost identical to our students’ results from previous years – when they were under the old curriculum. That’s good news for our college and all the many people involved in the curriculum change, but most of all for the students.
The new curriculum is intended to prepare students for being physicians in the new environment of health care, which includes rapid access to enormous amounts of medical facts and data. The curriculum places far less emphasis on memorization of facts and instead increasingly provides students with hands-on learning opportunities and small-group interactions, as well as training in bedside diagnostic technologies. We want them to embrace technology and research and be more inquisitive.
We think the new curriculum is not only more exciting and innovative for students but also more contextual and practical. It will allow students to master important tools of the medical field – such as ultrasound and electronic medical records – while fostering independent research, community-based team problem solving, and interprofessional education. We want our students to work in groups and take part in projects. In the end, we believe this will better prepare them for team-based health care delivery.
With the new curriculum – at the request of the students – we moved to a pass-fail grading system during the first two years of medical school. It was felt that if students don’t receive an actual grade, they are less likely to feel a need to compete with one another and more likely to collaborate and cooperate.
The Step 1 exam has become tremendously stressful for students, as the score they receive on the exam can determine their future path in medicine. The residency programs in the most competitive specialties – such as dermatology, neurosurgery, orthopaedics and ophthalmology – have hundreds of applicants for every position they have available in the match, making it virtually impossible to review each application in details.
Unfortunately, even though it was never intended for such a purpose, these programs often use the Step 1 score to "screen" applicants. Institutions set an arbitrary cutoff score for the Step 1 exam and will not consider applicants who score below this value. If you are below this cutoff score, you have a poor chance of obtaining a residency in these specialties, and you will need to take your medical career in another direction.
The Step 1 test has taken on much greater importance over the last several decades as the number of graduating medical students in the U.S. has increased dramatically, while the number of residency positions – particularly in the most competitive specialties – have remained relatively flat.
Ironically, by moving to a pass-fail grading system in the pre-clinical years, we have eliminated an objective measurement of student performance relative to their peers that also could be used by residency training program to evaluate students.
This has had the unintended consequence of increasing the pressure for students to perform well on Step 1. Furthermore, the exam remains largely a test of factual knowledge and not necessarily one that tests the individual’s ultimate ability to be an outstanding physician.
Recognizing this situation, we provide our students six weeks off at the end of their pre-clinical curriculum to prepare for Step 1. We also provide them access – at our expense – to an online commercial test-prep site that includes a bank of practice questions with feedback.
I think you can see how stressful the process, and Step 1 in particular, is for becoming a physician.
Although the best scenario would have been an improvement in Step 1 scores with the new curriculum, this year’s results should nevertheless be viewed as a success and validation of the new curriculum.
In spite of some issues that were identified in the first years of implementation of the new curriculum, our students did not lose any ground in the Step 1 exam scores, plus they now have several additional months available to them for clinical experiences that they would not have otherwise had.
In addition, they now have exposure to new topics, which we believe will make them better physicians over the long run – even if they are challenged by the current USMLE exam process.
Let me conclude by congratulating all our faculty and second-year students for the strong showing on the Step 1 exam. I especially want to acknowledge and thank the second-year students for their flexibility and tenacity in helping make the curriculum better, while at the same time dealing with the stress of mastering the materials and skills needed to be great physicians.
Thanks for all your efforts.