USMLE Changes and What You Need To Know

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USMLE Exams are a set of standardized tests that every medical student needs to take. This past May, the USMLE program announced major changes to the USMLE Step 1 and 2 exams. Read on to see what these changes are and their effects:

Step 1

Step 1 is the first examination in the USMLE series. It is an 8-hour examination aimed to evaluate the basic science knowledge of medical students and is typically taken at the end of year 2 of medical school. It is scored between 1-300 with a score of 194 designated as passing. On February 12, USMLE announced the Step 1 would transition to a P/F scoring system.

Numerous reasons were cited for these changes. Many residency programs started using USMLE Step 1 scores as a primary means of filtering residency applicants, often using arbitrary thresholds which did not correlate with the student’s potential to be an excellent doctor. Furthermore, since USMLE Step 1 has a very narrow score standard deviation, absolute test score differences between two students did not reflect their differences in medical knowledge.

Primarily though, studies have consistently shown that Step 1 propagates racial disparities; Black and Latino students have had significantly lower scores on Step 1 than Caucasian students. Using Step 1 filtering threshold resulted in lower numbers of Black and Latino medical students receiving competitive residency interviews.

Lastly, with the rise of USMLE Step 1 aids such as First Aid, Pathoma, or Sketchy, students would neglect their medical school curriculum in years 1 and 2 to prepare for Step 1. I personally recall the sharp decrease in medical school lecture attendance as we got closer to Step 1 dedicated study period. Unintentionally, students were shortcutting their medical education to perform well on a single examination.

In order to counter the racial biases and unintended consequences of the USMLE Step 1 examination, USMLE Step 1 will be P/F starting in January 2022. For students who took the examination before this date however, the three-digit score will still be displayed on applications. The hope is this change can lead to reduced biases against minority medical students and alleviate unnecessary negative impacts. However, it is important to be aware of the downstream effects of these changes. Evan Masutani, UCSD MSTP candidate, shares his thoughts:

 

“The decision to remove numerical scores from STEP 1 concerns me.  It will likely just shift the stress for medical students.  Previously, medical students had effectively two chances to score well: Step1 and Step 2 CK.  Now, Step 2 CK, which remains scored, will inevitably become a much more high-stakes examination.  There will be no second chances.  Furthermore, the lack of numerical Step 1 scores will create an evaluation vacuum for residency program directors (PDs), who, to my understanding, were not consulted about this change.  These PDs, who are busy physicians themselves, will now be forced to come up with new, similarly imperfect metrics to evaluate applicants.  More emphasis will likely be placed on research papers, hours of community service, and the medical school’s name brand.  The result will be an even more stressful and costly arms race for medical students hoping to stand out from their peers.  Given these additional stressors and costs, I fail to see how this change would effectively address inequalities we see in medicine. The best way to address both stress and inequalities in medicine is probably to lobby Congress to fund more residency seats, such that supply actually meets demand.”

Juliet Nicodemus, UCSD MSTP Candidate, believes these USMLE Step 1 changes might help to focus more the early medical education on patient care though:

“The number one goal of medical education should be to educate competent and compassionate physicians. If numerical scores for Step 1 get in the way of that goal, I wholeheartedly support making Step 1 pass- fail. My experience with pre-clinical courses becoming pass-fail was that it encouraged collaboration among classmates and greater attention towards the practice of medicine in addition to the memorization of important medical information. Ideally, making Step 1 pass-fail will further these changes. In addition, having taught medical students over the last few years, I’m acutely aware of the fact that they push themselves extremely hard, regardless of whether there are numerical grades or pass/fail. I’m not concerned that pass-fail will decrease the amount of material they learn or the rigor with which their learn it.”

The ultimate effects of Step 1 changing to P/F will only be revealed through time, but Step 1 is a major stressor for medical students and this change is hopefully one step toward reducing burnout.

 

Step 2 CK

Step 2 CK is part one of the two-part USMLE Step 2 exam, following a similar format to the USMLE Step 1 exam. It is a 9-hour multiple-choice exam that focuses on the clinical application of medical knowledge. The exam is scored between 1-300 with a score of 209 designated as passing. On May 15, the USMLE program announced that it would increase the “number of items assessing systems-based practice, patient safety, legal/ethical issues, and professionalism.” They have also released updated practice materials for these changes.

Step 2 CK is an important score component in residency application along with Step 1. As of January 2022, when Step 1 will become P/F, Step 2 CK may be weighted more heavily to select residency candidates. Since Step 2 CK is focused on clinical knowledge, this change may be warranted; however, this change may not benefit students who may have done well on Step 1 but not as well on Step 2 CK. Ultimately, the goal is to evaluate students holistically and the Step 2 CK score will only be a component of the student’s application. Additionally, as USMLE regularly is evaluating their examinations, USMLE Step 2 CK may potentially become P/F in the future also.

 

Step 2 CS

Step 2 CS is part two of the two-part USMLE Step 2 exam specifically assessing medical student clinical skills. Unlike Step 2 CK, which is a written examination, Step 2 CS is meant to simulate patient encounters that medical students would encounter in real life. Step 2 CS was reimplemented in 2004 after its discontinuation in the 1960s in an effort to promote physician education in patient communication and interaction. The exam is approximately 8 hours and consists of 12 standardized patient encounters.

Step 2 CS examinations require a scale of organization different from the written Step 1 and Step 2 CK examinations, as patient actors, evaluators, and objectiveness are required. As a result, Step 2 CS is offered in only 5 cities, forcing a majority of medical students to travel long distances to take this required examination. On top of the testing burden, 95% of MD/DO students taking Step 2 CS passed. After reevaluating the usefulness of Step 2 CS, National Board of Medical Examiners (NBME) and Federation of State Medical Boards (FSMB) discontinued the examination.

Discontinuation of the Step 2 CS means that evaluation of student patient interactions will likely come from medical school recommendation letters and the Dean’s letter. Most MD/DO schools have their own patient encounter scenarios, called OSCEs or Objective Structured Clinical Examinations, which help develop medical student communication skills. Additionally, clinical rotations are critical for developing these skills. Although the Step 2 CS discontinuation may lead to less standardization in medical student clinical skill evaluation, this announcement probably comes as a relief. Perhaps in the future, there will be a way to make standardized clinical skill examinations more accessible to medical students, especially as technology develops exponentially. For the more immediate future though, the evaluation of clinical skills will be placed on medical schools.

These USMLE changes may be the start of a revolution in medical education. As the coronavirus pandemic taught us, physicians and healthcare workers are critical. Physicians suffer from strikingly high burnout and depression rates. There are many changes that need to be implemented to address this crisis in medicine and these USMLE changes may be the start.

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