Should Medical Schools Teach to the Boards?

flying cadeuciiIn the 2012 National Residency Match Program Survey, which is sent out to residency program directors around the country by the NRMP, the factor that was ranked highest with regards to criteria considered for receiving an interview—higher than honors in clinical clerkships, higher than extracurricular experiences or AOA election, and even higher than evidence of professionalism, interpersonal skills, and humanistic qualities—was the USMLE Step 1 score.

When considering where to rank an interviewed applicant, the Step 1 score took a backseat to some of the aforementioned criteria that are perhaps more telling of what kind of person the interviewee is, although it was still one of the highest considered criteria for ranking applicants as well.

When a single exam is given this level of importance in determining a future physician’s most critical period in career development—their residency—we have to look carefully at our system.

Two points of consideration come to mind. First, is it wise to weigh a test score so heavily? Many students and faculty could easily point out that student performance on exams by no means always reflects their clinical acumen and social skills when seeing patients.

Medicine is, after all, an art far more than a science.

Nonetheless, it would be foolish to assume that scores have no worth—a high score on an exam, particularly a behemoth such as the USMLE Step 1, points out many qualities in an individual: hard work, persistence, discipline, and frankly, an understanding of textbook medicine.

And thus, we are left somewhere in the middle—perhaps we should weigh scores less than we do, but when you have to sort through thousands of applications, the only standardized metric to quickly compare is, in the end, a number somewhere between 192 and 300.

This brings me to my second point of cogitation—if we are to accept that the system will run with a heavy dependence on a single score, does the said exam test what is clinically essential and do medical schools teach their students what is needed for this exam?

As a second year student currently beginning my boards preparation, I know there is a problem here. Most students in my class and around the country rely heavily on additional preparation materials that cumulatively cost nearly $1000 in preparation for the USMLE.

Recently, after completing two years of our clinical curriculum, many of us felt uneasy at best with regards to mastery of boards content when taking a practice NBME exam before our 1 month of allotted study time.

After paying thousands of dollars in tuition, I would expect more.

My school, like many top research institutions, prides itself on not teaching to the boards. We have lectures from several world-renowned physicians and scientists, many who present cutting-edge clinical and basic science research as part of our curricular program, but many lectures ultimately have superfluous minutiae when framing our educational objectives in the context of the USMLE.

As students with an insatiable curiosity and passion for learning, we gladly and earnestly absorb from and appreciate the wisdom of our instructors, but as future applicants to extremely competitive residency programs, I can’t help but wonder if our medical education system is structurally misaligned.

Abraar Karan (@AbraarKaran) is a medical student at UCLA.

13 replies »

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  5. I believe that no doctor should be judged based on their boards scores. It is indeed a test of knowledge, but doesn’t fully cover what a good physician should have. Keep your head high, Abraar. Knowledge of the field and compassion is key to a physician’s success. Good luck!

  6. I appreciate all of the fantastic and engaging comments.
    Dr. Val, thank you for your kind words of encouragement. I whole-heartedly agree.

  7. Abraar, I feel your pain. It seems so unfair that a number defines the kind of doctor you can become. But consider this: cream always rises. If you are hard working, intelligent, kind, and determined – you will be a success in ways you can’t even imagine at this point in your career. With a little creative spirit, you can parlay your training into anything from creating new hospital designs to founding a chain of heart-healthy restaurants, to being the CEO of an innovative medical robotics company. You can do anything you put your mind to… and if you believe in yourself, one day you will look back and laugh at how upset you were that you didn’t match in neurosurgery/dermatology/radiology, etc. You’ll see those who did are likely to have a much less interesting life. Winning the memorization/regurgitation game correlates with narrow career focus, burn out and depression.

    That being said – you’ve gotta pass, and your med school should absolutely take it upon themselves to give YOU every advantage going in. It’s shameful that medical students have to spend extra time on the side to learn the board information. It should be a clear part of the curriculum.

  8. A school in the Midwest recently underwent a curriculum change which involved focusing less on basic science and more on soft sciences and public health issues during the first two years of medical school. The first and so far only class to take Step 1 had 12 failures and saw the overall class average drop significantly from where it had been for the previous handful of classes. Whether or not schools should teach to the boards or not, they certainly shouldn’t leave their students hanging out to dry like that.

    I have long argued that with both MCAT and board scores, beyond a certain score, the only thing that should be reported is a passing score. Call it a High Pass if you want. I would choose 0.5 SD above the mean as the cutoff. Beyond that, I find it hard to believe that any separation achieved has any real world value, yet certain med schools will jump at the chance to recruit those students, and certain specialties will hardly consider applicants without the highest Step 1 scores. It is unlikely that administrators will ever go for such an idea. The bottom line is that having numbers to differentiate students with, no matter how meaningless, makes their jobs easier. They have no interest in validating the process and nobody is going to make them.

    We are also placing far too much weight on high scores that are often a reflection of nothing more than how many times someone made it through a question bank or review book. This is hardly right to begin with, but is even more absurd given the big differences in time off for dedicated study from school to school. Those students with varied interests and much to offer who can’t cite the page number in first aid where a certain acronym is found don’t even get their foot in the door with many specialties, and that is sad.

  9. I think we need to determine what educational form is best for the prospective physician, period. Unfortunately, the National Board Exam is just the first in a line of exams, since most Specialty Boards are now going to a recertification process, in addition to MOC. There is currently a huge backlash from the Internal Med docs against the ABIM for pushing MOC, which includes increased time and money for docs to continue in that specialty. What is the purpose of these exams? Does passing them mean you are/or will be a good physician? Do repeat exams every 7-10 years prove anything or add value to the physician’s learning process? Are there better ways to assess a physician’s or medical student’s competence?

  10. I do not think medical schools should teach to the boards, They should teach you how to think like a physician. Medical schools should then evaluate there students on knowledge, work ethic, and communication skills and use those evaluations to rank students. Medical schools have moved away from ranking students forcing residency programs to lean more heavily on board scores to determine rank lists.

  11. I do agree with David, if the exams don’t match curriculum maybe they should be updated but still hold some of their original format as there seems to be some good from that format too.

  12. I suppose an equally good question is whether the content of the boards should be updated to better reflect what is taught in medical schools. In theory, at least, the medical curriculum should complement the board exams, and the exams should reflect the curriculum.

  13. Thank you for your perspective. I remember many of my former classmates stressing out so much before having to take their board exams. It’s an interesting concept – changing the curriculum of medical schools, especially when so many schools are moving toward more group-based evidence-based medicine curricula.