By TALAL HILAL, MD
The United States Medical Licensing Examination (USMLE) Step 1, a test co-sponsored by the Federation of State Medical Boards (FSMB) and the National Board of Medical Examiners (NBME), has been the exam that people love to hate. For many years, blogs, Twitter feeds, and opinion pieces have been accumulating urging the presidents of the FSMB/NBME to stop reporting a 3-digit score and instead report a pass/fail score. This animosity towards the Step 1 exam originates from the reality that medical schools have increasingly focused their curriculum on teaching what the Step 1 wants you to learn – medical trivia that almost always has no bearing on how to approach a clinical problem.
This “Step 1 Madness” is unhealthy. The reasons for its existence are many: residency and fellowship programs allow it to exist by idolizing higher scores, some believe it is a metric that can predict future quality of care, board pass rates, etc. And some are naïve enough to think that what is tested on the Step 1 is actually useful medical knowledge! It may be due to a combination of the above that the Step 1 has found itself in such a peculiar spot. However, the emphasis on the Step 1 score means that medical students’ fate is being determined by a single test. Nobody wants their fate to be so unmalleable.
Those who were writing vehemently against a 3-digit score rejoiced when the FSMB/NBME announced on February 12 that the Step 1 will finally become a pass/fail test as early as January 2022!
My initial reaction was mixed. I have always felt that Step 1 was the single most important factor in securing a residency interview. The announcement made me think of my path to residency training in the U.S. As an international medical graduate (colloquially referred to as an “IMG”), I went from learning how to shave to becoming a medical student seemingly overnight. For a 17-year-old, medical school felt like American college but without the arts and history, and with frequent visits to the cadaver lab. For various reasons that I will not bore you with, I decided to pursue residency training in the U.S. This meant I had to buy a copy of “First Aid for the USMLE Step 1” – the holy book within which all medical trivia resides. My medical school, being Irish, could not care less about the USMLE, so I was on my own.
I would study the lectures given by my medical school professors and then find their corresponding chapters in the Step 1 books. Little did I know, I was supplementing my medical school curriculum by adding an American twist to it. The Krebs cycle did not only have a rate-limiting step catalyzed by isocitrate dehydrogenase; it was a much more important phenomenon characterized by 8 steps that I now had to memorize. I felt empowered by my knowledge of minutiae. Coupled with my medical schools’ emphasis on physical examination skills, I felt like I had the best of both worlds.
I spent a few sleepless nights before the Step 1 test thinking about what would happen if I failed? Where would I go for my medical training? As an IMG, I was already at a disadvantage with only 50-60% of all IMGs matching. This test, in my mind, had the potential to increase my chances of making it to the U.S.
But did it?
I did well, nothing earth shattering, but certainly a competitive score for an Internal Medicine residency spot at the time. I then took the Step 2 CS and passed. I pursued a clinical elective in the U.S and was able to secure a letter of recommendation from the attending with whom I worked – a short paragraph and a half saying I’m good with patients, or something to that effect. I applied for the residency match without having my Step 2 CK result and did not get a single interview. I thought I had a strong application.
I was devastated. I relied too much on the Step 1 and it got me nowhere.
With the Step 2 CK score added to my profile, I was officially certified by the Educational Commission of Foreign Medical Graduates (ECFMG). I tried my chances again the following year, received a few interviews and matched! I went on to complete a fellowship in hematology and oncology and the rest, as they say, is history.
For me, what made a difference was the Step 2 CK. Nothing else changed in my application within a year. I remained without scholarly or extracurricular activity (unless you count finishing a 30-hour video game on a weekly basis an extracurricular activity). I still wonder how I made it, and whether I would have invited myself for an interview if I were in the program directors’ shoes reviewing my application.
When I first heard of the announcement to change the Step 1 scoring to pass/fail, I had my reservations, but the more I thought about it the more I realized that it may be a blessing in disguise for many IMGs. Sure, those who score 2 SDs above the mean on their Step 1 will be at a disadvantage; they will not stand out anymore, but that will be the case for all applicants – IMGs and non-IMGs alike.
I know of a few IMG colleagues whose scores were off the charts (260 and above) and it seemed that that alone was the catalyst for a steady stream of interview invitations. But I know of more IMGs who took 1-3 years after graduating medical school just to study for the Step 1, many of whom never had the guts to take the exam for fear of scoring low and never matching. A pass/fail test means that this panic-inducing hurdle will be removed. IMGs can focus on the Step 2 CK, which is more relevant anyway, and maybe spend time reading Tolstoy instead of memorizing the names of the rotator cuff muscles and their insertion site on the humeral head.
So, the next logical question is – What will happen to IMGs when this goes into effect?
The answer, I speculate, is nothing. Programs that interview IMGs do so because they need them and/or like them, and maybe to advertise that they are more inclusive and diverse. IMGs represent 25% of licensed physicians in the US, many of whom are working in underserved communities that are not as attractive to American physicians to live and work in. These areas are so desperate for physicians that they have provided incentives for IMGs in the form of tracks for permanent residency in exchange for their service. With the physician shortages driven by an aging population, IMGs will always be needed as long as they pass the Step 1.
It is important to remember that a substantial proportion of programs do not interview or rank IMGs – approximately 40%, no matter how high they score on the Step 1. They don’t, of course, advertise that but we IMGs know who they are. IMGs applying to these programs will be filtered out by virtue of their IMG status. Nothing will change there.
For IMGs, the Step 2 CK was always important, and since it will remain numerical, it is likely that it will become more important; until test takers take to the street to change it to pass/fail when “Step 2 CK Madness” ensues.
The average IMG Step 1 score is similar to that of a non-IMG. This means that IMGs that stood out have done so not because of the Step 1, but through scholarly activity and U.S clinical experience (i.e. electives). I admit, attaining these new medals can be difficult in places where an infrastructure for research does not exist, and where medical schools limit where and how many electives a student can have, let alone allow them to travel to the U.S. for extended periods of time to work with Dr. Jones (name is made up) at Johns Hopkins University. Funding mechanisms or loan options are limited in countries from which the majority of IMGs come from (e.g. India, Caribbean, Pakistan, Mexico). Nevertheless, many IMGs spend exorbitant amounts of money doing observerships after medical school that have little to no value while they study for their Step 1 aiming for that 260. Those IMGs can now take the test earlier, and spend their money doing electives in medical school.
This announcement is a disruption that has the potential to facilitate improvements in the residency/fellowship program selection processes, and perhaps medical school curricula. It will disadvantage test takers who score 2 SDs above the mean on the Step 1, but that is the trade-off to create a system with one less faulty metric to filter students.
I Tweeted “If the Step 1 was a pass/fail when I took it, I most likely wouldn’t be where I am today.” All the “Likes” and engagement I received were from IMGs. I may have used hyperbole in that statement, but I suppose the essence of it holds true. Where would any of us be if it wasn’t for some metric or achievement that society collectively decided to value? I just hope that the next metric that comes along is truly valuable.
Talal Hilal (@THilalMD) is a hematologist and medical oncologist at the University of Mississippi.