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!
By BRYAN CARMODY
Let me show you some data.
I’m going to show you the Match rate and mean Step 1 score for three groups of residency applicants. These are real data, compiled from the National Resident Matching Program’s (NRMP) Charting Outcomes in the Match reports.
- U.S. Allopathic Seniors: 92% match rate; Step 1 232.3
- U.S. Osteopathic Seniors: 83% match rate; Step 1 225.8
- International Medical Graduates, or IMGs (both U.S. and non-U.S. citizen: 53% match rate; Step 1 223.6
Now. What do you conclude when you look at these numbers?
In the debate over the U.S. Medical Licensing Examination’s (USMLE) score reporting policy, there’s one objection that comes up time and time again: that graduates from less-prestigious medical schools (especially IMGs) need a scored USMLE Step 1 to compete in the match with applicants from “top tier” medical schools.
In fact, this concern was recently expressed by the president of the National Board of Medical Examiners (NBME) in an article in Academic Medicine (quoted here, with my emphasis added).
“Students and U.S. medical graduates (USMGs) from elite medical schools may feel that their school’s reputation assures their successful competition in the residency application process, and thus may perceive no benefit from USMLE scores. However, USMGs from the newest medical schools or schools that do not rank highly across various indices may feel that they cannot rely upon their school’s reputation, and have expressed concern in various settings that they could be disadvantaged if forced to compete without a quantitative Step 1 score. This concern may apply even more for graduates of international medical schools (IMGs) that are lesser known, regardless of any quality indicator.”
The funny thing is, when I look at the data above, I’m not sure why we would conclude that IMGs are gaining advantage from a scored Step 1. In fact, we might conclude just the opposite – that a scored Step 1 is a key reason why IMGs have a lower match rate.