By PRANAV PURI, PUNEET KAUR, and MARCUS WIGGINS, MBA
As current medical students, the ongoing COVID-19 pandemic represents the most significant healthcare crisis of our lifetimes. COVID-19 has upended nearly every element of healthcare in the United States, including medical education. The pandemic has exposed shortcomings in healthcare delivery ranging from the care of nursing home residents to the lack of interoperable health data. However, the pandemic has also exposed shortcomings in the residency match process.
Consider the United States Medical Licensing Examination (USMLE) Step 1. A 2018 survey of residency program directors cited USMLE Step 1 scores as the most important factor in selecting candidates to interview. Moreover, program directors frequently apply numerical Step 1 score cutoffs to screen applicants for interviews. As such, there are marked variations in mean Step 1 scores across clinical specialties. For example, in 2018, US medical graduates who matched into neurosurgery had a mean Step 1 scores of 245, while those matching into neurology had a mean Step 1 score of 231.
One would assume that, at a minimum, Step 1 scores are a standardized, objective measure to statistically distinguish applicants. Unfortunately, this does not hold true. In its score interpretation guidelines, the National Board of Medical Examiners (NBME) provides Step 1’s standard error of difference (SED) as an index to determine whether the difference between two scores is statistically meaningful. The NBME reports a SED of 8 for Step 1. Assuming Step 1 scores are normally distributed, the 95% confidence interval of a Step 1 score can thus be estimated as the score plus or minus 1.96 times the standard error (Figure 1). For example, consider Student A who is interested in pursuing neurosurgery and scores 231. The 95% confidence interval of this score would span from 215 to 247. Now consider Student B who is also interested in neurosurgery and scores 245. The 95% interval of this score would span from 229 to 261. The confidence intervals of these two scores clearly overlap, and therefore, there is no statistically significant difference between Student A and Student B’s exam performance. If these exam scores represented the results of a clinical trial, we would describe the results as null and dismiss the difference in scores as mere chance.
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.
One of the most fun things about the United States Medical Licensing Examination (USMLE) pass/fail debate is that it’s accessible to everyone. Some controversies in medicine are discussed only by the initiated few – but if we’re talking USMLE, everyone can participate.
Simultaneously, one of the most frustrating things about the USMLE pass/fail debate is that everyone’s an expert. See, everyone in medicine has experience with the exam, and on the basis of that, we all think that we know everything there is to know about it.
Unfortunately, there’s a lot of misinformation out there – especially when we’re talking about Step 1 score interpretation. In fact, some of the loudest voices in this debate are the most likely to repeat misconceptions and outright untruths.
Hey, I’m not pointing fingers. Six months ago, I thought I knew all that I needed to know about the USMLE, too – just because I’d taken the exams in the past.
But I’ve learned a lot about the USMLE since then, and in the interest of helping you interpret Step 1 scores in an evidence-based manner, I’d like to share some of that with you here.
If you think I’m just going to freely give up this information, you’re sorely mistaken. Just as I’ve done in the past, I’m going to make you work for it, one USMLE-style multiple choice question at a time._
Recently, I was on The Accad and Koka Report to share my opinions on USMLE Step 1 scoring policy. (If you’re interested, you can listen to the episode on the show website or iTunes.)
Most of the topics we discussed were ones I’ve already dissected on this site. But there was an interesting moment in the show, right around the 37:30 mark, that raises an important point that is worthy of further analysis.
ANISH: There’s also the fact that nobody is twisting the arms of program directors to use [USMLE Step 1] scores, correct? Even in an era when you had clinical grades reported, there’s still seems to be value that PDs attach to these scores. . . There’s no regulatory agency that’s forcing PDs to do that. So if PDs want to use, you know, a number on a test to determine who should best make up their class, why are you against that?
BRYAN: I’m not necessarily against that if you make that as a reasoned decision. I would challenge a few things about it, though. I guess the first question is, what do you think is on USMLE Step 1 that is meaningful?
ANISH: Well – um – yeah…
BRYAN: What do you think is on that test that makes it a meaningful metric?
ANISH: I – I don’t- I don’t think that – I don’t know that memorizing… I don’t even remember what was on the USMLE. Was the Krebs Cycle on the USMLE Step 1?
I highlight this snippet not to pick on Anish – who was a gracious host, and despite our back-and-forth on Twitter, we actually agreed much more than we disagreed. And as a practicing clinician who is 15 years removed from the exam, I’m not surprised in the least that he doesn’t recall exactly what was on the test.
I highlight this exchange because it illuminates one of the central truths in the #USMLEPassFail debate, and that is this:
Physicians who took Step 1 more than 5 years ago honestly don’t have a clue about what is tested on the exam.
That’s not because the content has changed. It’s because the memories of minutiae fade over time, leaving behind the false memory of a test that was more useful than it really was.
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 inAcademic 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.