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USMLE Step 1: Leveling the Playing Field – or Perpetuating Disadvantage?

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.

Ready?

  • 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?

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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.

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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.

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