New pass / fail format stuns medicine


The news that the US Medical License Examination (USMLE) program will change your Step 1 rating of a 3-digit number to pass / fail as of January 1, 2022, has provoked a lot of shocking responses from students and doctors.
J. Bryan Carmody, MD, MPH, an assistant professor at Eastern Virginia Medical School (EVMS) in Norfolk, Virginia, told Medscape Medical News that he was "stunned" when he heard the news on Wednesday and said the change presents "the most big". opportunity for medical school education reform since the Flexner Report ", which in 1910 set standards for modern medical education.

The numbers will continue for some tests
The co-sponsors of USMLE, the Federation of State Medical Boards (FSMB) and the National Board of Medical Examiners (NBME), say that the Step 2 Clinical Knowledge (CK) and Step 3 exam will continue to be numerically graded. Step 2: Clinical skills (CS) will continue with your pass / fail system.

The change was made after Step 1 was strongly criticized for playing an overly important role in the process of becoming a doctor and for having students study for the exam instead of fully participating in their medical education.

Ramie Fathy, a third-year student at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia, who is currently studying for Step 1, told Medscape Medical News that it would have been nice personally to have the option to pass / fail, but predicts that both good and unintended consequences in the change.
The positive news, Fathy said, is that less emphasis will be placed on the Step 1 test, which includes memorizing basic scientific details that may or may not be relevant depending on the choice of subsequent specialty.
"It does not necessarily measure what the creators of the test intended, which was whether or not a student could understand and apply basic science concepts to the practice of medicine," he said.

"The current system encourages students to obtain the highest possible score, which, after a certain point, translates into memorizing many small details that become less and less relevant," Fathy said.
Can the pressure move elsewhere?
However, Fathy is concerned that without a scoring system to help decide who stands out in Step 1, the directors of the residency program will depend more on the reputation of the candidates' medical school and the influence of the individual. He writes a letter of recommendation, factors that are often influenced by family resources and social status. That could create a new economic division on the way to becoming a doctor.
Fathy said he and his teammates are looking for information on what will be the step bar and what happens with Step 2 CK. USMLE has promised more information as soon as it is available.

"The question is whether that test will replace Step 1 as the standardized metric of student proficiency," said Fathy, which would put more pressure on students on the medical path.

Will the anxiety in Step 2 increase?
EVMS Carmody agrees that there is a danger that students will spend their time studying for Step 2 CK at the expense of other parts of their education.

A significant reform will depend on the approval / disapproval movement being combined with other reforms, more importantly, application limits, said Carmody, who teaches preclinical medical students and works with the residency program.

He has been blogging on step 1 approved / failed during the past year.

Currently, students can apply for as many residences as they can afford and Carmody said the number of applications per student has increased in the last decade.

"That puts program managers under an impossible burden," he said. "With our system based on Step 1, there is a significant inequality in the number of interviews people receive. Programs end up inviting too much to the same group of people who look good on paper."

People outside that group respond by sending more requests than they need to get some interviews, Carmody added.

With caps, students would have an incentive to apply only to those programs in which they had a sincere interest, he said. Program managers could also better evaluate each application.

Changing Step 1 to pass / fail may have some effect on medical school exhaustion, Carmody said.

"It's one thing to work hard when you're on call and your patients depend on it," he said. "But it would be difficult for me to stay up late every night studying something that I know is not going to help my patients in my heart, but I have to do it because I have to do better than the person who is studying in the apartment next door me."

The test deviated from the original purpose
Joseph Safdieh, MD, assistant dean of clinical curriculum and director of the department of neurology of medical students at Weill Cornell Medical College in New York City, sees the movement as positive in general.

"We should not use a single metric to define or describe the overall profile of our students," he told Medscape Medical News.

"This has been a very significant point of anxiety for our medical students for many years," Safdieh said. "They were frustrated because their 4 full years of medical school were apparently reduced to a number."

The test was originally created as one of the three parts of the license, he said.

"In the last 10 or 15 years, the exam has been transformed into a litmus test for very specific residency programs," he said.

However, Safdieh is concerned that Step 2 cultivates the same anxiety and that it becomes too much of a focus without the metric of Step 1, "although it could be argued that the test more accurately reflects the clinical material," said.

Safdieh is also concerned that students who have selected a specialty by the time they take Step 2 can find at the end of the game that they are less competitive in their field than they thought they were and that they have to make a final change minute.

Safdieh said he believes Step 2 will be the next to go through the pass / fail route. When reading the announcement between the lines, he believes that the co-sponsors of the test failed to pass / fail at the same time because it would have been "a nuclear bomb for the system."

He gave co-sponsors credit for taking what he called a "bold and transcendental decision to initiate a radical change in the general transition between undergraduate and graduate medical education."

Safdieh added that few in medicine expected Wednesday's announcement.

"I think many of us expected them to go to the quartile classification, not to get that far," he said.

Safdieh said that among those who can see the effects downstream of the pass / fail step are schools on the high seas, such as those in the Caribbean.

"Those schools rely on Step 1 to show that their students are complying with rigor," he said.

But he hopes this will lead to a more comprehensive review.

"We hope this will force a change in the system so that residence directors consider more than the ability to take exams. They will examine publications and scholarships, community service and defense and performance in medical school," Safdieh said. .

Alison Whelan, MD, director of medical education at the Association of American Medical Colleges (AAMC), said in a statement: "The transition from medical school to residency training is a matter of great concern in academic medicine.

"The decision of NBME and FSMB to change the USMLE score report Step 1 to pass / fail was carefully considered to balance student learning and well-being," he said. "The medical education community must now work together to identify and implement additional changes to improve the overall UME-GME transition system for all stakeholders and the AAMC is committed to helping lead this work."

Fathy, Carmody and Safdieh have not disclosed relevant financial relationships.

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