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Why Not Wait? Eight Institutions Share Their Experiences Moving United States Medical Licensing Examination Step 1 After Core Clinical Clerkships

Daniel, Michelle MD, MHPE; Fleming, Amy MD, MHPE; Grochowski, Colleen O’Conner PhD; Harnik, Vicky PhD; Klimstra, Sibel MD; Morrison, Gail MD; Pock, Arnyce MD; Schwartz, Michael L. PhD; Santen, Sally MD, PhD

doi: 10.1097/ACM.0000000000001714

The majority of medical students complete the United States Medical Licensing Examination Step 1 after their foundational sciences; however, there are compelling reasons to examine this practice. This article provides the perspectives of eight MD-granting medical schools that have moved Step 1 after the core clerkships, describing their rationale, logistics of the change, outcomes, and lessons learned. The primary reasons these institutions cite for moving Step 1 after clerkships are to foster more enduring and integrated basic science learning connected to clinical care and to better prepare students for the increasingly clinical focus of Step 1. Each school provides key features of the preclerkship and clinical curricula and details concerning taking Steps 1 and 2, to allow other schools contemplating change to understand the landscape. Most schools report an increase in aggregate Step 1 scores after the change. Despite early positive outcomes, there may be unintended consequences to later scheduling of Step 1, including relatively late student reevaluations of their career choice if Step 1 scores are not competitive in the specialty area of their choice. The score increases should be interpreted with caution: These schools may not be representative with regard to mean Step 1 scores and failure rates. Other aspects of curricular transformation and rising national Step 1 scores confound the data. Although the optimal timing of Step 1 has yet to be determined, this article summarizes the perspectives of eight schools that changed Step 1 timing, filling a gap in the literature on this important topic.

M. Daniel is assistant dean of curriculum and assistant professor, Departments of Emergency Medicine and Learning Health Sciences, University of Michigan Medical School, Ann Arbor, Michigan.

A. Fleming is associate dean for student affairs and associate professor of pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee.

C.O. Grochowski is associate dean for curricular affairs, Duke University School of Medicine, Durham, North Carolina.

V. Harnik is associate dean for curriculum and assistant professor, Department of Cell Biology, New York University School of Medicine, New York, New York.

S. Klimstra is Ehrenkranz Associate Dean of Academic Affairs and professor of clinical psychiatry, Weill Cornell Medical College, New York, New York.

G. Morrison is senior vice dean for education and professor of medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.

A. Pock is associate dean for curriculum and associate professor of medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland.

M.L. Schwartz is associate dean for curriculum and associate professor, Department of Neuroscience, Yale University School of Medicine, New Haven, Connecticut.

S. Santen is assistant dean for educational research and quality improvement and professor of emergency medicine and learning health sciences, University of Michigan Medical School, Ann Arbor, Michigan.

Funding/Support: None reported.

Other disclosures: The University of Michigan School of Medicine, Vanderbilt School of Medicine, and New York University School of Medicine have Accelerating Change in Medical Education grants from the American Medical Association.

Ethical approval: Reported as not applicable.

Disclaimer: The views expressed are those of the authors and do not reflect the official policy or position of their universities, the Department of Defense, the United States Air Force, or the United States Government.

Previous presentations: Learn Serve Lead, the Association of American Medical Colleges Annual Meeting, Seattle, Washington; November 11–15, 2016.

Correspondence should be addressed to Michelle Daniel, University of Michigan Medical School, 6123 Taubman Health Sciences Library, 1135 Catherine St., SPC 5726, Ann Arbor, MI 48109; telephone: (401) 525-0251; e-mail:

© 2017 by the Association of American Medical Colleges