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Challenges Associated With Moving the United States Medical Licensing Examination (USMLE) Step 1 to After the Core Clerkships and How to Approach Them

Pock, Arnyce, MD; Daniel, Michelle, MD, MHPE; Santen, Sally A., MD, PhD; Swan-Sein, Aubrie, PhD, EdM; Fleming, Amy, MD, MHPE; Harnik, Vicky, PhD

doi: 10.1097/ACM.0000000000002651

An increasing number of medical schools have moved away from traditional 2 + 2 curricular structures toward curricula that intentionally integrate basic, clinical, and health systems science, with the goal of graduating physicians who consistently apply their foundational knowledge to clinical practice to improve the care of patients and populations. These curricular reforms often include a shortened preclerkship phase with earlier introduction of learners into clinical environments. This has led schools to reconsider the optimal timing of United States Medical Licensing Examination Step 1. A number of schools have shifted the exam to the period immediately after core clerkships. Although this shift can provide pedagogical advantages, there are potential challenges that must be anticipated and proactively addressed. As more institutions consider making this change, key educational leaders from five schools that repositioned the Step 1 exam after core clerkships share strategies for mitigating some of the potential challenges associated with this approach. The authors describe six possible challenges: lack of readiness without consolidation of basic science knowledge prior to clerkships; risk that weaker students will not be identified and provided academic support early; clerkship or clinical shelf exam performance weaknesses; extension of Step 1 study time; an increase in student anxiety about residency specialty choices; and/or a reduced time frame to take and pass board exams. These potential challenges may be addressed using three main strategies: effective communication with all stakeholders; curricular design and assessments that facilitate integration of basic and clinical sciences; and proactive student coaching and advising.

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

M. Daniel is assistant dean of curriculum and associate professor of emergency medicine and learning health sciences, University of Michigan School of Medicine, Ann Arbor, Michigan; ORCID:

S.A. Santen is senior associate dean of evaluation, assessment, and scholarship of learning and professor of emergency medicine, Virginia Commonwealth University School of Medicine, Richmond, Virginia.

A. Swan-Sein is director, Center for Educational Research and Evaluation, and assistant professor of educational assessment, Columbia Vagelos College of Physicians and Surgeons, New York, New York.

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

V. Harnik is associate dean of curriculum and associate professor of cell biology, NYU School of Medicine, New York, New York.

Funding/Support: None reported.

Other disclosures: The University of Michigan School of Medicine, Vanderbilt School of Medicine, and NYU School of Medicine have Accelerating Change in Medical Education grants from the American Medical Association. Virginia Commonwealth University School of Medicine receives funding from the American Medical Association for Dr. Santen’s consulting on the Accelerating Change in Medical Education grant.

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.

Correspondence should be addressed to Vicky Harnik, NYU School of Medicine, 550 First Ave., MS-G51, New York, NY 10016; telephone: (212) 263-2274; e-mail:

Written work prepared by employees of the Federal Government as part of their official duties is, under the U.S. Copyright Act, a “work of the United States Government” for which copyright protection under Title 17 of the United States Code is not available. As such, copyright does not extend to the contributions of employees of the Federal Government.

© 2019 by the Association of American Medical Colleges