Letters to the Editor
To the Editor:
The Invited Commentaries by Chen and colleagues1 and by Katsufrakis and Chaudhry2 highlight a much-needed debate. The United States Medical Licensing Examination (USMLE) Step 1 is used by residency programs in all medical specialties to select applicants, despite a paucity of direct empirical evidence connecting Step 1 scores and clinical performance.3 If the numerical score of Step 1 does not directly correlate with residency performance, why is it scored at all?
The problem gains further perspective given the dramatic increase in residency applications submitted per individual. In internal medicine, the average number of applications per student has increased by 203% since 2010, while the proportion of positions per applicant has only increased by 8%.4,5 Reviewing more applications than ever before has become a daunting task for program directors (PDs). It is no wonder that PDs tend to rely on more “objective” data, such as the USMLE Step 1 score as a filter. Further, all available evidence suggests that medical students entering residency are more qualified today than ever before, with more well-rounded applications and exposures than other generations.6,7
However, if the USMLE Step 1 score is used as a filter to attempt to predict success in residency, it cannot be held to different standards than the rest of the medical school curriculum. We need ongoing evaluation to establish or refute a correlation between Step 1 performance and meaningful clinical outcomes. Ideally, we should try to focus our efforts on ascertaining whether residency programs make better decisions selecting residency candidates when taking Step 1 scores into consideration.3
Our medical community is facing a crisis of burnout among physicians and trainees. Any idea with the potential of alleviating some of the pressure medical students face needs to be carefully evaluated, and moving Step 1 to pass/fail scoring is no different. As such, we look forward to the upcoming discussions that will take place thanks to these meaningful publications.
Bruno Alvarez Concejo, MD
Resident, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas; email@example.com; ORCID: https://orcid.org/0000-0002-2695-8159.
Stephen Philip, MD, MS
Resident, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas; ORCID: https://orcid.org/0000-0003-4205-3787.
Timothy J. Brown, MD
Chief resident, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas; ORCID: https://orcid.org/0000-0002-4843-4639.
1. Chen DR, Priest KC, Batten JN, Fragoso LE, Reinfeld BI, Laitman BM. Student perspectives on the “Step 1 climate” in preclinical medical education. Acad Med. 2019;94:302–304.
2. Katsufrakis PJ, Chaudhry HJ. Improving residency selection requires close study and better understanding of stakeholder needs. Acad Med. 2019;94:305–308.
3. McGaghie WC, Cohen ER, Wayne DB. Are United States Medical Licensing Exam Step 1 and 2 scores valid measures for postgraduate medical residency selection decisions? Acad Med. 2011;86:48–52.
5. National Resident Matching Program. Results and Data: 2018 Main Residency Match. April 2018.Washington, DC: National Resident Matching Program.