Letters to the Editor
We thank the authors who have contributed to this discussion on the United States Medical Licensing Examination (USMLE) Step 1, and we are especially pleased to see medical student representation. The diversity of viewpoints presented in these comments underscores the wide-reaching impact of the USMLE Step 1 on undergraduate medical education (UME).
Like Griffith mentions, we agree that UME has become focused on the differentiation of students through Step 1 scores, arguably to the detriment of their training. However, we are not opposed to differentiation altogether. Syed and Sykora describe in detail how the Step 1 climate strains the student–faculty relationship. To lessen student anxiety and improve efficiency, Schmuter proposes that Step 1 test preparation materials be incorporated into curricula. Though this would negatively impact faculty autonomy and detract from clinically relevant course content, we ultimately agree. Students should not be penalized for residency selection simply because they adhered to their school’s curriculum.
As for Weissman, we do not deny that Step 1 is one of the few standardized tools available to program directors (PDs). However, its use in residency selection is unfounded and has been described as “off-label.”1 Further, the Step 1 climate is unfair and even harmful to medical students, as we have previously described. The current situation remains unacceptable.
We see two broad approaches to a potential solution. First, Step 1 could be made pass/fail with concomitant policy adjustments to ease the pressure on residency selection. Recent proposals include reducing overapplication2 by early listing of residency program preferences,3 as well as others.4 Second, the issues surrounding Step 1 could be addressed entirely through such policy changes without changing the examination to pass/fail. We strongly favor the first approach because as long as Step 1 scores are available, PDs are likely to continue using them. Of note, Step 1 could conceivably be remade as a psychometrically valid tool for differentiating medical students, but this would take years to design, validate, and implement.
We appreciate Cottrell and Ferrari’s admonition to pause and reflect on this moment, where the need for UME reform is increasingly recognized. We believe that multiple changes may be pursued concurrently to address this complex problem. Although making Step 1 pass/fail may involve unanticipated consequences, other measures are relatively straightforward (e.g., requesting students to list program preferences early). Though this moment incites apprehension in various stakeholders, it also provides an unprecedented opportunity to improve UME. Logistical concerns abound and are certainly valid, but we would be remiss to lack in imagination.
1. Carmody JB, Rajasekaran SK. More on the role of USMLE Step 1 in resident selection. Acad Med. 2019;94:921.
2. Carmody JB, Sarkany D, Heitkamp DE. The USMLE Step 1 pass/fail reporting proposal: Another view. Acad Radiol. 2019;26:1403–1406.
3. Whipple ME, Law AB, Bly RA. A computer simulation model to analyze the application process for competitive residency programs. J Grad Med Educ. 2019;11:30–35.
4. Andolsek KM. One small step for Step 1. Acad Med. 2019;94:309–313.