Letters to the Editor
To the Editor:
In their Invited Commentary regarding the United States Medical Licensing Examination (USMLE) “Step 1 climate,” Chen and colleagues describe observations of student disengagement with their curriculum in favor of commercial resources.1 The authors propose changing the scoring from numeric scoring to a pass/fail system. Since such a change has implications for patient safety, aggregation of perspectives from students and faculty nationwide is essential to ensure that any changes also consider the student–faculty partnership.
As students at a pass/fail medical school, with examination questions primarily from the National Board of Medical Examiners (NBME) and only occasionally from faculty, we have observed similar patterns of disengagement throughout our preclinical years—primarily manifesting as declining lecture attendance and decreased utilization of faculty-created materials in favor of commercial resources. The adequacy of these materials for teaching essential clinical knowledge is questionable, but the consequent impact on faculty should not be overlooked.
Faculty strive to impart students with new paradigms of reasoning to prepare them for clinical practice. Our faculty are mostly practicing physicians who wish to mold students into the most prepared trainees possible, but the board exam-focused climate is an obstacle to this goal. The highly specific facts tested on the USMLE often do not align with the faculty’s opinion of what knowledge is clinically essential. Faculty already write a minority of the test questions, but there is student pressure for further NBME dominance to maximize board readiness. We have often witnessed faculty frustration with their lack of agency in setting the curriculum and students’ disinterest in nonboard material. For example, our cardiovascular course explores circulatory physiology in more depth than USMLE Step 1 due to the faculty’s belief that this knowledge increases clerkship preparedness. However, many students expressed dissatisfaction with a faculty-written exam that exceeded the scope of Step 1, despite the clinical importance of this knowledge.
Such events demonstrate how the USMLE Step 1 climate strains the student–faculty relationship. Reforming the scoring system can potentially benefit students, but we wish to emphasize the role of faculty in this discussion. Easing this climate can offer faculty greater freedom in curriculum design, allow students to better engage with instructors, and reduce faculty disengagement from medical education. Many stakeholders are clearly present in this debate, most importantly our future patients. Our experiences are a reminder of the potential of this change to improve the student–faculty partnership.
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.