Letters to the Editor
To the Editor:
I read with interest Chen and colleagues’ thoughtful analysis of the current United States Medical Licensing Examination (USMLE) “Step 1 climate,”1 and Dr. Andolsek’s Invited Commentary, which provides compelling reasons why Step 1 scoring really must change, with excellent suggestions for alternative measures for stakeholders.2 Nevertheless, one thing seems missing from the current conversation. Many assert in these debates that program directors (PDs) need some score or measure to help differentiate and compare applicants, and Step 1 is therefore useful for providing such a standardized comparison. But the unexamined underlying question is: Why? Why do PDs need to “differentiate” applicants?
Many PDs (and department chairs and institutions) believe that they will have the “best” residency programs if they attract and recruit the “best” students, and a marker of “best” is high board scores, high grades, or a high number of students who are in Alpha Omega Alpha Honor Medical Society (AOA). But what does that say about an institution’s program if it accepts students with Step 1 scores of 260 who are at the top of their class and members of AOA, and at the end of residency, they turn out to be excellent physicians? Any residency program can do that. Really, the mark of the “best” program should be taking those in most need of excellent training—the mediocre students—and training them to be excellent physicians. Students of high academic achievement will do well wherever they train.
Really, the problem residents are few, and most of them involve professionalism/work ethic issues. This is certainly an area that should be the focus of medical school to residency handoff and communication. The vast majority of students who pass Step 1 on the first try will likewise pass their specialty certification. In this era of entrustment, residency programs need to “trust” that students graduating from U.S. medical schools will emerge with the requisite competencies to do well in residency and beyond. This is not blind trust; the data show the vast majority will do fine in residency, with or without the false and unwarranted differentiation provided by a preclinical immersion examination.
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. Andolsek KM. One small step for Step 1. Acad Med. 2019;94:309–313.