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Letters to the Editor

In Reply to Green et al

Harnik, Vicky PhD; Santen, Sally A. MD, PhD; Fleming, Amy MD, MHPE; Sein, Aubrie Swan PhD, EdM

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doi: 10.1097/ACM.0000000000003199
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We thank Dr. Green and colleagues for their comments on our Perspective about moving the United States Medical Licensing Examination Step 1 to after the clerkships. They recommend that the timing of Step 1 should be based on mastery of the material and not a single optimal time in the curriculum. Our series of 5 articles in Academic Medicine have outlined the rationales for moving Step 1, including the noninferiority—and perhaps increased scores—when the exam is placed after the clerkships, the stability of Step 2 Clinical Knowledge scores in this paradigm, and the many perspectives on Step 1 movement logistics and managing struggling students. We agree that the approach to Step 1 timing can be based on mastery, but Step 1 should be placed according to the pedagogical rationale of the curriculum and not be an isolated decision.

The Comprehensive Basic Science Self-Assessment and other study tools and data can be used to both prepare for and determine mastery or readiness to pass the exam. However, schools should intentionally create curricular and assessment systems that can maximize student learning and support students preparing for Step 1. At the 8 institutions we studied, the later placement of Step 1 was associated with curricular reform in conjunction with an increased focus on the scientific foundation throughout the curriculum. The opportunity to revisit foundational science during the Step 1 study period in the context of students’ clinical year was an intentional part of that reform.

As Step 1 is currently a gatekeeper for residency specialties and programs, taking Step 1 later can help students understand and set goals for Step 1 scores and mastery, in alignment with their anticipated residency goals. However, even with defined study periods and Step 1 deadlines, we are finding that student stress, anxiety, and desire for high scores can lead to students studying for extended periods and delaying exams until they feel everything is mastered. We anticipate in a time-variable system, with increased responsibility for the student to make the ultimate timing decision, that this stress would be amplified. We think it is optimal for institutions to intentionally situate the timing of Step 1 within the curriculum and for students to work with learning specialists and student affairs to monitor exam preparation, and more importantly, anxiety and well-being, to allow the Step 1 assessment to best reflect a student’s mastery.

Vicky Harnik, PhD
Associate dean of curriculum, associate professor of cell biology, New York University Grossman School of Medicine, New York, New York;
Sally A. Santen, MD, PhD
Senior associate dean of evaluation, assessment and scholarship of learning, and professor of emergency medicine, Virginia Commonwealth University School of Medicine, Richmond, Virginia; formerly at University of Michigan Medical School, Ann Arbor, Michigan.
Amy Fleming, MD, MHPE
Associate dean for medical student affairs and professor of pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee.
Aubrie Swan Sein, PhD, EdM
Director, Center for Education Research and Evaluation, and assistant professor of educational assessment in pediatrics and dental medicine, Columbia Vagelos College of Physicians and Surgeons, New York, New York.

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