To the Editor:
Recent discussions about the timing of the United States Medical Licensing Examination (USMLE) Step 1 frame the issue as a dichotomous choice. Institutions can choose to leave the exam in its traditional curricular location or move the exam to a postclerkship time frame. Arguments have been made that the latter choice better prepares students for the clinical focus of the exam and allows for conceptual integration of basic science principles.1,2 Although these benefits may exist, we challenge the notion that they exist in equal measure for all students. We propose that a more flexible approach to scheduling better aligns with the current focus on competency-based medical education (CBME).
Within a CBME framework, mastery is an individualized achievement.3 Not every student will master curricular content at the same time. Yet, cohorts of students are all expected to take Step 1 during a single time period, either before or after their core clinical clerkships. This is logistically expedient but may be educationally misguided.
Validated tools needed to assess individual readiness and mastery of relevant exam content already exist and are in wide use across medical schools. Preclerkship grades, performance on commonly used commercial preparation products, such as UWorld question banks, and the National Board of Medical Examiners’ own Comprehensive Basic Science Subject Assessment forms give us the data we need to predict performance in real time.4,5
The search for a single “optimal” time for Step 1 may prove fruitless.1 Institutions need not choose between leaving the exam in its traditional curricular location and moving it to after clerkships. Instead, they should consider identifying a limited number of appropriate locations within the curriculum where students can study for and take the exam and demonstrate the mastery they have worked so hard to achieve.
Emily P. Green, PhD, MA
Director, Faculty Development, Warren Alpert Medical School of Brown University, Providence, Rhode Island; Emily_Green@brown.edu.
Paul George, MD, MHPE
Associate dean for medical education, Warren Alpert Medical School of Brown University, Providence, Rhode Island.
Allan R. Tunkel, MD, PhD
Senior associate dean for medical education, Warren Alpert Medical School of Brown University, Providence, Rhode Island.
1. Daniel M, Fleming A, Grochowski CO, et al. Why not wait? Eight institutions share their experiences moving United States Medical Licensing Examination Step 1 after core clinical clerkships. Acad Med. 2017;92:1515–1524.
2. Jurich D, Daniel M, Paniagua M, et al. Moving the United States Medical Licensing Examination Step 1 after core clerkships: An outcomes analysis. Acad Med. 2019;94:371–377.
3. Powell DE, Carraccio C. Toward competency-based medical education. N Engl J Med. 2018;378:3–5.
4. Morrison CA, Ross LP, Fogle T, Butler A, Miller J, Dillon GF. Relationship between performance on the NBME comprehensive basic sciences self-assessment and USMLE Step 1 for U.S. and Canadian medical school students. Acad Med. 2010;85(10 suppl):S98–101.
5. Gohara S, Shapiro JI, Jacob AN, et al. Joining the conversation: Predictors of success on the United States Medical Licensing Examinations (USMLE). Learn Assist Rev. 2011;16:11–20.