Being the son of 2 medical educators, I (L.R.) was always a “class-goer,” a label I wore proudly during most of second year of medical school. For all of January 2017, I sat in the second row of hematology pathophysiology (heme path) class, where I probably annoyed my classmates by asking too many questions. This is also where I began to fall in love with my intended specialty. For much of my preclinical education, class was not just for learning—it was a community where I was influenced and inspired by my teachers. But as the United States Medical Licensing Examination (USMLE) Step 1 began to loom larger, I became increasingly involved in another community on Reddit, where today I am a known content creator on the forums r/medicalschool, r/step1, andr/medicalschoolanki. My major claim to online fame is the authorship of a Step 1 flash card deck that “went viral,” though for the sake of keeping my real-life and online identities separate, I prefer to not reveal which deck.
Reddit is a discussion website parsed into forums called “subreddits” which can be focused around almost any topic imaginable. The most infamous subreddit is r/the_donald, which served as a breeding ground for Russian propaganda and right-wing conspiracy theories during the 2016 U.S. presidential election. Ethics aside, subreddits like r/the_donald exemplify how ideas that germinate in small online enclaves are easily spread through other forms of social media and through real-world social circles.1 Amongst the medical school subreddits, a thriving community exists around posting memes (widely shared images with edited text that often convey an inside joke), providing emotional support for struggling students, and developing preparation strategies for taking the USMLE Step 1 exam. I have observed that the Step 1 study strategies used by an overwhelming number of current medical students come from online forums, though this has not been formally surveyed or studied.
Students like me become involved with and contribute to these forums because they provide access to crowdsourced study resources that confer distinct advantages for Step 1 preparation.2r/medicalschool is currently the largest and most active medical student Reddit forum, logging over 183,000 subscribers as of this writing. For context, that is more subscribers than U.S. allopathic medical graduates in the last 9 years combined.3 Browse r/medicalschool for 5 minutes, and the gestalt of the discussion becomes readily apparent—that medical educators do not understand the pressures that students of today face, and that classroom-based curricula serve as woefully inadequate preparation for (what students believe is) the single most important goal of preclinical medical education: a high Step 1 score.
Speaking with the perspective of both a forum insider and a student heavily involved with medical education at my home institution (I have served as a teaching assistant or tutor for numerous subjects in our preclinical curriculum), I believe online forums have much to reveal about how contemporary medical students relate to their school and to their teachers. An understanding of these online communities may prove useful for medical educators and administrators who are looking to bridge the widening gap that a “Step 1 climate”4 has created between students and teachers. As a national discussion on Step 1 reform continues to develop, lessons from these forums should also play a role in directing that discussion.
USMLE Step 1 scores have precipitously increased in importance for residency selection. Per the 2010 National Resident Matching Program director survey, 73% of program directors cited using Step 1 scores in interview offer decisions. That number rose to 94% in 2018.5,6 Though the primary purpose of Step 1 is medical licensure, the exam’s secondary function in residency applicant selection is openly acknowledged by the National Board of Medical Examiners,7 despite the well-described problem that Step 1 scores are not designed or validated as a measure of residency performance or professionalism.8,9 Though the USMLE has stated intent to move away from esoteric factoid-reliant questioning, students who have recently gone through their preclinical education and Step 1 exam understand that a competitive score is made in the minutiae (see Supplemental Digital Appendix 1 at http://links.lww.com/ACADMED/A805).10,11
Venturing onto r/medicalschool, you will find accepted “facts” about studying for a good Step 1 score. First and foremost is the use of Anki, an open-source flash card app with a powerful spaced-repetition algorithm. In 2014, Redditor u/brosencephalon shared a Step 1 Anki deck on r/medicalschool. This “Bros deck” became the first of several major viral Anki decks. Medical students flocking to these online communities use, edit, and spread these card decks to their classmates, and they are thought to be critical to Step 1 success. These decks are so massive (some exceeding 20,000 cards) that students will begin studying them a year or more before their Step 1 exam date. From the meticulous study log I kept from January 4 to June 12, 2017 (test day), I personally spent 4–6 hours per day working through my 10,000-card Anki deck of choice, racking up a total of 117,498 reviews over that period, for an average of 743 cards reviewed per day (see Supplemental Digital Appendix 2 at http://links.lww.com/ACADMED/A805). A 2015 survey of 72 students at Washington University School of Medicine in St. Louis revealed that an average of 5,086 unique flash cards are used by students during their USMLE preparation period.2 On the basis of forum recommendations and advice from their peers, students couple this type of flash card schedule with a number of commercial Step-prep resources (UWorld, Pathoma, First Aid) to build a rigorous, months-long study schedule devoid of any input from a brick-and-mortar medical school. In my experience, this is increasingly the new normal in preclinical medical education.
As an Invited Commentary from several students published in Academic Medicine in 2019 expertly highlighted (and as any current student will tell you), medical students in year 2 primarily eschew classroom obligations for more time with Anki and commercial resources.4 This is fueled in part by a pervasive attitude in online forums that, because preclinical classes do not exclusively cover boards-testable content, they are a waste of time (see Supplemental Digital Appendix 3 at http://links.lww.com/ACADMED/A805). Meanwhile, a medical school’s curriculum cannot be accredited (nor should it be accredited) without the inclusion of content on professionalism, ethical conduct, interpersonal skills, systems of health care delivery, and the use of medicine for social justice.12 None of these topics are emphasized or adequately covered on Step 1. Yet, all of these topics are essential to producing a competent physician. Efforts on the part of a medical school to incorporate subject material on these core topics in the curriculum are met with impatience and scorn by students who see them as impediments to their Step 1 score (and therefore career goals). Forums amplify this scorn, while providing an alternative curriculum that is solely focused on producing a high score. The implicit message imparted on students by this climate is that professionalism, ethics, and social justice are secondary to success in medicine.
Wellness initiatives are also topic of harsh and frequent derision on student forums. Wellness initiatives are generally perceived by students online as more of a public-facing endeavor on the part of an institution than an honest attempt to alleviate well-documented problems with student mental health and burnout.13,14 Particularly during the second year of medical school, when students may be studying for 10–14 hours per day and stress is particularly high, sessions on wellness and resilience are viewed as a stress inducer, not a stress alleviator (see Supplemental Digital Appendix 4 at http://links.lww.com/ACADMED/A805). Furthermore, these curricula are felt to carry an implicit message that it is not the system that is flawed and in need of reform—it is the students themselves who are simply unable to cope. Given that many educators and administrators implementing these wellness interventions trained before the rise of the current “Step 1 climate,” the perception that educators are “out of touch” is magnified by these efforts. Medical education administrations ultimately come to be seen as both endorsers of this hypercompetitive system and as impediments to the student’s passage through it.
By contrast, Reddit forums like r/medicalschool provide adaptations to the current climate, not just coping mechanisms. To be clear, the community on r/medicalschool tends to have a healthy and destigmatized view on mental health, with posters regularly advising their struggling peers to seek mental health care when necessary. But stress regarding resource selection, time management, and study planning is often answered with concise, actionable advice. I regularly receive and reply to direct messages from users on Reddit asking for the type of advice that a learning professional or study counselor hired by an institution should be providing. The fact that struggling students may be more willing to seek academic help and mentorship from an anonymous online peer than from an educator at their own institution says something meaningful about the alienation students feel from those who are tasked with teaching them.
The current system is clearly untenable. When students move their intellectual home out of the classroom and onto the Web, a school loses its ability to design and implement a curriculum that reflects institutional values.15 Furthermore, implicit lessons on courtesy, self-discipline, and professional socialization that come from engagement in a real-world academic community go untaught.16 Students also forego the possibility of career-changing mentorship. My heme path professor’s lectures sparked the development of my professional passion. Sadly, I was 1 of 5 students who regularly attended.
However, as r/medicalschool reveals, the phenomenon of medical student disengagement is not a “millennial” or “laziness” problem, as has been implied by key players in the Step 1 climate.7 Problem-based learning models, resilience sessions, and other “modern” or “innovative” curricular interventions designed to increase student involvement and address wellness concerns do not focus on the underlying issue.17 Student disengagement from their home institutions is fundamentally a Step 1 problem, though it is accentuated by attitudes and resources that forums serve to incubate and disseminate.
A path to Step 1 reform should be made with this context in mind. One popular proposal is to drop the numeric score from Step 1, which would force the exam to function in the way it was originally intended—as a pass/fail exam for determining licensure.11 However, if that happens, residency program directors will require (or seize upon) other standardized measures by which to evaluate applicants. Online forums remind us that we should be cautious and cognizant of the context in which we implement broad educational reforms. Though intended to relieve medical student stress and competition, the shift of most medical schools to pass/fail preclinical grading (108 out of 140 allopathic schools by 2017) arguably only distilled that stress and competition into Step 1 and placed it on a national stage where forums and forum content creators gained more influence over what “healthy” or “reasonable” study schedules look like than qualified educators now have.18
These types of unintended consequences are important to consider while plotting a path for Step 1 reform. A pass/fail Step 1 should not be implemented without a plan to avoid a similar or existing assessment (e.g., USMLE Step 2 Clinical Knowledge) taking its place. New selection measures should be concurrently deployed that include dimensions of physician competency that cannot be easily taught via flash cards or commercial resources. These should be developed with deference to the students who will bear the brunt of testing and transitioning to these new measures. Thoughtful, widespread conversation regarding the balance between standardized assessment and institutional curricular autonomy should be central to Step 1 reform discussions, with special attention given to how the student–educator relationship is affected. While these conversations play out, students and educators can take actions now to rebuild rapport and work on realigning their interests. For medical educators, that might mean temporarily tailoring preclinical coursework to meet the needs of students who are still likely to pass through an unreformed Step 1 system—teaching to the test, for now. And to my fellow Reddit users, I suggest refocusing your frustration on the broader systemic issues at play. Approach the classroom with some perspective on the incredible amount of work that goes into teaching and the opportunities that exist beyond your test score.
While this is a story written from the perspective of author L. Ronner, L. Linkowski spurred him to write this account and played an essential and protracted role in shaping and referencing this work. L. Ronner would like to acknowledge Dr. Eileen Scigliano, course coordinator for the Icahn School of Medicine at Mount Sinai hematology pathophysiology class, for serving as the strongest example as to why classroom education is so important. He would also like to acknowledge Dr. Peter Gliatto, professor of medicine, medical education, and geriatrics and palliative medicine, for his earnest commitment to student well-being and willingness to serve as a sounding board for ideas related to this piece.
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