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Passing the boards: Reassessing “Step 1 madness”

medical booksCharles Prober, MD, senior associate dean of medical education at Stanford, has long been concerned about the misuse of Step 1. The national standardized test, which must be passed in order to get a medical license, is also often used inappropriately, according to Prober, as a screening tool by residency programs.

But his concern about the test — dubbed “Step 1 madness” by some med students and the first of three required for medical licensure — extends even further to what he and others believe are the unnecessary and sometimes detrimental effects on both the education of medical students and their stress levels.

In a commentary published this week in the journal Academic Medicine, Prober and his co-authors — which includes the president of the National Board of Medical Examiners, the non-profit that develops and manages the test — issue a “plea to reassess” its role in residency selection. They write:

There is an increasingly pervasive practice of using the score, especially the Step
1 component, to screen applicants for residency. This is despite the fact that the test was not designed to be a primary determinant of the likelihood of success in residency... [I]t is disconcerting that the test preoccupies so much of our students attention with attendant substantial costs (in time and money) and mental and emotional anguish.

Prober and his colleagues go on to explain how students sequester themselves for four to nine weeks on average studying full-time for the day-long multiple-choice examination, which is usually taken sometime following their second year of medical school. The stress to pass the test, which is designed to test  "important concepts of the sciences basic to the practice of medicine," is particularly high because students know a poor score may keep them from qualifying for the first step to get into a residency program — the interview:

Despite its intended purpose, many residency program directors continue to use applicants’ USMLE Step 1 scores as a sole or primary filter for selecting candidates to interview... In general, the more competitive the residency discipline (e.g. orthopedic surgery, radiation oncology, dermatology, ophthalmology, and otolaryngology,) the higher the Step 1 score needed to pass through the filter.

The authors express the opinion that it is "ill advised" to use the test for a purpose for which it was not developed, that the test is not a good predictor of who will do well in residency and that it is being misused for "convenience" as a easy to apply mechanism to reduce large applicant pools. Their solution isn’t to get rid of the test, which is still a valuable tool, but to create additional measurement tools of equally important skills for selection by residency programs.

"A more rational approach to selecting among residency applicants would give greater attention to other important qualities, such as clinical reasoning, patient care, professionalism, and ability to function as a member of a health
care team," they conclude.

Previously: Using the flipped classroom model to bring medical education into the 21st-century and Student transitions in medicine: putting blinders on
Photo by jcalyst

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