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One small step for medicine, one giant leap for medical students

studying in library

If the first two years of medical school were a religion, then the textbook known as First Aid for USMLE Step 1 would be our bible, and the United States Medical Licensing Exam Step 1 would be our confirmation.

Let me explain: As spring arrives, bringing along with it overdue sunshine and blooming flowers, and as the rest of the world peeks out from underneath its heavy winter coats, medical students across the nation will soon be banishing themselves into self-abnegation for a handful of weeks in preparation to take the most important exam of their medical careers.

This eight-hour exam is intended to test the culmination of our medical education thus far, squeezing the entirety of our first two years into some 300 questions. And our performance on this exam will not only decide whether we can practice medicine, it will also largely determine what kind of medicine we will practice and where in the country we will practice it. Indeed, it is no secret that those students who enter the most lucrative medical fields or train at the most competitive hospitals also have the highest test scores.

So like the monks of the middle ages who memorized entire books, we will soon isolate ourselves into the dark corners of a library and attempt to cram as many medical facts into our memory as humanly possible — drug names and their side effects, bacteria species and effective antibiotics, diseases and their symptoms, and human anatomy down to its gritty details.

Indeed, the test draws its questions from every corner of medical literature. The only problem is that much of the content that is tested in this exam overlaps very little with the actual medicine practiced in the hospitals. It is not uncommon to stumble across a question asking us to identify the presenting symptoms of a rare disease afflicting perhaps 1 in every million people.

It’s an annual tradition that is anachronistic and even masochistic. Instead of gauging conceptual thinking, the test intends to push the limits of human recall. Based on the logic of this test, book-smart doctors make the best doctors. It only makes us wonder why a skill like rote memorization is so heavily emphasized in the 21st century when patient data and medical information are easily accessible simply by reaching into our pockets, when the patent is even able to look at his or her chart at home and gain a basic understanding of their health using a tablet.

These days, medicine no longer faces the problem of information paucity as it once did. An eidetic memory is no longer a prized skill. Rather, what doctors face these days is information overload. Consequently, the skills that are most important now in the clinics are the ability to sift through and interpret large amounts of data and clearly communicate that information to a team, all the while maintaining a professional and compassionate relationship with the patient. A test that still finds its basis in evaluating memory capacity says very little of these qualities.

Yet the implications of this test have become so inflated that it’s come to carry an opportunity cost that can’t be ignored. To put this in perspective, each medical student will spend an average of six weeks dedicated solely for preparing for this exam. He or she will also likely purchase several study resources, from practice tests to commercial study guides to question banks, all of which can add up to hundreds of dollars — don’t forget the exam registration fee of $600. That is more than 2,300 person-years lost to cramming for an exam. And we aren’t even considering the emotional toll as we are pressured to compete with our peers.

Wouldn’t some of this time and money be better spent allowing medical students to volunteer abroad, conduct research, or, better yet, learn medicine by treating real diseases and examining real patients instead of being cooped up pouring over a textbook?

That is not to say that medical students shouldn’t be tested. Certainly, there needs to be a certain threshold that all medical students must meet before they are allowed to proceed onto the hospitals. Instead, what we should consider is adopting a pass or fail grading system: The Step 1 exam should be only be interpreted as an indicator that the medical student is prepared to progress forward in his or her training and has a rudimentary understanding of disease management. This way, residency programs would no longer be tempted to extrapolate a student’s entire profile based on a number and would be forced to use more substantive metrics to determine their competence as a doctor — their clinical reasoning, their ability to maintain resilience and composure during high pressure situations, their patient interaction and empathy.

Alas, this change will not come soon enough. My classmates and I will soon put our lives on pause for next few weeks as we take on a life of asceticism. To all our family and friends who are supporting us in our medical journeys, we’ll see you in a few weeks.

Stanford Medicine Unplugged is a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week during the academic year; the entire blog series can be found in the Stanford Medicine Unplugged category.  

Steven Zhang is a second-year medical student at Stanford. When he’s not cramming for his next exam, you can find him on a run around campus or exploring a new hiking trail. 

Photo by jarmoluk

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