USMLE Step 1 going to be combined w/ Step 2 in couple of years

Hey I was wondering if anyone knows how this change will affect us? I am a 2nd year about to start my research years and plan on taking my USMLE in June. Well, this change will go into effect when I would be taking my USMLE Step 2, 4 years later. Has anyone else heard of this? What is everyone else planning to do?

I hadn't heard about that... now I'm curious.

It's been discussed, but there seems to be no firm plans to actually implement this change.

spursss said:

Hey I was wondering if anyone knows how this change will affect us? I am a 2nd year about to start my research years and plan on taking my USMLE in June. Well, this change will go into effect when I would be taking my USMLE Step 2, 4 years later. Has anyone else heard of this? What is everyone else planning to do?

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This is the second or third time I have seen someone mention this lately. What is the rational behind wanting to do this exactly?

Also, I remember hearing something last year about Step I being changed somehow (I can't remember off the top of my head but it would have significantly impacted MD/PhDs). I haven't heard anything about that since like last spring. What was that change again? And did anything come of it?

I heard that they just announced at their big ACGME meeting in Washington DC this weekend that this change was going to happen in 2 years. So basically they have made it official. I also heard that they are doing this because residency directors are tired of students not taking (or caring to take) the step 2 exam before applying to residency. Anyway, that is all I know. I was hoping others had heard more about this. Seems like it will greatly impact those students that are planning to take the USMLE in the next couple of years and then start doing their research before beginning their medical clerkships.

spursss said:

I also heard that they are doing this because residency directors are tired of students not taking (or caring to take) the step 2 exam before applying to residency.

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Wouldn't it just be simpler to institute a universal requirement to take step ii before being ranked?

Also, when is this mega test going to be administered? I really, really don't want to have to take step I (essentially) twice 🙁
Not to mention the incredible suck factor of having to relearn m1/2 after a phd and during clerkships...

I'm torn. While I feel that combining step 1 and 2 is a good idea because the practice of ranking people based on the m1/2 classes I don't like. However, I feel that this change will almost require people to go to grad school after m1. This will make it longer to graduate because you won't get credit for m2 classes to count towards grad school and will also not have the same medical knowledge base during grad school (which I admit isn't used too often).

I'm not torn. This sucks. I would understand if your performance on Step II meant anything at ALL, but it doesn't. First off, there is no correlation with resident performance and Step I or Step II, so right there that should tell you something. These tests become too important and for little reason. Right now, qualified applicants blow off step two by waiting until after rank lists are due before taking the exam, since in reality, the test can only HURT them. By making this test mandatory to be ranked, it becomes MORE important, making it more likely their career path is decided by how much you slept the night before the test or how quickly you can read long narrative questions.
I think that there needs to be a standard test for basic medical knowledge before residency, but it should be pass/fail. If they do give grades, you should be the only one to see them. Why not release your score on the CS exam? Why is that test somehow less important than the others? It's the only one with patients in it, fer christsake.

gbwillner said:

...Why not release your score on the CS exam? Why is that test somehow less important than the others? It's the only one with patients in it, fer christsake.

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Actually, they will start doing this too.

A classmate who's involved in the AMA told me that the students went to the NBME and argued against the CS exam. The students said it is too expensive, everyone passes it, it is incredibly difficult to schedule with too few exam sites, it doesn't separate out poor docs, and we don't even get a grade at the end.

What does the NBME take away from this meeting?...that they should report the scores

Oy vey... glad I'm past Step 2 now. When I started the MSTP program, there was no Step 2 CS.

My primary goal now is to get through internship, take Step 3 and become licensed ASAP, before they come up with some other super-dee-duper idea like Step 3 CS! 🙄

Changes to the USMLE - an article written by Tri-Institutional MD-PhD Program Director, Dr. Olaf S. Andersen:

http://weill.cornell.edu/mdphd/bm~doc/changes-to-the-usmle-an-a.pdf

Correct me if I'm wrong, but to summarize that article basically states... There are no major changes currently. There may be some in the future.

The combination of Step I and Step II has been discussed for years now, but I have seen nothing definitive that it will happen. This article also mentions it, but again nothing definitive.

and WTF is the point of the figure on p. 42?!?!?!

Summary seems pretty up to snuff.

I think the guy who wrote this has a pretty good head on his shoulders: I have to agree with the ideal that basic science should be maintained throughout med school... it's what differentiates docs from nurses/PAs, but honestly, no one in a basic science dept wants to teach at all. let alone give the same lecture(s) every month to a group of ~5-20 med students on top of their current responsibilities. to have it done well, the impact on research and basic science professor morale would be devastating.

The good news is that it sounds like they want to switch the testing questions towards critical thinking/research analysis. lord knows i spend way too much time on pubmed for my own good.

Neuronix said:

Correct me if I'm wrong, but to summarize that article basically states... There are no major changes currently. There may be some in the future.

The combination of Step I and Step II has been discussed for years now, but I have seen nothing definitive that it will happen. This article also mentions it, but again nothing definitive.

and WTF is the point of the figure on p. 42?!?!?!

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The article says:

"...Based on the CEUP recommendations, it is reasonable to assume that there will be changes to the USMLE program..."

"...The changes will be incremental and evolutionary, and unlikely to prompt sudden or radical shifts in the basic science curriculum design or delivery..."

"...Step 1 will continue to focus on the "scientific foundations" of medicine: it also will will test the students' qualitative and quantitative reasoning ability and ability to use literature sources, with greater integration of abnormal structure and function and translational science. The clinical vignettes that inform many Step 1 questions will continue to improve in clarity and relevance, and factoid questions will disappear."

"Students taking Steps 2 and 3 will soon notice that increased numbers of clinical test questions will draw on scientific materials and reasoning processes that were emphasized in the preclinical curriculum. To an increasing extent candidates taking Steps 2 and 3 will be tested in their ability to integrate fundamental science with medical knowledge—with increased emphasis on biostatistics, epidemiology, qualitative and quantitative reasoning ability and use of the literature plus, of course, their clinical skills. Competency in medical knowledge, clinical reasoning and judgment and the ability to integrate the advances in translational science into clinical practice is likely to become increasingly important in Step 3..."

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I think the article says: the USMLE is changing (it is happening now), incrementally and evolutionarily and within 5 to 7 years, as a result of all the accumulated incremental and evolutionary changes to the tests, the current framework of the USMLE may become obsolete and will need to be gradually overhauled.

Finally it says: "...Thus, basic scientists—in particular physiologists—are likely to have an even greater role in medical school curriculum, going beyond the current "preclinical years.""

"...Thus, basic science departments will need to consider how to become involved in the teaching in years 3 and 4. This represents both an opportunity and a challenge; the latter because teaching in the clerkships usually is done in small-group sessions, with the same material being taught as often as 12 times/year! Basic science departments probably also need to consider how additional pathophysiology and translational science can be incorporated into what is traditionally considered the first year curriculum—in a manner that strengthens the basic science teaching..."

Figure 4 (p. 43) in the article is a metaphor - "The appropriate metaphor for changing the USMLE is not "turning the battleship" but "maneuvering a battle fleet at high speed" (Figure 4)—where each interested party has its own set of priorities."

The author is being humorous and comparing changing the USMLE to naval maneuvers in warfare - I think it is a funny comparison...

foo said:

Changes to the USMLE - an article written by Tri-Institutional MD-PhD Program Director, Dr. Olaf S. Andersen:

http://weill.cornell.edu/mdphd/bm~doc/changes-to-the-usmle-an-a.pdf

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The changes described will most certainly happen. The key, as Dr. Andersen alluded to, is how basic science faculty respond to the challenge. If, like at my school, most of the basic faculty are turned off and withdraw from planning out a new curriculum, this will have devastating consequences for the type of physicians that are trained. The basic sciences will continue to be forced out of the curriculum and medical students will fail to learn and retain the basic concepts that underlie physiology, pharmacology and disease.

It also is under-recognized (and not really mentioned in the article) that the post-MD stages of training even more dramatically under-teach the basic sciences. Residents themselves hate thinking about or getting asked about basic mechanisms of disease or drug action, because in their minds these things do not directly affect patient care and they have 20 other responsibilities to be thinking about at that time (i.e. "How do I get my work done?"). Therefore, the basic concepts tend to be de-emphasized and drained out by the system.

Vader said:

It also is under-recognized (and not really mentioned in the article) that the post-MD stages of training even more dramatically under-teach the basic sciences. Residents themselves hate thinking about or getting asked about basic mechanisms of disease or drug action, because in their minds these things do not directly affect patient care and they have 20 other responsibilities to be thinking about at that time (i.e. "How do I get my work done?"). Therefore, the basic concepts tend to be de-emphasized and drained out by the system.

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For those overworked residents, there's no incentive to invest in basic science, and the attendings don't find their lack of understanding of basic mechanisms problematic either. Recognizing this, it is no suprise that the future residents/attendings (aka current medical student) aren't bothered by the very limited presence of basic science in their curriculum. On the other hand, I'm not really sure how an emphasis on basic science will help them in the clinic, assuming most of them do not conduct research to any meaningful extent...

PS: nice talk at the retreat😀, though I felt there was more to it than what you have shown us...

Basic science is a use it or lose it phenomenon. You can emphasize it more on Step II, but it's just going to be lost after that, because basic science does not influence patient care. So I think it's silly myself to integrate more basic science where it's not necessary. But, again, everything written by both the USMLE and that article is fairly nebulous and gradual, so I think for now things are going to be reactionary to the exact changes and pace of that change.

The trend is toward enhanced vertical integration in medical school curricula. That is one of the main points that Dr. Andersen is making in the article and amazingly even the USMLE folks seem to recognize the importance of vertical integration.

Why vertical integration? Why teach basic material in 3rd and 4th year during rotations? For the very purpose of teaching medical students to get away from algorithmic, cook-book medicine and instead learn to think critically about medical problems, search for and assess the evidence, and incorporate advances in medical science into their practice. This is especially important for those of us clinicians who will deal with complex or unknown medical problems that defy categorization. The algorithmic approach only takes you so far, can really be done by physician assistants, nurse practicioners, etc, and does not allow for the flexibility to deal with disease entities that have yet to be categorized. Having a deep understanding of physiology allows for a description of disease that does not fall neatly into pre-defined categories. In academic medicine especially, where you see these types of mystery cases on a frequent basis, it is essential to have a deep understanding of basic material and with it the ability to generate new hypothesis that can be tested.

Besides the above arguments, there is also the notion that reviewing the basic material later can actually make learning the clinical material easier and make sense. I.e. why do we give patients D5W and not free water IV? Why does hypokalemia cause a metabolic alkalosis? Why do we give calcium to help treat hyperkalemia? N-acetylcysteine to treat acetaminophen toxicity? Why do atypical antipsychotic medications have an antidepressant effect? Why do you get a pulsus paradoxus in pericarditis? How does amphotericin B work to kill fungi? It is much easier, at least for me, to remember these things if I understand the underlying physiology or basic biochemical mechanisms.

Also, having a good understanding of the basic mechanisms helps in filtering out the things that are done clinically that make absolutely no sense. I.e. testing for "hypercoagulablility panels" in patients with stroke--almost never positive since the factors tested really are associated with venous thrombosis, not arterial. Why is hyponatremia rarely corrected with normal saline? Why is nearly every patient in the surgical ICU on big gun antibiotics like Zosyn, even for UTIs?

We should be in the business of making medicine more scientific, not less.

Vader said:

...We should be in the business of making medicine more scientific, not less.

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One, I agree whole-heartedly in this sentiment. We should have reasons for everything we do, and those reasons should be supported by evidence.

Vader said:

...I.e. why do we give patients D5W and not free water IV? Why does hypokalemia cause a metabolic alkalosis? Why do we give calcium to help treat hyperkalemia? N-acetylcysteine to treat acetaminophen toxicity? Why do atypical antipsychotic medications have an antidepressant effect? Why do you get a pulsus paradoxus in pericarditis? How does amphotericin B work to kill fungi?...

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However, I have asked similar questions of my interns, residents, fellows, and attendings, and the vast majority look at my like I'm insane. Or, they dodge the question by giving an answer to a similar issue that they do know, but don't actually answer my question.

The few attendings that listen to my question and actually give it thought are worth their weigt in gold.

RxnMan said:

However, I have asked similar questions of my interns, residents, fellows, and attendings, and the vast majority look at my like I'm insane. Or, they dodge the question by giving an answer to a similar issue that they do know, but don't actually answer my question.

The few attendings that listen to my question and actually give it thought are worth their weigt in gold.

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Of course they do--I've had this happen plenty of times too. The movement currently among medical educators is to strip down basic science in the medical curriculum to such a degree that it becomes self-reinforcing that basic science appears "irrelevant". These students then become the interns, residents and attendings that downplay the importance of the basic science. They also frankly don't remember as much basic material because of the current lack of vertical integration. Much of any physician's clinical practice at first glance appears fairly algorithmic--most patients seen will have one of the many "known" diseases. However, how the algorithm applies or does not apply to the particular patient is where clinical decision making comes in. This requires a good knowledge of the available evidence and the critical thinking skills to apply this knowledge in the particular patient's situation.

The problem with the current education approach (i.e. lack of vertical integration) is that it makes medicine a cookbook profession and removes thinking from the equation. Other members of the medical team are capable of delivering medical care if the care is highly algorithmic. But what happens when there is a complication? Or the patient has multiple medical problems that affect a variety of organ systems/physiological processes? Or is on multiple medications that affect the patient's physiology? Or a patient that presents with a "mystery" problem that does not fit the cookbook categorization or treatment algorithim?

I'm glad that the NBME/USMLE seems to recognize that we need to reinforce the basic science through vertical integration, rather than doing away with it. Physician-scientists need to be at the forefront of teaching their colleagues about the science, thereby demonstrating how important it is to patient care.

Hey everybody. I`m the new guy here. Great forum. Interesting thread here. I`m wondering if there are any new developments 9 years later on this matter (combining steps 1 and 2 ). Thanks!

No... It didn't happen, and probably won't happen soon. A change that is more likely to happen is to morph into P/F licensing examinations.