How does reorganizing Step I affect MD/PhDs in training?

[RxnMan]

---

Members do not see this ad.

I received an email (below) from Freddy Nguyen, the president of APSA, concerning how LCME is reorganizing Step 1 and 2 . The exam has not been examined since it's inception, and in that vein I believe it is due for an overhaul. Changes are not expected to happen before the end of the decade, but it may affect MD/PhD training in unexpected ways:

By now, many of you may have heard that the USMLE Step 1 will be going away and according to the LCME will be combined into the current Step 2 exam. Our policy committee will soon be embarking on a fact finding mission to find out more about the rationale behind this move, and the potential impact of such a move. Some of the concerns out there is the de-emphasis on the basic sciences on the test which will translate to a de-emphasis on basic science teaching. The other concern more specifically to the dual-degree candidates is that you will now be an extra 3-4 years removed from the basic science learning to when you are tested. This will force the Step 2 exams to be required to take at the end of your 3rd year of medical school instead of being an after-thought that is taken after residency interviews/matching process.

I have heard from several of you with concerns about this and I would encourage everyone to be engaged in this conversation as it could not only impact the way MD-PhD training is done (i.e. the 2-P-2 model versus the P->M model) but could have a detrimental effect on the potential pool of qualified physician-scientist trainees.

This is a very important issues that we are working on and we are engaging several organizations to coordinate our efforts on this issue and so your input is greatly appreciated.

These changes may not only directly effect students in MD/PhD programs, but how the science of medicine is taught in this country. In the effort to start conversation, what do you all think about this?

MD/PhD applicants can read up about the USMLE here before commenting.

 

[Mountain Cow]

Wow!
😕

 

[Newquagmire]

you will now be an extra 3-4 years removed from the basic science learning to when you are tested

this effectively puts those of us who have already taken Step 1 in a "double jeopardy" situation and at a significant disadvantage relative to MD students...

 

[Fencer]

Most changes in examinations have come with "grandparent clauses". These changes occur whenever a new examination is developed at the level of initial medical licensing exam or for board certifications. I would expect that if any major change in the initial medica is implemented that those of you who already passed or will be taking step I prior to implementation will have a several year grace period to take an old step 2 before the new exam is mandatory for everybody. I would expect an overlap period with some students who passed step 1 (MD/PhD or MD/other program) have a choice of taking a new or old step 2, while everybody else (MD) has already transitioned to the new step 2.

 

[gstrub]

What is the deal on this? Where do they say they are eliminating it?

 

[RxnMan]

- gstrub: From the links I gave, you'll see that they are thinking about combining Steps 1 and 2 and moving it to the 3rd year. They (LCME) are still torn about it because they believe that there should be some test that you have to pass prior to inflicting you on patients.

- Newquagmire: I believe that MD/Phders will be grandfathered in too. Look at the history of board certification in emerging specialities. People who were practicing in the new field prior to the BC (the founders, really) either automatically qualify for the new exam or take the old exam within a certain window. I seriously doubt that current MD/PhD students are at any risk.

But the more important issue is science in medicine in the US.

The Steps also set up the pacing of school - 2 years of science, 2 years of clinical. From my own experience, I was doing H&Ps 1st year. Back in the day, that used to be what you learned as an intern. The cost of accelerating the clinical aspects is at the expense of the science. Are MDs going to become glorified technicians?

 

[QofQuimica]

Are MDs going to become glorified technicians?

You have no idea how tempted I am to make a smart comment to that.

Joking aside, I think what would happen is that MD/PhD schedules would have to change. You would do med school years 1 through 3, then take the boards. But you'll still have to take your grad classes and learn science. It might be that regular MD students will get less science, but maybe that's ok. I doubt any med student in the country would argue that every factoid we learn is really all that important. 🙂

 

[Vader]

My sense is that MD-PhD programs might change to a 3-4-1 split to accommodate the emphasis toward clinical medicine. It might even be advantageous in some respects to have the 3rd year clerkships under your belt before starting the PhD.

 

[Neuronix]

I would 100% agree with this strategy. However, a question is going to inevitably arise so I might as well ask it now. How do you keep students from leaving the program with almost free medical school tuition when they're almost done with medical school? It has been argued (I can pull a ref for this if someone wants) that the reason the 2-4-2 system was established was to partially prevent this from happening.

If things go to a PhD first then MD type of system (suggested here: http://drslounge.studentdoctor.net/showpost.php?p=5789457&postcount=8), mark my words, the reason is almost entirely shown in the paragraph above this one.

 

[marctam86]

one way around that would be to make the student pay tuition for the medical school years, then get a refund after the doctoral research years. a nuisance, definately, but probably a necessary one from an mstp director's standpoint.

 

[CCLCMer]

After looking through the proposed changes, I think both MD and MD/PhD programs will be forced to make their curriculums more integrated than they currently are. CCLCM is already doing this (i.e., we have clinics, research, and coursework simultaneously during all five years of the program).

 

[gstrub]

Neuronix,
I had to sign a promisary note at my school that said if I dropped out of the program without completing both phases (if I switched to MD only after M2, for example), I would have to pay back all the "aid" they had granted (tuition, stipend, fees, interest, etc). So we are quite motivated to grind it out...that may work in the system above.

 

[Neuronix]

I had to sign a promisary note at my school that said if I dropped out of the program without completing both phases (if I switched to MD only after M2, for example), I would have to pay back all the "aid" they had granted (tuition, stipend, fees, interest, etc). So we are quite motivated to grind it out...that may work in the system above.

According to personal communication with the NIGMS MSTP Director, this is a bluff. Not only legally they can not hold you accountable for the money (one school tried a long time ago and lost in court), but currently the NIGMS would back you up as well if they tried to kick you out of medical school over it (they wouldn't). So basically, any MSTP that tries to make you sign something (most don't) is just trying to psyche you out.

Also, with regards to CCLCMers suggestion, just how integrated can you get things? Doing 2 days of clinic and 2 days of research and 1 day of classes throughout the program? I hear about integration from all kinds of medical schools. What it actually amounts to is mostly the first two years of medical school with a smidgen of patient interactions (often standardized patients) then the last two years of medical school with required research 4th year and maybe a half day of coursework. Maybe they add to your stress by making you pretend to do research throughout, but little is accomplished. I can't imagine it can get more integrated than this without a total rethinking of the medical school cirriclum. You NEED so many months of clinics but you can't start them until you've had 1-2 years of basic science. For a PhD you need to really focus on your PhD and you can't be distracted too much from your research or you won't get anything accomplished. So, I simply don't know how it would be possible to increase integration.

 

[Mountain Cow]

Maybe I missed it, but any idea of WHEN they are talking about making the change?

Also, any idea how far along these discussions are (i.e. are they just floating the idea, or is implementation imminent)?

 

[Vader]

I would 100% agree with this strategy. However, a question is going to inevitably arise so I might as well ask it now. How do you keep students from leaving the program with almost free medical school tuition when they're almost done with medical school? It has been argued (I can pull a ref for this if someone wants) that the reason the 2-4-2 system was established was to partially prevent this from happening.

If things go to a PhD first then MD type of system (suggested here: http://drslounge.studentdoctor.net/showpost.php?p=5789457&postcount=8), mark my words, the reason is almost entirely shown in the paragraph above this one.

Yes, I agree that attrition would only become more of a problem. Then again, at least at my program almost half of MD-only students take off time between 3rd and 4th year to do research, etc (albeit most of them take only 1 year to do this rather than 3-4+ that would be required for a PhD).

Given that medical education is moving away from the didactic model and more toward the apprenticeship model, it will be a challenge for MD/PhD programs to integrate the curricula between medical and graduate school. Historically, the most readily available and practical way to integrate medical and graduate school has been to give credit for basic science classes that overlap. This overlap will be reduced or eliminated if the medical curriculum moves toward a 4-year apprenticeship, with a single licensing exam near the end. Like you mentioned, it will be difficult for students to spread out the 4-year apprenticeship over 7-8 years and try to balance significant research time throughout, i.e. in a fully integrated curriculum model.

I hope there is discussion of these issues at the upcoming MD/PhD program retreats, as this is truly a critical issue that will affect generations of future physician-scientists. We need creative solutions to address these upcoming challenges.

 

[CCLCMer]

Maybe I missed it, but any idea of WHEN they are talking about making the change?

Also, any idea how far along these discussions are (i.e. are they just floating the idea, or is implementation imminent)?

Apparently recommendations will be made in January. I think some kind of change is definitely going to happen, but I have no idea when or how it will happen, or how current students will be grandfathered in if they've taken Step I and then took off a few years to do a PhD.

Neuro, I PMed you.

 

[OddNath]

Maybe I missed it, but any idea of WHEN they are talking about making the change?

Also, any idea how far along these discussions are (i.e. are they just floating the idea, or is implementation imminent)?

Here's the last line from the official info from USMLE: http://www.usmle.org/General_Information/review.html

"Although it is difficult to predict subsequent time lines prior to receiving the final recommendations, major changes to USMLE design and structure will likely take a minimum of two years, after spring 2009 approval, to implement."

So, looks like a new test wouldn't be available until 2011 at the earliest, so people applying for residency in fall 2012 would be the 1st ones to be affected. This is right around when I'd be done...so I'm gonna take the current step 2 after MS3 (and before PhD) so that I won't have to be involved with all this new-test-funny business. Frankly I'd be kind of pissed if they no longer looked at Step 1 by the time I applied, after all the work I put into it.

 

[semolina]

Here's the last line from the official info from USMLE: http://www.usmle.org/General_Information/review.html

Frankly I'd be kind of pissed if they no longer looked at Step 1 by the time I applied, after all the work I put into it.

Funny, I would be quite happy if my step 1 score became irrelevant by the time I apply to residency, after all the work I put into it (with marginal returns).

It seems that keeping the traditional 2-3-2 approach would work fine in the event of a consolidated USMLE after MS3. It would just mean that scores for MD/PhD students would have to be taken in light of a 3-5 year study break or, better yet, largely ignored by program directors and more weight given to our research record (which, I'm guessing would benefit some if not most of us).

 

[MelRoos]

I have to say I am not a fan of the med/grad simultanious integration. At my school, we did our graduate work instead of our intro to clinic during 1st and 2nd years, then did the intro to clinics during years 4 and 5- so during your dissertation. It was a huge pain for all four years. We were disadvantaged on tests in years 1 and 2 b/c we weren't getting the whole picute, then again when picking back up the clinical b/c we weren't taking the concurrent basic science course and didn't have all the relevant diagnosis, path, treatment in our heads for osce's and pt encounters... I realize we all have to integrate when we are done- but sometimes the learning process should be protected.

 

[RxnMan]

APSA has produced a survey for med students and residents regarding this issue. If you are a medical student, resident, or fellow, please see a summary of the proposed changes in the USMLE at http://survey.physicianscientists.org/.

An 18 question multiple-choice survey has been developed by the student leadership of the American Physician Scientists Association (APSA) to generate as much student input as possible regarding attitudes and perceptions of the tentatively proposed changes. We are surveying medical students, residents and fellows who have or will take the USMLE exams. Please proceed to http://survey.physicianscientists.org for a link to the survey. The survey should take you approximately 10 minutes to complete.

(this announcement modified from the original APSA announcement)