My two biggest complaints about the USMLE

[RiskyFugu]

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Yeah, it's a difficult exam. Yeah, it's long. Blah blah.

But here are two very legitimate complaints about the exam -- i.e. things they really ought to change.

1. Witholding from you diagnostically-helpful pieces of information about patients you'd be 100% guaranteed to have in a real life clinical setting. For example, they often leave out chronology, or they will omit major clinical findings in certain diseases that make the diagnosis much more straightforward. Lab values and/or imaging that could help you rule-in or rule-out a diagnosis are virtually never given to you even though they would undoubtedly be acquired in a real life setting. I know, I know, they're doing this to see if you know all of the little details. But in doing this us, they are adding a degree of difficulty to the clinical scenario that is purely artificial. Jumping over the hurdle over making a diagnosis based on abridged information, and then having to remember the minutia bout that diagnosis is not particularly representative of reality.

2. Not providing the reference ranges for the lab values, and forcing us to go hunting for them. Totally unnecessary. When you have 75 seconds to recall two or three facts pertaining to a disease (i.e. "This patient's condition that can be treated by inhibition of this receptor"), it is not an unreasonable thing to ask that the reference ranges for the given labs be posted in the question.

Am I wrong on these two points?

 

[vr123]

I totally agree with you. The thing is they're trying to make the exam questions harder. This assures a better distribution. If everything were given like it is in real clinical practice, then almost everyone would (or should, we hope, since we are all gonna be treating patients) get like 98% questions right. And then there wouldn't be a good spread of scores. Plus, the mean score keeps going up and up as it is, and they're trying to hold that back as much as possible. That's just my view on it.

 

[NRAI2001]

I disagree with the steps obsession with 2nd messengers, memorizing random chromosome number... And also how they can take a complicated topic and test you on the most minute and clinically useless detail that really doesn't demonstrate any real level of understanding of anything besides being able to randomly recall what most people would usually just ignore bc it so useless to know.. Ok rants over

 

[knuckles]

I don't really see the problem. If you know what's important you're going to pass.

If you really want the high score, then you're going to have to show that you work harder, you retain knowledge better, and you're possibly more intelligent than your competition. This is the reason why the most competitive specialties use step scores. It's to determine the best of the best.

Obviously there are other factors besides the step taken into account for residency selection, but I'm betting the step is a decent prognosticator of one's performance in their respective residency. Certain residencies definitely have higher demands than others. I wouldn't doubt that on average, a 250 scorer is a harder worker and smarter than a 220. No offense intended to any of those scoring average. Like I said, there are plenty of other parts of the application that are to be considered.

 

[Dedikated2liftn]

Yeah, it's a difficult exam. Yeah, it's long. Blah blah.

But here are two very legitimate complaints about the exam -- i.e. things they really ought to change.

1. Witholding from you diagnostically-helpful pieces of information about patients you'd be 100% guaranteed to have in a real life clinical setting. For example, they often leave out chronology, or they will omit major clinical findings in certain diseases that make the diagnosis much more straightforward. Lab values and/or imaging that could help you rule-in or rule-out a diagnosis are virtually never given to you even though they would undoubtedly be acquired in a real life setting. I know, I know, they're doing this to see if you know all of the little details. But in doing this us, they are adding a degree of difficulty to the clinical scenario that is purely artificial. Jumping over the hurdle over making a diagnosis based on abridged information, and then having to remember the minutia bout that diagnosis is not particularly representative of reality.

2. Not providing the reference ranges for the lab values, and forcing us to go hunting for them. Totally unnecessary. When you have 75 seconds to recall two or three facts pertaining to a disease (i.e. "This patient's condition that can be treated by inhibition of this receptor"), it is not an unreasonable thing to ask that the reference ranges for the given labs be posted in the question.

Am I wrong on these two points?

As other have said before, you have to have a way of sorting out the good from the better (in regards to students). Also, there are questions put on the test that are poorly phrased/worded that do constitute a handful of experimental questions...maybe if a critical lab value is omitted, it might be one of the aformentioned. In regards to the references ranges, they do offer the downloadable FRED software for the Free 150 (also U World makes use of the same software). As a result, if you know how to search for the value you're looking for (the search function is listed when you pull up the Ref Ranges), it doesn't have to be laborious.

 

[PokerDoc]

I think youre missing the point of step I a bit. Its a basic sciences exam.. step II is supposed to test your clinical knowledge. You should be able to get the right answer on step I from the basic science info provided, not the clinical.

 

[WellWornLad]

I'd agree with 1 if it meant the difference between passing and failing. As it stands, I think there were enough straight-forward questions with complete information to pass without getting too tricky.

As for 2, I don't think it's too much to ask that we know normal-ish lab values. Frankly, I'm thankful they even give us the option of looking them up. After 2 years of tests with questions modeled after clinical scenarios and lab values, I only had maybe 3-4 questions where I felt I had to look up normal ranges.

 

[RiskyFugu]

I'd agree with 1 if it meant the difference between passing and failing. As it stands, I think there were enough straight-forward questions with complete information to pass without getting too tricky.

As for 2, I don't think it's too much to ask that we know normal-ish lab values. Frankly, I'm thankful they even give us the option of looking them up. After 2 years of tests with questions modeled after clinical scenarios and lab values, I only had maybe 3-4 questions where I felt I had to look up normal ranges.

Normal lab values (i.e. reference ranges) seem to vary quite a bit, depending on the source. For the USMLE, it should be their values that we are consulting. Not the ones in our heads.

Moreover, sometimes the abnormal lab values given to you may not be that abnormal. I had a couple of questions on my exam where the hyponatremia was very slight.

The bottom line is that for a lot of these lab values you need to check the reference ranges.

But let's look at it another way: Tests are given to discover information, correct about a student's knowledge. What information does the NBME think it's getting by not putting the reference ranges next to the lab values?

 

[vr123]

Normal lab values (i.e. reference ranges) seem to vary quite a bit, depending on the source. For the USMLE, it should be their values that we are consulting. Not the ones in our heads.

Moreover, sometimes the abnormal lab values given to you may not be that abnormal. I had a couple of questions on my exam where the hyponatremia was very slight.

The bottom line is that for a lot of these lab values you need to check the reference ranges.

But let's look at it another way: Tests are given to discover information, correct about a student's knowledge. What information does the NBME think it's getting by not putting the reference ranges next to the lab values?

I agree, I don't see why they can't do that. They are probably just trying to grab a few seconds from us while we look through the lab values thing.

On an unrelated note, RiskyFugu have you actually had Fugu? (apologize for the tangent).

 

[RiskyFugu]

I agree, I don't see why they can't do that. They are probably just trying to grab a few seconds from us while we look through the lab values thing.

On an unrelated note, RiskyFugu have you actually had Fugu? (apologize for the tangent).

I have. And let me tell you, it is truly some good sh|t!

 

[NotMeNow]

Yeah, it's a difficult exam. Yeah, it's long. Blah blah.

But here are two very legitimate complaints about the exam -- i.e. things they really ought to change.

I see your point, but I am going to have to disagree. In 'real life' sometimes you have incomplete information and more commonly you have a non-classical presentation. In terms of imaging, you should have some idea what you are considering before you order the test. That being said everything on my exam was very classical.

In terms of lab values - I don't really see the big deal - it takes 10 s to look up the values, and rewards those that know normal values.

 

[RiskyFugu]

I see your point, but I am going to have to disagree. In 'real life' sometimes you have incomplete information and more commonly you have a non-classical presentation. In terms of imaging, you should have some idea what you are considering before you order the test. That being said everything on my exam was very classical.

In terms of lab values - I don't really see the big deal - it takes 10 s to look up the values, and rewards those that know normal values.

Well, I know the normal lab values too, at least for the big things.

Again, though, the numbers I have in my head don't match the ones that the NBME use.

 

[xanthomondo]

I see your point, but I am going to have to disagree. In 'real life' sometimes you have incomplete information and more commonly you have a non-classical presentation. In terms of imaging, you should have some idea what you are considering before you order the test. That being said everything on my exam was very classical.

In terms of lab values - I don't really see the big deal - it takes 10 s to look up the values, and rewards those that know normal values.

Woo that's the med school mentality! Reward memorization over understanding concepts!

 

[VoiceofReason]

step 1 is too bloated and convoluted for the initial examination of an M.D. candidate. It should be simply basic science principles w/ an emphasis on hardcore physiology in my opinion

 

[Mr hawkings]

I think youre missing the point of step I a bit. Its a basic sciences exam.. step II is supposed to test your clinical knowledge. You should be able to get the right answer on step I from the basic science info provided, not the clinical.

So why make you spend time reading a long clinical vignette. Why pretend like its all relevant. Is it just to add another level of annoyance cos some of us are too neurotic to resist reading every word of the Q for fear of missing something important only to realize that the i could have answered the Q by reading the last sentence alone.

 

[sexyman]

I didnt think the exam was nearly as "detail oriented" as everyone says that it is. At least my exam felt like big picture topics.

As for the lab values- thats really not that big of a part of the exam. I cant imagine anyone struggling on the USMLE because they spent too much time looking up lab values...

 

[BigRedder]

In real medicine, the lab printout tells you what is abnormal. You barely have to do math. In real medicine, they give you forms to fill out when taking histories for an admission. You don't forget to ask about pets. In real medicine, the system is in place to ensure your success. In a test, the clinical scenario is merely a facade placed over a basic science question. Usually they give you too much information on the real exam.

Concerning those long vignettes: They are probably the best measure of clinical acumen. In real cases, there is a huge amount of information, and only a couple important findings. Filtering out useless information is what separates us from a computer program!

 

[bbydoc]

In real medicine, the lab printout tells you what is abnormal. You barely have to do math. In real medicine, they give you forms to fill out when taking histories for an admission. You don't forget to ask about pets. In real medicine, the system is in place to ensure your success. In a test, the clinical scenario is merely a facade placed over a basic science question. Usually they give you too much information on the real exam.

Concerning those long vignettes: They are probably the best measure of clinical acumen. In real cases, there is a huge amount of information, and only a couple important findings. Filtering out useless information is what separates us from a computer program!

very well put, couldnt have said that better.

 

[jackieMD2007]

I wouldn't doubt that on average, a 250 scorer is a harder worker and smarter than a 220.

As a teacher for a standardized test company, I would. The 250 scorer is a better test taker. That's all.

Students who score higher on USMLE Step 1, just like on the SAT or on the MCAT tend to fall into one (or more) of the following categories:
1-extremely good at standardized tests (innately or trained that way or both)
2-prepared more effectively for the exam than others
3-received topics on test day that they were very comfortable with
4-do not experience exceedingly high levels of internal stress on test day and are good at positively self-talking to themselves when they feel stressed or less confident

I don't think any of the above, 1-4 make people a SMARTER or a HARDER WORKING person than anyone else. They don't become "better" college students, doctors, lawyers or business school students or more successful in their careers; just as persons scoring around the average on standardized tests don't become "average" members of the profession, whatever that means. 🙄

Your performance ONE DAY on a standardized test doesn't say anything about your abilities or who you are as a person.

 

[topscorer]

I don't really see the problem. If you know what's important you're going to pass.

If you really want the high score, then you're going to have to show that you work harder, you retain knowledge better, and you're possibly more intelligent than your competition. This is the reason why the most competitive specialties use step scores. It's to determine the best of the best.

Obviously there are other factors besides the step taken into account for residency selection, but I'm betting the step is a decent prognosticator of one's performance in their respective residency. Certain residencies definitely have higher demands than others. I wouldn't doubt that on average, a 250 scorer is a harder worker and smarter than a 220. No offense intended to any of those scoring average. Like I said, there are plenty of other parts of the application that are to be considered.

I can see where this point is coming from, but the mantra I have been fed is kinda opposite

this would make you want to believe that the super competetive residencies that require 245+ scores are more difficult and require harder working students.

I was under the impression, that the most competitive residencies/fields, are not actually difficult TO DO, are actually just difficult TO OBTAIN, and are actually require much less work and knowledge on a daily basis than easier fields to obtain, IM or FP

for example, not only are the average work hours for a DOCTOR of derm, plastics, oto, optho, much less than the average doctor of fp or im, but the average RESIDENT hours per week are also much less

and i would imagine knowing everything about the eye is much easier than having to know everything about everything all the time kinda like IM or FP, constantly being on the ball, being approached from any angle any system changing from room to room. vs glaucoma, cataract, glaucoma, cataract

the point is, the highest paid fields are the most competetive simply because of the VERY FEW NUMBER OF spots available, not because of the DIFFICULTY of the field. these numbers continue to stay low because the field is so UNDIFFICULT/sitdown, doctors never retire and new spots never open up, and it is of course in their best interest to keep the number low simply due to supply and demand

and for busy busy doctors, step 1 is simply the most universal and EASIEST way of limiting amount of applications u need to read so it becomes the separator.

thousands grains of salt please

 

[knuckles]

I never said that the residencies were more demanding or harder per say. If they're more competitive, of course residency directors will use that to their advantage to get the best students they can. Anyway, we're in agreement it seems about this point.

As far as Step 1 being the mot universal, you're correct. It's the single uniform score across every application that is supposed to be objective and timeless. Whereas all our grades are subjectively given, with different medicals schools having grade inflation/deflation, and different attendings evaluating different, the step score is unbiased to an extent.

 

[RiskyFugu]

As a teacher for a standardized test company, I would. The 250 scorer is a better test taker. That's all.

Students who score higher on USMLE Step 1, just like on the SAT or on the MCAT tend to fall into one (or more) of the following categories:
1-extremely good at standardized tests (innately or trained that way or both)
2-prepared more effectively for the exam than others
3-received topics on test day that they were very comfortable with
4-do not experience exceedingly high levels of internal stress on test day and are good at positively self-talking to themselves when they feel stressed or less confident

I don't think any of the above, 1-4 make people a SMARTER or a HARDER WORKING person than anyone else. They don't become "better" college students, doctors, lawyers or business school students or more successful in their careers; just as persons scoring around the average on standardized tests don't become "average" members of the profession, whatever that means. 🙄

Your performance ONE DAY on a standardized test doesn't say anything about your abilities or who you are as a person.

And let us not forget that there are a lot of external factors that go into how someone does on the day of a big exam: recent deaths in the family, car accident, poor test conditions, illness.

I actually did quite well on the Step 1, but I will say that it is one of the lousiest exams I’ve ever taken. Very unrepresentative. My exam was loaded with biochemistry, microbiology, and cardiovascular questions. I would say, in fact, that these three topics made up 60% of my exam. Over the course of the exam I encountered just one endocrinology question, two neurology questions, and two anatomy-related questions. There were a number of topics I don’t recall ever having been touched. Don’t get me wrong: it was a very difficult exam. But you’d think that the people who make the USMLE would want a well-rounded exam.