Should USMLE STEP 1 be eliminated?

[OncoCaP]

I heard some interesting things about USMLE STEP 1 today (how it might be changed).

Anyway, what would you all think about eliminating STEP 1 altogether? Seems like it would significantly change medical education. I could see how it could be better, giving schools more flexibility in how they teach pre-clinical. On the other hand, STEP 1 provides a standardized first "step" toward competing for internships / residencies. What do you think?

Looks like there is already an interesting thread on this in an obvious place that I should have checked first. Anyway, it might be an interesting topic for discussion here since I'm asking more about whether it would be a good idea and what it means for our medical education right now.

http://forums.studentdoctor.net/showthread.php?t=467963

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[Pinkertinkle]

It'll be a sad day when Step 1 is eliminated, leaving ms1's and ms2's at the mercy of the basic science Ph.D.'s.

 

[alphaholic06]

It'll be a sad day when Step 1 is eliminated, leaving ms1's and ms2's at the mercy of the basic science Ph.D.'s.

I totally agree with this.

 

[Law2Doc]

It'll be a sad day when Step 1 is eliminated, leaving ms1's and ms2's at the mercy of the basic science Ph.D.'s.

Agreed. It might start making basic science year courses and class rankings actually count for something. Which breeds competitiveness. Which breeds gunners. Leads to a very negative vibe. Suddenly your laid-back classmates who all helped and rooted for each other to succeed will find themselves competing head to head with each other for course grades which actually count for something, rather than against faceless people at other schools (as they did when Step 1 was the end-all be-all of the basic science component). Either you give residency directors a better yardstick to use or you risk course grades becoming that yardstick. Which ends up not being any better, probably worse.

 

[Slide]

When I read the part about a rumor stating the merger of the two exams into a big exam 4th year, the first thought in my mind was "helllllll no".

Right now I don't see any major flaws in the current system. As much as I dread taking the Step 1 in less than two years, I also see the values and strengths of using it for residency apps. Doing away will probably require that our preclinical grades count for something, consolidating the test at the 4th year (which I'm sure I'll remember very little of what I learned), or having the test assess clinical skills only and trivialize the basic science years (which I believe should not happen). Why do committees insist on fixing things that aren't broken?

 

[OncoCaP]

At my school we are numerically ranked somehow (but they don't tell us where we are until maybe the end, I suppose). Most of this is based on our clinical rotations. I guess if preclinical grades started counting, maybe we would see grade inflation ... no school in its right mind would give very many B's or C's.

I was not too happy about this idea at first, but it is growing on me. I'm not sure why we need a board exam over material most physicians will forget ... unless it somehow tells PDs how you'll do as a resident.

With respect to Slide's comment on the medical education system being problem free (not broken): I'm not sure that the system is perfect. I guess some powerful individuals see some problems that they do think need to be corrected or maybe they just want to save money.

 

[PeepshowJohnny]

There needs to be a standardized way to compare medical students across different medical schools. Otherwise we're going to see massive medical school grade inflation and greater emphasis placed on place of training vs. individual achievement and work.

 

[Rzrbker]

If you remove the Step I as an objective tool for residency program directors to utilize what will they primarily use? If they use primarily class rank it would undoubtedly breed a more competitive/hostile environment in med schools. My school doesn't have this competitive aura it's great. Then they would have to resort to, we'll I guess he went to XXXX school it's better than top 10% of the class at YYYY school... it would be terrible.

They will have to have some type of objective test. Every aspect of educational life does for evaluating a group of people. ACT/SAT, GRE, LSAT, MCAT, etc.

 

[The Buff]

There needs to be a standardized way to compare medical students across different medical schools. Otherwise we're going to see massive medical school grade inflation and greater emphasis placed on place of training vs. individual achievement and work.

Totally agree. Plus, most of the stuff they test you on at least has some relevance to things you might need to know in the future. It is not a total waste of time to brush up on the highlights of first and second year.

 

[Slide]

At my school we are numerically ranked somehow (but they don't tell us where we are until maybe the end, I suppose). Most of this is based on our clinical rotations. I guess if preclinical grades started counting, maybe we would see grade inflation ... no school in its right mind would give very many B's or C's.

I was not too happy about this idea at first, but it is growing on me. I'm not sure why we need a board exam over material most physicians will forget ... unless it somehow tells PDs how you'll do as a resident.

With respect to Slide's comment on the medical education system being problem free (not broken): I'm not sure that the system is perfect. I guess some powerful individuals see some problems that they do think need to be corrected or maybe they just want to save money.

I should've reworded some of my words. I'm not trying to state that the medical education system system is problem free; if anything, you are right that it is not perfect. What I meant to say is that there are some things that are surprisingly fine in the current medical educational environment, and again the powers-that-be are trying to "fix" something that doesn't need to be fixed. I'm ok with minor changes to the Step I, but something radical as doing away with it? Ack.

 

[45408]

There needs to be a standardized way to compare medical students across different medical schools. Otherwise we're going to see massive medical school grade inflation and greater emphasis placed on place of training vs. individual achievement and work.

If you read the other thread, the second or third posted had a lengthy article, in which they stated that if the Step 1 became pass/fail or eliminated altogether, then the NBME would come up with another yardstick to measure students with, so schools could evaluate their students and their curriculum.

 

[DrKitty]

Why is there this idea of preclinical grades not being important? They ARE included in your Dean's letter, with the data that compares them to your classmates' grades. It certainly wouldn't look good if you have ****ty preclinical grades, even if you have a good Step I score. I think people like to think that preclinical grades don't matter, since it makes them feel better when they don't get the exam score they want or makes it easier to get by during first 2 years.

 

[sendwich]

Why is there this idea of preclinical grades not being important? They ARE included in your Dean's letter, with the data that compares them to your classmates' grades. It certainly wouldn't look good if you have ****ty preclinical grades, even if you have a good Step I score. I think people like to think that preclinical grades don't matter, since it makes them feel better when they don't get the exam score they want or makes it easier to get by during first 2 years.

because i've heard of several residency directions/admissions people saying that pre-clinical grades are pretty low on the list in terms of how much weight it holds in getting people into programs. there's been a lot of threads here that discussed just how "important" preclinical grades are.

no one cares if you honored histology.

and i'm not saying this because i dont do well in class. i'm doing pretty well personally.

 

[DrKitty]

because i've heard of several residency directions/admissions people saying that pre-clinical grades are pretty low on the list in terms of how much weight it holds in getting people into programs. there's been a lot of threads here that discussed just how "important" preclinical grades are.

no one cares if you honored histology.

and i'm not saying this because i dont do well in class. i'm doing pretty well personally.

I heard the opposite, especially if you are thinking of academic medicine or top residency programs. Also, good grades in courses such as anatomy, physiology, pathology surely would help, especially if they are relevant to the specialty you are applying for. I guess my point is, no matter how many times people say that preclinical grades don't matter, everybody would still try to do their best to get the best grades they can, since everybody knows it can't hurt.

 

[DrKitty]

I am not part of your "everybody." Good preclinical grades don't interest me, and there are schools that do a much better job of covering board-relevant material than others. As far as preclinical courses being important for specific specialties, two students will always be compared by step 1 before grades are considered since there is absolutely no way whatsoever for PD's to understand what the grades mean across programs. Many "top" schools give P/F only, and they certainly aren't at a disadvantage.

Instead of relying on what you heard, look at the NRMP outcomes (available in my signature several posts above). No mention of grades. Regarding a prior post, not all MSPE's include class rank information.

Are you saying that you personally don't care about your preclinical grades and that you don't do your best in studying for the exams?

 

[45408]

I heard the opposite, especially if you are thinking of academic medicine or top residency programs. Also, good grades in courses such as anatomy, physiology, pathology surely would help, especially if they are relevant to the specialty you are applying for. I guess my point is, no matter how many times people say that preclinical grades don't matter, everybody would still try to do their best to get the best grades they can, since everybody knows it can't hurt.

Not particularly likely. Yale doesn't even have pre-clinical grades, and a lot of highly ranked schools simply use pass/fail. It's kind of hard to get score a "good grade" when it's either a pass or a fail. Sure, if you've failed a class and had to remediate, it will look bad, but Step 1 and third year rotations are usually a lot higher on an RD's list of priorities.

Surprise, I do try my best, because um, most of this information will be on Step 1.

 

[DrKitty]

Not particularly likely. Yale doesn't even have pre-clinical grades, and a lot of highly ranked schools simply use pass/fail. It's kind of hard to get score a "good grade" when it's either a pass or a fail. Sure, if you've failed a class and had to remediate, it will look bad, but Step 1 and third year rotations are usually a lot higher on an RD's list of priorities.

Surprise, I do try my best, because um, most of this information will be on Step 1.

A lot of P/F schools still have "behind the scenes" class rank system. Not that it matters to anyone, but I personally wouldn't believe aybody who says they don't care about their preclinical grades.

I don't mean to argue with anybody. We can close this topic, as this thread was originally meant to discuss an entirely different topic.

 

[Lorrayne]

Surprise, I do try my best, because um, most of this information will be on Step 1.

Exactly.

 

[alwaysaangel]

A lot of P/F schools still have "behind the scenes" class rank system. Not that it matters to anyone, but I personally wouldn't believe aybody who says they don't care about their preclinical grades.

I don't mean to argue with anybody. We can close this topic, as this thread was originally meant to discuss an entirely different topic.

Yeah but in general its heavily slanted toward clinical year grades. Here like 30% of your class rank comes from pre-clinical years and the rest is your clinical evals. So yes, of course it matters everyone, but at most schools its not enough to breed competition. I love my class because we do work so hard together. Are there people trying to honor everything? Sure, but they're usually the ones sending out their study guides to everyone. They don't try to succeed on the failure of others.

And if you don't believe people who says they don't care about preclinical grades thats your option. But I'm curious what kind of school are you at that makes you feel this way? Here we are H/P/F, and I guarantee you - anyone claiming they just want a pass - really do just want a pass, because they'd rather go drinking on Saturday night. I just can't imagine going to a school where everyone was really killing themselves to get H, but I guess if you were at a H/HP/P/MP/F school that would happen. Is that the sort of grading system your school has?

 

[Depakote]

The thing about Step I is it provides an objective measure the same as the MCAT did... it gives a single uniform measure for every student out there. Plus, it assures that every school is teaching the right material and that students that somehow scrape by getting the bare minimum grades do manage to retain the material.

It is also the objective measure that allows DOs and FMGs to be assessed by the same standards and given equal footing in the residency match process.

I don't see how a single unifying leveling factor would ever be removed for a more subjective and less reliable one.

 

[DrKitty]

Yeah but in general its heavily slanted toward clinical year grades. Here like 30% of your class rank comes from pre-clinical years and the rest is your clinical evals. So yes, of course it matters everyone, but at most schools its not enough to breed competition. I love my class because we do work so hard together. Are there people trying to honor everything? Sure, but they're usually the ones sending out their study guides to everyone. They don't try to succeed on the failure of others.

And if you don't believe people who says they don't care about preclinical grades thats your option. But I'm curious what kind of school are you at that makes you feel this way? Here we are H/P/F, and I guarantee you - anyone claiming they just want a pass - really do just want a pass, because they'd rather go drinking on Saturday night. I just can't imagine going to a school where everyone was really killing themselves to get H, but I guess if you were at a H/HP/P/MP/F school that would happen. Is that the sort of grading system your school has?

I am not saying everyone at my school is killing to get honors.
In fact, whatever I said above has nothing to do with the school I attend; I just expressed my personal opinion.

 

[QuantumMechanic]

A lot of P/F schools still have "behind the scenes" class rank system. Not that it matters to anyone, but I personally wouldn't believe aybody who says they don't care about their preclinical grades.

I never have actually seen someone substantiate this statement. Where I go, our M1 is p/f, and there's no mysterious behind-the-scenes ranking that is still going on based on our first year performance.


As for getting rid of Step 1, in theory it might be a better idea to test us on everything at the end of medical school. (Have a bar exam instead of a series of steps), but this really isn't feasible since the time required for such a test would take alot of time out of 4th year. Not that 4th year is crammed with alot to do anyway, but it would make it miserable. Also some schools view passing Step 1 as a competency to go onto the wards (evidenced by their not allowing students to continue onto 3rd year without a passing score). This is probably not a good way to look at it (see Penn and Duke's philosophy).

The current system seems satisfactory. However it is rather inefficient to have second years take a month off to study for an licensing exam that many could pass could pass with only a couple weeks of studying. Since the score actually matters, it makes it a bigger deal than what it should be (instead of being like Steps 2 and 3).

 

[NotAProgDirector]

As a residency director, it seems clear to me what will happen should the USMLE reformat it's exam.

1. The USMLE/NBME lists as one of it's core precepts that medical schools still want an exam at the end of 2nd year for promotion. Although that exam will be outside the USMLE licensing process, you can bet that most schools will use it and then report it in the Dean's letter. So, for those of you horrified that Step 1 might disappear, it's probably just going to change it's name.

2. The "Ready for GME" new USMLE step proposed seems designed for the 4th year student. You can bet that all residency programs will require that you have a score reported prior to ranking, and the competitive programs will require scores for application. Hopefully, the USMLE will see this and make sure that there is capacity to allow all 4th year students to take the exam in July-October. If not, prepare for a horrible game of musical chairs (for exam slots).

From a PD perspective, this is not a big disaster (again, assuming that there is capacity for all fourth year students to take the exam early in the fourth year). DO's and IMG's will still be able to take this exam -- unclear if they will be able to take the exam available for allopathic grads at the end of the second year which could be a problem, but probably not with a solid "New USMLE" score.

Let's not forget that it will presumably save everyone an exam fee, unless they decide to charge twice as much for the new and improved exam.

 

[TrapperJohnMD]

I never have actually seen someone substantiate this statement. Where I go, our M1 is p/f, and there's no mysterious behind-the-scenes ranking that is still going on based on our first year performance.

How did your school determine you passed? Surely you had to take at least one test, most likely a minimum of 3. Those tests were graded, and if your % correct met the preset pass level, or was within 1 SD or your class average -then you passed. Those #'s dont disappear just because your transcript only says P or F. Most likely they are used for some form of rank.

I'm just speaking from my experience with my school --which stresses a non-competitive atmosphere. The only thing that matters is our test scores. We either get a P (pass) C (concerns) or F (fail). P= >/= class average, C= 1 SD below average, F= 2 or more SD below average. We ARE ranked based on test score percentages, somewhere, by someone. One of the second year professors even admitted they do this to identify those who may have trouble with 2nd year material. Whether or not this goes into the deans letter, or has any other significance probably can't be determined.

Point is this: If you are tested, and that test is graded by the school you ARE ranked (formally, informally or otherwise).

 

[Tiki]

Why is there this idea of preclinical grades not being important? They ARE included in your Dean's letter, with the data that compares them to your classmates' grades. It certainly wouldn't look good if you have ****ty preclinical grades, even if you have a good Step I score. I think people like to think that preclinical grades don't matter, since it makes them feel better when they don't get the exam score they want or makes it easier to get by during first 2 years.

Uh, they weren't in my dean's letter, only my third and some fourth year grades were in my dean's letter.

 

[Re3iRtH]

Yeah but in general its heavily slanted toward clinical year grades. Here like 30% of your class rank comes from pre-clinical years and the rest is your clinical evals. So yes, of course it matters everyone, but at most schools its not enough to breed competition. I love my class because we do work so hard together. Are there people trying to honor everything? Sure, but they're usually the ones sending out their study guides to everyone. They don't try to succeed on the failure of others.

And if you don't believe people who says they don't care about preclinical grades thats your option. But I'm curious what kind of school are you at that makes you feel this way? Here we are H/P/F, and I guarantee you - anyone claiming they just want a pass - really do just want a pass, because they'd rather go drinking on Saturday night. I just can't imagine going to a school where everyone was really killing themselves to get H, but I guess if you were at a H/HP/P/MP/F school that would happen. Is that the sort of grading system your school has?

Just remember that a P/F school can be just as competitive as a
school with grades, cause I've seen it. There are people in most
med schools that don't want to waste their time helping others, or
simply just don't have that type of personality. And when you get 160
people who have been competitive thier entire life into a single room,
don't expect that to change overnight.

Just for the record, my institution just cannot have a competitive
atmosphere just by the nature of it. PM me if interested in details.

 

[alwaysaangel]

Just remember that a P/F school can be just as competitive as a
school with grades, cause I've seen it. There are people in most
med schools that don't want to waste their time helping others, or
simply just don't have that type of personality. And when you get 160
people who have been competitive thier entire life into a single room,
don't expect that to change overnight.

Just for the record, my institution just cannot have a competitive
atmosphere just by the nature of it. PM me if interested in details.

I'm sure it can be. Its rather sad that people still bother though. I was just speaking out of my experience (we're H/P/F and about as cooperative as it gets) and was trying to figure out where the person I responded to was getting her conclusion. Whether it was actual experience or just a theoretical belief.

 

[QuantumMechanic]

How did your school determine you passed? Surely you had to take at least one test, most likely a minimum of 3. Those tests were graded, and if your % correct met the preset pass level, or was within 1 SD or your class average -then you passed. Those #'s dont disappear just because your transcript only says P or F. Most likely they are used for some form of rank.

I'm just speaking from my experience with my school --which stresses a non-competitive atmosphere. The only thing that matters is our test scores. We either get a P (pass) C (concerns) or F (fail). P= >/= class average, C= 1 SD below average, F= 2 or more SD below average. We ARE ranked based on test score percentages, somewhere, by someone. One of the second year professors even admitted they do this to identify those who may have trouble with 2nd year material. Whether or not this goes into the deans letter, or has any other significance probably can't be determined.

Point is this: If you are tested, and that test is graded by the school you ARE ranked (formally, informally or otherwise).

At my school, no, first year performance is purely pass/fail with respect to what goes on the Dean's Letter and and in respect to how we get ranked.

Obviously there are informal ways I suppose. For example, we get evaluated on our PBL groups performance by our facilitator which I'm sure ends up in the Dean's letter (but everyone in my group that I talked to received equally shining evals...so whatever), but performance in years 2-4 is much more important to my school, since we all came from different backgrounds, making 1st year an unfair time period for such significant evaluations.

 

[humuhumu]

The major change I'd like to see is a list of "testable" drugs published by the NBME. That way we wouldn't have to guess about which "legacy" drugs are still showing up, or which newer drugs are now considered fair game. A similar list would be useful for viruses, bacteria, fungi, and parasites.

 

[osli]

I furthermore think that there should be another exam in there...

MS 1
Step I
MS 2
Step II
MS 3-4
Step III (formerly CS) and IV (formerly CK)
PGY
Step V

That would create havoc among schools who differ in approach to pre-clinical curricula. i.e., subject based vs. systems based might cover entirely different scopes of material during the first year.

 

[TrapperJohnMD]

At my school, no, first year performance is purely pass/fail with respect to what goes on the Dean's Letter and and in respect to how we get ranked.

Obviously there are informal ways I suppose. For example, we get evaluated on our PBL groups performance by our facilitator which I'm sure ends up in the Dean's letter (but everyone in my group that I talked to received equally shining evals...so whatever), but performance in years 2-4 is much more important to my school, since we all came from different backgrounds, making 1st year an unfair time period for such significant evaluations.

Did you never take an exam? Were your grades solely based on narrative evals by profs? When taking an exam did they just count the # correct until they hit the pass mark and just not grade the rest? I still dont see how your PURE pass/fail exists. It may go into the deans letter as P/F, my school does this --but someone must have your scores, in an excel sheet or something, lined up in a table with all your other classmates (read youre ranked).

Are you trying to say that grades or not, if you pass 1st year --youve just passed (or failed) & those grades, and ranks are tossed out the window, effectively making a clean slate for everyone when 2 year begins, and THAT is where your actual ranking begins?

 

[QuantumMechanic]

Did you never take an exam? Were your grades solely based on narrative evals by profs? When taking an exam did they just count the # correct until they hit the pass mark and just not grade the rest? I still dont see how your PURE pass/fail exists. It may go into the deans letter as P/F, my school does this --but someone must have your scores, in an excel sheet or something, lined up in a table with all your other classmates (read youre ranked).

Are you trying to say that grades or not, if you pass 1st year --youve just passed (or failed) & those grades, and ranks are tossed out the window, effectively making a clean slate for everyone when 2 year begins, and THAT is where your actual ranking begins?

Yes, we took exams. No, our grades are based on if we passed the tests (plus some minor evaluation from PBL sessions). No, they told us how we did on the exam (percent correct). However the only other comment on our exams was 'Pass' or 'Fail' (rarely would anyone get the latter). Obviously if you barely pass they have meetings with those students to make sure they are doing OK, but nothing permanent goes on the Dean's Letter (even if you had to get talked to about barely passing) about performance during first year relative to our peers at this school. If you fail, you have to remediate those courses, but that's a rare occurrence. Our Dean doesn't want to screw us over and the school's philosophy is that M1 is a transition period (making it unfair for judgement) and a foundation for the last 3 years of med school, which are ultimately more important to clinical practice than minutia from biochemistry and anatomy that will be long forgotten months after it is tested.

We have been repeatedly reassured by our Dean that this is the case about M1 performance and class rank. I don't understand why you doubt our school's philosophy since other highly-regarded schools also de-emphasize competition amongst students.