'Secretive Meeting' Threatens USMLE Reform, Critics Say

Pranav Reddy, MD, MPA; Kunal Sindhu, MD; Bryan Carmody, MD, MPH


June 21, 2019

It finally happened.

Three months ago, the most important conference in medical education, the Invitational Conference on USMLE Scoring (InCUS), took place behind closed doors. Authors from the five stakeholders who convened the meeting—the Association of American Medical Colleges (AAMC), American Medical Association (AMA), Educational Commission for Foreign Medical Graduates (ECFMG), Federation of State Medical Boards (FSMB), and National Board of Medical Examiners (NBME)—have finally revealed what was deliberated at the meetings and made preliminary recommendations.

Prior to the event, we worried that this invitational conference would not sufficiently consider the well-being and needs of medical students. We wondered whether a secretive meeting with a guest list and agenda determined by corporate entities with financial interests in the outcome could lead to meaningful change. We were afraid that any recommendations would only serve to protect the status quo and delay reform. Unfortunately, but unsurprisingly, we appear to have been right.

How Proposed Changes Were Decided

For those who have not closely followed the recent debate, some context may prove helpful. For years, increasing residency applications have contributed to a growing administrative burden for program directors. Unfortunately, misappropriation of USMLE scores to screen applications has turned Step 1 into a de facto "residency aptitude test." We have pointed out that the exam, intended to inform a binary determination on competency for licensure, is increasingly irrelevant to clinical practice.

We have also argued that increased focus on test preparation has negative impacts on medical student well-being and institutional curricula, through the creation of an adverse "Step 1 climate." A change from Step 1's current three-digit scoring system to a pass/fail system would satisfy the test's purpose for licensure, allow students to focus on more relevant educational experiences, and facilitate holistic applicant review and reform of application inflation.

To address these concerns, the USMLE's sponsor organizations (the NBME and FSMB) along with three other stakeholder organizations (AAMC, AMA, and ECFMG) organized the InCUS, which was held in March 2019. Forty-five invitees joined 20 executives from the aforementioned organizations to discuss the issues in undergraduate and graduate medical education (UME and GME) and make recommendations regarding the future of Step 1 scoring.

In a podcast recorded in advance of the conference, NBME Vice President Michael Barone said, "[What] InCUS is allowing us to do is bring together all the stakeholders, a group of invitees who really are going to challenge us, who are going to ask us to look at different ways of doing things or are going to engage in thought and perhaps come to the conclusion that there are many, many changes that need to happen in that UME-to-GME transition system." This latter prediction proved eerily prescient when the preliminary recommendations from the conference were released.


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