USMLE Scores Should Not Dictate Specialty Choice

Kunal Sindhu, MD


October 02, 2019

Should a single test determine your future?

Growing up in a rural village in newly independent India in the 1950s and 1960s, my uncle was educated in a system where the results of a single end-of-year exam determined whether students would advance to the next grade. These tests also determined who received scholarships to attend college. In a poor village that had not seen anyone enroll in a tertiary educational institution in years, these scholarships were crucial.

When it came time for my uncle to take his test, he did quite well. But he came up 2 points short (out of 1000) and did not earn a scholarship. For weeks, he was devastated. He ended up working in various jobs. By the time he was finally able to go to college, he had lost his passion for physics, his first love. Over five decades later, he still wonders whether his path in life would have been different had he scored just a couple points higher on his exam.

When I was studying for Step 1 in medical school, I could not help but think about my uncle's experience. I knew that a few odd questions sprinkled over the course of a grueling, 8-hour exam could dramatically impact my future. I knew that residency program directors consistently cite Step 1 scores as one of the most important factors they use in selecting applicants. I knew that many residency programs employ minimum Step 1 score cutoffs in screening residency applications; I probably would not even be considered for an interview if I did not score highly enough.

'This Has to Stop'

Now in residency, I can appreciate just how ludicrous this arrangement actually is. For one, Step 1 is a poor tool to use to select residents: It is not correlated with the acquisition of clinical skills and tests content that is not relevant to modern medical practice. This should not be surprising, given that Step 1 was originally intended to be a competency exam for licensure. It was never meant to be used to stratify medical students.

Second, external factors over which I had no control could have easily affected my performance on test day. A poorly timed illness or the receipt of bad news prior to the exam very well could have depressed my overall score. These extenuating circumstances would surely be lost on residency programs considering my application for an interview. In other words, plain bad luck could have barred me from entering entire specialties.

Some might argue that these are simply theoretical concerns and that Step 1 is rarely the reason that medical students end up entering specialties that they did not plan to originally. I disagree. In fact, Step 1 may play a much larger role in the specialty decisions of medical students than I had even realized.

A recent series of tweets by an astute medical trainee helped alert me to this possibility.

Not only are some medical students potentially choosing a path that will not satisfy them most, but the community is possibly missing out on passionate specialists as well. A December 2018 study in Medical Science Educator shed more light on the prevalence of this phenomenon. The authors surveyed 793 medical students at the Albert Einstein College of Medicine who took Step 1 between 2011 and 2015. Among the respondents to questions about specialty choice, more than 1 in 4 (27.5%) reported that they changed their specialty because of their Step 1 scores. Equally concerning were the reasons behind the changes: 39% suddenly developed "new interest in [previously] 'out of reach' fields," 39% "no longer [felt] competitive for some fields," and 10% "did not want to waste [their] score." In other words, a significant number of physicians may not be practicing in the field of medicine that most appealed to them.


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