USMLE Step 1 Going Pass/Fail: 5 Changes That Should Be Next

David R. Chen


March 11, 2020

Last year, a senior resident told me, "It's hard to grade medical students during their first clerkship. They don't know anything." Although I had spent the preceding months trying in vain to memorize the entirety of First Aid for the USMLE Step 1, that resident was right.

Delivering oral case presentations was humiliating, the EHR was an unholy vortex, and I had no sense of when it was even appropriate to speak. Despite the best efforts of my primary care–focused institution, I entered the clinical phase of medical school like a stranger in a strange land: underprepared and uneasy. My experience was not unique. Much of this underpreparation and uneasiness is due to the unsavory effects of Step 1 on preclinical education. "Step 1 mania," with its incessant emphasis on "high-yield" exam material, has long undermined a medical student's ability to devote time to the other important aspects of becoming a quality physician. Thankfully, Step 1 mania is about to die.

The National Board of Medical Examiners (NBME) recently announced that Step 1 will change to pass/fail as early as 2022. This may be the biggest change in medical education since the first version of that exam was introduced in the 1950s. Although many have focused on the challenges that this will pose in terms of residency selection, this move opens up several opportunities. Even if Step 2 CK (Clinical Knowledge) replaces the current role of Step 1 in some ways, the priorities for preclinical education still stand ready to be reexamined and reset.

The gateway to reforming medical education has opened, and it's time to go to work. Here are my five suggestions for what should come next.

Change 1: The NBME Should Change What Step 1 Covers

The scoring system for Step 1 is changing, and the content should change with it. The stated purpose of Step 1 is to ensure mastery of the sciences and scientific principles for "maintenance of competence through lifelong learning." Only, it doesn't really.

Few who have recently taken the exam defend the clinical value of its content. As my colleagues and I have described previously, "Step 1 highlights lingering anachronisms, histological curiosities, and select chromosomes." In contrast to what gets tested on Step 1, Competency-Based Medical Education (CBME) emphasizes the application of knowledge to "clinical situations that physicians often face." That seems like an approach that will prepare us far better for what's to come.

Now that it will be pass/fail, Step 1 should be overhauled and regularly updated in accordance with CBME. Practicing clinicians from diverse specialties should be consulted to select and remove material that is outdated, incorrect, or now irrelevant. Commonly misunderstood basic science and clinical topics should be identified and featured more prominently on the exam. For example, dermatologists may report that the description of skin lesions is of more value than memorizing histology, and questions could be developed to assess this skill.

Now is the time to consider more than just the end result of Step 1 and revise what students see on the test itself.

Change 2: The NBME Should Produce a Standardized, Free Resource for Step 1

Speaking of test-taking...

At every level of education prior to medical school, the teachers who give the examination were the ones choosing its content. Step 1 mania short-circuited this design. Because what is tested on Step 1 goes beyond individual institutional curricula, students mostly use third-party study resources. Previous generations of medical students learned from Harrison's Principles of Internal Medicine. Today we learn from resources like cartoon drawings and a crowdsourced electronic flashcard deck called Brosencephalon.

The NBME should commission a high-quality, expert-vetted, regularly updated, free-of-charge resource for Step 1 preparation. Medical educators and clinical leaders across the nation should collaborate to produce this resource, which would quickly become the gold standard. Institutions could then use it as a springboard for their own curriculum. This resource would also serve to better limit and define the scope of Step 1, as material not covered would not be featured on the exam.

Finally, this resource should be free. The NBME is a profitable organization, and the costs of this project could easily be covered by income generated from exams such as Step 1. This won't free us from the shackles of med school debt, but a penny saved certainly feels more than earned here.

Change 3: Institutions Should Embrace the Spiral Curriculum Model

In the basic science courses taken prior to medical school, concepts are covered in separate, compartmentalized units. This approach simply doesn't work for medical education. The interdependence of organ systems and disciplines—not to mention the sheer quantity of information available to master—overwhelms our best attempts at compartmentalization. Although institutions are increasingly endorsing an integrated approach, this mostly just refers to joining basic and clinical sciences.

Instead, the model of the spiral curriculum should be implemented. That curriculum reinforces and integrates material in ascending order of importance and difficulty. For example, a basic understanding of the organ systems, pharmacology, and anatomy should precede learning about common pathologies. This, in turn, should precede learning about rarer pathologies and the nuances of diagnosis and treatment.

The novelty in this approach lies in separating foundational material from higher-level content; ideally, the former is reinforced when addressing the latter. Students could be taught the management of common diseases like diabetes and hypertension prior to even beginning clerkships. This would impress upon us the algorithmic nature of clinical medicine and give us the confidence with which to approach other problems. In short, we would know something before starting our clerkships.

Clinical medicine is a challenging, lifelong pursuit; we shouldn't have to wait until clerkships to begin thinking like a clinician.

Change 4: Clinical Skills Should Be Emphasized in the Preclinical Phase

Medical knowledge is just one of many skills required to succeed as a doctor. Or so I'm told.

Other integral skills include EHR use, delivering case presentations, communicating across disciplines, researching clinical questions, and even understanding medical culture as a whole. We are rarely formally taught any of these things. This is not because they are somehow unteachable or because our faculty do not realize their importance. We aren't taught them because residents and attendings lack the time and training to teach them.

The clerkship learning environment is intensely interpersonal and subjective; for some, it is outright hostile. We are introduced to an unfamiliar environment while simultaneously being evaluated. Not only does this feel unproductive, but it also feels unfair.

The preclinical phase should place a heavy emphasis on skills that go beyond merely memorizing medical knowledge. My institution and many others do provide some clinical exposure prior to clerkships, but there is ample room for improvement. Students should be formally taught these skills in the classroom but also in the clinic and hospital settings. With this emphasis, we could enter clerkships equipped with tangible skills and a clearer understanding of expectations. I'm betting that this would help more than just us students, as the clerkship environment would be more collegial, enjoyable, and educational as a result.

Change 5: Social, Political, and Economic Issues Should Be Part of the Preclinical Curriculum

We know that factors such as race, gender, sexual orientation, and class constitute the social determinants of health. We need a historical perspective to truly understand these disparities and provide our future patients with the care that they need.

We know what happens without this emphasis and exploration. A study found that many medical students believe that black people experience less pain than white people. Another found that black patients presenting with a heart attack are less likely to receive revascularization therapy. We are in no way immune to implicit bias, and we need to be educated on these issues early on in our training.

We also know that political and economic factors such as models of care, health insurance, and drug pricing have profound effects on the experience of clinical care. The contexts in which medicine is practiced should be an integral part of medical education, not something we discover once we are already practicing.

Although the acquisition of medical knowledge and clinical skills should not be sacrificed, a more efficient curriculum would create space for learning these complementary and increasingly essential topics. This broader awareness would undoubtedly increase advocacy among physicians, not only for their patients but also for themselves.

With Step 1 mania soon ending, the floodgates for change in preclinical medical education are about to open. What comes next is anybody's guess. My fear is that we will allow inertia to set in, resulting in yet another system we do not consciously choose. My hope is that we collectively decide that medical school is first and foremost about establishing a robust foundation for a fulfilling career. I believe that implementing the changes outlined here would produce happier medical students—and ultimately better physicians. In the end, isn't that the point of medical education?

David R. Chen is a fourth-year medical student whose previous work on the "Step 1 Climate" was published in Academic Medicine.

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