I was and remain a critic of the United States Medical Licensing Examination (USMLE) Step 1 exam. My criticism is this: much of the content, perhaps even most of it, is a set of esoteric science factoids, which have little practical relevance. Don't believe me? Find a doctor sitting in clinic, slide up next to them, and ask them a few sample questions. After five or six, they will exclaim, "I don't know! Stop asking me useless things."
A corollary to my concern is that the numerical score provided by this exam carried weight. For years, specialties of medicine fell along a spectrum of Step 1 scores. app with higher wages typically drew applicants with higher Step 1 scores. Faculty would advise medical students who fell below a certain score that urology or dermatology was not practically within their reach.
This bothered me. It was bad enough to test facts tangential to good clinical care, and to spend so many years on this material, but to double down on that and use a score of such information to determine what specialty a trainee could pursue -- well, that seemed truly insane.
Beyond only my grievances with the exam, many in the medical community have seen a need for Step 1 reforms for some time. But the approach the exam's sponsor organizations ultimately landed on -- moving to a pass/fail system -- has serious unintended consequences.
My Proposed Reforms
The solution to the predicament was simple, as I saw it. Change the content of Step 1 and modernize it. Focus on the skills needed to be a physician in the 21st century, and not those needed to practice in the early 20th. Add more epidemiology, biostatistics, clinical trial appraisal. Consider that the days of biochemistry being the basic science of medicine are past, and now the real basic science is evidence-based medicine. In a world where so much information is available at one's fingertips, how can a doctor craft encounters that maximize patient outcomes? Memorization is dead. Navigating medical science is alive.
The second reform we needed was to redo the specialty pay scales. I am not suggesting we pay all specialties the same, but we should reorient medical salaries to fields where we want to recruit the best minds, and away from those that are oversaturated. Primary care, pediatrics, and obstetrics are underpaid. I won't name the fields that I think are overpaid, but one only has to look at the most desired fields to get some idea of possible suspects.
By paying some of these fields a little less, we immediately change the supply/demand equation, and we won't need blunt methods to weed out hundreds of competent and otherwise excellent applicants. We will simply get fewer applicants because at least some interest in those fields is contingent on the salary. I hope we can be honest and say that!
Of course, some fields of medicine will always be highly sought after. Perhaps cardiac transplant surgery is one example. But ask yourself: which specialties would still draw the highest Step 1 scores, and 100 applicants per spot, if the pay was $100,000 less per year?
A Faulty Solution
Instead of my proposed two-pronged reform, the solution embraced was to make Step 1 pass/fail beginning in January 2022. This means students will no longer receive a score to help them compete for a sought-after residency. After you pass, there is no additional brass ring possible. Alongside this change, many medical schools have already moved to pass/fail classes, and pass/fail clerkships. For some students at elite universities, there is almost no way to rank applicants. Key word: Almost.
As long as some specialties pay more and have more demand than spots, there will always be competition. In a well-intentioned effort to take the pressure off Step 1, we did not eliminate the competition, we merely shifted it. I believe the new competition is publishing papers.
Publishing academic research will always remain a numerical way to distinguish oneself from one's peers. Yes, we all went to a top medical school, and yes, we all passed Step 1, but who published one middle author case report, and who published three first author, original articles? The new arms race of publication may be worse than the Step 1 competition. All the factors we worried about as biases with standardized testing -- such as race, socioeconomics, class -- may be exacerbated by publishing, which rewards trainees with access to productive mentors.
Moreover, the publishing arms race extends the suffering of training. Now to compete for sought after specialties, applicants feel the need to take a year or two off to do research and publish more papers. A year or two off and a productive mentor is a surefire way to churn out papers. How else can one compete? Using a Step 1 score to pick dermatology residents was not fair, but is using the ability to take 2 years off and do lab work any fairer?
I was the sort of medical student who could not wait any longer to become an attending. In part because of finances. I didn't come from money, had six-figure dept growing by the day, and needed to earn a faculty income. Students in a similar financial situation are penalized by the new arms race that rewards those with access to money to subsidize prolonged training and research.
The third draw back of the new competition is the sheer production of low-quality research articles. Yes, some medical students do transcendent work, but if we are honest, most contribute to the noise of biomedical publication. Retrospective, confounded chart reviews, case reports, and redundant review articles are the principal outputs of training, but often add little to the overall body of medical science, and sometimes may even distract or confuse.
We failed Step 1 reform for the same reason we keep making medical education worse. Every time I listen to conferences or lectures geared at medical learners, I ask myself if anyone still remembers the central goal of medical education. Yes, some students will run labs and some will win the Noble prize. Yes, some students will create non-profits, become activists, and change the world. Yes, some will run hospital systems, or even become U.S. senators or President. But, perhaps we might consider that most graduates will provide medical care.
Providing medical care remains our core mission. Knowing when and how to use medicines, perform surgery, coordinate procedures, diagnose, and treat ailments. These are the core competencies of medical education, and yet, they are increasingly forgotten. Trainees often have to learn these skills on the job after enduring a curriculum that focused on everything but this central task.
Step 1 never did a good job of preparing students for the journey towards mastery of medical care, and should have undergone a gut renovation. Instead, we slapped a new coat of paint on it, and put it on sale. Medical specialty reimbursement desperately needed a thoughtful restructuring to incentivize trainees to pursue understaffed fields and to reduce overwhelming interest in specialties that are exorbitantly reimbursed with too few spots. Instead, we kept the wages, but made it harder for program directors to sort through 100 applications per spot. By doing so, we shifted the competition. The obvious outlet was publication, a metric that favors those with wealth and connections to productive mentors.
I dream of a world where medical students get a curriculum that focuses on teaching them to be a great doctor. Elective time exists for students who want to become activists, writers, or run laboratories. Assessments challenge students to work harder, measure their progress, and highlight areas for improvement. Healthy competition exists when necessary, but physician reimbursement encourages the best minds to pursue disciplines with the greatest need. These often have the most spots. Research is a calling and not a credential. In this better world, Step 1 isn't pass/fail; it is dead and gone, and from its ashes rises a medical education that tries to teach people what it truly means to be a doctor, an honorable and difficult task.
is a hematologist-oncologist and associate professor of medicine at the University of California San Francisco, and author of .