Scoring change may reset medicine’s table

The USMLE — United States Medical Licensing Exam — was envisioned as a one-size-fits-all solution to a problem that vexed U.S. medicine since for more than 100 years: how to assure uniform knowledge and competency among new physicians before those physicians approach the bedside.

At the time the USMLE was introduced, the U.S. medical education community was grappling with the appropriate means to integrate graduates of non-U.S. (foreign) medical schools into medical practice in the U.S. Those graduates — both foreign born and U.S. citizens — were barred from taking both parts of the certification exam offered by the National Board of Medical Examiners (NBME), which was required before one could take the Federation Licensing Exam (FLEX). This was the route to licensure used by graduates of U.S. medical schools (osteopathic schools used their own licensing exams).

Instead, the international graduates took part 1 of the National Boards — which tested pre-clinical knowledge — and then sat for a separate exam administered by the Educational Council for Foreign Medical Graduates (ECFMG). Graduates of U.S. medical schools could take either both parts of the NBME or the Federation.

All that changed in 1992 with the introduction of the USMLE, a 3-part exam that became the universally accepted “test” for medical licensure (international medical graduations must first be certified by the ECFMG before taking the exam). The USMLE Step 1 exam tests pre-clinical knowledge, which is the curriculum generally covered in the first two years of medical school.

But in the decades since, there have been changes in the way physicians are educated as medical schools shifted to competency-based training, expanded enrollment, and opened doors to more women and minorities. What worked in 1992 was showing signs of age in the 21st Century — specifically concerns about the fairness of the three digit scoring used for each part (300 is a perfect score, 202 is a passing grade) — so the Federation of State Medical Boards (FSMB) and the NBME convened the Invitational Conference on USMLE Scoring April 2019, during which the “stake-holders” agreed to change scoring on the USMLE Step 1 exam to pass/fail.

That change will be implemented in 2022, and not everyone is happy.

The New England Journal of Medicine addressed the current state of play for the USMLE in four essays representing views of medical educators and residency directors.

At this point, it is an understatement to say that residency directors are not enthusiastic about the change, for two reasons:

  1. In most cases, the Step 1 score served as a critical screening tool for use in selecting candidates for residency programs.
  2. Many residency directors didn’t get invited to the “Invitational Conference on USMLE Scoring.”

As Lisa L. Willett, MD, a residency director at the University of Alabama at Birmingham, wrote, “Although the conference was intended to have a broad representation of key stakeholders in medical education, the graduate medical education (GME) community felt underrepresented, and many residency program directors voiced concerns about unintended consequences for both students and residency programs. Already overwhelmed with the current process for residency recruitment, some program directors believe that the change will further dilute the transparency and trustworthiness of the information that medical schools provide to residency programs.”

And Willett is not alone in voicing her concerns, as program directors from Vanderbilt and the University of Michigan led by Brian Brolet, MD, of Vanderbilt explained.

“To characterize residency program directors’ responses to binary Step 1 result reporting, we developed and validated a 19-item survey through phases of prepilot and pilot testing,” they explained. “After receiving exemption from the Vanderbilt University Medical Center institutional review board, we invited program directors of ACGME-accredited residency programs in 30 specialties to participate in the anonymous electronic survey. Individualized requests for participation were sent over the course of 4 weeks. A total of 2095 unique responses (response rate, 44.5%) were obtained. The majority of participants were male (64.5%), and participants had served as program directors for an average of 6.9 years. Internal medicine (10.0%) was the most commonly represented specialty, followed by family medicine (9.8%) and surgery (7.4%).”

What did they find?

“Only 15.3% of program directors agree with changing Step 1 to pass/fail, and 77.2% expect this change to make objective comparison of applicants more difficult… Although it remains to be seen how medical students will respond, only 24.9% of program directors believe that student well-being will improve as a result of the scoring change,” they wrote.

The results of the survey suggest that most program directors will now rely on the results from Step 2 — the test based on core clinical clerkships — to help in screening. That test is retaining the 3-digit score, so it could now become the focus of test-anxiety, which was cited as a reason for the switch to pass/fail for Step 1.

But there are those who support the move to pass/fail grading because they suggest that it will lead to greater diversity in medicine.

Minorities are disadvantaged by the 3-digit scoring scheme, Quentin R. Youmans, MD, of Northwestern University Feinberg School of Medicine in Chicago, and colleagues from the University of Pittsburgh School of Medicine and Ohio State University College of Medicine, wrote in another perspective.

“The odds are stacked against students from underrepresented minority groups starting early in their scholastic journeys,” they wrote. “Beginning in grade school, they may be subject to teachers’ racial and ethnic biases that can hinder their achievement. Socioeconomic factors such as neighborhood poverty and parental educational attainment may limit their access to high-quality schools, test-preparation resources, and supportive mentorship, widening the achievement chasm. These structural factors have resulted in a leaky pipeline for medical careers, as many talented potential physicians choose other fields instead. Minority students who do make it to medical school face bias in evaluations and are less likely to receive coveted accolades such as induction into the Alpha Omega Alpha honor society. These educational disparities greatly heighten the pressure on students to set themselves apart by excelling on the Step 1 exam.”

Eventually, Youmans and colleagues wrote, this change in USMLE scoring could transform medical care by making medicine a more diverse profession: “Increasing representation means that minority patients will see more doctors who look like them in specialties historically dominated by white physicians.

“Given the evidence that patients who see physicians of their own racial or ethnic group are more likely to trust and accept medical recommendations, receive age-related screenings and other preventive care, and receive subspecialty care, the benefits of diversifying the medical workforce are easy to imagine,” they continued. “A diagnosis of localized melanoma might be made in a young black man before it has metastasized to his liver or lung. A middle-aged black woman might opt to have her cholesterol screened, discovering high levels early enough to start her down a path of appropriate preventive measures. A Latina grandmother with severe coronary disease might agree to undergo coronary-artery bypass graft surgery when she would not otherwise have done so. It is therefore critical that medical education, and the health care system overall, take measures to address the racial and ethnic imbalance in our medical workforce, and lowering barriers like the USMLE exam is a good first step.”

And, the change may pave the way for a recalibration, or “reboot,” of American medicine, Charles G. Prober, MD, of Stanford Center for Health Education, Stanford University, wrote in his perspective.

“I was recently asked whether it was time to reboot the 1910 Flexner Report on medical education with Flexner 2.0. In light of advances in biomedical science, health system reforms, enhanced medical technology, a new focus on personalized health, and improved pedagogical strategies, I believe that such a reboot is necessary,” he wrote. “I think the conversion of Step 1 to pass/fail removes a key barrier to curriculum reform, facilitating a recalibration of medical education priorities and the design of Flexner 2.0. One innovative approach to the education and training of physicians was outlined by Cooke et al. on the 100th anniversary of the Flexner Report. My own dream of medical education reimagined involves students and faculty learning side by side in a richly interactive and engaging environment that fosters evidence-based discussions, critical thinking, and the development of the knowledge, skills, and behaviors required ’to cure sometimes, to relieve often, [and] to comfort always.’”

Peggy Peck, Editor-in-Chief, BreakingMED

Prober disclosed financial relationships with Aquifer, RedEdPORTAL, and Scholar Rx

Willett had no financial disclosures.

Drolet had no financial disclosures.

Youmans had no disclosures.

Cat ID: 588

Topic ID: 88,588,288,585,588,589,590