{"id":626,"date":"2022-04-18T04:06:30","date_gmt":"2022-04-18T08:06:30","guid":{"rendered":"https:\/\/digital.hbs.edu\/platform-peopleanalytics\/?post_type=hck-submission&p=626"},"modified":"2022-04-19T18:18:29","modified_gmt":"2022-04-19T22:18:29","slug":"take-step-1-back-to-square-1","status":"publish","type":"hck-submission","link":"https:\/\/d3.harvard.edu\/platform-peopleanalytics\/submission\/take-step-1-back-to-square-1\/","title":{"rendered":"Take Step 1 back to square 1"},"content":{"rendered":"\n\n\n

As described in Moon\u2019s Forbes article<\/a>, in February 2020, the FSMB and NBME announced that the Step 1 exam will become pass\/fail in 2022. The diagram below summarizes the steps and key exams in the majority of allopathic (M.D.) physician training pathways in the US. Each of the exams (MCAT, Steps 1-3, board exams) cause an extreme amount of pressure on high-achieving trainees in a competitive environment roughly every 1-4 years. <\/p>\n\n\n\n

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Summary of exams taken in training pathways of most allopathic (M.D.) physicians in America. Colored blocks indicate steps in training, and arrows below indicate when exams are usually taken. The first 2 years of medical school are usually spent in classrooms studying the science and basic concepts of medicine (biochemistry, statistics, public health, anatomy, how healthy bodies work, how diseases can alter these systems, etc). Step 1 is supposed to test for minimum competency of these foundations before transitioning into hospitals. Of note, some medical schools do have significant variations in their curricula, e.g.<\/em>, some medical schools have had their students take Steps 1 and 2 both after clinical core rotations. It is impossible to predict what most schools will do after 2022 because it takes time to make major changes in medical school curricula since schedules of each class of students affects other classes of students and limited resources (e.g.<\/em>, there is a limit on how many students can be doing clinical rotations at the same time).<\/sup> You may also notice that Step 2 CS disappears after 2022. Step 2 CS (clinical skills) was an 8 hour exam with standardized patients to assess abilities in History & Physical exam (verbal and physical interactions with patients). It required students to travel to 1 of 5 testing centers in the entire US. It was put on hold during the COVID-19 pandemic, and then permanently canceled in 2021. <\/sup><\/figcaption><\/figure>\n\n\n\n

Step 1 was designed as a minimum competency exam<\/a>. It has always been \u201cpass\/fail”, but a numeric score and percentile were also reported. Competitive residency programs, lacking other measures to compare applicants<\/a>, relied on Step 1 scores to help rank applicants for the Match<\/a>. Less competitive residency programs relied on scores to try to predict trainees who may fail specialty board exams<\/a> in the future. A chart summarizing results from NRMP\u2019s annual report<\/a> on Match results are shown below; see also complete Excel files of AAMC\u2019s Tables B1<\/a> and B2<\/a>. <\/p>\n\n\n\n

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Median and interquartile range of Step 1 scores of matched and unmatched residency applicants by specialty. Note the significant difference between matched applicants in very competitive specialties like dermatology (~250) and less competitive specialties like family medicine (~220). <\/sup><\/figcaption><\/figure>\n\n\n\n

If the problem was student stress\/wellness and residency programs inappropriately using Step 1 scores, they could still allow students and schools to see their score details and only include the pass\/fail status in residency applications. It can be helpful to students and schools to see how they perform compared to their peers nationally and help improve pre-clinical education.<\/p>\n\n\n\n

They should revise the content of Step 1. As a result of better resources in the highly profitable test prep industry, students\u2019 scores and the minimum competency “pass” threshold have both risen over the years<\/a>. In order to obtain a high score, students must understand core concepts but also memorize an absurd volume of obscure factoids that are irrelevant to 99.99% of physicians (e.g.<\/em>, which amino acid has 3 different titration points [histidine]). Step 1 questions should focus on the most fundamental concepts and clinically relevant content.<\/p>\n\n\n\n

Residency programs need some objective measures that help compare students from around the world (international applicants). Without Step 1 scores, programs will have to rely more on other measures (e.g.<\/em>, school prestige<\/a>, publications, leadership\/volunteering, Dean’s Letters, Step 2 scores). Extracurricular opportunities can vary significantly among schools and among students; students who have family responsibilities, financial limitations, or work part-time during school would be disproportionately disadvantaged due to the significant time and resources required<\/a> to rack up those activities. Dean’s Letter closings can be extremely subjective, and explicit or implicit in coding students’ rank within the school, and doesn’t help compare students from different schools. Before 2022, students who were disappointed in their Step 1 score had a chance to significantly improve their Step 2 score; students satisfied with their Step 1 score could delay taking Step 2 until after the Match. After 2022, all residency programs will probably require a Step 2 score. Students and schools will feel pressure to take Step 2 sooner<\/a> with more weeks of dedicated study time to have better scores that are available in time for residency applications. All of these consequences could hurt students, schools, and residency programs.<\/p>\n\n\n\n

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Data<\/h2>\n\n\n\n