February 20, 2020 09:19 am Cindy Borgmeyer -- Medical students scored a major win last week when the United States Medical Licensing Examination program announced its intention to change score reporting for the USMLE Step 1 exam from the current three-digit numeric score to pass/fail beginning in 2022. Relieving that pressure is expected to enhance student well-being and open up time for more clinical and educational opportunities, which, in turn, could boost interest in family medicine.
According to the program's co-sponsors -- the Federation of State Medical Boards and the National Board of Medical Examiners -- the decision announced on Feb. 12 came in response to extensive input from various stakeholders, including a letter the AAFP fired off on behalf of students, residents, family medicine faculty and practicing FPs last July.
For those not immersed in the particulars of today's medical education environment, a little background may be helpful.
Introduced in the early 1990s as an assessment tool intended to help inform licensing decisions by state medical boards, other uses that various stakeholders have developed for the USMLE over time -- including its use in screening and selecting candidates for graduate medical education programs -- have increasingly raised concerns about medical student efforts to maximize USMLE scores to the possible detriment of their ability to focus on other educational/curricular offerings.
In response, the FSMB and NBME, together with the AMA, Association of American Medical Colleges and Educational Commission for Foreign Medical Graduates, convened the Invitational Conference on USMLE Scoring in March 2019 to explore and engage with stakeholders about issues specific to USMLE score reporting and the broader process of transitioning from undergraduate medical education to GME.
In its July 22 letter, which was signed by (then) AAFP Board Chair Michael Munger, M.D., of Overland Park, Kan., the Academy said it sought to "highlight concerns in addition to those expressed during the InCUS process and to propose solutions with a more immediate impact than the proposed InCUS recommendations" contained in the conference's summary report.
To that end, the AAFP solicited input from its members in academic family medicine, including students, residents, undergraduate and graduate medical education faculty, and family medicine residency program directors, as well as the academic family medicine organizations -- the Society of Teachers of Family Medicine, Association of Departments of Family Medicine and Association of Family Medicine Residency Directors -- regarding their perceptions of the InCUS process and its findings.
For one thing, the letter stated, the preliminary recommendations in the InCUS report were vague and focused primarily on further studying the issue. Although further study may be helpful in some areas, the groups noted, immediate action -- including changing USMLE Step 1 score reporting to pass/fail -- also is needed.
Tabatha Wells, M.D., an assistant professor in the Department of Family and Community Medicine at Southern Illinois University, Springfield, and faculty in the school's family medicine residency, spoke to other concerns raised in the letter. As a member of the AAFP Commission on Education, she was involved in last year's discussions about this issue.
"Medical schools vary in how they prep students for the exam and are under tremendous pressure by licensing bodies to have students that perform well," she told AAFP News. "This can come at a cost to what curricular and extracurricular offerings the school offers, which can also affect students' well-roundedness, personal and professional development and specialty/career exploration."
Another benefit of changing Step 1 scoring to a pass/fail system, said Wells, would be that it reduces the effects of "social determinants that impact student experience with standardized testing and access to test prep materials," which can negatively affect students' preparedness for exams. That effect, in turn, "perpetuates inequities and disparities that impact test performance but do not relate to competence or skill of a future physician," she added. Changing the scoring method would also be beneficial to learners who suffer from test-taking anxiety.
Wells acknowledged that although some students will be uncomfortable with the change, given the current high level of competition for coveted residency positions and the accompanying drive to excel at virtually everything, "I think it will actually take the stress off taking a high-stakes, one-day exam that can drastically change their future plans."
And then, of course, there are the cumulative costs of the USMLE exams -- currently upwards of $2,500 -- which add to an already substantial student debt problem.
Margaret Miller, a fourth-year student at East Tennessee State University's Quillen College of Medicine and the current student member of the AAFP Board, spoke to the costs -- in both time and money -- involved in preparing for and completing the Step 1 exam.
For her, the costs have been exorbitant and began even before she took the exam: "Changing to pass/fail should significantly reduce the amount of money spent on test-prep materials, which cost me upwards of $1000," Miller told AAFP News.
But more significant, she said, was the emotional toll. "I met my now-husband just six months before I took Step 1, and he still remembers how withdrawn and moody I was leading up to the exam," she said. "For two months, my daily schedule went like this: study from 8 a.m. to noon, an hour at the gym (while listening to recorded lectures), study until 8 p.m., eat dinner while watching video lectures, spend an hour or two with my significant other, go to bed. Repeat."
It was a painfully isolating experience, Miller recalled, and one that most, if not all, students go through. And for those who put in more time studying, the price was even higher. "Many had to push back their third-year clinical rotations to get more time to study for Step 1, which I would argue makes absolutely no sense when the goal is to train clinicians."
It's a charge the Academy also leveled in its July letter. "The current overemphasis on USMLE Step 1 is having overwhelming negative impact on students," the letter stated. "A pass/fail score will help provide a more meaningful learning environment, improved emotional climate, and better student-student interactions, which can lead to better academic performance."
Renee Crichlow, M.D., couldn't agree more. As a faculty member at the University of Minnesota North Memorial Family Medicine Residency Program and assistant professor in UMinn's Department of Family Medicine and Community Health, she's seen close up what the consequences of that overemphasis can be -- and how bad it can get.
"Students spend significant amounts of money and increase their debt and emotional stress dealing with the Step 1 test," Crichlow told AAFP News. "Students have often reported contemplating suicide, and some have even committed suicide in response to the stress they felt regarding Step 1."
As for those who question the wisdom of giving up what for some has become a key component of the resident screening or selection process, Wells points to her university's medical school and residency program, which she said have always had holistic approaches to admissions. "I hope this change will help allow more residency programs across the board to use a holistic approach to admissions rather than just use a high-stakes exam score -- as students are so much more than one day of their life."
Crichlow echoed that sentiment. "USMLE Step 1 was never designed to be or meant to be a screening test for program directors to filter residency applications," she stressed. "A student score on this test has no predictive value or correlation with how well they will do as a physician."
Overall, Miller said, she hopes the change "heralds a new dawn in medical education."
"I hope that specialties and programs will make attempts to be more transparent in their recruitment process, letting students know what they can do to make themselves more desirable," she said. "I also hope that in the coming years, programs will take the time to sit down and reevaluate their application process to remove any implicit or explicit biases."
The Academy has released a dual statement from AAFP President Gary LeRoy, M.D., of Dayton, Ohio, and Senior Vice President for Education Clif Knight, M.D., in which the two applaud the United States Medical Licensing Exam program's move to change score reporting for the USMLE Step 1 from a numeric score to pass/fail and outline other suggestions the AAFP has pushed the program to adopt.
“While this change is only a first step, it will reduce the limiting impacts of a single standardized exam on career exploration and selection, which is increasingly important as we face a looming shortage of primary care physicians," said LeRoy.
"A physician is a whole person -- and should be seen as more than a single test score," Knight added. "A more holistic selection process would provide students better options to explore medical specialties that align with their career goals and differentiate themselves to residency programs."