Student Perspectives on the “Step 1 Climate” in Preclinical Medical Education

Abstract

The United States Medical Licensing Examination Step 1 was implemented in the 1990s as the most recent version of the National Board of Medical Examiners’ preclinical licensing examination originally created in the late 1960s. For the purposes of state licensure, the exam is pass/fail, but the Step 1 numeric score has in recent years become central to the residency application and selection process. Consequently, a medical student’s Step 1 score is increasingly viewed as a key outcome of preclinical medical education. In this Invited Commentary, students from various institutions across the country draw on their shared experiences to argue that the emphasis on Step 1 for residency selection has fundamentally altered the preclinical learning environment, creating a “Step 1 climate.” The authors aim to increase awareness of the harms and unintended consequences of this phenomenon in medical education. They outline how the Step 1 climate negatively impacts education, diversity, and student well-being, and they urge a national conversation on the elimination of reporting Step 1 numeric scores.

Quantifying the Financial Value of Clinical Specialty Choices and its Association with USMLE Step 1 Scores

“…Medical students spend a substantial portion of time preparing for USMLE Step 1, but this is a rational response to the incentives they face. 19 To the degree USMLE Step 1 scores serve as gatekeepers to higher NPV specialties, the financial consequences of a student's USMLE Step 1 score could amount to millions of dollars. Students who obtain high USMLE Step 1 scores are able to clear the cut-off scores applied by program directors and remain competitive for a broad range of clinical specialties.…”

Medical School Resourcing of USMLE Step 1 Preparation: Questioning the Validity of Step 1

“…The focus of this assessment is medical knowledge [3]. The "Step 1 climate" [1] has led to learners and faculty focusing exclusively on this content, which inadequately addresses domains necessary for minimally competent physicians, such as patient safety, quality improvement, population health, and teamwork [13]. Trochim highlights several threats to construct validity relevant to this argument about USMLE Step 1 [14].…”

“…Continuing concerns have been raised about the burgeoning "Step 1 climate" overtaking medical schools and causing significant distress for medical school students, faculty, and staff [1,2]. The United States Medical Licensing Exam (USMLE)…”

“…Step examinations are a required gateway to physician licensure, a fact noted on their website as the purpose of the four examinations [3]. However, as Chen et al [1] have alluded, the first of these examinations has mutated into something beyond the creators' intentions.…”

“…Whether formative or summative, medical students perceive a test as a test [7]. Chen et al [1] point out exemplary performance on USMLE Step 1 is the students' only concern. The single three-digit score and its misuse as the gateway to career choice and residency match have led to students' obsession in constantly striving for maximal numeric achievement.…”