The Invitational Conference on USMLE Scoring (InCUS) recently allowed public statements from medical students in regards to the potential USMLE Step 1 score change. The USMLE Step 1 was originally a pass/fail exam. However, this changed due to increased emphasis on the test to select residency candidates. Step scores have a huge influence on match outcomes, but have not been shown to have any correlation with an individual’s quality of clinical practice. The USMLE Step 1, as with other standardized tests, demonstrate bias against certain racial and ethnic groups.
In March, the InCUS convened to discuss possible solutions to this. There were a number of recommendations that were made. There were suggestions to reduce the influence of the exam by returning to pass/fail, quartile, or other forms of scoring. It was recommended to increase research on the USMLE performance of students and how it relates to clinical practice. Another recommendation was to minimize racial differences in the USMLE performance. The final recommendation was to create a cross-organizational panel to create solutions for the assessment and transition challenges from UME to GME, targeting an approved proposal, including scope/timelines by the end of calendar year 2019.
AMSA believes in the well-being of all of our students, and for many years the Step 1 exam has caused increased stress on students, mentally and financially. This should be addressed, especially if the exam is not an accurate barometer of an individual’s clinical performance.
Here are the public comments AMSA submitted in response to the four proposals. These comments were made with reference to AMSA’s governing documents, and were therefore based upon the decisions of AMSA members made in the House of Delegates.
Recommendation #1: Reduce the adverse impact of the current overemphasis on USMLE performance in residency screening and selection through consideration of changes such as pass/fail scoring, categorical/tiered scoring, and composite scoring.
AMSA urges the National Board of Medical Examiners (NBME) to report student performance as simply Pass/Fail to both students and state licensing boards, and provide medical schools with only a Pass/Fail statistical evaluation of the performance of their student population as a whole, with no documentation of individual student scores. We encourage each medical schools’ faculty to develop its own internal evaluation process, other than exclusive use of National Board examinations, utilizing a variety of testing devices to assess both the cognitive and noncognitive aspects of student performance and curriculum quality. We oppose the use of national board examinations for medical school accreditation, residency selection, student promotion, and as the exclusive mode of curriculum evaluation.
Recommendation #2: Accelerate research on the correlation of USMLE performance to measures of residency performance and clinical practice.
Here at AMSA, we believe in evidence-based practice in all realms. It is essential that we know if the numerical scoring of the USMLE correlates to residency performance or clinical practice. As it exists now, the USMLE scoring system to many appears to be an arbitrary assessment that residency and test prep companies use to their advantage. The current numerical scoring system also leads to students spending more money, to apply to more residency programs, and to utilize third party test prep companies in order to achieve a higher score, to ensure that they match into the specialty of their choice.
Recommendation #3: Minimize racial demographic differences that exist in USMLE performance.
AMSA believes that the increased representation of minority students in medical schools, not only as a result of concern for social equity, but also because such representation leads to positive and necessary changes in the attitudes of students, faculty and administrators, and hence to positive improvements in the health of society and in the health care delivery systems.
We must address racial demographic differences that exist in USMLE performance to ensure that we have diverse representations of physicians across all specialties. This is essential, because we must have a diverse physician workforce to represent our diverse patient population.
Recommendation #4: Convene a cross-organizational panel to create solutions for challenges in the UME-GME transition, such as
- reducing the number of applications perceived by residency applicants as necessary to obtain a position;
- improving residency program directors’ ability to more holistically evaluate candidates; or
- improving the trust of school-based assessments for residency screening and selection.
AMSA has been on a number of cross-organizational panels over the years. This includes the NMBE and the NRMP, where we have had representatives speak on behalf of our organization. This also includes a group of medical student organizations in the U.S. that have come together to work together on many issues, such as the border crisis. We represent over 30,000 physicians in training, and we believe that our voice should be heard. Many of our students take the USMLE exams, and apply to residency programs in the U.S. We strongly believe in prioritizing students’ well-being, and the USMLE have been known to cause high levels of mental distress among students. It would be ideal to have a more holistic approach to assess candidates, which would more than likely lead to an increase in students’ well-being. This may also help with the financial burden of applying to residency, as students might not feel as pressured to apply to such a large number of programs if a more holistic method to assess applicants were to be used.
Isaiah Cochran, M.D.
Chair, Medical Education Action Committee