АҚШ Медициналық Лицензиялау Емтиханының 1-қадамы: Өзгерістер мен маңызы

First part of the U. S. Medical Licensing Examination

The United States Medical Licensing Examination (USMLE) Step 1 is a standardized test that assesses a medical student's knowledge of basic science concepts and their application to clinical medicine. The exam is one of three components required for medical licensure in the United States and is typically taken by students after their second year of medical school. The USMLE Step 1 consists of 280 multiple choice questions administered over an eight hour period. The exam covers topics such as anatomy, biochemistry, pharmacology, and physiology, among others. Scores used to be reported on a three digit scale, but as of February 2022 is reported as pass/fail.

Before 1992, the NBME Part I examination was the primary basic science examination for medical students at the end of their second year. When the three part United States Medical Licensing Examination was launched, the NBME Part I exam was incorporated into its new format, the USMLE Step 1 examination. Over time, the exam has evolved into a more clinically applied examination of the foundational sciences. The exam became computer based several years later. In May 2015, the USMLE began emphasizing concepts related to patient safety and quality improvement across all parts of the USMLE exam series, including Step 1. While traditionally, students took the USMLE Step 1 exam after completing foundational sciences and before core clinical clerkships, in the past decade, a growing number of medical schools have reformed their curricula to have students take the USMLE Step 1 after core clinical clerkships or preliminary clinical training. In response to concerns about the role of USMLE Step 1 scores in residency selection and the negative impact on medical student mental health, the United States Medical Licensing Examination (USMLE) announced significant changes to the exam in 2020. One of the major changes was the transition to a pass/fail scoring system from the previous three digit score reporting system. The change was made to encourage a shift in focus from "high stakes testing" to "learning and individual improvement," as well as to alleviate some of the stress associated with the exam. These changes were implemented starting in January 2022, with the first USMLE Step 1 scores reported in the pass/fail format in February 2022. The changes to the USMLE Step 1 exam have elicited mixed reactions from the medical education community. While some see the shift to pass/fail and the shorter exam format as positive steps toward reducing the pressure on medical students and promoting a more holistic approach to residency selection, others are concerned.

Step 1 is designed to test the knowledge learned during the basic science years of medical school as applied in the form of clinical vignettes. This includes anatomy, behavioral sciences, biochemistry, microbiology, pathology, pharmacology, and physiology, as well as to interdisciplinary areas including genetics, aging, immunology, nutrition, and molecular and cell biology. Epidemiology, medical ethics and questions on empathy are also emphasized. Each exam is dynamically generated for each test taker; while the general proportion of questions derived from a particular subject is the same, some test takers report that certain subjects are either emphasized or deemphasized.

The medical community has criticized the USMLE and residency programs for using Step 1 scores as the main screening tool in selecting applicants for a residency interview. Residency program directors had historically utilized the scores as a means of filtering applications down to a more manageable number that allowed for a more thorough review of the remaining ones. A significant amount of residency program directors believe that the conversion to Pass/Fail will make applicant screening more arduous. In fact, an applicant's Step 1 score has been cited by residency program directors as their most important criterion in selecting graduating medical students for their residency program. Studies on Step 1 performance found that "Step 1 is neither precise nor does it predict student performance beyond a certain threshold. With a standard error of eight points, two applicants with scores as far as 15 points apart may not be meaningfully different and yet several programs use singular cutoff points as screening tools."

A 2017 study showed that students started studying for Step 1 during their preclinical curriculum and increased the intensity of their study time until it reached 16 hours a day over a period of 4–6 weeks before the exam in a period referred to by medical students as "dedicated". Instead of relying on their medical school curriculum, the students focused heavily on third party study materials that according to some critics did not help them learn the medical school curriculum.

Since 2001, there has been a strong plea to remove the Step 1 score barrier that disproportionately affects select racial and ethnic groups. "Using Step 1 scores to screen residency applications puts students who are underrepresented in medicine at a disadvantage." Black and Latino students receive markedly lower scores on Step 1 than white students. Depending on the threshold score, an African American was 3 6x less likely to be offered an interview. A 2001 study in internal medicine residency showed that "when Step 1 scores were used to screen applicants for interviews, a significantly greater proportion of Black students were refused interviews." A 2019 study on Orthopedic Surgery residency programs (the specialty with the lowest percentage of underrepresented students) showed that between 2005 and 2014, Black and Latino applicants were accepted into residency programs at a significantly lower rate (61%) than white applicants (71%). Further studies showed a lack of diversity within specialties and that those underrepresented students were more likely to go into specialties that have lower Step 1 cut offs like Primary Care. The American Academy of Family Physicians and Association of American Medical Colleges supported changing Step 1 to pass or fail to reduce racial bias. The AAFP wrote that changing Step 1 to Pass/Fail creates a "more equitable student evaluation and residency selection process, as it will reduce the impact of racial and other biases on residency selection. Factors that impact student experience with standardized testing (such as access to test preparation) perpetuate inequities and disparities that impact test performance, but do not predict or capture competency or skills for future physicians." The ECFMG and AMA supported this transition as well.

According to the NMBE's InCUS survey results, there were mixed responses regarding support for "consideration of changes such as pass/fail scoring categorical/tiered scoring, and composite scoring." Per the survey, those in agreement with changes include 26% of residency program directors, 32% of current or former state board members, 39% of interns, residents, and fellows, 39% of medical school faculty, 44% of medical students, 67% of course directors, and 75% of Associate/Assistant Deans (of medical schools). Notably, medical students and program directors were among parties with only a minority in favor of this change, despite being the most directly affected. Parties associated with medical schools, namely course directors and Deans were noted to have the most support for changes. The USMLE parent organizations, including the AAFP, AMSA, Further, they supported the move to Step 1 Pass/Fail citing unintentional negative impact of a single standardized exam on career exploration and selection.

According to the NMBE's InCUS survey results, there were mixed responses regarding support for "consideration of changes such as pass/fail scoring, categorical/tiered scoring, and composite scoring." Per the survey, those in agreement with changes include 26% of residency program directors, 32% of current or former state board members, 39% of interns, residents, and fellows, 39% of medical school faculty, 44% of medical students, 67% of course directors, and 75% of Associate/Assistant Deans (of medical schools). In particular, students from DO (Doctor of Osteopathic Medicine) and "low tier" MD schools may be at considerable disadvantage compared to students from prestigious schools. However, the timing of Step 2 CK is often only months before residency applications are submitted, meaning a poor score could jeopardize a student's application without allowing time to change tracks or bolster other application components. International medical students and graduates expressed growing concerns that the change will further decrease IMG (International Medical Graduates) chances of matching into US residency programs. Historically, IMGs have been at a significant disadvantage when applying to US residency programs. Outside of scores, residency program directors consider letters of recommendation, clinical grades, and research. Since international medical students come from medical schools with different grading systems and do not usually have access to well known faculty and American research opportunities, USMLE Step 1 is often seen as a major opportunity to boost IMG residency applications with a high score. Without a numerical score on the USMLE Step 1, there is speculation that IMG's will be further be pushed out of the race for residency program spots. This was supported to some extent by General Surgery program director respondents, which significantly agreed that the changes to Pass/Fail "Will put IMGs at a disadvantage" 56.0% [48.6–63.4%]. In February 2020, InCUS concluded that residencies were overemphasizing Step 1 and not using it for its original purpose for which it was designed as a means of licensing. Upon reaching these conclusions, the USMLE program announced a plan to change Step 1 score reporting to a Pass/Fail system in an effort "to reduce overemphasis on Step 1 performance while allowing licensing authorities to use the exam for its primary purpose of medical licensure eligibility." The USMLE stated that transition will occur no earlier than January 1, 2022. In July 2020, the USMLE stated that "All scores for Step 1 exams taken prior to the date of the policy change will continue to be reported using the three digit numeric score on all USMLE transcripts. The USMLE program does not retroactively alter transcripts." Studies on Step 1 performance found that "Step 1 is neither precise nor does it predict student performance as residents beyond a certain threshold. With a standard error of eight points, two applicants with scores as far as 15 points apart may not be meaningfully different and yet several programs use singular cutoff points as screening tools." This, as well as the impact on student learning, cost of preparation, diversion of student time toward exam preparation, and desire to decrease racial bias, are amongst the reasons that the USMLE switched to Pass/Fail reporting of Step 1 at the beginning of 2022.

See Support for USMLE changes and Objection to USMLE changes in Changes to Step 1 scoring.

During the COVID 19 pandemic, the USMLE and NBME were met with criticism from some members of the medical community, including the American Medical Association (AMA), for miscommunication, delays and lack of flexibility during the COVID 19 global pandemic. They were also criticized for reducing the length of the exam at newly established testing centers in some U. S. medical schools to be able to accommodate more students for testing as those changes would diminish the standardization of the tests. There were concerns that these issues would lead to many applicants having incomplete applications during the 2021 match season which would then negatively affect the ability of program directors to effectively evaluate candidates. Prometric eventually added testing sites at some medical schools and re opened testing centers with new safety protocols. USMLE also reverted the announced changes to the exams length.

On June 4, 2020, the USMLE announced a plan to administer tests at medical schools throughout the nation, but that these exams would notably lack experimental questions, while exams administered at testing centers during the same time period would still have these experimental questions. These experimental questions accounted for 80 of the 280 on the exam, which would have led to the decreasing the total test taking time from 7–8 hours to 5–6 hours. Some commenters expressed concerns since this practice would have "destandardized" the text and test takers would have been "experimented" on without consent. This was met with significant backlash from students and the medical education community as this was felt to be a "tone deaf assumption that medical trainees with more time may instead redirect their effort toward Netflix and Instagram." Within a few days, Katsufrakis and Chaudhry issued an apology and removed the phrase.

NBME and USMLE were met with criticism when they announced their raising cost for Step standardized tests. Kevin MD wrote, "Safeguards are needed to ensure fees for mandatory testing such as the USMLE do not exceed reasonable operating costs, particularly for financially vulnerable medical students." Registering for Step exams test cost between $645 and $985. The NBME executives received public criticism related to their increasing salaries. "Former NBME President Dr. Melnick's compensation increased from $399,160 in 2001 to over $1.2 million in 2016, almost in parallel with the tripling of USMLE costs." "According to the 2017 Form 990, Schedule J, two lower executives received total compensation over $700,000; another two over $600,000; another three receiving over $500,000, and another 6 receiving over $400,000."