There has been a profound deterioration in the education of our medical students. I only make this contention after having taught over a hundred medical students across five continents, often one-on-one and for extended periods. Although the majority of those I’ve taught have been students educated at international medical institutions, a substantial number have been those from U.S. medical schools. While I do recognize that those that find their way to me are a tiny subset of those that are struggling, nonetheless, I have been appalled deficiencies I find in their understanding of human physiology and pathophysiology. I believe that the single most important contributor to this deterioration is standardized testing as it exists in its current form and its increasing role in the residency application process.
High USMLE scores are near-unanimously perceived among medical students as decisive to their applications to residency programs. This is validated by NRMP data; USMLE Step 1 scores may be the most important determinant in gaining the attention of competitive residency programs. This is not to suggest that letters of reference, contributions to research, service and/or education and personal relationships/interpersonal skills are not important. However, a poor USMLE score may sabotage an otherwise solid application.
In a 2018 survey of 1,333 program directors, 94 percent and 70 percent of responses assigned the USMLE Step 1/COMLEX level 1 score and any associated failed attempt an average importance rating of 4.1 and 4.5 (out of 5), respectively, amongst factors dictating whether an interview would be offered. As a matter of perspective, no other factor was cited as often, and only three other factors had a substantially higher assigned scores: 1. Being flagged as in violation of the Match, 2. Evidence of professionalism and ethics and 3. Perceived commitment to the applied specialty.
Somewhat surprising is that USMLE scores and associated failed attempts continued to be decisive in creating rank-order lists of interviewed applicants with 78 percent and 47 percent of program directors assigning scores of 4.1 and 4.5, respectively. The only factors that scored higher at this stage were impressions of interviewees by faculty and house staff, feedback from residents and interpersonal.
Keep in mind that just gaining admission to a U.S. medical school is competitive; most recently only over 7 percent of 51,000 applications. This 7 percent compete among themselves and thousands of international medical graduates for a limited and proportionately decreasing number of residency positions across various specialties. As a surrogate of competitiveness, the overall unmatched rate for 2018 stood at 4.9 percent and 36.9 percent for U.S. and international medical graduates, respectively. For the six most competitive specialties in the same year, defined by the same, unmatched rates ranged between 10-13.7 percent and 50.3-61.5 percent for U.S. and international medical graduates, respectively. Within this strata, USMLE Step 1 and Step 2 CK scores below which applicants are seldom interviewed, ranged between 235-250, which, based on an off-the-cuff tabulation, reflects a percentile of > 85 percent, assuming a standard deviation of +/- 15.
I cite these numbers not to bore you with empirical data, but to illustrate the drive, discipline and academic excellence one must demonstrate in order to enter a U.S. medical school and obtain a residency position of choice. For those applicants with an eye on the more competitive specialties, preparation starts from day one of medical school, if not earlier and often at the expense of a solid foundation in basic medical science.
Think about it. Performance on the USMLE Step 1 — a single-day multiple-choice exam usually taken at the end of the second year of medical school, reportedly assessing competency (not achievement) in basic medical sciences — may be the most heavily weighted component of the residency application process.
This format and its misguided use as an achievement exam to discriminate between residency applicants are steering medical students and by extension medical education towards test performance. No longer are we interested in how a medical student thinks; no longer are we interested in how a medical student leverages their understanding of medicine to solve novel problems. Instead, test performance and ultimately the match result is the yardstick by which programs are reputed.
In my seven years of teaching students for the USMLE, I rarely encounter an American medical student who has voluntarily engaged the foundational texts of the basic medical disciplines or has been required to review the seminal scientific papers from which our understanding of medicine is derived. Rather, their education consists of lecture notes and USMLE focused review books that fail to capture and subsequently confer the foundational mechanistic and probabilistic way in which human biology operates.
Adding fuel to the fire, as an assessment, we ask for “single best answer” responses from a list, not a demonstration of one’s thought process or other skills more essential to the long-term practice of medicine. Few medical students ask the why and the how. The goal, it seems, is to memorize the needed facts and recognize key associations that will allow one to score the highest they can on the USMLE. The expense is curiosity, and the result is a generation of physicians entering clinical training with a knowledge base derived from test-preparation material.
My worry is we are spawning a generation of algorithmic “providers,” not physicians, ill-equipped to further advance medicine and its evolving practice.
“The Curious Radiologist” is a radiologist.
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