As a “dinosaur” emerita professor of pathology who still teaches medical students, I have witnessed some of the United States Medical Licensing Examination (USMLE) Step 1-induced climate changes compellingly. No, I am not a reactionary yearning for the past. Medical education has never been perfect. In the not too distant past, students were taught in an environment ruled by arrogant, dogmatic autocrats. Some things have changed for the better. Professors no longer reign supreme. (That role has now been assigned to administrators.) Current use of small group sessions and problem-based learning has a definite advantage over the all-lecture formats of yore. Ideally, the former has the potential to enhance communication, courteous behavior, and listening skills as well as encourage debate. These skills are not evaluated by Step 1 of the USMLE examination but are indispensable tools for the practice of medicine.
For us dinosaurs, the current climate is unhealthy. I am concerned that the focus on USMLE Step 1 scores is teaching future physicians that life is a single answer, multiple choice examination and, ipso facto, that guidelines are mandates that must be followed without regard to patients’ cultures, individuality, values, and needs. In the real world, a patient is more likely to care about “what works for me.” than efficacy and effectiveness. David Sackett, considered the father of evidence-based medicine, himself acknowledged that good medical practice cannot be done by cookbook adherence to external evidence but must include clinical expertise and attention to individual patient values and preferences. Students and physicians must also realize that many of today’s USMLE facts will become tomorrow’s myths.
Unless attendance is mandatory, students eschew lectures in many, if not most, American medical schools. First-year medical students may be counseled not to waste precious USMLE study time listening to us old farts? Lectures do vary in quality and may lack efficiency.
Nonetheless, when used selectively, lectures have the potential to introduce students to health care’s complexity and controversies. Lectures can encourage student reflection about modern medicine’s conundrums. I fear we are entering a teach to the test world where preclinical teaching faculty are held responsible and sanctioned if students fail to perform above average on a standardized test. Ideally, our job should be to excite, instill interest, and make students eager to learn more.
I recall that I passed my National Board Part 1 examination but have no knowledge of my score. Passing was good enough. Averageness and acknowledgment of one’s flaws should be accepted with equanimity and resolve to improve but not to seek perfection. In medical school, average does not mean mediocre, and none of us are flawless. Recently, I gave some of my students a copy of Dr. Richard Smith’s Thoughts for New Medical Students at a New Medical School. We then discussed the concept of “good enough medical student.” A good enough medical student, like the “good enough mother,” is the goal to which one should aspire. Dr. Smith’s delightful (and highly recommended) counsel tells us that worthy medical student skills include the ability to accept and acknowledge ignorance, continuously learn, question the status quo, and remain humble. Does the current USMLE climate encourage these virtues or simply engender a quest to be top scorer?
A teacher must get to know the whole student to be an effective mentor. In this thoughtful USMLE Step 1 commentary, the authors appropriately quote Albert Einstein: “Everyone is a genius. But if you judge a fish by its ability to climb a tree, it will live its whole life believing that it is stupid.” Students have unique personalities, and their skill sets vary. Specialty selection should be based both on student interest and on how well student’s personality and skills match to that specialty. I doubt that the USMLE Step 1, a test originally designed to be a pass/fail basic science competency examination, can determine specialty specific interest and skills.
Can teachers continue to inspire, excite, and mentor students who have become obsessed with a single high stakes test? Will dinosaur teachers become extinct as a result of USMLE climate change, or can we shift the paradigms? If any of the suggested changes to USMLE Step 1 scoring and usage are to succeed, we must also convince students and administrators that high test scores may not be predictive of humble, competent doctors who know how to listen and comfort patients. Becoming a physician requires hard work and dedication, but it should also be fun and fulfilling.
Vicki J. Schnadig is a pathologist.
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