How USMLE Step 1 Going Pass/Fail Will Affect Medical School Curricula

Here’s How the USMLE Step 1 Going Pass/Fail is Going to Affect Medical School Curricula

For those who have not yet heard the big news, the USMLE Step 1 will be transitioning to a pass/fail scoring system starting in January 2022. 

While this may sound like great news, as there will be less stress associated with Step 1, it is clear that this change will have significant secondary effects particularly on students at Osteopathic medical schools. The most likely change is that the conversion of USMLE  Step 1 to a pass/fail scoring system will lead USMLE Step 2 CK to become the standard by which residency programs measure and compare applicants for interviews and for the residency match. 

If we start with this premise, then we can dive a little bit deeper into the secondary effects of the USMLE Step 1 pass/fail decision on the curriculum schedule and peer tutoring programs at many medical schools. Using a little bit of logic, we can make the following predictions about what to expect in the future:

• Medical schools will begin shrinking or eliminating dedicated study periods for Step 1

• Medical students will begin requesting and/or taking time off for dedicated Step 2 CK preparation.

• Schools with traditional schedules will struggle to carve out time for dedicated Step 2 CK study periods.

• Peer tutoring programs at many medical schools may become harder to staff due to the lack of availability among senior students.

• Pressure on shelf exam performance will increase and may detract from time spent on clinical work.

Let’s take a closer look at why each of these hypotheses may become a reality.

Shrinking the dedicated Step 1 Study Period

Nearly every medical school provides at least 6 weeks of time when there are no classes or competing obligations so that students preparing for Step 1 can focus solely on exam preparation. Over the years, many medical schools have been forced to increase the amount of time available for dedicated Step 1 prep as the intensity of student focus on the exam has increased.  Back in the early 2000s many schools provided 2 to 4 weeks of prep time or even none at all. In 2019-20, there are schools that provide as many as 12 weeks of dedicated prep time, and often this is preceded by a several week block of lectures or PBL/TBL that aim to help students prepare for the exam. This does not include the increased numbers of students who further delay their exam, often starting clinical rotations 1 or 2 months behind their classmates. The ever increasing time spent on dedicated Step 1 preparation was one of the big reasons that medical school deans and administrators favored making Step 1 pass/fail.  

Now that this change has happened, it is very likely the medical schools will try to ‘claw back’ some of this time from their students’ schedules. Schools with a ‘5th preclinical semester’, common among Caribbean medical schools, may shorten or even eliminate this period and transition to clinical rotations. How much the dedicated study period and/or integrative blocks would be reduced is highly speculative, but almost certainly some of this time will remain. Step 1 is still a difficult exam to pass. Also, it is very hard to take away a ‘benefit’ after people have become accustomed to receiving it. A conservative guess is that many schools will shrink the dedicated study period to 4-6 weeks maximum. 

Dedicated time off for Step 2 CK preparation.

At many medical schools, there is no dedicated study period for Step 2 CK.  There are a variety of reasons for this. One important reason is that core clinical rotations often end in late June and students need to start electives and away rotations that are crucial for obtaining exposure in their field of choice and for obtaining letters of recommendation for their residency applications.  With the focus shifting to Step 2 CK, students may now start requesting dedicated time off to prepare for the exam. It is likely this study period will be 1 month or less because clinical rotations, especially elective rotations that follow the core rotations, usually last one calendar month. If students want a dedicated or semi-dedicated study period they are likely to schedule time off, complete a research rotation, or choose a clinical rotation with very low hours obligations. Students on a tight residency application timeline will be making a tradeoff that less clinical elective time will be more-than-compensated-for by a better Step 2 CK score . 

At other schools like Mt. Sinai School of Medicine, there is an elective 2-week review course for Step 2 CK prep. This is a course that Dr. Ken Rubin (CEO and Cofounder of Elite Medical Prep) and I at Elite Medical Prep run every July right after the conclusion of the major clinical year rotations.  Students at Mt. Sinai typically use the course as an adjunct to their independent preparation during a limited dedicated study period. In total, students often take only 2 to 4 weeks of dedicated study time, which contrasts with the 6 weeks (or more) that Mt. Sinai students spend on Step 1 prep. A significant number of Mt. Sinai students also delay taking Step 2 CK until the Fall, especially if their Step 1 score was strong. But that will no longer be an option. Step 2 CK scores will be crucial and will be needed by the time residency applications go out in early September. 

Finally, there is a small but growing group of medical schools where their students take Step 1 and Step 2 CK after completing their core clinical rotations.  At these schools–many of which are ranked in the top 25 (e.g. UPenn, Columbia, NYU, Harvard, Duke)–clinical rotations finish around January, and then a dedicated Step 1/Step 2 study period takes place.  For these students, there should be little in the way of a schedule adjustment needed since they already have the flexibility to devote time in the way they see fit. Furthermore, since most students at these schools have high MCAT scores, they will already have a background of strong standardized test-taking skills. 

For the students at schools without a dedicated Step 2 CK study period, students will now push for dedicated time off for Step 2 CK.  Even though a 1 month period may be offered because it matches the length of clinical rotations, students may push for yet more time off. If the schools are unable or unwilling to provide time off for Step 2 CK, students will start putting more effort into their Step 2 CK preparation during clinical rotations and then take Step 2 CK before the end or right at the end of core clinical rotations.  Although medical students can be a very important part of the clinical team, there are times when they are superfluous. Certain medical students have been known to be less-than-engaged in clinical care, opting instead to spend that time on shelf exam prep or working on research publications. Unfortunately, the competing stress and pressure to perform well on Step 2 CK may push more medical students to disengage from their clinical rotations in a fashion akin to the decreased attendance at preclinical lectures.  While it’s one thing to miss a lecture (often which is recorded), it is another to miss clinical learning experiences on rounds, in the clinic, in the OR, in the radiology reading room and in interdisciplinary meetings.  With UWorld and other Qbanks available at one’s fingertips, the draw of doing a set of questions may pull students’ attention away from precious on-the-wards learning opportunities that may be less directly oriented to Step 2 CK.

Let’s recall that Step 2 CK is objectively a harder exam than Step 1. There is more material to cover–many more diagnoses, drugs and bugs to learn, and lots of clinical management that is layered on top of this content. Additionally, the content changes for USMLE Step 1 and Step 2 CK that were recently announced and slated to go into effect on May 4th 2020 call for more pathophysiology and disease mechanisms to be tested on Step 2 CK. This puts a premium on deeper understanding of clinical content.  As Step 2 CK will be the last big test in medical school, there may be a frenzied ‘finals’ type of atmosphere akin to college, but with the students believing the fate of their medical career hangs in the balance. With that kind of pressure, all other competing obligations and learning opportunities will become secondary. Thus, the problems in pre-clinical education that drove the NBME to change Step 1 to pass/fail may be simply shifted over to the clinical side of medical school education.  

Creating dedicated Step 2 CK study time may be hard for medical schools

As mentioned above, the existing medical school curricular structure best equipped to handle a dedicated study period for Step 2 CK is perhaps one where clinical rotations end in January of the 3rd year (or thereabouts). Schools that follow this schedule allow their students a dedicated block of time after clinical rotations to take Step 2 CK and possibly Step 1.  Looks easy. Medical schools will just move around their schedules to end preclinical earlier and start rotations, right? Wrong.  

The change-over from a 2-year preclinical organization to a 1.5 year preclinical curriculum can be very challenging and can take several years to organize in the best-case scenario. Overhauling course curricula, changing lecture and small group schedules, and shortening laboratory courses–especially anatomy–requires lots of moving parts and lots of cooperation from busy academic and clinical faculty. Many medical schools describe a 5 year process (at minimum!) to overhaul a curriculum, in the best of circumstances.

Just because the preclinical curriculum gets shorter, the challenge does not end there.  At some point there will have to be a transition class where students on the shorter curriculum will enter core rotations while others on the older, longer system will still be in core rotations.  When this happens there will be double the number of medical students on the wards. This scenario happened nearly 10 years ago at Columbia P&S (where I attended medical school as an MD/PhD student) when they made the switch. The students were not happy. Having 6-8 medical students rounding on the same 5-6 patients on a clinical team is not a great learning environment.  The problem that Columbia faced will probably be more severe if schools try this now. First, most schools still struggle to find enough clinical training slots for their medical students because there are many more schools now than there were 10 years ago and but there are fewer training sites. Several Caribbean medical schools have made agreements to secure clinical training sites at hospitals that used to host medical schools that were more local. Other clinical sites have been shifted from existing schools to new medical schools such as the new Kaiser Permanente Medical School. Second, most medical schools have increased their class sizes substantially.  One can foresee a scenario where medical students outnumber patients on the wards, particularly in smaller hospitals or in places where the patients may be less willing to have medical students participate in their care. Finally, the number of inpatient stays–inpatients provide the bread and butter of clinical learning on many core clinical rotations–has been consistently dropping over the last decade.  So, the sudden increase in students will coincide with a drop in available patients to learn from.  Looks problematic, to say the least.

Another solution that some schools may explore is to transition to Longitudinal Integrated Clerkships (LIC), the program pioneered at Harvard Medical School. Dr. David Hirsh (at Harvard) has presented data showing that this may be a far more effective way of educating medical students on their clinical rotations. According to data presented by Dr. Hirsh, the LIC format leads to increases in Shelf exam and Step 2 CK performance.  Creating an LIC format for clinical rotations is a big administrative undertaking with many stakeholders, and one that may be far harder than overhauling pre-clinical education.

For many Caribbean medical schools, their pre-clinical curricular structure and clinical rotation system may help some students but hurt others.  For example, at St. George’s University in Grenada, each calendar year there are two cohorts of students who start medical school either in January or in August.  The January starting cohort can complete two full years of pre-clinical coursework and then finish their core rotations in the January before their residency application submission in September.  That leaves several months to prepare for Step 2 CK and complete many clinical electives. Per the SGU website, this January cohort is currently smaller than the August cohort, but one would expect that to change in future years.  For students in the August cohort, the challenge to complete core rotations and study for Step 2 CK simultaneously or right after core rotations end may be too much. In that case, the SGU extended timeline program may be something more of their students consider. It permits students to complete their two years of core and elective rotations over a 3 year period at no additional tuition cost (however there is still the cost of living and mounting interest on students loans!).  However, other medical schools, offshore or based in the US, may also adopt this mechanism to help their students cope with the demands of Step 2 CK becoming the primary numerical measure on one’s application.

Peer tutoring programs will face new challenges

Many medical schools and medical students realize significant benefits from organized peer tutoring programs. Currently, these are programs where 2nd, 3rd and 4th year students tutor students in the classes below.  At most schools these programs are coordinated by learning advisors and associated deans of student affairs. The challenge of these programs is that the demand for tutors regularly outstrips the supply of tutors, some of whom are paid and others who do this on a volunteer basis.  Because Step 1 is typically taken at the end of 2nd year, many schools can draw upon two classes of students to provide tutors.  My recent conversations with one dean at a prominent medical school indicated that the 3rd year students typically provide most of the tutoring for Step 1.  This is because the material is fresher for them, and because 4th year students spend much of the year focussed on interviews and the associated travel and application related issues and then graduate in April or May.  With the shift to Step 2 CK as the most important USMLE test, many schools may struggle to find sufficient numbers of tutors.  Student demand may not increase, but the pool of eligible and available tutors could drop precipitously.  This is because most students will be taking their Step 2 CK during the beginning of their 4th year of medical school.  The senior class of medical students will have graduated and will be scattered at different hospitals grinding through the first months of their intern year. Recruiting tutors from among the interns and residents at the teaching hospitals affiliated with a particular medical school will also be challenging, particularly since there will be little incentive for a resident working 80 hours per week to volunteer their time to tutor.

Pressure on shelf exam performance will increase and may detract from time spent on clinical work.

Because the NBME Shelf exams mimic much of the content on Step 2 CK, students are expected to put increased emphasis on these exams during their rotations.  As soon as a student notices their performance is falling behind that of their classmates, is borderline, or below passing level, the pressure to get help will be immense.  Medical schools may struggle to come up with solutions to address this tutoring shortage. Our team at Elite Medical Prep has developed a group tutoring system that helps students who have failed clinical Shelf exams to remediate their exams. This system builds on our prior success with small group tutoring in the preclinical setting, which we have presented at national and international medical education meetings. We expect more schools will reach out to organizations such as ours to work with their students directly and/or provide organizational and training assistance to develop peer tutoring solutions at their medical schools.

As you can see, the effects of the Step 1 pass/fail system will reverberate throughout medical schools.  Medical students will face the primary effects, but the medical school administration, both in the pre-clinical and clinical phases, may have to overcome significant secondary and tertiary effects, detailed above.

If you are a medical school learning advisor, dean, or faculty member it would be great to hear your feedback on the ideas presented above and learn more about the changes your school is contemplating in response to the new USMLE Step 1 pass/fail system.