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Y’all, come on a journey with me. A journey of speaking up, high stakes testing in medical school, and Netflix jokes. This is the state of USMLE Step 1.

(A thread)
Recently, some medical students spoke up about a problem they saw with a big test that we all take called Step 1. First, some background.

USMLE Step 1 is a super high stakes test after the first two years of medical school.
Your score on the USMLE Step 1 basically determines the fate of your medical career - score well, and the doors to residency are open. Score low or fail, and well, tough luck. Give up on your dreams of entering a competitive specialty and maybe on being a doctor all together.
I hate this test. It’s a lot of memorization about information we rarely use and almost always look up in real life. It’s a relic of a time before the internet when doctors were human computers.
Remember Hidden Figures? Where there was a room full of people called “computers" doing math on paper to calculate rocket trajectories before they had computers to check the work? Like that. Only now we all have tiny computers in our pockets and can look things up.
Their conclusions in images below, full article free link here @AcadMedJournal: journals.lww.com/academicmedici… In speaking with our clinical mentors, we have learned that the Step 1 Climate has radically transformed within the last 10 years...[further conclusion available in linked article]There are steps we can and should take to improve the Step 1 climate within preclinical medical education...[further conclusions available in linked article].
Then the leaders of the organizations responsible for the USMLE Step 1 write back. Deep in their commentary is this gem, about how if the exam were pass/fail, students might watch too much Netflix. journals.lww.com/academicmedici… (Thanks to @jbcarmody for noticing.)
ARE YOU FREAKING KIDDING ME WITH THIS.

Students are literally driven to suicide and mental illness over this one high stakes test that was never designed to do that and you are responding with Netflix jokes?

Because I am not laughing.
They agree that the purpose of the exam was never for high stakes residency placement.

"Does Step 1 performance predict residency success? To our knowledge, no study has been done to answer this question."

journals.lww.com/academicmedici…
They agree that the primary purpose of Step 1 was for State Licensing boards, not residency selection. My, how far have we drifted from that intent.
I'm a medical educator in simulation interested in non-Step 1 competencies like team competency. Efforts in my field to do more in pre-clinical education are often hindered by the burden of Step 1.

As Katsufrakis & Chaudhry note, “we know that assessment drives learning.”
Assessments like Step 1 are driving learning in the wrong direction, not only for our learners, but for our patients.

Our patients don’t need human computers. They need humans. Humans who have not been locked in a room memorizing useless facts for years so they can ace tests.
Humans who know what to say when they say, “Doctor, am I dying?”

Humans who are strong enough to say “I don’t know” and “I need help.”

Humans with empathy.

Humans who can lead the diverse interprofessional teams and complex health care systems we’ve created.
Others have written extensively on how we need to re-vamp the medical school curriculum to create the physicians modern society needs, and how Step 1 in it’s current form is a major barrier. @VPrasadMDMPH is quite outspoken about it. ncbi.nlm.nih.gov/pmc/articles/P…
Financial motives must also be taken into account. What are the financial motives of those administering the USMLE Step 1 in it’s current form to change it? How profitable is it currently? How much would it cost to change?
How much money are medical students pouring into their studying & testing taking?

Who is in charge here and what are their motives?
Ultimately, this is a difficult problem, and one that we need to solve together. It's not about us, the clinicians. It's about our patients. How are we using assessment to drive learning towards what our patients and our health care system needs?
Condescending to this generation of medical students about their very real concerns is no way to start working together to fix it.

Do better. @AAMCtoday @NBMEnow @Katsufrakis #USMLE
To all the medical students working late nights and pouring your money, sweat, and tears into Step 1: I'm sorry that our profession is clinging to a relic.

You are more than a test.

Please keep speaking up about the realities of how bad it is.

Please help us fix it.

/end
Update: follow the money. Thread from @jbcarmody on the financial conflicts of interest of the @NBMEnow.
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