Thread by @vishal_khetpal

This week, the @NBMEnow announced that the USMLE Step 1 would be moving to P/F as early as 2022. Folks far smarter than I am like @jbcarmody and @BenMazer have had a lot to say about this seismic change in US #MedEd, but I wanted to offer some other thoughts on this. 1/

For those of you unfamiliar with medical education, Step 1 is a basic sciences exam often taken after the 2nd year of med school. It’s original (and really still, primary) purpose is to serve as one of 4 licensing exams to practice medicine in the US. 2/ en.wikipedia.org/wiki/USMLE_Ste…

The issues surrounding this exam are very well documented on @jbcarmody’s blog, thesheriffofsodium.com, and aren’t worth repeating at length here. 3/

Tl;dr: Step 1 scores are increasingly used in residency admissions in ways not intended when the test was made, have created a culture of intense test prep in med schools that’s not linked to patient care, and have created a huge financial burden for med students. 4/

@kelseycpriest and other med students wrote about this in a great editorial for @AcadMedJournal in 2018, describing "Step 1 mania" well and kicking off this debate effectively. 5/ ncbi.nlm.nih.gov/pubmed/30570499

Making Step 1, it's argued, could be an initial step (pun not intended) to change all of this. Some key lines of thought (including criticism) were published in a @statnews First Opinion featuring @MaxJordan_N, @OrlyFarber, @LashNolen, and @AnnaGoshua 6/ statnews.com/2020/02/14/che…

A lot of initial concerns too were about how this might negative affect students from DO programs and international schools looking for positions in the US, or how it could just place emphasis on scores from the other licensing exams. 7/

Most of the discussion, fundamentally, has focused on what this means for “us” – the people in medicine interacting closely with this exam (medical students, residency program directors, etc.). 8/

But really, I think, the debate around Step 1 is far bigger than “us”. It’s about our patients, and about what becoming a physician in 2020 America really means. 9/

I think #MedEd today faces 2 huge challenges – (1) it’s training too many physicians who don’t come from the same corners of society as their patients, and (2) it often pushes a narrow blueprint for career success in medicine. 10/

To anyone in med school, it is obviously apparent that our student bodies don’t look like our patients. We’re from disproportionately high-income backgrounds. 11/
aamc.org/system/files/r…

Most minorities are underrepresented. The number of black men in med schools has actually *decreased* since the 1970s. 12/
nbcnews.com/health/health-…

Native American med students, in the entire country, number in double-digits. 13/ aamc.org/news-insights/…

Students from rural communities are severely underrepresented too. 14/ healthaffairs.org/doi/full/10.13…

Does Step 1 reinforce these trends? 100% yes – through creating an arms race that favors folks with financial flexibility and insider knowledge about the med training pipeline. @emmabgo reported this in a great piece for @nytimes earlier this year. 15/ nyti.ms/34j7UKS

When medicine is less diverse, our patients lose. We overlook issues facing different groups of people; we carry more blindspots in our world view. There’s good data out there suggesting that patients trust us more when we share identities with them. 16/ npr.org/2019/06/03/729…

But there’s another type of diversity too that we don’t often talk about – a diversity of thought and career goals in medicine. There’s something in med school that makes us less empathetic, more prone to burnout, more conforming, and often less creative. 17/

I think this process really starts with Step 1, when it cannibalizes med school from Day 1, and forces well-intentioned folks in #MedEd to innovate curriculum with both hands tied behind their backs. 18/

A scored Step 1 reinforces this idea that there’s obvious success and obvious failure; that your worth and value are often defined by a number (one, ironically, that is probably not as defining and clear-cut as we think). 19/
thesheriffofsodium.com/2019/05/13/ano…

Maybe making Step 1 P/F can help reverse that trend. Because today, we definitely need physicians who find career value and success in many different ways (many of whom are on #medtwitter), rather than achieve success through a singular blueprint. 20/

We need doctors researching big questions in medicine, training the next generation of physicians, and taking care of our patients in all parts of the country. 21/

But along with those responsibilities, we also need them interacting with local newsrooms (@john_biemer), engaging with patients on TikTok (@AustinChiangMD), advocating at seats of government, and starting bold businesses (@Farzad_MD), among other goals. 22/

I can’t say what will happen with this change in Step 1, but ultimately I hope it leads to something better. fin/