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Step 1 vs. Netflix and Instagram

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“...if students were to devote more time to activities that make them less prepared to provide quality care, such as binge-watching the most recent Netflix series or compulsively updating their Instagram account, this could negatively impact residency performance and ultimately patient safety.” This quote, from Improving Residency Selection Requires Close Study and Better Understanding of Stakeholder Needs (Katsufrakis & Chaudhry) is part of a response to the publication, Student Perspectives on the “Step 1 Climate” in Preclinical Medical Education (Chen, et al) and is generating a heated discussion of the United States Medical Licensing Examination (USMLE) Step 1 examination.

Chen, et al, discuss how the USMLE Step 1 evolved from its original purpose - as a pass/fail licensing exam - to a numeric score that residency programs emphasize, leading to a negative impact on undergraduate medical education. Examples of unintended harms include disengagement from institutional curricula and focus on commercial resources, increasing disparities, and a negative impact on well-being. The proposed solution: eliminating numeric score reporting.

Katsufrakis and Chaudhry respond with potential consequences for USMLE Step 1 pass/fail grading, alternate proposals for reporting of numeric scores or timeframe for reporting as well as a discussion of additional ideas surrounding residency applications beyond the USMLE Step 1. They note that if evidence existed for a better approach to numeric scoring, it would be presented to the relevant governing organizations for consideration. Additional proposals for enhancing the residency application process included: encouraging residency programs to improve data available to applicants, allowing applicants to target appropriate programs; developing other numerical metrics related to important characteristics such as research, volunteerism, etc; and third-party evaluation and validation of medical schools’ Medical Student Performance Evaluation (MSPE). Their conclusion emphasizes the need for further conversation and a conference in 2019 to further discuss potential changes.

While the Katsufrakis and Chaudhry response has valid points, they are overshadowed by the tone-deaf assumption that medical trainees with more time may instead redirect their effort toward Netflix and Instagram. The Twitter medical community brought up robust points such as @ShannonOMac’s (Dr. Shannon McNamara) thread on the current state of USMLE Step 1 testing where she notes that,

“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.”

Another thread by @jbcarmody (Bryan Carmody) delves into the National Board of Medical Examiners’ (NBME) finances. Between 2001 and 2017, NBME’s program service revenue has tripled from $47.5 million to $153.9 million. The NBME has a vested interest in maintaining its examinations; especially profitable ones such as the USMLE Step 2 Clinical Skills (CS), which has a 96% pass rate (for U.S. medical graduations) and a $1,300 price tag.

An informal poll of my co-residents while writing this article led to responses that ranged from disgust to apathy. One of my colleagues was visibly outraged when I read the excerpt above while another noted that the USMLE Step exams are a “necessary evil.” I believe that the path to becoming a physician requires assessment. But I also recognize that there is substantial value in life experiences. Most individuals enter the practice of medicine to help others, and with extra time, would be afforded the opportunity to direct their energy to activities for personal or professional growth -- even if it’s Netflix and Instagram (which both offer educational media).

Amanda Xi, MD, MSE is currently a resident at Massachusetts General Hospital (MGH) in Boston, MA and upon graduation will be continuing at MGH as a critical care fellow. She is an active blogger at her self-titled website and also active on Twitter (@amandasxi), Facebook, Instagram (@amandaeleven), LinkedIn, and Doximity. She is also a 2018–2019 Doximity Author.

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