Step 1 Mania: The Case for #USMLEPassFail

Last week, I gave a Grand Rounds presentation at my institution on #USMLEPassFail. Many of you have asked me to share the slides or video, so I made a podcast and uploaded it to The Sheriff of Sodium’s brand new YouTube channel.

Check out the lecture here!

A couple of things:

  • I managed to get through the Grand Rounds lecture in an hour – and though I tried to be true to the original, the podcast ended up being an hour and a half. Without the pumping adrenaline and intermittent roars from the crowd, I guess my pace was a little slower.
  • Because I hate listening to the sound of my own voice, I did not carefully proof the audio, preferring instead to offer this apology in advance for any verbal stumbles.
  • I used the Explain Everything app to make this. I’m not sure how to make the PowerPoint animations and transitions show up in the app, so the slides are just stills in this podcast.

Lecture notes

2:59 – Prologue

This is the story of how I first got interested in this topic, with brief mention of The Great Netflix/Instagram Kerfuffle of late 2018 (7:25).

9:25 – Chapter 1: In the beginning…

A brief history of the formation and early growth in the NBME. Note in particular the organization’s original mission, and the description of the structure and components of the original NBME exam (11:45).

15:28 – Chapter 2: The USMLE is born

A review of the driving forces behind the creation of the USMLE in the early 1990s. Note also how the USMLE differed from its early predecessors (by being a criterion referenced test); the original rationale for score reporting; and a certain disclaimer that you will no longer find on NBME publications.

24:00 – Chapter 3: Step 1 Mania

Overview of how the increasing importance of USMLE Step 1 scores in residency selection has placed increasing pressure on students to score higher and higher. Pay attention to the trends in Step 1 scores over time, and the estimate of how many test questions are actually used to distinguish candidates.

33:59 – Chapter 4 – What’s on Step 1?

Just a few real USMLE Step 1 practice questions to remind us – in real terms – what kind of important facts students are learning to achieve high scores on Step 1.

39:22 – Chapter 5: Costs

It’s cool that we have this across-the-board metric – but what is it costing us? There is a substantial opportunity cost. Plus, the test also likely disadvantages under-represented minorities in medicine and harms student mental health.

47:42 – Chapter 6: Who benefits?

The main beneficiary of Step 1 Mania is the test’s primary sponsor, the NBME. Application Fever is also beneficial for the AAMC.

58:52 – Chapter 7: Objections

A brief review of some of the most common objections to a pass/fail Step 1. But what about basic science? Are Step 1 scores correlated with outcomes that matter to physicians and patients? What about the association between board certification and Step 1 scores?

1:28:39 – Chapter 8: InCUS, and beyond

Quick discussion on InCUS, with brief mention of my concerns about financial COI and the construction of meeting (previously discussed here, here, and here), before closing with a plea to get involved if these issues matter to you.