AAMC Reporter: December 2007

Changes Possible for Medical Licensing Exam

Administrators of the United States Medical Licensing Examination (USMLE), which doctors must pass before practicing medicine in this country, are considering eliminating the first step of the exam's three sections. Proposals being circulated at the National Board of Medical Examiners (NBME), which oversees the USMLE along with the Federation of State Medical Boards (FSMB), suggest integrating basic and clinical concepts throughout all examination components rather than segregating the basic science content in Step 1.

In 2004, the USMLE governing committee requested that these parent organizations, along with the Educational Commission for Foreign Medical Graduates, review the exam to gauge overall effectiveness, and determine whether changes were necessary.

"With all the changes in the medical school curriculum, it's time to go back and ask stakeholders if this exam is meeting their expectations as effectively as possible," said Peter Scoles, M.D., NBME's senior vice president of assessment programs.

The committee will issue final recommendations to key stakeholders in January. Any major change would likely take at least three years to implement.

The group noted that separate exam components for basic and clinical sciences unnecessarily separated the two, and recommended blending them together, to mirror similar trends in medical education.

"Most medical schools are striving to integrate the basic sciences with the clinical sciences now more than ever before," said Ruth-Marie E. Fincher, M.D., vice dean for academic affairs at the Medical College of Georgia. "But yet the USMLE still creates a demarcation between the two."

If Step 1 of the current USMLE was eliminated, this could provide more motivation for medical school faculty to continue combining basic and clinical science fields, a move that stands to advance student learning, she said.

"Many students have a sense that learning the basic sciences is a hurdle," Fincher said. "After Step 1, they think they can forget the basic sciences and get into the clinical medicine. This change would be helping them understand the relevance of basic science."

Pharmacology, she said, is one basic science subject that students may absorb better if taught simultaneously with clinical medicine.

Other academic physicians fear that Step 1's eradication will reduce basic science education in medical school. "We can't help but believe the basic science content will be diminished on the USMLE program with the elimination of Step 1," said David M. Engman, M.D., Ph.D., associate professor of pathology and microbiologyimmunology at Northwestern University Feinberg School of Medicine. "If the basic science section of the exam decreases, we fear that the basic science in medical education will decrease accordingly."

While the teaching of science clearly relevant to clinical practice (e.g., related to the mechanisms of disease) may not be reduced in the classroom, Engman is concerned that more fundamental information may be less emphasized. This could lead to problems when physicians are presented with a new disease or treatment protocol, said Michael Friedlander, Ph.D., chair of Baylor College of Medicine's neuroscience department, and past chair of the AAMC Council of Academic Societies.

"It is important to arm people with very fundamental principles of science, because then they can examine new information critically," he said.

Friedlander supports integration, but said it is important to devote some class time exclusively to basic science education.

"In the real world, you cannot separate the two fields," he said. "But to really understand a scientific principle, you have to take time to learn that subject."

It is unclear how much the medical school curriculum would change as a result of Step 1's possible elimination, and what those changes would specifically entail. According to Fincher, basic science education could increase in the later years of training.

"Some schools would feel liberated to develop innovative curriculum change," Fincher said. "[Others] would feel as if they need to change their curriculum to incorporate more basic science in years three and four to prevent their students from being at a disadvantage in taking an exam—presumably toward the end of medical school—that covers both basic science and clinical medicine."

Fincher said, however, that alterations are not an inevitable result of this proposal.

"The possible change from a three-step to a two-step licensing examination does not necessarily compel curriculum change," she said.

Friedlander also voiced uncertainty, but said that a diminished basic science program seems likely.

"There could be all kinds of reactions from medical schools," he said. "But if this change is made, students could demand more curricular time focused on clinical medicine" to be better prepared for the exam.

A streamlined USMLE could also make it more difficult for educators to evaluate students—and for students to evaluate themselves. Step 1 is administered during medical school, while Step 2 is usually taken at the end of medical school, and Step 3 is taken during residency. Thus, an important early assessment tool may be lost if Step 1 is eliminated entirely.

"With [Step 1], students are getting a bead on how they're doing compared with the rest of the country," said Ruth B. Hoppe, M.D., associate dean emeritus at Michigan State University College of Human Medicine. "Taking it out removes this early marker."

For Friedlander, this move could be advantageous. Without Step 1 on which to rely, medical schools could develop more creative tools for measuring the basic sciences, he said.

"One positive thing is that Step 1's elimination could force educators to use other metrics when evaluating students," he said. "On the other hand, if no metric is found to assess the basic sciences, their importance will be further diminished."

A Step 1 equivalent exam is one alternate assessment mechanism, Fincher said. This test could evaluate basic science performance and provide national comparison data early in a student's medical education career, but would not be a part of licensure. Medical schools could individually decide whether to administer this exam. Finally, removing a step from the exam could put undue pressure on students to do well on the remaining two steps.

"A single exam would be extraordinarily stressful for medical school students. There would not be a chance to compensate for illness, a family emergency, and so on," said Molly Osborne, M.D., Ph.D., associate dean for student affairs at the Oregon Health & Sciences University School of Medicine.

The NMBE's Scoles said conversations are still ongoing, but that holding a discussion about updating the exam was appropriate.

"The USMLE was designed more than two decades ago," he said. "At that time, it matched the licensing environment very closely. After 20 years, it's good to take another comprehensive look at the exam."

—By Elissa Fuchs

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