M.D./Ph.D. Directors Association

Working Group 3: M.D./Ph.D. Training and the USMLE

The problem that was discussed was the Seven-Year Rule for taking USMLE Steps 1-3. Specifically, what is at stake; what can we do to minimize/prevent the damage?

A. Background; What Is At Stake?

1. The policies relating to licensure vary among states. We do not know what is going on in the different State Medical Boards, but the Federation of State Medical Boards is strongly in favor of a rigorous enforcement of the rule that USMLE Steps 1-3 must be completed within seven years. We therefore must assume that any changes in policy are likely to be for the worse - unless we do something. The attitude expressed by the Federation of State Medical Boards at the last meeting of the Composite Committee of the National Board of Medical Examiners and the Federation of State Medical Boards is cause for alarm.

2. A rigorous implementation of the Seven-Year Rule for taking USMLE Steps 1-3 would "sabotage" MD-PhD training as we know it. The issue is not only MD-PhD training, as clinical training programs in states that enforce the seven-year limit rigorously may have difficulties recruiting MD-PhDs. (Even if one can become licensed in another state, and then "transfer" the license, it would create a disincentive to go to such states.)

B. What Can We Do - And How?

1. Given the elitist nature of MD-PhD programs, we must be careful not to create a backlash when we argue our case.

2. State Medical Boards may not be sympathetic to arguments that emphasize the need for biomedical research (during MD-PhD students' training); but they may accept arguments that focus on the teaching of medical students and the quality of healthcare. The latter is affected by the quality of clinical research; we may be able to stress the importance of research training by that route.

3. The National importance of MD-PhDs is evident in the fraction of NIGMS' pre-doctoral training budget that goes to the MSTP Program (~1/3). (But we should argue this case on our own.)

4. When we argue our case, we need to be respectful of the State Medical Boards. They have good reasons for wanting specific policies because the "problem physicians" who need to be disciplined, with the benefit of hindsight, often stand out as having had difficulties passing the Board exams.

i.e., we need to state that we understand the need for rules; but we request that the Boards consider the specific circumstances that face MD-PhDs when formulating licensure rules. We justify this request by the number of MD-PhDs that graduate each year (~500), and the special (and long) training these graduates receive. (But we need better data on the number of graduates, see below.)

C. Proposed Policy

That MD-PhD students in organized programs be given 10 years to pass USMLE Steps 1-3, conditional on their passing USMLE Steps 2 and 3 within five years.

(An Organized Program is a training program with a Program Director. We decided not to be specific with respect to thesis topic, etc.)

The proposal means that MD-PhDs are treated like any other when it comes to taking Steps 2 and 3, which test clinical skills. (MDs take Step 1 in Year 2 and Step 2 in Year 4 of their training.) The extension from seven to 10 years is justified by the duration of the MD-PhD training (nominally seven years), as compared to the MD training (nominally four years).

Further justification: MD-PhD students do as well as MD students at Step 2. (But we need better data, see below).

We cannot accept proposals to "solve" the problem by having MD-PhD students take Step 1 at a later time. It would prolong the students' training, and it would eliminate the important "learning tool" of having the students integrate all their basic science knowledge when preparing for the test.

D. How To Proceed

1. At the national level:

A letter from Paul Insel, as President of Association of MD-PhD Program Directors, to each State Medical Board in the country. This letter should state the problem, and propose a specific solution. An attachment to the letter should list the names of all program directors and their institutions. If we can identify other individuals, who would be able to write a similar letter, we should request them to do so too.

(It is likely to be counterproductive to have each program director write a letter to all State Medical Boards; it is likely to be seen as inappropriate meddling.)

The timing of this letter may be critical, and it may be best if the letter is conveyed to the State Medical Board by some local entity, i.e., a Dean with the appropriate connections.

For this effort to be successful, we need to: a) have good data on how many MD-PhDs that graduate each year; b) have good data on how well MD-PhD students fare on USMLE Step 2.

2. At the state level:

The program directors in each state should coordinate their efforts. We should contact our State Medical Board and State Medical Society - to initiate a discussion of the problem. (This contact may best be initiated through our deans.)

The reason for including the State Medical Societies is that it may easier to sway the State Medical Board if we have the State Medical Society on our side - and we certainly do not wish to have them in opposition to us.

We should request information about the current practice, express our concerns about the seven-year rule, and propose that the Board considers a policy that considers the special circumstances of MD-PhDs. (Unfortunately, we need to become knowledgeable about the politics of our State Medical Board and State Medical Society.)

We may need to approach the state legislatures - to request that the laws relating to medical licensure (at best) have wording that considers MD-PhDs or (at least) do not have wording that we find to be unacceptable.

We should involve the clinical program directors in our institutions. They also have much at stake.

THERE IS URGENCY TO THIS: the Composite Committee of the Federation of State Medical Boards and the National Board of Medical Examiners meets twice a year. The next two meetings will be January and June, 2000. It is likely that a decision regarding this issue will be made at one of these meetings. We need to make our case within the next six months.

20 August 1999