Dissertation Overview

Context & Overview:

Medical licensure in the United States (US) consists of a three-part, standardized examination taken throughout a future doctor’s education. The first part, called “Step 1” is taken towards the end of a student’s second year of medical school. In order to move on from classroom learning to their clinical experiences, students must simply pass this exam - showing they have an adequate knowledge of anatomy, physiology, pathology, and pharmacology learned during their first two years of medical school. A student’s score on the Step 1 exam, however, has been used as a filtering metric by which to sort students to determine what residency program and specialty they get into. Residency is the next step after graduating from medical school and the program a student gets into determines their specialty (pediatrics, surgery, dermatology, etc.) and thus their earning potential, as some specialties pay more than others. Because of the importance of this single exam, medical students across the country began purchasing expensive commercial resources designed to prepare them for this test. They utilized these resources instead of engaging in their medical schools’ curricula. Ultimately, students who had the financial resources to pay for these test-prep materials scored higher on the Step 1 exam and were able to get into higher-paying specialties. Because of the disruption to medical education and the perpetuation of inequalities in medicine, the licensing bodies decided to make the Step 1 exam pass/fail beginning in January 2022. The idea behind removing the score as a sorting metric was to promote a more holistic review of medical students and encourage more engagement in medical school curricula. My dissertation will assess the perceptions of medical students and faculty to gain a bigger picture understanding of the effects this change may have on medical education and student engagement.

Methods & Data:

I have conducted semi-structured interviews with medical students across all four years at Indiana University School of Medicine (IUSM) - Bloomington to determine their perceptions of the Step 1 exam, commercial test-prep resources, and the IUSM curriculum. Interviews with basic science and clinical faculty are currently in progress to add-in faculty perceptions as well. These interviews will then be analyzed using thematic analysis to find themes in each interview and compare within and between groups to find commonalities and divergences to describe, holistically, the medical education system as it shifts from a scored to pass/fail Step 1 exam.

Significance & Preliminary Findings:

Formalized medical education in the US has been continuously evolving since its beginning in the late 18th century as we strive to find the best way to educate future physicians. Today, there is more knowledge of the human body and medical interventions than ever before. Additionally, physicians are responsible for the “softer skills” of medicine such as understanding different cultures, engaging in ethical solutions, and being compassionate to their patients. These are all components that we need to instill in our medical students so they can become quality members of a healthcare team. The focus on the Step 1 exam took student attention away from learning the important ethical and cultural competencies taught at medical schools and put all emphasis on memorizing medical factoids, disrupting the balance of what will make a “good” doctor. Changing the Step 1 exam to pass/fail will, hopefully, allow students to engage more fully in their medical school curricula, and thus the “soft skills” of medicine, instead of spending thousands of dollars to simply perform well on a standardized test. Although my preliminary findings are mixed on if this is the case at IUSM-Bloomington, even if the shift does allow for more engagement with the softer skills of medicine, new metrics by which to differentiate medical students applying to residency will need to be created. In order to combat the continuing inequities within medicine, these new metrics need to be holistically and thoughtfully designed. The findings of my dissertation will shed some light on this process as it is going through the major change of eliminating the Step 1 numerical score including benefits and drawbacks as seen from the perspective of stakeholders throughout the medical education continuum. These findings can help others to investigate how their institutions and medical students are handling the transition to a pass/fail Step 1 and provide insight for medical licensing boards to see this process from the bottom up instead of from the top down.