2020 UPDATE: As the USMLE Step 1 is now going to change to a pass/fail system this article may no longer be relevant to your needs.
This debate has gone on way before my time in the medical field, and will likely continue long after. However, there seems to be a really simple answer to this that some medical schools and teachers may be too ignorant, too pompous, or too out-of-touch with reality to admit. Medical schools should, first and foremost, prepare you for the boards.
There. I said it. Start the hate mail.
Some of you may be confused by this statement. Others may be screaming in praise of what sounds obvious to the seeming majority of student, yet may be overlooked by your institute or select teachers. They say they want to teach it “their way” or that they are trying to “prepare you for being a doctor.” Their goals may be noble, but this philosophy has some holes in it.
Academic vs Clinical
The Residency Program Director Survey is conducted every few years to assess what attributes residency programs look for in their students. Consistently, board exams rank near the top (or at the top) of the list. One summation that has been said to me is “Step 1 scores get you the interview, Step 2 gets you the residency.” So our reality, despite what your instructor may desire (and what we may desire as well), is that the boards are pretty darn important.
We all know that our USMLE Step exams, know as the “board exams”, are the life-blood of our futures. I’m not say I agree with this aspect, but the numbers don’t lie. And until more residency directors begin to utilize patient-care based models for assessing a medical student’s worth, this is where we are stuck.
Note: I have heard rumors for several years that residencies are moving away from board exams and taking a more “holistic” approach to residency applicants. However, I have yet to see hard data on this.
Don’t get me wrong. I’m not saying that medical schools should ONLY prepare you for the boards. I’m sure some instructors and programs are quite adept at conveying board-related material in clinical manners. They may use problem-based learning activities, have online lectures for home study, or provide a wider array of online and at-home testing materials for student included with tuition.
Some may be able to provide continuity of education from basic sciences to clinical scenarios. Public health, medical ethics, and even procedural techniques can be taught at schools with the proper administration and resources. The more well-rounded an educational environment, the better the student and their patients will ultimately be. However, this all should come after proper preparation for the wall between basic sciences and clinical experiences: the boards. This is not the story I hear most.
Blood, Sweat, and Tears
But don’t most US medical school graduates pass the boards?
Sure they do. And so do the majority of international/foreign medical graduates as well. This statistic, however, explains nothing of the hardship and personal sacrifice that student and their families had to make in order to become “exam ready.” Though those interviewed from higher-tier schools may only take 2-3 months for exam-prep time, some students take years (often 2 is not unheard of) off for dedicated study time. This is time and money wasted, rent and bills to sustain oneself, income not gained, and can be a perpetually increasing stress point.
Granted, this may seem like an oversimplification…because it is. It would take a dissertation to explain all of the differences in schools, programs, curriculum, and individuals students when it comes to the multitude of academic and life differences during this period of time. After all, we are talking about several years of a student’s life just for the OPPORTUNITY to sit for the board exams.
Teachers in other academic realms fight against “teaching to the test”, and many claim that standardized tests are ineffectual. But where does the fault lay: with the teachers or with the test? Maybe it’s time for a similar change in medicine.
Graduate rates have also fallen quite significantly in the past few decades. I can’t help think that this dichotomy of what is expected of student in medical school and residency plays a part in this.
Medical School Ethics
Medical students should be quite familiar with the concept of “paternalism.” Once upon a time, doctors thought it was perfectly fine to make the decisions for the patient without their consent because they believed it was the best choice for the patient. However, this archaic paradigm has been replaced with patient autonomy.
Despite this significant change in doctor-patient relations, the same advancements have not been seen in teacher/institute-student interactions in some medical schools. We pay medical schools to prepare us for becoming doctors, yes. However, without passing the boards our journey ends there. Even with passing the boards, if our score is not high enough our journey may end or lead us to a specialty that we did not envision ourselves in. Some specialties are known to have higher burnout rates, but if your choice is accept a residency at a specialty you do not prefer or wait another year and attempt the Match again nearly all students would take the former.
A Look Forward
In a time of increasing dropout rates, physician shortages, and an ever-increasing awareness of physician burnout and suicide perhaps we should do more than just teach students. Maybe we should guide them in how to attain their goals. Maybe we should teach them how to succeed. A re-structuring of the residency process is needed. But until then, it may be best for medical schools to drop the paternalism and personal philosophies to decrease student stress revolving around the board exams.
