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Flattening Medical Exam Standards Will Imperil Health Care Quality

August 2, 2019
By Kim-Lien Nguyen, M.D.

Among the endless metrics for assessing the quality of health care, one that is exceedingly important for measuring physician quality is on the chopping block.

I'm talking about the plan to make the U.S. Licensing Medical Exam (USMLE) Step 1, which all medical students take at the end of their second year of studies, a pass/fail test. This proposed change was quietly announced by the owners of the test and has received almost no media coverage. USMLE is owned by the Federation of State Medical Boards and the National Board of Medical Examiners. The test is given to those seeking an initial license to practice medicine.

Such a pivotal change, which I find troubling, merits greater attention and debate. Comments on the proposal closed on July 26.

Removing Objective Criteria

Over the past 20 years, medical schools have mimicked larger trends in higher education to become more diverse by deemphasizing standardized testing for admissions. Once medical students are in the door, administrators have attempted to address disparate levels of achievement by embracing pass/fail grading systems that emphasize experiential learning over mastery of foundational concepts.

The lack of objective metrics has led to a greater reliance on numerical scores from the Step 1 exam. For the directors of residency and fellowship programs, these scores serve as easily quantifiable proxies of ability. Medical residency and fellowship programs are where doctors train to become specialists and determine their careers. Medical school graduates apply to the residency programs of their choosing, and the residency programs rank applicants based on level of desirability. Graduates and programs are paired through a formal matching process known as the National Residency Matching Program.

A change to pass/fail would represent the culmination of years of watering down of medical education in ways that have significant repercussions for medical training and patient care.

Increasing Pressure on Students

In theory, these well-intended efforts aim to reduce pressure on medical students and increase diversity. Yet they are likely to have the opposite effect. Without objective standards such as standardized testing or grades, residency directors will have to focus on who you know and what you are. Using the who-you-know standard will place even more pressure on students to secure entrance into prestigious colleges and medical schools because the proxy of academic pedigree and the network of elite institutions will carry more weight when it comes to placement in residency and fellowship programs.

This will increase the medical school rat race by forcing students to focus on accumulating secondary laurels such as myriad leadership activities or pledging indentured servitude to research professors who will have outsized influence on their residency prospects because of the absence of other objective standards.

Undermining Credibility

Without objective means such as grades and Step 1 scores to measure ability, the what-you-are standard will make it easier to justify race-based quotas in residencies and fellowships. Marginalizing the importance of standardized testing may make it easier to expand opportunities for individuals who can check the right gender and race boxes, but it comes at a cost for people who do not have the "right" networks and fall outside of the "right" categories.

Admission to residency programs based on networks and categories is, by definition, arbitrary. In a world without standards, people may simply assume that medical trainees got into their programs because of their elite connections, race, or gender. This would delegitimize medical students' efforts and the process itself. Standardized testing, for all of its alleged flaws, is the key to genuine equal opportunity.

Making the Grade

The presence of objective metrics allows medical students to focus their energies on mastering the material and demonstrating they have the ability to succeed as physicians even if they do not come from the most prestigious institutions or well-connected families.

If elite networks and pedigree had been the key a generation ago, Asian-American students like me would have had limited access to medical school and residency slots and would have been on the outside looking in, just as Jewish students were a generation earlier when elite universities and hospitals had Jewish quotas to limit the number of accepted applicants.

In a profession where highly refined skills, impeccable judgement, and swiftness of mind can make the difference between life and death, standards that rely on networks and categories of race and gender undercut the point of medical training.

Lowering Quality, Standards

Medicine and merit should go hand in hand. When you face significant illness, you want to see physicians whose decades of rigorous training in medical school, residency, and fellowship serve as proxies for their competence.

The recommendation for pass/fail reporting of Step 1 scores represents an unvarnished attempt to abolish the last merit check in medicine. Although this approach may open the door for greater diversity in residency and fellowship placements, it perpetuates a pattern of evisceration of quality and standards.

No one wants to see a physician who gets diagnoses right only half the time. Watering down the system by eliminating numeric scores on Step 1 equates to root rot that will gradually undermine the medical profession.

Kim-Lien Nguyen, M.D., (klnguyen@ucla.edu) is a cardiologist and assistant professor of medicine at the David Geffen School of Medicine at UCLA. The views expressed are her own. An earlier version of this article was published at www.statnews.comon June 28. Reprinted with permission.

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