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USMLE Did What?!

Okay okay. This week we gave you an all new episode targeting our fellow physicians however, who knows how this can impact healthcare in general so everyone can take a listen! Earlier this month the rumors we were hearing back around summertime were finally put to bed and we found out that the Step 1 exam will now be pass or fail starting 2022? For now we’re assuming that Step 2 will be the determining factor in terms of residency placement as that will have a scoring system but this too may go away at some point.

Any who, with that said we wanted to briefly discuss all the different step exams we need to take to become you know... a doctor and then talk about what this may or may not mean. Because, who really knows what’s going to happen. Also, we want to educate those who are thinking about applying, are applying or are already in medical school about the board exams in general as well as, what this may mean for them. If you haven't yet listened to the episode, STOP and click the link under the podcast tab to listen to the episode now!

Step 1

So what is the Step 1 exam exactly? This is the exam you take right after you finish your two years of basic sciences. For those of you that don’t know... this is the exam for which you sit and study anatomy, physiology, pharmacology, cell biology, biochemistry to name a few .. After this you study for this huge board exam that’s like 8 hours long, taken in one day at a prometric site (where most standardized tests are taken) and is I believe 280 questions (supposedly, each section is up to 40 questions but you can have less than this because some may bee experimental and thrown out). That means you have about one minute and 30 seconds per question haha. I don't know if you think this is a lot of time or not but that's not the point. For us, this was the most nerve wrecking exam just because we've never had to take an exam like this and also all the pressure that revolves around this test (being the determining factor of what you can and can't do in terms of your career choice).

Step 2 CK

Step 2 CK is the next hurdle to conquer. This test is taken after your third year. Usually after which you did all of your “required” clinical rotations which include internal medicine, family medicine, pediatrics, psychiatry, surgery and OB-gyn. I hope I’m not missing anything. So this exam, most of us will say is easier. Not sure if that's because we’ve learned how to study or if it’s due to it not being our first rodeo or genuinely maybe it is just an easier exam. Either way this exam is also around 9 hours, 318 maximum number of questions divided into 60 minute blocks with 40 questions per block.

So these first two tests basically determine where you go for residency. The first one focuses on a bunch of tertiary questions (the molecular or conceptual basis of things... I guess you can say) and the second one is how you can apply it to the clinical or real-life setting.

Step 2 CS

On top of this you take a Step 2 CS exam which is basically like a mock history and physical you do with a bunch of fake patients and then write a sample note on a computer. Basically, bring out your acting skills for this. You have 12 patient encounters and the total time is about 8 hours. It’s timed so you have 25 minutes to do the interview, physical exam, and to type up your note with differentials. The breakdown is 15 minutes for the encounter and 10 minutes for the patient note. This one is pass or fail whereas, the other two the score REALLY mattered. Used to I guess... This exam is also viewed as a proficiency exam because it has been a thing that foreign medical graduates have struggled with this one.

Step 3

Finally, you have the Step 3 exam which most people take in residency. It has a question component and then like an online medical "SIMS" portion where they give you a case and you have to answer what you will do next (order a test, give a prescription, etc.). This second portion goes through various prompts and guides you kind of, if you’re doing something for your patient or not. BEWARE it can end abruptly but that likely means you’re doing something right (I had a scare with this which is why I thought it would be good to mention it).

This test is a two day test that you can take back to back (which is what I did) or up to two weeks apart. Day one there are 233 multiple choice questions divided into 6 blocks (an hour per block) with 38-40 questions per block. This day is typically 7 hours. Day 2 on the other hand, is about 9 hours, 180 questions broken into 6 blocks of 30 questions each with about 45 minutes per block and 13 case simulations (aka CCS cases) with a maximum of 10-20 minutes of time depending on the case.

This one is more so one you take during residency and does not really matter on the score although some people will say the scores do matter for certain fellowships. My suggestion, is to take this exam before residency. Why? Because if you have the time utilize it wisely. You don't want to sit there planning around your schedule to find study time during residency. It will help to have the clinical background for the CCS portion but not really for the multiple choice component because if you're in a particular specialty you likely forgot about the other ones lol.

Now back to the matter at hand. Every year they make changes to these exams by either changing the number of questions or adding a section that they will talk about. For example, for this year (2020) they will add additional questions to the Step 1 exam that deal with communication skills. For the Step 2 exam they will add questions regarding patient safety, ethics, professionalism and systems-based practice. For these little changes nobody really cares or gets worked up about but the big ones like what we are about to delve in further is a HUGE deal.

So what are the NEW BIG changes?!

  1. The Step 1 exam (the one we hated the most and worked so hard to get through) is becoming a pass or fail exam. No more scoring system.

  2. The number of attempts on taking these exams will go from six to four

  3. You can’t sit for Step 2 without passing Step 1 (which for us at least was always a rule)

The big one is obviously number one so that’s what we will focus on. This policy is going to take effect at the earliest in January of 2022. Step 2 CK and Step 3 will still have the 3 digit numeric score.. For now. The other explanations regarding what went into this decision or how it will impact everyone were really vague so that's why we came up with some of our questions and I’m sure some of yours as well:

Question One

What does this mean?

Well we don’t know. There’s going to be a lot of speculation about this for some time and we will have to see how this affects the applicants that end up going through this process.

Question Two

Will it be harder to pass the USMLE exam in general?

Why we ask this is because we know people from all walks of life. So some have struggled to get through this exam and either didn't pass or barely passed leading them to either not getting a residency at all or not the residency of their choice. Not to mention all the debt they are in now because of this... So this change can work both ways. If you play Devil's advocate yes from one standpoint it will be nice to have more people making it through, from another standpoint we all know that one person we were all like is this person really going to take care of my grandma one day?! Yes, I know it's sad to say but some people go into the field for the wrong reasons. Just like any other field. This is an important factor and needs to be considered. If the exam becomes harder versus easier these thoughts may lurk in your mind but really.. WE WANT ANSWERS!

Question Three

Will this mean more specialties will become available for people who can’t get those CRAZY high scores? You know what we mean, will dermatology now be an option for anybody?

That wouldn’t be right from one standpoint and amazing from another. Again if we play both sides maybe that internal medicine doc could've been the plastic surgeon he or she wanted to be. But what does he or she do now? Is it fair that the new graduates may have that opportunity? A question within a question here but you know it's warranted.

Question Four

How will this affect foreign grads?

Both US IMGs and FMGs leveraged their step scores to show that they are as competitive compared to their AMG counterparts. Will this open more doors or close them? We really won’t know till these people go through the match that year. Also, this will likely be adapted as we move along.

Question 5

How will this impact medicine in general and, also impact those who worked so hard to get to where they are or chose another specialty?

Kind of going off of Question 3, there is definitely going to be some animosity because as foreign grads certain specialties were a no go unless you got a 270 so how does that work now that this is an option. Can't wait to see what this turns into.

Question 6

How will they make their decision on who to take or not to take to a specific residency program and really why is this change occurring in the first place?

The logic is to take emphasis off just the SCORES and generating better overall well-being in medicine. I’m sure you heard about physician suicides and burnout which trickles to and fro the attendings as well as, the medical students. But, how will this affect the future as well as, the past. Is this really a feasible thing? The reason we ask all of these questions is because when you apply for residency they have some basic information about you which includes your scores, your picture, geographical location, etc. It will be interesting to see what transpires now.

Anyways lots of things to learn when it comes to this so we just have to see how it goes. Let's give USMLE, FSMB, NBME and whoever else is a part of this some time to provide us with more information but also keep in mind whenever that match year rolls around that’s when we will really begin to see what impact this has.

Brace yourselves because as you know … that’s one secret they’ll never tell... you know you love me.


Gossip Girl

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