The COVID-19 pandemic has put a hiatus on institutions we didn’t think were a hiatus, allowing us to ask critical questions about their relevance and necessity.
One of these institutions is the United States Medical Licensing Examination (USMLE). During COVID-19, Prometric sites shut down, delaying exams for many. In response to public outcry, Step 2 CS has disappeared. Prior to COVID-19, there had been calls to reform expensive licensing exams, which made Stage 1 a pass / fail exam.
Now is the time to consider the necessity and relevance of step 3.
Stage 3, as the name suggests, is the third in a series of USMLE board exams before taking a specialist board exam (e.g. pediatrics, internal medicine, etc.). Stage 3 takes place over 2 days, i.e. 7 hours of testing on the first day and 9 hours on the second day.
According to the USMLE website, the exam content “reflects a model of data-driven general practitioner medical practice in the United States. Test items and cases reflect clinical situations that a general practitioner, again undifferentiated, could encounter in the context of a specific setting. “
A “general practitioner” and “undifferentiated” doctor simply no longer describes doctors in their first year of medical training. At this point, doctors have become much more specialized than when this test was introduced.
For example, I am a pediatric resident. During my internship year, I cared for children and their families with complex disorders, many of which are only seen in pediatrics. By studying for this test, I relearned the management of the acute exacerbation of chronic obstructive pulmonary disease and other disease processes that are simply of minimal clinical relevance to pediatrics and my patients.
Of course, as doctors we should have basic knowledge of general medicine. Our general knowledge of medicine has already been tested in step 2, an exam taken in the final year of medical school. Many programs suggest taking the test as early as possible in the internship year, because for most residents, the longer the time spent in residence, the further the doctor is away from the material in step 3.
What I found most shocking during my 16 hours of testing was perhaps the blatant racist medicine that USMLE is testing and still applying. For example, several questions asked what was the most important risk factor / disease factor for a disease process. The “correct” answer was often race.
Examining the COVID-19 pandemic can help illustrate why this is problematic and racist. We understand that a risk factor for mortality from COVID-19 is identifying with the African American race, not because of a biological explanation, but because the social inequalities created by systemic racism make it so. true. The structure of a Step 3 question would distill this complex problem into a multiple choice question that a risk factor for COVID-19 mortality is African American race, without acknowledging that social inequalities make this statistic true. . This leaves learners and candidates with no choice but to choose an answer that involves a biological race construction, which is incorrect and perpetuates racist beliefs.
Having questions with “correct” answers like these takes medicine further away from the anti-racist profession than it needs to be, and harms both trainees and patients.
Additionally, Stage 3 is in addition to the growing entities of residential burnout and depression. Stage 3 is one of those residency factors that adds to resident burnout. It seems like a meaningless hoop to jump through – it takes away what people get from the sense of residence, adds to financial debt, and adds unnecessary stress.
This time and energy could be spent learning more about a patient’s pathological process, learning more about common clinical issues in pediatrics. Instead, I spent months relearning medical school knowledge that is no longer relevant to my patient care. The time spent studying for the exam can vary, although it is conventional wisdom to take about 2 months studying for the exam.
During the 2 days spent taking the exam, residents often need to find cover, or the 2 days will be half of the 4 days that the Accreditation Council for Graduate Medical Education tells residents to have free to their clinical tasks per month.
Financially, the cost of taking and studying for the exam equates to about a full paycheck of a resident’s salary. The price for Stage 3 is $ 895, and the price for common Stage 3 preparation materials, such as a UWorld question bank, costs $ 495.70, for a total of $ 1,390 – roughly a residence paycheck or a month’s rent.
Of course, most programs reimburse the cost of step 3. However, these “education” funds might instead help educate future physicians on things relevant to raising their knowledge in the area of their choice, such as podcasts and educational conferences.
Although at some point Step 3 may have helped strengthen the knowledge of the “undifferentiated physician,” it has now become a redundant and harmful entity on the path to medical education. With limited educational value, enormous time and financial burden, now is the time for a coordinated outcry towards Stage 3.
Medical students, residents and our patients deserve better than to pay in a system that does not value their time, relationships and advancement of knowledge.
Madeline Wozniak, MD, is a pediatric resident in the Seattle area.
This message appeared on Kevin®.