USMLE Step 1, a curse or a blessing?

The USMLE Step 1 tests whether students understand and apply concepts and principle of basic sciences to the practice of medicine. In contrast to what most of international medical students are taught (especially in the third world), this test never test isolated facts that many students tend to memorize. For such students (I was one of them), the test can be a curse.

It’s a nightmare for many students, especially, those who go to medical schools, which don’t prepare them for the test, don’t integrate basic sciences to clinical practice or don’t do both. Students with high failure rate in the USMLE Step 1 indicate and reflect poor teaching technique in basic science in the school they attended. Schools and academic staffs should be accountable for low percent of students passing USMLE 1.

A study was published in the Advances in Medical Education and Practice, showed that releasing USMLE Step 1 medical schools’ scores increases the accountability and the national standards in these schools. Eltorai ¹.

Although, USMLE Step 1 for some is a blessing, especially those who score high. It opens many doors in choosing their selected residency training programs, indicates how dedicated the candidate for research and science and increases the chances for the newly graduate physicians to get accepted in some jobs (for example in Saudi Arabia.)

High score in USMLE showed strong correlation with passing the in-service exam during the residency training (this is good indicators for many program directors) and for the final board. Kay, Jackson, Frank ².

Most American Medical Graduates have from 4-6 weeks to prepare for USMLE Step 1. Some students attend commercial coaching courses, but a study was done on 468 students showed those who attended commercial courses, score no higher than those who self studied (P-value<0.05). Werner, Bull ³.

But, when it comes to International Medical Graduates (IMG), the story is totally different. I have seen more International Medical Graduates fail the test or score lower, especially in Step 1. All the previous above studies can’t be applied to IMGs, as the population is different than the USA students.

     I summarize why IMGs score lower or fail USMLE Step 1:

1.    Taking a test different than your tongue language, would definitely affects some exam takers.

2.    Studying Basic Science during or just after studying English Language during the beginning of University study.

3.    Poor teaching techniques in Medical Schools and lack of awareness among medical students about the importance of the USMLE Step 1. For instance, I personally didn’t know about the test until I reached my third year in medical school. A friend of mine knew about the test in his internship. The later students know about the test, the more difficult it’s for them to have the time to prepare.

4.    Comparing to their counterpart IMGs, American Medical Graduates take Step 1 just after few weeks of finishing the basic science courses. While many IMGs take the test after they graduated from medical school or even after practicing for few years. Thus, for many, trying to rehabilitate them with commercial courses (like Kaplan, Falcon and etc.) will not help, because those courses are meant to coach and brush up your knowledge, not to teach basic sciences from scratch.

5.    Many IMGs (even some AMGs) underestimate the importance of practicing cases. Since the beginning of USMLE, the exam evolved greatly to be more clinically oriented. That’s why even Step 1 has more than half of the questions start with clinical description. All these efforts to mimic the real life physician-patient encounter and catch students whom memorize isolated facts.

6.    Don’t have coach/advisor or don’t ask reliable students who already took the test before them.

7.    Rush to take the exam (You can’t retake the exam to make up for low score, unless you fail, which is pernicious picture).

8.    Take too long to prepare for it. Usually taking too long time leads to burnout or erodes your self esteem

In conclusion, USMLE Step 1 is not an easy test, but still doable. The difficulty of the test becomes apparent when students underestimate the time needed for preparation, don’t understand how the test evaluates students or don’t practice enough to apply basic science principles and concepts on multiple-choice questions. Commercial courses are to coach and not to rehabilitate students with dusty ill-founded background on basic sciences. Thus, think critically before you invest your money and time.

references

1.    Eltorai AE. Publishing medical schools' USMLE Step 1 scores: increase preclinical education accountability and national standards. Advances in medical education and practice. 2013;4:135-136.

2.    Kay C, Jackson JL, Frank M. The Relationship Between Internal Medicine Residency Graduate Performance on the ABIM Certifying Examination, Yearly In-Service Training Examinations, and the USMLE Step 1 Examination. Academic medicine : journal of the Association of American Medical Colleges. Jan 2015;90(1):100-104.

3.    Werner LS, Bull BS. The effect of three commercial coaching courses on Step One USMLE performance. Medical education. Jun 2003;37(6):527-531.