The cost(s) of the USMLEs

“One number seems to nullify years of study, research, leadership and service.”

The last post covered the purpose and validity of the USMLE exam, highlighting limitations in its current use as a screening tool for the residency selection process.  In this post, I’ll briefly cover some of the potential harms in continuing to use the examination for this purpose, largely based on this excellent review article.

Cost ($). The mean medical student spends upwards of $2,000 preparing for and taking Step 1 of the USMLE, often paid for by ever increasing student loans.  The cumulative cost – simply for registering – for Step 1, Step 2 CK and CS, and Step 3 is $3,485.  For a foreign medical graduate, the cost is $4,490 (for the same tests).

This does not include any travel or test preparation materials or classes, and currently, the test prep industry is quite solvent. An average student will purchase at least 3-4 test prep resources and 3 practice exams prior to taking Step 1.

Teaching to (or learning to) the test.  Given the known importance of USMLE scores, the preclinical curriculum is influenced by the test, and studies demonstrate that students preferentially prepare for Step 1 at the expense of other aspects of their preclinical curriculum.    Given the largely isolated nature of USMLE test preparation, social and collaborative learning may be de-emphasized.  Important aspects of medical school training such as professionalism, interpersonal skills, and critical and innovative thinking may potentially be sacrificed.  Clearly medical school curriculum is outside my wheelhouse, but I’m not the only one concerned by this prioritization. A study this year authored by medical students argued that test prep materials are “the de facto national curriculum of preclinical medical education.”

Workforce Diversity. Data demonstrates the USMLE (like many standardized tests) may be biased against ethnic and racial minorities, and use of these scores as a metric for screening resident applicants may therefore further cement these disparities.  A 2019  study authored by the National Board of Medical Examiners found that female students scored 5.9 points lower on Step 1 compared to white males, and Asian, Hispanic and Black testers scored 4.5, 12.1 and 16.6 points lower than white males, respectively.  Given known differences in access, outcomes and trust in the healthcare system amongst different minority populations, it is imperative that the physician workforce reflect the diversity of the populations they serve.  The current makeup of enrolled medical students nationwide falls short of national demographic data, and this divide is even greater in competitive residency specialties.

Well-Being.  It goes without saying, but a single test that can determine one’s career after such a substantial investment of time and effort leading up to it is going to be anxiety provoking.  Perhaps relatedly, the mean Step 1 score has been steadily rising.  In 1992, the mean score was 200, which would fall at the 9^th percentile today. For ophthalmology residency, the mean matched Step 1 score this past year was 244, while it was 235 ten years ago. The mean unmatched score this year was 231 (the mean match score for all applicants in the National Residency Matching Program is 233), while the mean in 2009 was 212.  This test-taking arms race has been shown to lead to isolation, anxiety and depression.  Given medical students (and all healthcare professionals) are at an increased risk of burnout, depression and suicidal ideation, we should be focusing on efforts that mitigate rather than exacerbate the situation.

With all the preceding points from these past two posts in mind, the Federation of State Medical Boards and the National Board of Medical Examiners have released joint recommendations that the USMLEs move to a pass-fail scoring system.  This suggestion will be further considered in the final post on this topic.

Thanks for reading!