The COVID-19 pandemic put a pause on institutions that we did not think were pausable, allowing us to ask critical questions regarding their relevance and necessity. One such institution is the United States Medical Licensing Examination (USMLE). During COVID-19, Prometric sites closed, delaying exams for many. In response to public outcry, Step 2 CS has become defunct. Before COVID-19, there had been calls to reform the expensive licensing exams, which successfully made Step 1 a pass/fail exam. The time has now come to examine the need and relevance of Step 3.
Step 3, as the name implies, is the third in a series of USMLE board examinations before taking a specialized board exam (e.g., pediatrics, internal medicine, etc.). Step 3 takes place over two days, involving 7 hours of testing on the first day and 9 hours of testing on the second day. Per the USMLE website, the exam’s content “reflects a data-based model of generalist medical practice in the United States. The test items and cases reflect the clinical situations that a general, as-yet undifferentiated, physician might encounter within the context of a specific setting.”
A “general” and “undifferentiated” physician simply no longer describes physicians in their first year of medical training. At this point, physicians have become much more specialized than when this test came into existence. For example, I am a pediatric resident. During my intern year, I cared for children and their families with complex disorders, much of which is only seen in pediatrics. In studying for this test, I re-learned the management of acute exacerbation of chronic obstructive pulmonary disease and other disease processes that simply have minimal clinical relevance to pediatrics and my patients. Of course, as a physician, we should have some baseline knowledge of general medicine. Our general knowledge of medicine was already tested in Step 2, an exam taken during the final year of medical school. Many programs suggest taking the test as soon as possible intern year, as for most residents, the longer spent in a residency, the further the physician is from Step 3 material.
Perhaps what I found most shocking during my 16 hours of test-taking was the blatant racist medicine that USMLE is still testing and enforcing. For example, several questions asked what the biggest risk factor / largest morbidity factor for a disease process was. The “correct” answer frequently was race. Looking at 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 as African-American race, not because of any biological explanation, but because the social inequities created by systemic racism make this true. The structure of a Step 3 question would distill this complex issue to a multiple-choice question that a risk factor for COVID-19 mortality is African American race, without acknowledging that social inequities make this statistic true. This leaves learners and test-takers no other option than to choose an answer that implies a biological construct of race, which is incorrect and perpetuates racist beliefs. Having questions with “correct” answers like these further moves medicine away from the anti-racist profession that it needs to be, and it harms both trainees and patients.
Additionally, Step 3 adds to the growing entities of burnout and depression in residency. Step 3 is one such factor in residency that adds to resident burnout. It appears to be a meaningless hoop to jump through — it takes away from what people derive meaning from in residency, adds to financial debt, and adds to unnecessary stress.
Time and energy that could be spent learning more about a patient’s disease process, learning more about common clinic problems in pediatrics, instead I have spent months re-learning knowledge from medical school that is no longer relevant in my care of patients. The time spent studying for the exam can vary, though conventional wisdom is to take about 2 months studying for the exam. The two days spent taking the exam often residents have to find coverage, or the two days will be half of the four days that the Accreditation Council for Graduate Medical Education dictates that residents have free of clinical duties per month.
Financially, the costs incurred to take and study for the exam equate to approximately an entire paycheck of a resident’s salary. The price of Step 3 is $ 895, the price of common Step 3 preparation materials such as a UWorld question bank cost $ 495.70, totaling $ 1,390, just about a paycheck in residency or a month’s rent. Sure, most programs reimburse for the price of Step 3. However, those “education” funds could instead help educate future physicians for relevant things to elevate their knowledge of their chosen field, such as educational podcasts and conferences.
Though at one time Step 3 may have helped bolster knowledge for the “undifferentiated physician,” it has now become a redundant and harmful entity on the path of medical education. With limited educational value, enormous time, and financial burden, the time has come for a coordinated outcry towards Step 3. Medical students, residents, and our patients deserve better than paying into a system that does not value their time, connection, and advancement of knowledge.
Madeline Wozniak is a pediatrics resident.
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