Usmle

Every year, thousands of medical students prepare for one of a set of licensing exams that are largely considered to be some of the hardest standardized tests in any profession – the USMLE. There are actually four USMLE exams that are taken over a period of two or three years – typically in the middle and later years of medical school, or soon after graduating. But do the USMLE exams test what doctors need to know? In my not-so-humble opinion – no, not really.

The USMLE exams are named Step 1, Step 2CK, Step 2CS, and Step 3. Let’s look at each and then put it all together.
Step 1 is a review of the basic sciences that are learned in the first two years of medical school. Topics include basic microbiology, anatomy, histology, pharmacology, pathology, biochemistry, and embryology, with a smattering of smaller topics thrown in. There is very little “make a diagnosis or decide on a treatment” type material in Step 1, and that’s fine. They need to know that a medical student as at least a basic understanding of the fundamental science principles that form the basis of modern medicine. The test takes an entire day, and involves over 350 multiple choice questions (because medicine is a really “multiple choice” profession, right? geesh).

Step 1 must be taken and passed before a medical student can progress to third year, where the student is first sent to the hospital to see real patients. Ironically, there is little in the way of patient care and management that is tested on Step 1. A student can score well by mastering the nuances of the Kreb’s citric acid cycle (an important biochemical pathway), and not have the slightest idea how to interview a patient for interact with a sick person. The individual medical school likely has some internal exams for those things, but it’s not part of the USMLE at this point.

Slightly before or near graduation, the student will take Step 2. Step 2 is actually two different exams that are taken on different days. The Step 2CK exam (CK stands for Clinical Knowledge) is a full day multiple choice exam. It focuses on making medical diagnoses, deciding on treatment plans, and a variety of other clinically relevant topics. You have to know a bit about everything, from emergency surgery, to psychiatry, to what to do for high cholesterol. They can, and do, ask just about anything.

The Step 2CK exam is a moderately bad way to text medical knowledge. The scenarios presented in the questions are almost always over-simplified to the point of absurdity. They ask you to make black and white decisions based on limited information. In the real world, with real patients, the decision making process is almost totally different than what it is on the USMLE Step 2CK. You could make an argument that it’s just a test to see if you have a clue what you’re doing, but I don’t buy that – the information is just not that realistic. Medicine is not a multiple choice profession.

The second part of Step 2 is the CS exam, standing for Clinical Skills. This is the best of the four USMLE exams, at least for determining how a person will react with a real patient. In this exam, a student is presented with a series of trained actors who are pretending to have a medical issue that you are there to help them with.

The actors are given very precise training by doctors. You see them in rooms that are set up to be identical to a typical doctors exam room. The patients are even in gowns. You are scored on everything that takes place the moment you enter the room – including whether you shake hands and introduce yourself.

You have about 10 minutes to interview the patient, and do whatever physical exam you think is necessary. Some tests, like pelvic exams, are not allowed. After the interview and exam, you leave the room to write up notes, just like a real doctor would. You are graded on the notes as well. This exam is by far the best predictor of your ability to function as a new doctor in a clinic or hospital. If you totally lack the ability to speak and talk to a person, you’ll fail.

The last of the USMLE exams is Step 3. This exam is similar to the multiple choice Step 2CK exam, with a few nuances. It’s taken after graduation, before the end of the first year of residency. It’s as pointless as Step 2CK – actually, more so because at this point, you’re actually working as a doctor, under the supervision of senior doctors.

The USMLE exams are, in general, not a particularly good way to test medical students. They miss many of the important elements of being a good doctor, putting far too much focus on obscure and seemingly random bits of medical science trivia. Sure, much of that is not totally irrelevant, but it’s over emphasized on the USMLE. Unfortunately, with the volume of students who taken these exams every year, there is no efficient alternative for ensuring a medical student knows now only the science of medicine, but the personal interactions that are needed to be a good doctor.