The Changing Landscape of Pre-clinical Medical Education

In mid-February, the National Board of Medical Examiners (NBME) and Federation of State Medical Boards (FSMB) announced that the United States Medical Licensing Examination (USMLE) Step 1 scoring would be changed to pass/fail as early as 2022.1 Many rejoiced about the potential for residency programs to emphasize other parts of applications rather than a test that does not evaluate the most clinically-relevant medical knowledge, while others expressed concern about the logistics of the decision and whether it would truly have its intended effect. Regardless of where you stand on the issue, it is important to recognize the implication this has regarding how preclinical education may change in upcoming years in medical schools across the country.

Separate from the debate of Step 1 scoring, preclinical medical education has been evolving quickly, particularly over the last decade. In 2018, 108 medical schools used pass/fail grading. This is up from 87 in 2014, while only 24 schools still used letter or numerical grades.2 This trend was driven largely by a call to improve student wellness and was strongly supported by the American Medical Association (AMA) who published an official resolution in 2012.3 Other reasons cited for the proposed change were increased student collaboration, more time for extracurricular activities, and lack of evidence to show negative effects on Step 1 and 2 scores.

The migration to pass/fail, in conjunction with increased use of technology, has already impacted how schools and outside stakeholders approach preclinical education. Many schools have reduced attendance requirements, allowing students to study on their own schedules and using their own techniques. Lectures are often recorded, allowing students to pause or speed up the lectures at their discretion. Concurrently, the emphasis on Step 1 has resulted in the standardization of resources across the country. Almost all students are familiar with First Aid, SketchyMedical, Pathoma, and a few other core Step 1 resources. Sketchy and Pathoma, specifically, consist of videos to convey the important pathology, pharmacology, and microbiology concepts necessary for Step 1. This raises the question about the utility of in-class lectures, especially ones that do not “teach to the test.” If students are by-and-large relying on the same five-or-so resources for their preclinical education, while also skipping the lectures provided by their schools, what is the value of the education provided by their schools (and at a much greater cost)?

This is not to say schools should discard their curricula in favor of standardized outlines and recorded videos. On the contrary, changing Step 1 to pass/fail can help facilitate medical schools regaining control of preclinical medical education. First, however, several questions must be addressed:

• What can schools offer that standardized Step 1 resources and recorded lectures do not?
• If Step 1 does not optimally cover material that makes for good doctors (cited by those who proposed changing the test to pass/fail), which material should schools focus on?
• How can the curriculum be transformed so as to maximize learner engagement, especially when traditional medical school lectures have, arguably, failed at this?

Already medical schools have begun to address some of these questions. One way this has been done is by introducing problem-based learning (PBL). PBL encourages learners, often in small groups, to become more actively involved in learning and collaborate with one another, often while applying basic science concepts to more clinically relevant material.4 Though this style of learning certainly does not fit all learning styles, it is a good way to encourage active learning and is reflective of how material is learned during the clinical years, thus offering a good introduction to an important method for learning medicine.

Another potential way to adapt preclinical education to the learning styles of the current generation is the incorporation of free open access medical education (FOAM). FOAM consists of visual and auditory resources such as podcasts, blogs, and videos that allow for knowledge sharing, often with more up-to-date information than textbooks and in-person lectures due to the quicker distribution of online resources.5 Certainly FOAM presents its own issues (particularly how to assess which resources can be trusted), but it is also an example of how to adapt medical education to millennial learners. FOAM has been embraced by emergency medicine, with other specialties following suit, and has been successfully incorporated into many residency programs’ curriculum, so the possibility of expanding FOAM to the preclinical years as a supplement to other educational tools is not far-fetched.

While these issues exist separately from Step 1, they are now more relevant than ever, as making Step 1 pass/fail eliminates the need to emphasize only the material on the test and only in a way that drives students to aim for high Step scores at the expense of other important lessons. Regardless of how you feel about Step 1 scoring, the impact on preclinical education cannot be ignored. In light of this change, medical schools should start re-evaluating their preclinical curricula now to prepare for a world without Step 1 scores.

References:

1. United States Medical Licensing Exam. Change to pass/fail score reporting for Step 1. https://www.usmle.org/incus/#decision. Accessed February 15, 2020.

2. Murphy B. How do medical schools use pass-fail grading? American Medical Association. https://www.ama-assn.org/residents-students/preparing-medical-school/how-do-medical-schools-use-pass-fail-grading. Published January 9, 2020. Accessed February 15, 2020.

3. American Medical Association. Supporting two-interval grading systems of medical education H295.866. Published 2012. Last Modified 2019.

4. Chang B. Problem-based learning in medical school: A student’s perspective. Ann Med Surg (Lond). 2016 Dec;12: 88-9.

5. Otterness K. Incorporating FOAM into medical student and resident education. Clin Exp Emerg Med. 2017 Jun; 4(2): 119-20.