Perspective Why Not Wait? Eight Institutions Share Their Experiences Moving United States Medical Licensing Examination Step 1 After Core Clinical Clerkships Michelle Daniel, MD, MHPE, Amy Fleming, MD, MHPE, Colleen O’Conner Grochowski, PhD, Vicky Harnik, PhD, Sibel Klimstra, MD, Gail Morrison, MD, Arnyce Pock, MD, Michael L. Schwartz, PhD, and Sally Santen, MD, PhD Abstract The majority of medical students science learning connected to clinical their career choice if Step 1 scores are complete the United States Medical care and to better prepare students for not competitive in the specialty area Licensing Examination Step 1 after their the increasingly clinical focus of Step 1. of their choice. The score increases foundational sciences; however, there Each school provides key features of the should be interpreted with caution: are compelling reasons to examine preclerkship and clinical curricula and These schools may not be representative this practice. This article provides the details concerning taking Steps 1 and with regard to mean Step 1 scores and perspectives of eight MD-granting 2, to allow other schools contemplating failure rates. Other aspects of curricular medical schools that have moved Step change to understand the landscape. transformation and rising national Step 1 after the core clerkships, describing Most schools report an increase in 1 scores confound the data. Although their rationale, logistics of the change, aggregate Step 1 scores after the the optimal timing of Step 1 has yet to outcomes, and lessons learned. The change. Despite early positive outcomes, be determined, this article summarizes primary reasons these institutions cite there may be unintended consequences the perspectives of eight schools that for moving Step 1 after clerkships are to to later scheduling of Step 1, including changed Step 1 timing, filling a gap in foster more enduring and integrated basic relatively late student reevaluations of the literature on this important topic. Historically, students take the United of Step 1 to follow completion of the from years 1, 3, and 4 on sample Step 1 States Medical Licensing Examination core clerkships. Other schools are still questions. Their results demonstrated (USMLE) Step 1 before clerkships; contemplating where to best place Step that students with more clinical however, there are compelling reasons 1 to optimize student learning and experience performed better, suggesting to examine this practice. According to performance. that moving Step 1 after clerkships might data published by the Association of raise scores. Unfortunately, the study was American Medical Colleges in 2015–2016, limited by a small sample size and the 130/142 of accredited medical schools Context use of practice questions rather than the have their students take Step 1 of the Research on the timing of Step 2 Clinical actual USMLE exam. USMLE during their first or second year Knowledge (CK) suggests that student of medical school.1 This typically occurs performance declines over time after At this time, consensus on the impact following completion of the basic science completion of the core clerkships.4 of moving Step 1 after the core clinical curricula, after a dedicated study period A similar decline in scores might be years on student outcomes is lacking. In of variable duration. Passing Step 1 is predicted for Step 1 as the distance the absence of empirical data, schools often a requirement for advancement to from completing the foundational are looking to peer institutions for clinical clerkships.2 A number of schools sciences increases. Ling et al5 found a guidance to aid them in decision making are undergoing curricular revisions 6.4% decrease in overall performance and advocating to their administrations. that shorten the traditional two-year on USMLE Step 1 basic science items Numerous queries on the optimal timing preclerkship curricula to 18 months or administered in unscored sections of of Step 1 are appearing on medical even 1 year,3 and an increasing number USMLE Step 2 CK. The magnitude of education listservs,9 and there is a need are altering or have altered the timing the decline varied by discipline, with for a collated resource of institutions the steepest occurring in biochemistry that have made the change. This article Please see the end of this article for information (17.5%). This and other studies by the offers the perspective of eight medical about the authors. National Board of Medical Examiners schools: Duke University School of Correspondence should be addressed to Michelle (NBME) examining basic science Medicine, Perelman School of Medicine Daniel, University of Michigan Medical School, 6123 knowledge retention6,7 raise the concern at University of Pennsylvania, New Taubman Health Sciences Library, 1135 Catherine St., that students may not perform as well on York University School of Medicine, SPC 5726, Ann Arbor, MI 48109; telephone: (401) 525-0251; e-mail: [email protected]. Step 1 questions after clerkships. Uniformed Services University of the Health Sciences, Vanderbilt University Acad Med. XXXX;XX:00–00. Other studies suggest that Step 1 School of Medicine, Weill Cornell First published online performance could improve with clinical Medical College, Yale University School doi: 10.1097/ACM.0000000000001714 8 Copyright © 2017 by the Association of American exposure. Petrusa et al investigated of Medicine, and University of Michigan Medical Colleges the performance of medical students Medical School. These schools have either Academic Medicine, Vol. XX, No. X / XX XXXX 1 Copyright © by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited. Perspective realigned or are in the process of moving allowed them to read and analyze the Basic Science Examination (CBSE) Step 1 to after completion of the core clinical vignettes quickly and with greater as a summative experience similar to clinical clerkships. Here we discuss our comprehension. Students presumably use Step 1 to help students consolidate rationale, the logistics, outcomes, and pattern recognition and can “think fast,” knowledge before entering clerkships. lessons learned, to begin to address the rather than using slower, more analytical These preclerkship curricular features are gap in the literature on this important thinking during the exam.12 Additionally, detailed for each institution in Table 1. topic. students have commented that practice with the NBME clinical subject “shelf” We have also identified important exams facilitates more effective and features of the clinical curricula to Rationale efficient progress through the clinical consider, including the total duration The primary reasons our institutions stem questions on Step 1. of the core clinical clerkships, grading cite for moving Step 1 after the core policies, and whether or not schools use clerkships are to help improve retention the NBME clinical subject examinations. of foundational science, to promote Logistics These core clinical curricular features more integrated basic science learning in There are a number of logistical issues are also detailed in Table 1. Notably, clinical contexts, and to better prepare associated with changing the timing in addition to traditional clerkship students for the increasingly clinical focus of Step 1 that span the curricular didactics, our schools all use a variety of Step 1. continuum. For peer institutions to best of pedagogical strategies for deliberate learn from our institutional examples, science integration in the clinical setting, At our institutions, we see a concern they must be able to determine whether including linkage of specific clerkships amongst faculty that students prepare our practices are applicable to their with basic science disciplines (i.e., intensively for Step 1, pass the exam, curricula. Table 1 outlines the logistical surgery and anatomy), special days and promptly forget their basic science. details surrounding Step 1 at each of dedicated to deep science dives, weeklong Research in medical education shows our eight schools, detailing timing and intersessions, four-week selectives, and that students retain two-thirds to curricular features of import. Appendix the deliberate encouragement of self- three-fourths of knowledge at one year, 1 offers the logistical details of additional directed, patient-based scientific inquiry. and slightly below 50% at two years schools making this change, and there Several institutions have invested in in the absence of deliberate retention are likely others. Duke University and question banks, and two schools use and retrieval practices.10 We believe the University of Pennsylvania have the learning platforms to help provide the that students cannot afford to forget longest experience with placing Step 1 testing effect of spaced repetition of basic significant portions of their scientific after the core clinical clerkships, with 24 science content during the clinical years. foundations. We want their foundational years and 19 years, respectively. The other We highlight these curricular features knowledge to be enduring, to enable schools made the change more recently as because we believe they help foster students to delve into the biochemical part of their curriculum transformations. retention and retrieval of basic science and molecular basis of disease when knowledge, and drive the integration working with patients. As part of Based on our collective experiences to of basic and clinical science learning,