Saturday, February 29, 2020

A More Holistic Approach To Finding Good Residents Or Just More Political Correctness

The recent news that the USMLE Step 1 will no longer issue a numerical score has stunned the medical community, especially all the medical students who have yet to take the test. The test takers will now only receive a pass/fail instead of the all important number that's used by residency programs everywhere to screen for acceptable candidates.

Why did the NBME, which administers the test, make this change? Their explanation is that they are trying to de-emphasize the importance of the Step 1 score so the students can concentrate on their clinical clerkships without being distracted by studying for the exam. Apparently some students are so anxious about the Step 1 that their clinical work suffered while they crammed for the test.

However there are some pretty notable flaws to this switch to pass/fail. The most obvious one is that now the emphasis will be on Step 2, since that still retains the numerical score. This comes at the even more crucial senior year when students are trying to juggle residency applications, impress their residency programs with their clinical excellence, and studying for Step 2 with its all too crucial score. I can't imagine that this change will make the students feel any less nervous about their prospects.

Then there is the conundrum residency directors now have in trying to winnow the number of applicants to their programs. Many subspecialty residencies, particularly the highly competitive ones like orthopedics, ENT, dermatology, use the Step 1 score as the first cutoff for choosing which applicants to ask for interviews. There's the absolute minimum score below which a program will not request an interview. Then there is the upper score where students will definitely be asked to come. Everybody else is in a gray zone. Because of this change to pass/fail, all applicants are now effectively in the gray area. Now admission directors will have to use soft evidence of an applicant's excellence, like research conducted or letters of recommendation.

If you've heard something similar to this before, that's because the move away from ranking students based on a number has been prominent in college undergraduate acceptance for years. There is a growing movement among colleges to do away with SAT and ACT exam scores. The University of California recently but just narrowly decided to keep these tests as part of their application requirements.

The reason colleges are removing test scores is because they have a high correlation with a student's socioeconomic status, not necessarily their ability to succeed in college. Students from high income families go to better high schools with more resources like AP classes to help them sail through the SAT. They also have more opportunities to take exam prep courses to give them a leg up on kids who can't afford those after school classes. Now many colleges emphasize a "holistic" approach to accepting high school students to college. They give students extra credit for coming from disadvantaged backgrounds and poor family situations.

However this creates its own complications. Look at the recent lawsuit against Harvard University. It's student admissions office was accused of discriminating against Asian Americans. Many of them had perfect SAT or ACT exam scores yet were denied acceptance to the school. Harvard's holistic approach to finding undergrads seemed to gloss over their high achieving test scores and instead punished them for a far more subjective "personal rating". They were considered less sociable and creative than their non-Asian American applicants.

Will this be the future of residency programs? While a large percentage of medical students are minorities, will the still mostly white residency directors judge the students on their race and perceived advantages in becoming doctors? Seems like this is just another lawsuit waiting to happen as some people are denied entrance to the most competitive programs and questions linger about why somebody got chosen over others since there are really no objective criteria anymore.

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