Step 1 Is Going Pass/Fail, And Here’s What That Means

All right guys, what do I think of this new news? That Step 1 of the National Medical Boards, this is the USMLE, who knows what the hell it is? I had to take it, medical students have to take it.

It’s that Step 1, that the score of which determines your future, at least according to legend and in fact reality, if you want to do a super specialty like radiology, dermatology, plastic surgery, orthopedics, these kinds of things are very competitive and so the score on this test, by the way it’s a multiple choice test, hours, you study for months, if not years. Stress, pressure, hair loss. I cracked a tooth studying for this thing ’cause I was grinding my teeth at night.

And I was at UCSF in the ’90s and this test, it was so important that, pretty much, the entire curriculum at one point was revolving around what to do and, in fact, I used a book called ‘First Aid for the Boards’ which, I eventually ended up meeting the authors, Vikas and Tao, and working with them to write questions. It’s a whole industry preparing medical students for this freaking test.

And they just announced that they’re gonna change it from a score out of 265, or 275 or whatever it is to a pass fail. Wo-hoo! So, people have asked me, “What do you think about this? “Yay, or nay or what?” And here is the actual nuanced answer. So there is a huge part of me that’s, like, “Screw this test.” All it does is waste hundreds of hours and months of time of people, students who are in the prime of their academic and creative lives. They’re in their twenties, or early thirties, they have so much energy and we suck all of it out for a test that has absolutely nothing to do with clinical medicine.

No patient you touch is gonna have anything to do with that test and I’ll tell you how I know this, because I got a 99th percentile score on that test. I studied by playing video games with my friends and going through mnemonics, going through First Aid, doing all that stuff, stressing, losing hair, look, and I got a great score. The third year came around, you take it some time after the second year, the third year came around, I did, when you’re supposed to actually see patients, I had no effing idea what I was doing.

I’ve never been so depressed and scared as going on the wards and realizing, “I have no clue what I’m doing”. That test has nothing to do with reality. But what do we use it for? We use it as a bar that you have to jump over so that you can get to the best residency program, or the best specialty, or whatever it is. And that’s what it’s used for.

So, make it pass fail, right? That’ll fix the problem because now we don’t stress people out. They just have to do well enough to pass this basic bar of understanding, knowing that they are diligent enough to do that and that’s fine. Okay, great. Seems to make perfect sense. I say, actually, delete the whole test, it’s a total waste of time, but I’m in the minority. Here’s the push back. What happens if you’re in a osteopathic medical school? Or you’re at a foreign medical school? Or you’re at a medical school in Caribbean? And you, maybe you screwed up in college, maybe you’re not the best test-taker, maybe you weren’t super diligent. Maybe you were a real screw-up, and you’ve got your act together, and you really wanted to be a doctor bad, and you ended up going to one of these other schools?

And again, there’s a whole spectrum of people that are amazing clinicians that come out of these schools. They distinguish themselves from the mainstream, upper tier medical schools by their board scores. If you take that away, now you have to, kind of, figure out, “Well, okay, how are they “going to distinguish themselves?”. And this is where we have to rethink all of medical education, ’cause why should we use a stupid, meaningless test to play games with people’s futures? We oughta be assessing medical students differently.

Looking at their humanistic attributes, taking the time they would’ve spend studying for this test and saying “Hey, do something amazing in the world. “Go to Africa and do something crazy. “Cure a disease. “Go do research. “Write a book. “Make an YouTube channel and educate people. “Do something creative, and also engaging “and meaningful in the world, “and show us who you are.” And we can look at that and go, “You know what, you’d make an amazing “orthopedic surgeon or whatever”. And maybe that’s how we oughta be doing it. So we’re asking the wrong questions.

All of medical education is fundamentally screwed up anyways because we, okay, hold on. I did a speech in 1999 at the end of UCSF Medical School. Go watch it if you haven’t seen it. I said exactly what I meant in that speech, which is almost everything we did seemed absolutely ridiculous, had nothing to do with patients, was demoralizing, depressing and broken, and that was 1999. Do you think it’s gotten better? It’s gotten worse.

We’re more about teaching to the test now than we ever were. We’re more about reducing what are gonna be our future healers to automatons. And then you have the AMA talking about, “Should we be teaching medical students “how to use the EHR so they can be more efficient?”. What are we doing? It’s as broken as it’s ever been. The whole thing needs to be fixed and we gotta start just by getting rid of Step 1. Let’s be honest with ourself.

It doesn’t help anybody. If you wanna screen doctors for diligence, you’re already screening them to get in the medical school. We oughta be then screening for who are these beautiful, creative, passionate people that are gonna contribute to their fellow human beings, humanity and society in general. And Step 1, Step 2 and Step 3 of the USMLE National Boards is not doing that. And I’m sorry if that’s gonna piss off people in the Caribbean, or the osteopathic schools who are using this. We need better ways to value your contributions than a bullshit test, all right?

So, here’s the call to action. We oughta be lobbying and creatively thinking about better ways to train, screen and promote the best medical students who are gonna make the best doctors. Almost never is that due to a very high test score, all right? And you’re looking at someone who got a very high test score, who’s marginally, I mean, I’m barely staying out of prison, all right? So, use that as a bar. That being said, all joking aside, this is serious, serious topic.

Talk to your med school administrators. We may need to talk to the legislatures. This may be a bigger movement, all right guys? Share this video. Like this video. Become a Supporter. And don’t, if you’re studying for USMLE right now, put down that book, smoke a joint, drink something, go out and see some absent friends, swipe left, whatever it takes, be a Goddamn human being, all right? ‘Cause you’re gonna be a better doctor for it. All right, we out.