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Comment & Response
April 2, 2014

Basic Science Content in the USMLE Step 1

Author Affiliations
  • 1Perelman School of Medicine at the University of Pennsylvania, Philadelphia
JAMA. 2014;311(13):1358-1359. doi:10.1001/jama.2014.1177

To the Editor When discussing changes to the United States Medical Licensing Examination (USMLE) Step 1, Dr Haist and colleagues1 concluded that “many medical students prepared for Step 1 with a ‘binge and purge’ mentality; because students failed to recognize the value of the basic sciences in medical practice, many memorized information for short-term retention.”

Haist et al1 used this position as a rationale for “planned changes to emphasize basic sciences throughout [the] USMLE.” The Viewpoint neglected to consider the alternative hypothesis that students take a binge and purge mentality not because they fail to recognize the value of basic science in medicine, but because they believe the focus of Step 1 is on clinically irrelevant minutiae that have little value in patient care.

For instance, Step 1 commonly tests students on their ability to analyze various bacterial growth plates and media to deduce what species of bacteria are present. Although this skill set may have been relevant in the past, most clinicians today likely cannot remember the last time they saw a blood agar plate. A recent meta-analysis2 showing that Step 1 scores are not associated with clinical skills acquisition provides additional evidence of the mismatch between the subject matter of Step 1 and actual clinical practice.

Because students may believe that much of the material on Step 1 is irrelevant to modern medical practice rather than fundamental basic science knowledge, it is no surprise they may have a binge and purge mentality, instead choosing to spend their time on other educational pursuits, such as research or additional rotations. The fact that students do not take a similar approach to the more clinically focused Step 2 and 3 examinations further supports this notion.

Although basic science certainly has an important role in patient care, testing future physicians on knowledge that seems clinically irrelevant fails to achieve the aim of ensuring that medical students can “apply foundational science in patient care.” The goal of enhancing the assessment of practice-related competencies with the USMLE is an important one.

However, as these examinations evolve, continuous evaluation of whether the proposed changes move toward this goal is necessary. Before components of Step 1 are added to the other USMLE examinations, this content should first be updated to ensure that it is truly related to foundational science for patient care.

Section Editor: Jody W. Zylke, MD, Senior Editor.
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Article Information

Corresponding Author: John S. Barbieri, BA, Perelman School of Medicine at the University of Pennsylvania, 3450 Hamilton Walk, Philadelphia, PA 19104 (john.barbieri@uphs.upenn.edu).

Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

Haist  SA, Katsufrakis  PJ, Dillon  GF.  The evolution of the United States Medical Licensing Examination (USMLE): enhancing assessment of practice-related competencies. JAMA. 2013;310(21):2245-2246.
McGaghie  WC, Cohen  ER, Wayne  DB.  Are United States Medical Licensing Exam Step 1 and 2 scores valid measures for postgraduate medical residency selection decisions? Acad Med. 2011;86(1):48-52.