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March 6, 2020

Change in Reporting of USMLE Step 1 Scores and Potential Implications for International Medical Graduates

Author Affiliations
  • 1Department of Medicine, University of Connecticut, Farmington
  • 2Department of Hematology and Oncology, University of Alabama at Birmingham
JAMA. 2020;323(20):2015-2016. doi:10.1001/jama.2020.2956

The US physician workforce includes allopathic physicians, osteopathic physicians, and international medical graduates (IMGs), who are physicians who received their medical school education outside the US or Canada. These physicians comprise both US citizens (US IMGs) and citizens from other countries (non-US IMGs) who have trained abroad. The US health care system has depended on IMGs to fill residency positions since the 1970s. Today, 1 in 4 physicians practicing in the US is an IMG.1 One estimate from 2001 suggested that if IMGs in primary care practice were removed, 1 of every 5 “adequately served” nonmetropolitan counties may become underserved and the percentage of rural counties with physician shortages could increase to 44.4%.2 This trend continues with the J-1 exchange waiver called the Conrad 30 Waiver, which enables IMGs to continue practicing in the US only if they commit to practice in a federally designated Health Professional Shortage Area, Medically Underserved Area, or Medically Underserved Population for at least 3 years.3 With a projected shortage of an estimated 125 000 physicians by 2025, IMGs will remain an important source of primary care physicians in rural and underserved areas.

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    1 Comment for this article
    Are Scores The Answer?
    Muhammad Furqan, MD | Cleveland Clinic
    The authors are strong proponents of the United States Medical Licensing Exam (USMLE) scoring system and propose that the scores are the single most important factor for International Medical Graduate (IMGs). They enlist several factors for their claims.

    First, they are of the view that program directors may be unfamiliar with training in international medical schools, and grades from international medical schools are not congruent with the grading system of US medical schools. I fail to understand how a three or two-digit score is a "standardization tool" while a pass/fail criterion is not. Passing a test means a
    candidate has competencies in tested material that is above an acceptable level, which is consistent for all the candidates. The pass/fail criterion creates a reasonable approach, even if we consider differences in medical education delivered overseas. They further state that mean Step 1 scores of matched IMGs have been higher than unmatched IMGs. USMLE administration has reiterated that USMLE is not a tool for hiring or allocating training slots. The inappropriate use of the scoring system created an additional burden on both American Medical Graduates (AMGs) and IMGs. Although IMGs were, in some instances, benefactors of this scoring system, the added pressure to score high and peer pressure ensued. Although the mean scores are high for IMGs, scoring low on USMLE became a stigma which may have additional psychological consequences. USMLE is a high stakes exam, and all the test-takers are well aware of this. Scoring, however, created an additional financial burden to account for all the "best-sellers" and "high-yield" resources. IMGs pay out of pocket to these for-profit companies. With the scores converted to pass/fail, IMGs will benefit financially by buying subscriptions for lesser periods.

    The authors argue in the second and third view that removing the scoring system will redirect focus on clinical electives, research, and networking, which will add financial cost for IMGs. Clinical electives and research experiences are important not only for residency but also for developing essential clinical and analytical skills. Networking and mentorship are also proven to have a positive influence on professional life. Moreover, IMGs can acquire these experiences in their own countries and do not have to travel to the US. It is known that the US experience is seen favorably for residency positions, but it is not an essential component. These skills are transferable, and letters from physicians of good national/international repute could certify these. IMGs will be able to focus more on clinical and research skills or explore unique opportunities that boost critical thinking and innovation instead of just cramming and reproducing knowledge in an exam setting.

    The time taken by IMGs just to score higher on USMLEs could be directed to acquire valuable experiences, and an MD-DO merger would open more possibilities.

    Medicine is a lot more than just fantastic scores. It involves connecting with patients, understanding their concerns, advocating for their needs and health, employing critical thinking in complex scenarios, empathy, producing quality evidence, and much more. The unwanted burden released off candidates by this change will help them to empower themselves with experiences and traits that are essential for taking care of patients and be researchers, health advocates, leaders, and role-models.