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My impression from talking to people in the field was that the exam is basically a hazing ritual with maybe 10-50% of the information being relevant for actually working and the rest being stuffed in to spread out the right tail/prevent ceiling effects.
It sounds like you're in the field or at least know it intimately. If you could unilaterally set the criteria for residency, what would you do to most effectively identify the best candidates?
You get shit on so much in medical education that I find most people forget what the exams are for and minimize their value. A good chunk of preclinical learning is laying the ground work for later knowledge growth (Step 1, the relevant exam, included). We also need something that isn't pure pedigree or totally luck of the draw and subjective evaluations to provide candidate discrimination. It also needs to happen early enough for people to filter themselves to specialties that will be actually realistic for them.
Basically Step 1 + Clinical Evaluations (but not preclinical grades) and the usual Letters of Rec/Research/EC.....that shit worked great.
However Step 1 was enormously stressful and got harder to write questions for due to exam prep resource inflation. Someone uncharitable may also note that minorities tended to underperform. So they made it pass/fail.
This killed student motivation in preclinicals (which is again, supposed to be foundational knowledge) and was a huge win for premier med schools (and loss for lower tier ones).
If I had to change one thing I'd increase the weight behind Letters of Rec - they are unpopular these days and admittedly make things harder for those without a medical family (and I was one of those) but done responsibly they can do a lot to recognize good and well trained candidates.
Returning to Step 1 - people get upset because a big chunk of the exam is "low yield" but that's because everyone successfully learns the basic stuff. And they need to. And the old exam format forced them to. The low yield stuff is also things that doctors should be vaguely aware of because you'll see individual rare cases all the time, just not a specific rare case.
Everything I hear about the medical training admission process suggests to me that it is one of the worst manifestations of Goodhart's law.
-Licensing exams with a passing score of 60%. Surely if the threshold is that low most of the material must not be all that useful. Why not make an exam out of genuinely useful material and set the threshold at >80%.
-"Volunteer" work to bolster your CV. I mean, it's not really volunteer work when it benefits you materially.
-"Research" work that's mainly about playing lab politics to tag your name on tons of publications instead of actually making contributions to scientific progress.
If my impression above is accurate, I suppose it makes sense that you'd default to trusting a colleague to tell you "this student is great and worth training". Even so, I'm told a lot of times people are so busy they just sign off of on anything a student writes up.
It all just makes me lose faith in the ability of institutions to identify and foster potential (in all fields, not just medicine). Then again, it seems American healthcare is still chugging along just fine for now, so maybe it all works much better than I think.
Yeah most of the research industrial complex is bullshit, fair enough.....but the rest of it makes sense.
Medical exams are hard (and not like most exams you see), someone who was in the top 5% of their class at a respectable undergrad institution can spend two years studying for Step 1 and still barely pass it. Shit is hard. Part of this is driven by how modern test questions are designed. Little of it is fact recall and questions are mostly second or third order. Some have multiple correct answers and you are supposedly to be figuring out what's most likely and even sometimes essentially from first principles (especially in Step 3). Step 1 is a bit hard to do this in because the material is more basic and it's (well, was) our primary "you get to go somewhere nice after graduation" exam because it happens earlier. Thus the vaguer content, but it does serve a purpose and every question ends up having clinical utility for someone, even if it's just a medical geneticist.
A good chunk of volunteering is bullshit but this requirement (absent the social justice end of things) is meant to establish life experience which you otherwise would not have because career changers are still pretty rare and medical education is all encompassing.
Letters for admission to med school are often the way you describe but letters for residency absolutely should involve someone who knows you well and has seen you work, if that doesn't apply for a student they were doing it wrong.
In 2021, before USMLE Step 1 moved to pass-fail, 98% of 1st-time takers from MD programs passed per here. By comparison, the first-time pass rate for the California bar exam (to practice law in the state) is roughly 45% per here.
I mean what I say quite literally, you can be a top of your class science student at a reasonably good institution, study for two years specifically for the test (including a multi-month "dedicated" period where your only job is to study for this test), spend thousands of dollars on incredibly well designed test prep material and that still might not be enough.* Keep in mind that this is after multiple filtration points designed to weed out people who aren't good at hard work and studying.
The bar is designed to be acceptable to fail multiple times, law school is not set up exclusively around passing the bar, and while admissions can be rigorous at top institutions it's got nothing on the adderall snorting madness which is med school.
*and while the fail rate is low, failing it fucks you over incredibly, and getting an average score looks you out of entire specialities and regions for residency.
That might qualifier is doing an awful lot of work here. The same student might also get crushed by a falling piano on the way to the test center. The point of statistics is to evaluate likelihoods, not possibilities.
This seems hysterical (marked by hysteria). The same data set showed that re-takers had an almost 70% chance of passing. Substantially anyone who manages to drag himself across the finish line will be able to make $200k/year as a GP in a high status profession (more if they're willing to live outside a major city, where the money will go further). I don't know in what universe this qualifies as being fucked over incredibly. Even the small minority of medical students who can't gain licensure to practice will still have fine life outcomes, by and large.
If you fail Step 1 (well back in the day, the new situation is evolving quickly) you are relegated to Family Medicine in a poor location or a malignant Internal Medicine program unless you have something very very strong going for you. The vast majority of students don't want family medicine, and they don't want to be in Iowa, and they don't anything to do with those IM programs.
If you went to medical school to be a surgeon (or a dermatologist, or an oncologist, or to live with your girlfriend in LA) then failing the exam can be pretty catastrophic. Some do drop out after failing "because the dream is dead." Not that I necessarily agree with that decision.
I think if you'd framed it in these terms originally, then I wouldn't have objected.
I agree. Failing your medical licensing exam (as 2% of test takers do) limits your ability to earn $1M/year as an LA plastic surgeon.
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