Pass/No-Pass Step 1: Navigating the Changing Path to Medical Education

Benjamin N. Schneider, MD, recently highlighted changes likely to accompany the elimination of Step 1 numeric grading.¹ According to Schneider, Step 1 pass/no-pass scoring will likely result in greater emphasis on Step 2 numerical scores.² He proposes a new focus on Accreditation Council for Graduate Medical Education (ACGME) Core Competencies in the wake of this revision.¹ We agree that future changes in medical education need to be even more intentional.

Increasingly, medical education exists outside the classroom, as students doubt their curriculum alone will provide the necessary preparation for national examinations.⁵ Consequently, the majority turn to commercially available educational resources³ over traditional didactic lecture attendance.⁴ The transition to a Step 1 pass/no-pass format is unlikely to change the self-directed learning behaviors of medical students. What then should medical programs do to regain the participation and confidence of their students? Rather than fight the pervasive use of external resources among students, we believe medical school curricula should (1) be reconstructed to promote rather than disparage self-directed learning, and (2) become more intentionally patient centered.

The Penn State College of Medicine University Park Curriculum attempts to fulfill these goals by replacing the traditional preclinical curriculum with longitudinal outpatient family medicine clinical immersions and small-group class sessions using identified learning objectives. Throughout their first year, students work closely with family physicians twice weekly engaging in longitudinal patient interactions. From these early clinical experiences, students develop defined educational goals. Subsequently, they pursue outside resources to thoroughly investigate select diagnoses encountered among clinic patients before reconvening to share and expand upon their peer’s academic explorations. The foundation of this pedagogical framework is early patient interaction that provides context for learning objectives, while fostering communication and clinical reasoning skills expected from budding physicians.⁶ Furthermore, these small-group discussions facilitate peer-to-peer teaching opportunities–an activity believed to enhance communication skills and improve learning strategies.⁷ Such longitudinal family medicine clinical experiences paired with student-driven, small-group learning serve as an effective transition to clerkships in the second year (vs the third year). Replacing the traditional block format, clerkships are arranged longitudinally throughout the year allowing students to build relationships and maintain continuity of care with several recurring patients. By initiating clerkships a year early, students can use their clinical experiences as a foundation for medical knowledge as they begin United States Medical Licensing Examination (USMLE) preparations in their third year. By fourth year, students have not only fulfilled USMLE requirements, but also have accrued invaluable longitudinal patient-care experiences giving them a more holistic understanding of the multiple medical specialties that exist within our complex health care system.

Medical education is shifting toward self-directed learning, a trend that is likely not going away regardless of recent Step 1 scoring modifications. Instead of striving to retain the traditional curriculum in hopes of improved student engagement, medical schools should utilize their most important educational resource: the patient. Through early longitudinal patient encounters, mastering clinically-based, small-group educational objectives, and promoting self-directed learning, medical schools can best achieve their ultimate goal: cultivating competent, patient-centered, humanistic physicians.