Investigating Critical Disparities in USMLE Step 1 Resources: Myocardial Infarction Symptoms in Women

In the United States, coronary heart disease (CHD) is the leading cause of mortality in both men and women.¹ Myocardial infarction (MI) is a common and potentially fatal complication of CHD. Women who present with chest pain are at risk of underdiagnosis.^1,2 Literature has shown that women may present with unique symptoms of myocardial infarction, and this may lead to delays in seeking care, being provided appropriate care, and resulting in poorer outcomes.^2-4 These unique symptoms include fatigue, nausea, and shortness of breath, along with the typical chest pain or discomfort associated with MI.^2-4 Other unique symptoms include confusion, syncope or presyncope, and vague abdominal symptoms.² Among women aged 55 or less is an increased mortality risk of acute MI compared to men of the same age.³ Prompt recognition of acute MI symptoms for women are crucial to optimizing outcomes.³ One method of improving care begins as early as the foundational medical learning stages. Because students frequently work on the care team as early as their first year of medical school, being able to recognize these differences in symptomatology between biologic sexes is critical.

Medical school in the United States is 4 years and typically split into two stages. The first stage is typically 2 years and is dedicated to learning the basic sciences with moderate to minimal patient interaction, although exceptions exist in certain curricula. The second stage is also 2 years in which students rotate through different surgical and primary care specialty services, including but not limited to emergency medicine, family medicine, general surgery, and internal medicine. The United States Medical Licensing Examination (USMLE) Step 1 exam measures students’ knowledge and ability to apply fundamental sciences to the practice of medicine. Typically, passing this exam signifies the transition from preclinical learning to clinical learning. To pass this exam and begin their final 2 years of clinical training, students often use Step 1 resources, which include books, videos, flash cards, and assessments.⁵ The purpose of this study was to analyze whether the most used and recommended resources for the Step 1 exam featured a mention of the unique presentation of myocardial infarction in women.

We conducted a cross-sectional analysis of the selected Step 1 resources on November 13, 2023. The Step 1 resources were based on the most recommended resources compiled and rated by the editorial staff of First Aid for the USMLE Step 1 2023. This search of resources included question banks, mobile apps, comprehensive resources, pathology, and physiology resources that had ratings of A–, A, or A+. Table 1 features a complete list of all resources analyzed. The terms “woman,” “women,” “female,” in combination with “myocardial infarction,” “acute coronary syndrome,” “heart attack,” “cardiovascular disease,” “STEMI,” “chest pain,” “NSTEMI,” “myocardial injury,” and “heart disease” were searched throughout each resource with a computer search function (Cmd+F for Mac users and Ctrl+F for Windows users). Following the computer search, the cardiology section of each resource was manually searched for any mention of differences in presentation of myocardial infarction between biologic sexes. Specific attention was further given to the myocardial infarction subsections of each resource to analyze any discussion of the search terms. For resources that did feature a discussion about the presence of differences between biologic sexes, the content was written and recorded in an Excel document. A list of these resources featuring the differences in presentation also was recorded.

We found that none of the Step 1 resources made a differentiation in MI symptoms between biologic sexes across all resources. The resources analyzed in the study included First Aid for the USMLE Step 1 2023, USMLE Outline, UWorld Question Bank, and NBME Practice Exams, among others. When discussing the symptoms of acute myocardial infarction, most of these resources included diaphoresis, nausea, vomiting, retrosternal pain, and pain in left arm or jaw. Table 1 features a full list of the resources, their respective editions and descriptions, and their provided ratings by First Aid.

The findings of this study highlight an important issue in medical education and clinical training. Studies indicate that the majority of medical students prepare for the Step 1 exam using resources such as First Aid for the USMLE Step 1 2023 and the UWorld Question Bank.^2,5 These resources, along with the list of resources provided by the “Top-Rated Review Resources” section of First Aid for the USMLE Step 1 2023—particularly the A-level resources—are the gold standard in preparing for this licensing exam.^2,5 This list is compiled by the editorial team of First Aid, which consists of medical students, residents, and physicians. This team gathers input from the broader medical student community, incorporating feedback from users of the resources. The recommendations are based on surveys, reviews, and evaluations to ensure that they reflect the most widely used and highly rated tools for Step 1 preparation.

Despite the increased mortality risk for young women with acute MI and the known unique presentation of symptoms in women overall,^3,4 none of the most used and recommended resources for the Step 1 exam in medical school address this discrepancy. This finding is of concern given the importance of the Step 1 exam in transitioning from preclinical to clinical learning and the frequency with which students use these resources. Medical students’ clinical rotations provide valuable opportunities for medical students to observe and learn about patient histories and presentations, including the unique symptoms of MI in women. If not adequately educated on this topic, particularly during licensing examination and its preparation, students may miss important clues during patient interactions. Additionally, improving education of this topic can help balance and shape the biases students develop while preparing for licensing exams.⁶ Addressing this knowledge gap is crucial for future physicians.

One limitation of this study was the reliance on the most recommended resources, because other resources may exist that do address the unique presentation of women with MI. The search was conducted manually, and this method may be prone to human error. Some resources may also feature information in an embedded format, which can limit their ability to be identified. Additionally, the nature of this study is cross-sectional, and the resources possibly have been updated since the completion of the data collection. However, that the highest rated resources for Step 1 exam do not feature such an important discussion is concerning.

Moving forward, efforts should be made to address this gap in common USMLE Step 1 study resources to help improve recognition of unique symptoms of myocardial infarctions in females. These efforts could involve incorporating this topic into medical school curricula, providing additional resources, or even modifying licensing exam content to ensure that it is more representative of the diverse presentations of acute MI. Improved education can play a role in improving care of female patients. Future research also should explore the prevalence of biologic sex education disparities in other areas of medical education and clinical practice, and identify interventions to promote more equitable care. Ultimately, improving recognition of unique MI symptoms in women can lead to better trained physicians and better outcomes. Medical education must continue to evolve to address emerging issues in clinical practice and ensure that future generations of physicians are equipped with the knowledge and skills necessary to provide high-quality, patient-centered care to all individuals.