In medical school, we take “Step 1” of our Nationalized, Standardized Board Exams before we start seeing patients in the hospital. Then, in order to graduate and start residency, we have to pass two parts of “Step 2.” “Step 2 Clinical Knowledge (CK)” is a 9-hour, computerized exam consisting of 8 1-hour blocks of 46 multiple choice questions. “Step 2 Clinical Skills (CS)” is a 9-hour, practical exam where you see 12 standardized patients, perform a history and physical, and write a note about the patient with a basic idea of your workup and diagnosis for the patient.

Now, there is some talk also about combining both Steps 1 and 2 into one exam taken during the final year of medical school. I’ll address this issue and then address the Boards more generally.

I would strongly oppose combining the two exams into one, for one main reason: Step 1 is what a number of residency directors use to help determine who to interview for their residency programs, especially at medical schools which lack grades (Stanford, where I am, lacks grades). I think this would quickly lead to all medical schools adopting grades, which I think is especially detrimental to learning, especially in the pre-clinical years. Medicine is now, for the most part, a team sport. I think it’s incredibly important for medical students to learn how to effectively communicate with their colleagues (classmates) and work together. And I think you don’t learn that when you have grades.

Grades encourage competition, gunner-ness, and cut-throat behavior, when what you really want is the promotion of cooperation. Especially in the pre-clinical years, when all you do is study and take exams. If you eliminate the major way that gradeless medical students are deciphered by residency directors, you give medical school deans all the more reason to put grades back in the curriculum. (I believe grades in the clinical years are a different story, so I won’t comment on them. I do believe, however, if you encourage cooperation in the first two years, you’re more likely to have collegial relations with your classmates when working in the hospital.)

On Step 1
Step 1 seems like a necessary evil in retrospect. It sucks, studying for it sucks, and it’s painful and nerve-wracking. But it forces you to put all your knowledge from the first two years in preparation for seeing patients. It forces you to review everything you’ve seen and forgotten, and integrate and optimize that little brain of yours. This ends up being a really good thing for seeing patients. My main critique is the subject material, but I’ll cover that elsewhere in my discussions of the curriculum.

On Step 2 CS
An utter waste. An utter. Total. Waste.

As I’ve said before , the administrators of this test take in $17 million each year for the exam so that a few hundred students each year don’t pass, take it again, and then most of them pass.

First, there’s only five cities in which one may take the exam. So if you’re not in Atlanta, Chicago, Philadelphia, Los Angeles, or Houston, you get to pay for airfare and hotel for the night, out of pocket (the exam is 7-8 hours long, so it’d be hard to fly in and out without staying the night). Next, most medical schools already require their students to participate and pass an exactly similar exam with standardized patients.

These Step 2 standardized patients are much worse–they have absolutely no personality, only poorly acting their roles. You’re being graded–at least partially–by your ability to show compassion. So you’re constantly pretending to have sympathy, while they’re pretending to actually require your sympathy. You ask, “Do you have any fevers or chills,” and they robotically reply, “No, Doctor, I do not have any fevers or chills.”

You’re also judged on seemingly worthless physical exam criteria like putting your stethoscope in the right place. So to the creators of Step 2 CS, it’s more important to be able to pretend to examine a patient than to actually identify a murmur or hear crackles on exam.

Next is the silliness of the exam itself: once you leave the exam room, you’re not allowed to re-enter. What? Are you kidding? How many times do I think to myself, “Gosh, I guess I need to do a neuro exam too,” and dart back in the room to do one?

Finally is the stupidity of the patient note. You have to come up with a differential diagnosis for the problem in question (this is good), but there’s no description of how wide a net to cast . The “workup” portion of the exam is incredible. It’s apparently more important to be able to come up with a list of lab tests and studies to order than to know what to do if someone is dehydrated and can’t tolerate oral liquids, or to give someone with symptoms of a heart attack oxygen and an aspirin.

Add in the fact that you receive absolutely no feedback on how you did from the standardized patients (it’s fine to just grade us, improvement is beyond the Step 2 CS) just adds icing to the cake.

Look, either make it a real, practical test, and really test to see if people know what to do with patients, or admit that it’s mostly to see if people can speak English. If it’s the former, put some life into it. If it’s the latter, make the International Medical Grads take it and please quit wasting my time and money.

If medical schools are doing their own standardized patient exams, why not allow the schools to proctor their own exams? They can certainly determine English language ability and if the students are competent to become doctors–after all, they are the ones granting the person the MD, aren’t they ?

On Step 2 CK
This actually wouldn’t be all that bad of an exam from the “review everything you’ve learned” point of view if it weren’t such a crappy exam. (No, seriously.)

First, most of us fourth year students take this exam and then spend much of the rest of fourth year vacationing in anticipation of the hell that is internship. So often most of what we learn from studying for the exam is lost to nicer memories like the sights of Europe or the beaches of Thailand.

Second, the exam contains way too much pre-clinical, worthless detail. You know, honestly, I truly do not care what the pathology might reveal on a tissue biopsy of someone with myxedema. It is not important to me nor my patients. It is, however, possibly important to know how to diagnose myxedema or treat it. (Thankfully, the exam is much more clinically-oriented than Step 1, but no way near enough.)

Third, the answer choices are often ridiculous. For a suspected pneumothorax, my options are not “ultrasound,” or “chest CT,” or “X-ray.” They’re things like a) thoracotomy b) needle thoracostomy c) MRI head d) diagnostic peritoneal lavage. I kid you not. If you want me to suspend disbelief for a minute and pretend I’m trying to manage these patients, then give me some realistic answers, people.

The Bottom Line
Keep Step 1.
Drop Step 2 CS.
Fix Step 2 CK.

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