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Acad Med. 2020 Mar 3. doi: 10.1097/ACM.0000000000003272. [Epub ahead of print]

Identifying and Supporting Students to Prevent USMLE Step 1 Failures When Testing Following Clerkships: Insights From 9 Schools.

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A. Swan Sein is director of the Center for Education Research and Evaluation, and assistant professor of educational assessment in pediatrics and dental medicine, Columbia Vagelos College of Physicians and Surgeons, New York City, New York; ORCID: 0000-0002-3139-4626. M. Daniel is assistant dean for curriculum and associate professor, departments of emergency medicine and learning health sciences, University of Michigan Medical School, Ann Arbor, Michigan; ORCID: A. Fleming is associate dean for medical student affairs, and professor of pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee. G. Morrison is the William Maul Measey president's distinguished professor in medical education, executive director, Innovation Center for Online Medical Education, and former senior vice dean for education and director of academic programs, Raymond and Ruth Perlman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania. J.G. Christner is dean and the Cullen Trust for Higher Education dean's endowed chair, Baylor College of Medicine, Houston, Texas. K. Esposito is professor of psychiatry and behavioral health, and executive associate dean for student affairs, Florida International University Herbert Wertheim College of Medicine, Miami, Florida. A.R. Pock is associate professor of medicine, and associate dean for curriculum, Uniformed Services University of the Health Sciences, Bethesda, Maryland. C.O. Grochowski is associate dean for curricular affairs, and associate professor of the practice of medical education, Duke University School of Medicine, Durham, North Carolina. J. L. Dalrymple is associate dean for medical education quality improvement, and associate professor of obstetrics, gynecology and reproductive biology, Harvard Medical School, Boston, Massachusetts. S.A. Santen is senior associate dean of evaluation, assessment and scholarship of learning, and professor of emergency medicine, Virginia Commonwealth University School of Medicine, Richmond, Virginia.


Several schools have moved the United States Medical Licensing Examination Step 1 exam after core clerkships and others are considering this change. Delaying Step 1 may improve Step 1 performance and lower Step 1 failure rates. Schools considering moving Step 1 are particularly concerned about late identification of struggling students and late Step failures, which can be particularly problematic due to reduced time to remediate and accumulated debt if remediation is ultimately unsuccessful. In the literature published to date, little attention has been given to these students. In this article, authors from 9 medical schools with a postclerkship Step 1 exam share their experiences. The authors describe curricular policies, early warning and identification strategies, and interventions to enhance success for all students and struggling students in particular. Such learners can be identified by understanding challenges that place them "at risk" and by tracking performance outcomes, particularly on other standardized assessments. All learners can benefit from early coaching and advising, mechanisms to ensure early feedback on performance, commercial study tools, learning specialists or resources to enhance learning skills, and wellness programs. Some students may need intensive tutoring, neuropsychological testing and exam accommodations, board preparation courses, deceleration pathways, and options to postpone Step 1. In rare instances, a student may need a compassionate off-ramp from medical school. With the National Board of Medical Examiner's announcement that Step 1 scoring will change to pass/fail as early as January 2022, residency program directors might use failing Step 1 scores to screen out candidates. Institutions altering the timing of Step 1 can benefit from practical guidance by those who have made the change, to both prevent Step 1 failures and minimize adverse effects on those who fail.

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