The brutality of step 1


Category : Medical Rants

Yesterday, 3rd students received their step 1 scores. For non-physicians, our medical licensure boards have 3 parts. Step 1 is taken after the basic science years – and thus focuses predominately on basic science. Step 2 is taken during the 4th year and reflects the clinical rotations. Step 3 is taken during internship and is a more practical extension of step 3.

I have no major problems with step 2 and step 3, but I abhor step 1 and its externalities.

Medical students spend the first 2 years with step 1 anxiety. This is a difficult test, which – in my opinion – adversely influences the teaching of basic science. Medical school leaders design the first 2 years of medical school so that their students have a good chance to pass the test.

We need to know basic basic science to be excellent physicians. But ask most clinicians, and they use little of their basic science education. We could design the proper courses, taught at the proper depth if we worked with outstanding clinicians and teach the basic science that they really need.

For example, you need to understand the basics of cardiac physiology, including the neurohormonal response to heart failure. You should understand how the major joints work (especially the most complex one – the shoulder). You need to understand basic neuropharmacology.

We teach too much depth, and thus the most important messages get lost. Basic science teachers generally suffer from The Curse of Knowledge. They try to teach everything that they know, and thus the students feel overwhelmed and often do not learn the really fundamental stuff.

When you teach a child to play basketball, you start with dribbling, passing and shooting. Basketball is a much more complex game, but you do not add complexity until you master the basics. The greatest basketball player in the NBA (Tim Duncan) has the nickname “The Big Fundamental.”

We should have a new Flexner report which emphasizes the need for mastering the fundamentals of basic science. Let the researchers take basic science 301 and 401, but let medical students master 101 and 102.

And make step 1 a test that reflects mastery of fundamentals. I believe this would improve moral, and improve scientific practice.

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Comments (4)

Wondering if you’ve seen “Sicko” yet and what your thoughts are on the state of U.S. health care.

It sounds like med classes are harder than grad school science classes. Basic sciences courses for research scientists are hit very hard at the undergrad level and then are very nebulous and open ended at the grad level.

The pharmacology courses I took, for instance, were very much lit based, lots of basic science and cell bio but only a little bit of memorizing drug names. Our tests were very much problem solving rather than recitation or multiple choice.

The flaw of every basic researcher is that they LOVE what they do, thus feel the need to share the love with their students. When a student-such as a premed-only wants to master the knowledge quickly for a grade, it is almost insulting. I have seen this result in some very hateful interactions between premeds and undergrad professors. These are likely the same folks who teach the med students. Each of them feels their field is utterly fascinating and worthy of complete understanding without considering the sum total workload imposed.

I guess the big problem is that to treat a patient you need pharmacology which relies on A&P, which relies on biochemistry, which relies on organic which relies on general chem and so on.

Perhaps a better solution would be a true premed undergrad program which focuses on extending this difficult two years of course work into a BS-MS type program that takes five years total. As it stands the glut of BS premed biologists drastically diminishes the earning potential of BS biologists, biochemists, and chemists when they don’t make med school.

Can you compare US MDs basic science to overseas MDs basic science and then look at patient outcome or a guesstimate of skill. That might show how much you really need the basic scinec

true enough.. med student use radically different methods of learning that PhD’s use then. PhD are focused on subsets of basic science issues, while MD’s/DO need to know the basics of a large array of disciplines.

The problem with easing up on the basic sciences is that more psuedoscience creeps in. Most physicians will admit that without the frameqwork of a rigorous basic science foundfation, we would be ill prepared to sort out the next true medical advance from the false. We are ill prepared as it stands now.

The same holds true with any profession, I think.

You’re spot on. Most of the first 2 years consisted of a flood of detail and random fact “pimping” that actually detracted from developing a group of medical professionals that understand fundamental building blocks of physiology, anatomy, chemistry, pharmacology, etc. The detail (and testing by PhDs on trivia vs. dynamic comprehension) made the first two years largely a waste of significant time and effort.

I find it amazing that I took a few days on dynamics of molecular skin adhesion and spent less than 1 hour in my first 3 1/2 years to understand how the US healthcare system worked. (I made up my own elective to address the gap at the end of my schooling). Funny priorities in my mind.

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