Amid the COVID-19 pandemic, medical education is receiving unprecedented attention. By and large, the focus has been on the immediate problem of what to do with medical students. The answer has hinged on medical students being designated as “non-essential” to patient care, and has (for the most part) entailed avoiding clinical activities. A long-term problem that has received less attention is, why are medical students non-essential in the first place? And can we envision a future where we are considered essential? The answer lies in our willingness to focus on training as opposed to distinguishing medical students, through establishing Competency-Based Medical Education (CBME) as the norm. Steps that would help us get there include preclinical curricular reform and shifting clerkship grading to pass/fail.
More than two years should be sufficient to teach medical students the skills necessary to contribute in times like these. Physicians assistants and nurse practitioners are essential after two and three years of training, respectively. Simply put, medical school is not designed to make clinical students essential members of the team. While no trainee should ever be given responsibilities they are not ready for, the vast majority of us want responsibility and quality training, including in the time of COVID-19. So why isn’t our training better?
As a nearly graduated medical student, I have come to the conclusion that the focus of medical school is split between training and distinguishing medical students. Modern pedagogy has not found its way into the modern medical school classroom. Some have argued that medical education has not significantly advanced from “when the Wright brothers were tinkering at Kitty Hawk.” In theory, the preclinical phase should be spent in preparation for the clinical phase, which in turn should be about preparation for residency. However, preclinical students spend mounds of time on impossible tasks, like memorizing First Aid for the USMLE Step 1, without learning concrete skills that can be applied to clerkships. As for clerkships, the quality of teaching is highly dependent on the attending’s or resident’s level of commitment to education. Oftentimes, we feel like flies on the wall rather than active participants in patient care.
Meanwhile, medical education is efficient at distinguishing medical students for the purpose of residency selection. Of course, the overwhelming focus of the preclinical phase is on Step 1 preparation (though this soon will change). Then come clerkships, where the focus turns to grades and hopes of gaining Alpha Omega Alpha (AOA) membership. Both Step 1 scores and clerkship grades provide a false sense of objectivity, and distinguishing students through these means creates unfortunate racial disparities. For Step 1, black and Latino students receive markedly lower scores than white students; we should also remember that Step 1 was designed as a pass/fail exam, and beyond the pass/fail designation scores were not meant to have much meaning. When it comes to AOA membership—a reflection of clerkship grading—one study found the odds of gaining membership were stacked 6 to 1 in white students favor compared to black students. Granted, evaluation is an important and necessary part of medical training. The danger is when it is misused, inequitable, and at odds with the purpose of training medical students. It’s time for training to take the front seat.
In the tug of war between training and distinction, there are plenty of leaders who prioritize the former. The last twenty years have seen the rise of Competency-Based Medical Education (CBME) and the implementation of the ACGME’s six Core Competencies. Schools have designed curricula around Entrustable Professional Activities (EPAs), which are well-defined tasks medical students can perform within a CBME framework. Focusing more on EPAs is the sort of thing that would make medical students essential.
While the focus on CBME is promising, we still need to actively address the obstacles of preclinical curricular reform and clerkship grading. For the preclinical phase, Step 1 has long been the tail that wags the dog, receiving far more time and attention than the institutional curriculum. Fortunately, the cessation of score reporting will finally make an overhaul for the preclinical curriculum possible, paving the way for critical changes such as the steps I have previously outlined. In a nutshell, the preclinical curriculum should become tighter and more efficient in order to reduce the time and energy we devote to Step 1. This would open up time for learning the other things that a well-rounded doctor would be expected to know. For the clinical phase, the University of California, San Francisco has taken the important step of making core clerkships pass/fail, which will undoubtedly improve things like equity and learning. Though it may be easier for top-tier universities such as UCSF to have pass/fail core clerkships and still produce “competitive” residency applicants, the benefits cannot be ignored. When Step 1 scores go away, there will still be Step 2 CK scores; and if core clerkship grades go away, there will still be subinternship grades. Given that such scores and grades are arbitrary and unfair, is it really that big of a loss to delay doling them out until the home stretch of medical school? And would we be willing to sacrifice a degree of distinguishing students in order to improve our training? Of course, these are merely obstacles to CBME, and once removed, there will still be the challenging task of implementing it. Nonetheless, without the pressure such scores and grades create, we could focus on what we went to medical school to do—learning medicine.
In the era of COVID-19, it seems as though the world is flipping upside down. While we certainly need to find immediate solutions for medical students, we should also be exploring why medical students are non-essential, and we should strive to create a future where we are essential. What we need more than ever is for national organizations like the National Board of Medical Examiners, the Association of American Medical Colleges, residency program directors, and individual institutions to take bold steps to improve the quality of our training—both short-and long-term. Maybe medical education flipping upside down is not such a bad thing.
David Chen is a medical student.
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