What Is Most Important to Program Directors Orthopedics

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• Published: 03 May 2021

A comparison of orthopaedic surgery and internal medicine perceptions of USMLE Pace 1 laissez passer/fail scoring

• Alyssa R. Scott¹,
• David Cui^one,
• Erik B. Lehmanⁱⁱ,
• Seongho Jeong³,
• Alia Chisty^one,4,
• Paul J. Juliano^1,5,
• William L. Hennrikus^1,5 &
• Eileen F. Hennrikus^1,4

BMC Medical Education volume 21, Article number:255 (2021) Cite this article

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A Correction to this article was published on 27 October 2021

This article has been updated

Abstract

Background

United States Medical Licensing Exam Step one volition transition from numeric grading to pass/fail, sometime afterward January 2022. The aim of this study was to compare how plan directors in orthopaedics and internal medicine perceive a pass/fail Pace 1 volition impact the residency application process.

Methods

A 27-detail survey was distributed through REDCap to 161 U.S. orthopaedic residency program directors and 548 U.Due south. internal medicine residency program directors. Program director emails were obtained from the American Medical Association's Fellowship and Residency Electronic Interactive Database.

Results

We received 58 (36.0%) orthopaedic and 125 (22.8%) internal medicine plan manager responses. The majority of both groups disagree with the change to laissez passer/neglect, and felt that the conclusion was not transparent. Both groups believe that the Step ii Clinical Noesis exam and clerkship grades volition accept on more than importance. Compared to internal medicine PDs, orthopaedic PDs were significantly more likely to emphasize enquiry, messages of recommendation from known kinesthesia, Alpha Omega Alpha membership, leadership/extracurricular activities, audition elective rotations, and personal knowledge of the applicant. Both groups believe that allopathic students from less prestigious medical schools, osteopathic students, and international medical graduates will be disadvantaged. Orthopaedic and internal medicine plan directors concord that medical schools should prefer a graded pre-clinical curriculum, and that there should exist a cap on the number of residency applications a educatee can submit.

Conclusion

Orthopaedic and internal medicine programme directors disagree with the change of Stride 1 to laissez passer/fail. They also believe that this transition will make the lucifer procedure more than difficult, and disadvantage students from less highly-regarded medical schools. Both groups will rely more than heavily on the Pace 2 clinical noesis exam score, but orthopaedics volition identify more importance on research, letters of recommendation, Alpha Omega Alpha membership, leadership/extracurricular activities, personal knowledge of the bidder, and audition electives.

Peer Review reports

Background

The Us Medical Licensing Examinations (USMLE) currently consists of three numerically scored knowledge based exams. On February 12, 2020, the Federation of Country Medical Boards (FSMB) and the National Lath of Medical Examiners (NBME) announced that the start of these three exams, Footstep 1, would change from the three-digit numeric score to reporting a laissez passer/fail outcome -- starting sometime after Jan 2022 [ane]. This change occurred later extensive national discussion on potential ways to optimize the transition from undergraduate to graduate medical didactics [one, ii].

The unintended consequences of a scored Step ane on medical students and residency programs were widely reported in 2008 by the Committee to Evaluate the USMLE Program (CEUP). CEUP recognized the diverse stakeholders afflicted past Step 1 score reporting and suggested a demand to redesign USMLE [ii]. Although a numerically scored Pace 1 provided an objective mensurate for residency programs to assess applicants from different backgrounds and medical schools, the perceived overemphasis on this exam was controversial. In March 2019, the Invitational Conference on USMLE Scoring (InCUS), sponsored by the Association of American Medical Colleges (AAMC), American Medical Clan (AMA), NBME, FSMB, and Educational Committee for Strange Medical Graduates (ECFMG), convened to review the USMLE'southward practice of numeric score reporting. InCUS concluded that licensing examinations for undergraduate medical students must exist reevaluated. FSMB and NBME took into consideration the recommendations from InCUS, and stated that the change to a pass/fail Step i would help residency programs to refocus on the main purpose of Step ane -- to assess medical licensure eligibility [1, ii].

Step 1 is one of the well-nigh of import factors used to screen applicants past internal medicine (IM) and orthopaedic surgery residency programs [1,2,3]. Some residency programs too place a loftier emphasis on other factors, such every bit grades in required clerkships, research experiences, extracurricular activities, letters of recommendation, and audition rotations. With the absenteeism of a scored Step 1, all residency programs volition need to reconsider the factors used to determine which applicants are selected.

The aim of this study was to compare the perceptions amongst programme directors (PDs) in orthopaedics and IM on the change of Step 1 from a graded to a laissez passer/fail exam, and its impact on the residency application process. Some groups take studied PD opinions of the Step one pass/neglect change; however, to the all-time of our knowledge, the current written report is the outset comprehensive survey to directly compare the impact on medicine and a surgical subspecialty [iv,5,6,7,eight,nine,ten,11,12]. We chose to written report IM PDs because IM has historically been a pop specialty that has had the near number of total applicants. We decided to study Orthopaedic PDs considering orthopaedics has historically received some of the highest number of applicants per residency position [3, xiii]. Past directly comparison medicine and a surgical subspecialty, we hoped to gain insight into the various priorities and perceptions among PDs.

Methods

This study was exempted past the Higher of Medicine'due south Institutional Review Board. We obtained publicly bachelor contact data for PDs at all active Accreditation Council for Graduate Medical Education (ACGME) orthopaedic surgery and IM residency programs through the American Medical Association's Fellowship and Residency Electronic Interactive Database (FREIDA Online). We identified and contacted 197 orthopaedic surgery PDs and 554 internal medicine PDs. A survey invitation e-mail with the appropriate informed consent data was sent to each PD. Submission of the survey indicated the respondents' consent to participate. All responses were collected anonymously.

This multi-heart, cross-exclusive enquiry survey was developed, housed, and distributed through REDCap Data Capture. The survey was developed using criteria analyzed in the 2018 National Resident Matching Plan (NRMP) Programme Director survey, which investigated the factors involved in selecting applicants to interview [3]. Our survey questions used unmarried-answer multiple-choice, multiple-answer multiple-choice, and a Likert scale ranging from 0 (strongly disagree or least of import) to 4 (strongly agree or most important) formats. Prior to distribution, the questions were pretested and tested with subsets of respondents resulting in a 27-item survey. No funding was utilized.

The orthopaedic electronic survey was distributed on Apr 17, 2020. A follow-up was emailed 2 weeks after the initial submission. The survey was closed on May five, 2020. The IM electronic survey was distributed on July 8, 2020. A follow-up was emailed ii weeks after the initial submission. The survey was closed on August v, 2020.

Orthopaedic and IM PD responses were summarized with descriptive statistics and percentages prior to whatever assay to bank check their distributions. Given that the effect variables were ordinal variables on a Likert scale of understanding or importance ranging from 0 to 4, nosotros used a Wilcoxon Rank Sum test to compare the medians of the survey responses of orthopaedic and IM PDs. For binary outcomes, nosotros used a Chi-Square exam to look for any differences betwixt the groups. Statistical significance was ready at p < 0.05, and all analyses were performed using SAS version ix.4 (SAS Institute, Cary, NC).

To ensure a more robust analysis, the authors combined those who scored 0 or i on the Likert scale into one category as "disagree" or "less important." Those who scored 3 or 4 on the Likert scale were combined as "concur" or "more than important."

Results

Of the 197 orthopaedic programs, we identified contact information for 161 to invite. Of those, 58 responded for a response charge per unit of 36.0%. Of the 554 total IM programs, we identified contact data for 548 to invite. Of those, 125 IM PDs responded for a response rate of 22.viii%. The Likert scale data, including median Likert scores, interquartile range, and p-values, are shown in Table 1. The unmarried-answer multiple-selection and multiple-reply multiple-choice information, including number of respondents for each survey question, and p-values, are shown in Tabular array 2.

Tabular array 1 A Comparison of Orthopaedic and Internal Medicine Programme Directors' Perceptions of the USMLE Step 1 Laissez passer/Fail Transition: Likert Scale Responses

Full size table

Tabular array 2 A Comparison of Orthopaedic and Internal Medicine Program Directors' Perceptions of the USMLE Pace one Pass/Fail Transition: Unmarried-answer and Multiple-answer Multiple-choice Responses

Total size table

How do internal medicine and orthopaedic program directors experience about the pass/neglect Pace one?

The majority of orthopaedic (82.viii%) and IM (74.iv%) PDs disagree with the change to pass/fail Step 1. Additionally, 86.2% of orthopaedic and 79.2% of IM PDs disagree that the determination to transition to pass/fail Step 1 was transparent. Only 43.one% of orthopaedic and 39.2% of IM PDs hold that a graded Step 1 measures the ability of applicants to succeed in their respective fields. Orthopaedic and IM PDs both equally disagree with the alter to laissez passer/fail Step ane (p = 0.313) and agree that a graded Step 1 does not adequately measure the ability of an applicant to succeed in residency (p = 0.574).

How volition a pass/fail Step ane affect internal medicine and orthopaedic residency programs?

Few orthopaedic (10.4%) and IM (20.7%) PDs agree that a laissez passer/neglect Step one will aid to create ameliorate futurity physicians. IM PDs felt more strongly than Orthopaedic PDs that the alter to pass/fail Step 1 volition make the lucifer process less fair and meritocratic (p = 0.028).

How will the pass/fail alter touch on the importance of the factors reviewed by internal medicine and orthopaedic residency programs when assessing applicants?

The majority of orthopaedic (89.7%) and IM (69.6%) PDs believe that Step ane volition become less important when it transitions to pass/fail, and 96.nine% of orthopaedic and 88.0% of IM PDs agree that Step 2 Clinical Cognition exam (CK) score volition be more important. Additionally, 77.vi% of orthopaedic and 67.2% of IM PDs say grades in required clerkships will be more than important. The majority of both orthopaedic and IM PDs believe that personal knowledge of the applicant and an audition elective will exist more important.

Compared to IM PDs, orthopaedic PDs were significantly more than likely to say the following components will exist of greater importance subsequently the change to pass/fail Footstep 1: enquiry experience (p < 0.001); messages of recommendation from faculty they know (p < 0.0.001); Blastoff Omega Alpha (AOA) membership (p < 0.001); leadership/extracurricular activities (p < 0.001); personal knowledge of the bidder (p < 0.001) and audition electives (p < 0.001).

How will diverse bidder groups be affected by the change to a pass/fail Step 1?

The majority of orthopaedic and IM PDs believe that allopathic (Medico) students not attending highly-regarded medical schools, osteopathic (DO) students, and international medical graduates (IMGs) will be disadvantaged by the change of Step 1 to pass/fail. Compared to IM PDs, orthopaedic PDs were more likely to believe that MD students who do not nourish highly-regarded medical schools (p = 0.011) and DO students (p = 0.001) will exist disadvantaged in the match processes due to the Step i pass/neglect transition.

How volition irresolute to a pass/neglect Footstep 1 affect medical students interested in internal medicine and orthopaedics?

Orthopaedic and IM PDs both have low expectations (< 30%) that the alter to a pass/fail Footstep i will allow students to focus more on learning medicine rather than studying for the Step test, to seek out more leadership and extracurricular activities, or to pursue more than hobbies and self-development. Orthopaedic PDs (39.7%), compared to IM PDs (9.six%), were more probable to believe a pass/neglect Pace 1 will encourage applicants to pursue more research experiences (p < 0.001). Less than 10% of IM PDs thought the pass/fail change would encourage more research experience. Compared to IM PDs (28.viii%), orthopaedic PDs (58.6%) were more likely to recollect that the Step ane pass/fail change would encourage students to attend more than audition electives (p < 0.001).

What are the future implications on residency applications and medical didactics?

With the change to pass/fail Step 1, a bulk of orthopaedic and IM PDs agree that medical schools should adopt a graded pre-clinical curriculum, and that there should be a cap on the number of residency applications an bidder can submit.

Word

The nowadays study shows that the majority of orthopaedic and IM PDs do not support the Step 1 laissez passer/fail alter. Both orthopaedic and IM PDs believe Footstep 2 CK volition exist significantly more important. Afterward the pass/fail change, orthopaedic PDs are significantly more probable than IM PDs to assign greater value to research experience, letters of recommendation from faculty they know, AOA membership, leadership/extracurricular activities, personal knowledge of the bidder, and audience electives. Both orthopaedic and IM PDs believe students who nourish highly-regarded medical schools volition exist advantaged by the move to make Step 1 pass/fail. However, more orthopaedic PDs believe DO students and Physician students attending less prestigious medical schools will exist disadvantaged, while more IM PDs believe IMGs will be disadvantaged.

In December 2018, USMLE contacted major stakeholders, including orthopaedic and IM PDs, for public comment regarding USMLE scoring, and received over 37,000 responses. In March 2019, InCUS was sponsored by the AAMC, AMA, NBME, FSMB, and ECFMG, to talk over the effect of USMLE scores, and to explore potential avenues for improving the current scoring arrangement. Following InCUS, USMLE presented their findings to the AMA Council on Medical Education, and fabricated their preliminary findings publicly available on their website. Earlier officially announcing the scoring transition in Feb 2020, USMLE provided updates via their website, social media outlets, podcasts, and presentations at national meetings [one, 2]. Despite these steps, in the present study, a bulk of orthopaedic and IM PDs believed that the transition to laissez passer/fail was not transparent, suggesting that USMLE, and various stakeholders in medical didactics, such equally PDs, may need to assess ways to better communication with each other.

Currently, standardized examinations play a major part in evaluating residency applicants across specialties, with Step ane often being considered the most of import examination [ane,ii,3]. In the 2020 NRMP Survey, PDs across all specialties were asked to rank the factors used to interview and charge per unit applicants on a scale of 1 (not at all important) to 5 (very important). When selecting which applicants to interview, orthopaedic and IM PDs provided high ratings, over 4/5, for Step i. Furthermore, over 90% of orthopaedic and IM PDs cited Pace 1 as an important factor for screening applicants for an interview [3].

There is minimal evidence supporting a scored Step 1'southward ability to screen for successful residents [14,xv,16,17,18]. Even in our survey, the majority of both orthopaedic and IM PDs felt that a graded Step i did not adequately measure the ability of an applicant to succeed in residency. Nonetheless, the majority of orthopaedic and IM PDs also disagree with the laissez passer/fail change, suggesting that Pace 1 functions mainly every bit a convenient screening metric. A bulk also support application caps, which may advise that back up for the numeric Step 1 is primarily necessitated by the burden of programs receiving loftier numbers of applications [i, 2]. Despite the express predictive value of standardized tests for time to come success, both orthopaedics and IM have used Step 1 every bit a screening measure out for applicants due to the lack of boosted objective criteria [3]. Historically, both orthopaedics and IM have emphasized standardized test scores. Co-ordinate to the NRMP, U.S. MD seniors applying to orthopaedics had an boilerplate Step 1 score of 248 and a Step two CK score of 255. U.S. Physician seniors applying to IM had an average Pace 1 score of 235 and a Pace 2 CK score of 248 [19]. In our study, the majority of orthopaedic and IM PDs written report that Step 2 CK scores will be more important.

The results of our written report as well suggest that these specialties may place a greater emphasis on factors outside of standardized exam scores, as both orthopaedic and IM PDs believe grades in required clerkships, personal knowledge of the applicant, and audition electives volition at present be more than important. Additionally, orthopaedic PDs are more probable than IM PDs to say research experience, AOA membership, letters of recommendation from kinesthesia they know, leadership/extracurricular activities, personal noesis of the applicant, and audience electives volition be more important. Based on our assay, orthopaedic PDs are also significantly more probable to believe a pass/neglect Step 1 will encourage applicants to pursue more than enquiry experiences and to say it will encourage students to attend more audience electives. Recently, many orthopaedic programs have been publicizing holistic changes in their residency choice criteria on social media. For case, the University of Missouri - Kansas City Orthopaedic Surgery Residency programme announced on Twitter that they would no longer be because Step 1 and Step 2 CK scores. They plan on considering other factors like personal statement, recommendation letters, dean'due south letter, research, audience rotations, grades in required clerkships, and interest in their program [20]. This is one example of an orthopaedic plan moving toward a more holistic application review. A possible positive consequence of this movement towards a more than holistic procedure is that students from nontraditional, underrepresented, or underserved backgrounds may have more opportunities to be selected for interviews [21].

Interestingly, in the 2020 Friction match, U.South. MD seniors applying to orthopaedics had an boilerplate of xiv.3 abstracts/presentations/publications, viii volunteer experiences, and xl.3% were function of AOA; those applying to IM had an average of half-dozen.two abstracts/presentations/publications, 7.iii volunteer experiences, and 17.4% were part of AOA [nineteen]. This difference may be due to the more competitive match procedure in orthopaedics. In 2020, U.S. Dr. seniors applying to IM had a match rate 97.one%, while orthopaedics had a match rate of 79.7% [19].

This work found that 83.ii% of IM PDs believe IMGs volition be disadvantaged by the change to laissez passer/neglect Step ane, while only 58.half-dozen% of orthopaedic PDs believe IMGs volition be disadvantaged. This difference may be related to the lack of IMGs in orthopaedics, and the prevalence of IMGs in IM residencies. In 2019, only 1.5% of orthopaedic residents were IMGs, while 38.viii% of IM residents were IMGs [22]. IMGs frequently rely on Step 1 scores to help them stand out when applying to US residency programs. Many residency programs ofttimes use Step one scores to apace sift through the large volume of IMG applicants [23,24,25]. IM PDs volition have to consider new criteria by which to evaluate IMGs, while orthopaedic PDs will probable not face this challenge to the same extent, as IMGs make up such a small-scale portion of those inbound the field of orthopaedic surgery.

The present study demonstrated that orthopaedic PDs are more likely to say DOs will exist disadvantaged by the change to a laissez passer/neglect Step 1. When applying for residency, Do applicants may confront additional challenges compared to Medico students [25, 26]. This may be due to a variety of factors, including express research opportunities for students at Practise schools compared to students at Doc schools, as most US osteopathic medical schools are typically not associated with large bookish institutions [26].

A limitation of this study was that we were unable to obtain responses from all orthopaedic and IM residency PDs. Our report may exist limited past sampling bias and non-response bias. Respondents and non-respondents may have differed systematically, as PDs who experience strongly about this topic may accept been more than inclined to respond. Nevertheless, nosotros believe our information demonstrates responses from a substantial portion of PDs in orthopaedics (58 PDs, 36.0%) and in IM (125 PDs, 22.eight%), with representation from all four regions of the United States (West, Midwest, S, and Northeast), customs/bookish programs, and private/public programs.

Another limitation of this written report is that some contact information provided by FREIDA Online did not vest to the PD, only instead the plan's coordinator or administrative assistant. Our email requested program coordinators and administrative administration to ship the survey to PD.

Conclusions

In conclusion, the majority of orthopaedic and IM PDs do not support the Step 1 pass/fail alter. Both groups will rely more heavily on Step two CK. Orthopaedic PDs are significantly more than likely to value research experience, letters of recommendation from faculty they know, AOA membership, leadership/extracurricular activity, personal noesis of the applicant, and audition electives.

Availability of data and materials

The datasets generated and/or analyzed during the current study are not publicly bachelor considering the survey was conducted independently at our institution, but are available from the corresponding author on reasonable request.

Modify history

• 27 October 2021

  A Correction to this paper has been published: https://doi.org/ten.1186/s12909-021-02988-y

Abbreviations

USMLE:

U.s. Medical Licensing Examinations

FSMB:

Federation of Land Medical Boards

NBME:

National Board of Medical Examiners

CEUP:

Committee to Evaluate the USMLE Program

InCUS:

Invitational Conference on USMLE Scoring

AAMC:

Association of American Medical Colleges

AMA:

American Medical Association

ECFMG:

Educational Commission for Strange Medical Graduates

ACGME:

Accreditation Council for Graduate Medical Education

IM:

Internal Medicine

PD:

Program Director

FREIDA Online:

Fellowship and Residency Electronic Interactive Database

NRMP:

National Resident Matching Program

CK:

Clinical Knowledge test

AOA:

Alpha Omega Alpha

IMG:

International Medical Graduates

COMLEX:

Comprehensive Osteopathic Medical Licensing Examination

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Acknowledgements

Not applicable.

Funding

No funding was utilized.

Writer information

Affiliations

1. Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, U.s.a.

   Frederick Mun, Alyssa R. Scott, David Cui, Alia Chisty, Paul J. Juliano, William Fifty. Hennrikus & Eileen F. Hennrikus

2. Public Health Sciences at Penn State Higher of Medicine, Penn Land Milton Southward. Hershey Medical Center, Hershey, PA, USA

   Erik B. Lehman

3. Section of Orthopaedics and Rehabilitation, Yale School of Medicine, Yale New Oasis Hospital, New Haven, CT, Usa

   Seongho Jeong

4. Department of Internal Medicine, Penn State Higher of Medicine, Penn Country Milton Southward. Hershey Medical Center, Hershey, PA, USA

   Alia Chisty & Eileen F. Hennrikus

5. Department of Orthopaedics and Rehabilitation, Penn State Higher of Medicine, Penn Land Milton South. Hershey Medical Middle, Hershey, PA, United states

   Paul J. Juliano & William L. Hennrikus

Contributions

All authors made substantial contributions to the conception and design of the project. FM, ARS, DC, SJ, and EBL caused, analyzed, and interpreted the information. FM, Every bit, WLH, and EFH were major contributors in writing the manuscript. All authors read and approved the final manuscript.

Authors' data

Eileen Hennrikus is a professor of internal medicine at Penn Land Higher of Medicine. William Hennrikus is professor of orthopaedics, and acquaintance dean of continuing teaching at Penn State College of Medicine. Paul Juliano is the plan director of Penn State's orthopaedic surgery residency programme. Alia Chisty is the programme director of Penn State's internal medicine residency program.

Corresponding author

Correspondence to Frederick Mun.

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Ethics blessing and consent to participate

The report was exempted past the Penn State Higher of Medicine's IRB.

Ethical declarations: Informed consent was obtained from all participants. There were no participants nether 18. All methods were carried out in accordance to relevant guidelines and regulations.

Consent for publication

Our survey invitation emails with the appropriate informed consent data were sent to each PD. Submission of the survey indicated the respondents' consent to participate. All responses were collected anonymously.

Competing interests

The authors declare that they have no competing interests.

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Additional file 1.

Internal Medicine and Orthopaedic Surgery Program Director Step 1 Pass/Neglect Perceptions Survey.

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Mun, F., Scott, A.R., Cui, D. et al. A comparing of orthopaedic surgery and internal medicine perceptions of USMLE Step 1 pass/fail scoring. BMC Med Educ 21, 255 (2021). https://doi.org/ten.1186/s12909-021-02699-iv

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• Received: 12 February 2021

• Accustomed: 23 April 2021

• Published: 03 May 2021

• DOI : https://doi.org/10.1186/s12909-021-02699-4

Keywords

• USMLE
• Step 1
• Pass/fail scoring
• Orthopaedic surgery
• Internal medicine

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Source: https://bmcmededuc.biomedcentral.com/articles/10.1186/s12909-021-02699-4

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