Opinion | Reimagining the Step 1 Exam Dedicated Study Period

The Step 1 three-digit score has long been one of the main statistics residency programs used to rank applicants, giving this single exam the power of determining the rest of a student’s medical career. As this was not the primary intent of the exam, the Step 1 examination was made pass/fail, therefore eliminating the three-digit scoring system.

As one of the last of the cohorts to take the United States Medical Licensing Examination Step 1 with the three-digit score, I spent 8 weeks reviewing, memorizing, practicing, and synthesizing the mass amount of material that was thrown out at us during my didactic years of medical school. Going into this stressful and overwhelming time, I heard very few positive stories from senior medical students from my institution, on online forums, or on YouTube. Yet, as my dedicated study period ended, I couldn’t help but reflect on my personal and academic growth during this time. While I recognize this isn’t a uniformly shared perspective, I can’t help but be grateful for the time we were given to step back and synthesize all the information we were taught throughout medical school and college.

Part of my gratitude may come from the unique experience of my class because of the pandemic. When the pandemic caused the termination of in-person educational sessions, we had to find ways to adapt to the isolation most students were thrust into during their dedicated period. Though independent study may come naturally to some, others who feed off social interaction struggled to be alone with their course materials and thoughts for more than 2 months. With that said, since our class spent the entire year in isolation, we were faced with the inevitability of social isolation and virtual learning early on, and either had to learn to cope with our discomfort or suppress it until we met again on the wards during our third year of medical school.

Apart from the unique circumstances of the 2020-2021 academic year, I couldn’t help but think about what I would’ve done if a three-digit score was not looming over me as I prepared for the exam. Early in my preparation, I was fortunate enough to get a passing score on a practice exam, and I even caught myself thinking, “If I didn’t have to worry about a score, I could take the test now and take the next 6 weeks off.” Now that I have completed my dedicated period and the Step 1 exam and I think about the amount of material I felt comfortable with at that point compared with now, I feel like I am a completely different physician-in-training. My biggest area of growth during this period was making connections between multiple fields and systems to develop a broad list of differential diagnoses, and narrowing and altering that differential as more information was divulged — a critical skill in the clinical setting.

As many medical schools shift toward a three-semester basic science curriculum and students consider forgoing a Step 1 dedicated study period in favor of an extended pre-clinical break, I argue we need to preserve this unstructured study period and encourage students to take the time to prepare for their exam and clinical years.

Of course, there is going to be an inevitable shift in importance from Step 1 as the primary determining factor for residency selection to Step 2, so there is a valid argument for considering moving the extended dedicated period to later in the medical school curriculum to allow students to prepare more thoroughly for Step 2. However, Step 1 offers a unique scenario in which the medical student can amalgamate all of their education to better understand the pathophysiology and pharmacology of disease. Not only does this time give students a chance to fully appreciate the information they have been drowning in for 2 years, but it also gives students an opportunity to start thinking like a physician before they enter the clinical setting. Additionally, the two exams are purposefully distinct. Since the Step 2 is focused more on what to do with different patient presentations, this exam builds upon Step 1 material and better lends itself to a less traditional review format.

While the decision has already been made to eliminate the three-digit score from the Step 1 exam, we still want to give students the time necessary to digest and appreciate the information from their basic science curricula. How should we move forward?

I posit it is time to reimagine the Step 1 exam dedicated period. Without the stress of having to achieve a certain score, this study period can be devoted to synthesis, self-care, reflection, and preparation for the clinical rotations to come. If medical schools want to ensure proper use of this unstructured time, they could consider enforcing a minimum study period duration, after which students must meet certain requirements to show they’re using the time in ways deemed acceptable by these institutions. Though some students will need more time than others, this time is crucial for all trainees to be able to shut off the metaphorical firehose and start learning to think like a physician. Thinking like a physician is a huge shift in the focus for this study period and what makes this reimagined dedicated period so unique. Instead of trying to “think like a question writer” or “crack the code” of the exam, students can instead learn how to look at problems on multiple levels, identify patterns, recognize tricky similarities between pathologies or patient presentations, and better recognize when a clinical scenario doesn’t fit the initial hypothesis. By preserving and reimagining this dedicated period, our future physicians will learn valuable skills beyond the stress and trauma often associated with the old Step 1 “dedicated” canon as they transform from student doctors to physicians-in-training.

Cullen M. Lilley, MS, is an MD/MA candidate at the Loyola University Chicago Stritch School of Medicine.

Last Updated January 07, 2022