Kenneth G. Poole Jr.

 When I was accepted to medical school coming out of Tennessee State University I knew very little about the long, arduous process ahead of me. Much like the community of HBCU collegiate faculty, family members, friends, and folks from my church home who were invaluable cheerleaders along my path, I thought the hard part was over. I was basically a doctor, right?

Wrong.

The reality was that the real work was just beginning. Medical school was full of challenges, obstacles, and hurdles that stretched me to the limits of what I thought was intellectually – and, at times, physically – possible. In addition to the immense volume of complex material and foreign medical jargon and nomenclature, I had to adjust to a socio-economic world I knew nothing about and unfortunately deal with some who thought I did not belong to be there.

Like virtually all medical students, the biggest academic mountain to overcome for me was the USMLE Step 1 examination. Known by all physicians as “Step 1,” the United States Medical License Examination Step 1 is the first of three examinations that are required to obtain a license to practice medicine. 

Step 1 is routinely taken between second and third years of medical school as a rite of passage between the two classroom years of medical school and the two clinical years, where students rotate in the hospital. Step 2 is divided into two exams generally taken the fourth year of medical school, and Step 3 is normally completed following graduation in residency training. These are separate and distinct from the board examinations physicians must take to obtain board certification for specific medical specialties following residency training. I had no clue that any of this existed prior to medical school.

Of the three, Step 1 is by far the most important. In fact, one could argue that Step 1 is the most important test that physicians take throughout their journey from high school through retirement. On the surface Step 1 is an examination that simply assesses basic medical knowledge that is foundational to patient care. Between the lines, however, Step 1 scores are used by residency programs to evaluate and screen applicants for coveted residency training slots.

At the start of medical school, I thought medical students picked their eventual specialties in the same manner that college students choose a major or minor area of concentration. Once again, wrong. 

I also was not aware of the income variability amongst physicians. All physicians do not make the same amount of money, do not have the same lifestyles, and are not afforded the same opportunities for career advancement. Medical specialty and employment dictates much of that. 

Per a 2018 Merritt Hawkins report, the average starting salary for a family medicine physician is $241,000; the average starting salary for a radiologist is $371,000; the average starting salary for a gastroenterologist is $487,000; and the average starting salary for an orthopedic surgeon is $533,000. 

It should also be noted that there is great variability in debt burden attributed to the astronomical costs of medical schools, with many students graduating debt-free and many graduating with upwards of $300,000 in student loans. As one can imagine, there is a great deal of competition for residency spots in high-paying specialties and at prestigious institutions, and politics, favoritism and bias are scattered throughout the process.

With that said, the raw, exposed truth is that physician specialty selection is predicated upon Step 1 scores, nuanced extracurricular activities, medical school performance, medical school reputation, and letters and phone calls that vouch for students. Of those, Step 1 scores are clearly the most objective measure. 

As a physician who holds a master’s degree in business administration and who has spent a considerable amount of time doing medical school admissions, I know a little something about standardized tests. As an African-American male physician who holds a master’s degree in business administration and who has spent a considerable amount of time doing medical school admissions, I’m more than fine stating that there is inherent cultural bias in standardized testing, which all too often puts racial and ethnic minorities at a disadvantage, particularly African Americans. 

There’s a “but,” however – and behind that “but” is the reality that standardized tests often provide the best opportunity to level playing fields rife with inequity, prejudice, and racism.

This week, the Federation of State Medical Boards (FSMB) and the National Board of Medical Examiners (NBME), co-sponsors of the USMLE, announced that Step 1 score reporting would become pass/fail no earlier than 2022 and that the allowable number of exam attempts on each USMLE Step exam would be reduced from six to four no earlier than 2021. So much for an opportunity to level that playing field. 

It’s unknown how pass/fail reporting for Step 1 will affect the residency application process. Will residency programs start looking at pre-medical collegiate performance, Medical College Admissions Test (MCAT) scores, or perhaps USMLE Step 2 scores? Will medical school reputation matter more? What about medical school performance or grades, which are commonly pass/fail at many medical schools? Or what about those letters and phone calls that vouch for students?

What is known is that testing aside, all of the aforementioned can be presented and interpreted with a great deal of subjectivity – opening the door to bias, especially against students of color, low-income students, students from less reputable medical schools, and students from foreign or international medical schools. The decision to do away with Step 1 scores just made navigating the mine fields of medical education more difficult for students from disenfranchised backgrounds. 

As medical school acceptance notices go out to tens of thousands of bright pre-meds hopeful of a fulfilling, lucrative career as a physician, it’s good on one hand to know that Step 1 will not hold the weight that it has for decades and will no longer decide where and how they’ll practice medicine for the rest of their lives. In that other hand is the sticky reality that something more subjective will.

To the young black man coming out of Tennessee State University who knows very little about the long, arduous process ahead of him, you certainly are not a doctor yet. The hard part is not over.

A graduate of Northwestern University Feinberg School of Medicine and Washington University’s Olin School of Business, Dr. Kenneth G. Poole Jr. is the medical director of Patient Experience for Mayo Clinic Arizona, chair of the Mayo Clinic Enterprise Health Information Coordinating Subcommittee, and a member of the Mayo Clinic Alix School of Medicine admissions committee. He is a North St. Louis County native and a product of the Mathews Dickey Boys and Girls Club, Hazelwood Public Schools, Lutheran North High School, and Tennessee State University. The views expressed above are his own and do not represent those of the Mayo Clinic. 

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