To Increase Diversity, Medicine Should Rethink USMLE Scores, Psychiatrists Say

Putting so much emphasis on standardized tests gives an advantage to people of more privileged backgrounds who can afford testing materials and tutoring programs, Durham argued.

“We already know that the ZIP code where you come from can determine your future from birth,” she said. “When families are living at or below the federal poverty level, they don’t have access to the same educational resources as a family with more money. Unfortunately, this typically affects more people of color than the white population.”

“Medicine is so much more than an exam score,” Hairston said in an email. “Where is the value for students who are dedicated to underserved populations, changing policies, collaborative care, and listening? If residency programs continue to value and screen students based on just this exam metric, things will remain the same, dictated by exams with proven bias.”

“I have no doubt that there is inequity in access to test preparation resources among medical students due to family income levels, parental education levels, etc.,” said Howard Liu, M.D., M.B.A., chair of the University of Nebraska Medical Center Department of Psychiatry, president of the Association of Directors of Medical Student Education in Psychiatry, and a member of APA’s Council on Communications. “For a first-generation student, the cost of rent can be stressful, let alone paying for high-priced test preparation materials and question banks. In addition, underrepresented students have faced years of systemic racism in education by the time they matriculate into medical school, which is another risk factor for lower performance on standardized exams.”

The American Association of Directors of Psychiatric Residency Training (AADPRT) Assessment Committee shares the concern that the USMLE’s approach to assessing readiness for state licensure has several limitations, said the committee’s chair, John Q. Young, M.D., M.P.P., Ph.D., in a statement. He added that the exams do not address competencies such as teamwork, collaboration, and integrity, which are “critical to the safe and effective practices of medicine.”

“Regarding diversity—the evidence is clear,” Young continued in the statement. “Health outcomes are better when the physician workforce mirrors the patient population that it serves. This is true in psychiatry. Increasing diversity in psychiatry should be a public health imperative.”

In addition to Young’s comments, AADPRT President Melissa Arbuckle, M.D., Ph.D., noted in an email that recruiting underrepresented students to psychiatry requires “a sustained commitment to anti-racism, to understanding and addressing disparities, and to supporting and nurturing underrepresented students.”

The Federation of State Medical Boards and the National Board of Medical Examiners decided to make Step 1 of the USMLE a pass/fail score starting no earlier than January 1, 2022.

The change, Jordan and Durham said, is a step in the right direction. But they worry that emphasis will simply be shifted to the Step 2 test score, thus not solving the problem but moving it down the line.

Moving to a pass/fail Step 1 score creates an opportunity to do what Adrienne Adams, M.D., M.S., refers to as holistic interviewing. Adams is the chair of AADPRT’s diversity and inclusion committee, an associate professor of psychiatry at Rush Medical College, and the director of the child and adolescent fellowship program at Rush University.

“I think it’s important to look at the whole person, not just a three-digit score,” she said. “How have they done with classes? What are some of the community activities or volunteer work they’ve done outside of school? Do they have research experience? What shows their resilience—did they have to work full time to support themselves in addition to attending school?”

“If we’re truly concerned about addressing health care disparities, it is imperative that we adequately train a diverse set of physicians that can meet our patients’ complex medical as well as social needs,” Jordan said. ■