USMLE Arms Race

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And so it begins.

Today marks the start of the dreaded ISP, or Intensive Study Period – that time when second year medical students attempt to refresh or re-learn everything from the past two years of their schooling.  We have just one month spend diligently cramming for the most important test of our lives.  The USMLE Step 1 is the first of three national licensing examinations for U.S. MD students, but its real importance lies in determining our career options.  Do well and the world is your oyster.  End up at the low end of the curve…well let’s just say your hopes of matching into a Dermatology or Plastic Surgery residency are rather stricken.  If you were planning to practice Family Medicine somewhere in BFE – well then it may just be your lucky day.


The real travesty of the high selection pressure imposed by STEP 1 is that it has come to resemble an information and economic arms-race not unlike the duel between the U.S. and U.S.S.R. during the Cold War – metaphorically, at least.  Medical students are some of the most competitive and hard-working people on the planet, but here this works against us.  A positive-feedback loop was created, in which students willing to pursue ever-more diminishing returns to memorize factoids that might appear on the boards slowly started to have an impact on average scores.  To compensate for this apparent grade inflation, the designers of the test had to find even more obscure, clinically irrelevant details to maintain their precious bell curve, and so forth.

Then the internet hit.  Now everyone has access to vast expanses of all these formerly secret and exclusive nuggets of trivia, carefully compiled by a host of new companies who have found themselves in the business equivalent of an all-you-can-eat buffet.  Desperate, anal-retentive med students represent the ultimate seller’s market.  $50 soft-cover test prep book?  Shut up and take my money.  $100 online pathology review lecture series?  Sign me up.  $300 question bank?  How could I hope to do well without it?  The list goes on.  I didn’t even mention the $1500-$3000 live prep courses available…ouch.


So now we are in a situation where an exam costing $560 requires an additional $400 at a minimum to prepare for.  I am unashamedly following the herd like a sheep in front of a cane, sporting my trusty 2013 edition First Aid ($40), Pathoma ($100) and USMLE WORLD question bank ($300).  Baaa.

I wish I could say it gets better, but sometime next year we’ll be taking STEP 2, an exam with both a written and practical portion (in Chicago, no less).  Cost?  Well, lets see – $1750.  Looks like the government will be making record returns on its 6.8% investment next year.  Pity it’s at my expense.

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