In the past several years, there have been many efforts to reform medical education and improve the rate of passage of the United States Medical Licensing Examination (USMLE), in particular, Step 1, which is the most difficult part of the USMLE. According to a recent report published in Medical Education by Steven A. Lieberman, M.D., and other professors in the University of Texas Medical Branch at Galveston (UTMB), the Step 1 examination has the lowest pass rate of all of the licensure sequence examinations, especially among under-represented minorities and women. UTMB has developed an approach that Lieberman and his colleagues report have had a remarkable effect on its students’ performance on the medical board exam.
Lieberman said that the overall rate of failure on the Step 1 exam has dropped from 7.5 percent to 2.3 percent, compared to a national rate in the 5 to 7 percent range. The change for minority students, which he described as “huge and surprising,” dropped from 16.9 to 3.9 percent, which is lower than the national failure rate for all students.
“Curriculum reform in medical education has been a big topic for the last couple of decades or so. By and large, the approach that’s been taken to try to improve students’ performance has been to fix one part of the educational system,” said Lieberman, who is UTMB’s John P. McGovern Distinguished Chair in Oslerian Medicine and vice dean for academic affairs. “None of these isolated approaches have had much success. We changed multiple aspects of the educational system and aligned them so that all of the horses were pulling in the same direction.” This was achieved by breaking down silos between departments, curriculum, student affairs, faculty development, admissions and pipelines, he added. The school also customized academic support to specific curriculum demands and to diverse student backgrounds, educational experiences and prior academic performance.
“Everybody probably does some of the things that UTMB is doing—more faculty development, pipeline programs, all of the different elements that they describe, but I’m not sure that everybody does the whole combination. UTMB really tried to do everything at once, and it seems to have paid off. In addition, they really support their educators,” said Dr. Patricia Butler, senior associate dean for educational programs at the UT Health Medical School at Houston.
It was important that the reform efforts recognize that many students who have been very successful as undergraduates find the medical school environment more challenging in part because it forces them to learn new study skills. Their undergraduate experience was made up mostly of lectures and exams that require the rote memorization of isolated facts, which Lieberman says is not conducive to the study of medicine.
“We want them to learn basic science so they can apply it to understanding patients and solving patient problems,” Lieberman explained. UTMB has moved away from heavy reliance on lectures and has changed its curriculum to include a lot more small-group, problem-based learning.
“It’s not just exam prep; it’s how we teach. Students spend six hours a week in small groups of eight or nine students with a faculty member. They work through patient problems and discuss basic science in the context of those problems,” he said. “We do have lectures and laboratory exercises to support them in their learning, but they do a lot of independent learning and self-directed study.”
A traditional medical school curriculum includes 23.5 hours per week of lectures, laboratories and rare small groups. UTMB’s integrated medical curriculum is made up of 16.3 hours, six of which are spent in small student groups with a faculty member, lectures, laboratories and other approaches. According to the report, the latter gives students time for self-directed learning; student-centered, active shared learning; and self-directed active, relevant problem solving.
Students in a traditional curriculum rarely take low-stakes formative assessment examinations, while UTMB students take these examinations weekly to assess higher-order thinking and receive feedback. UTMB also has an extensive academic advising system that includes professional academic counselors as well as peer or near-peer tutoring one-on-one and in groups for first- and second-year students.
“We test them the same way that we teach them to reinforce it, and the faculty have been developed to help students think in that problem-solving sort of way. Our academic support programs help the students learn the material in that problem-solving mode as well,” Lieberman said.
UTMB has a very diverse student body and, from 2000 to 2008, it ranked second in the percentage of under-represented graduates in the United States, exclusive of historically Black and Puerto Rican medical schools. It also partners with several schools in the UT system and throughout Texas that have high proportions of under-represented minorities in their undergraduate populations. The pipeline help prepare students for the rigors of medical school and many bring students to campus during their [undergraduate] summers to get some academic reinforcement and early clinical or laboratory research experience. Some of the programs prepare students with Medical College Admissions Tests and provide them with pointers and practice for medical school interviews.
“I think the report is an important contribution to the literature in thinking critically and comprehensively about how one does institutional curricular reform,” said Marc Nivet, diversity officer at the Association of American Medical Colleges. “The author stated that many attempts at changing the curriculum often do not think about the pipeline programs that they’re engaged in and this school made an intentional effort to include even the pre-medical pipeline programs that they develop into their curriculum changes, giving all students who are in those programs more of an opportunity to be successful both in their curriculum and ultimately passing Step 1 of the board.”