Medical school and residency applications will never be the same.
Within the past few months, two major events have upended decades-long norms in medical education. First, the United States Medical Licensing Examination (USMLE) Step 1 announced its move to a pass-fail score reporting system.1 Shortly afterwards, the coronavirus disease (COVID-19) pandemic arrived and shifted most of medical education online, and in the process, it drastically altered the medical school timeline.
Licensing exams, clinical clerkships, away rotations, and many other educational milestones have been postponed indefinitely, placing program directors in the unenviable position of needing to select future residents based on incomplete information. Given the competitiveness of dermatology, medical students applying into our specialty are understandably concerned about their prospects. For example, students without home dermatology programs may not be able to complete away rotations due to lockdowns; as a result, they may be precluded from research opportunities and letters of recommendation. Also, the uncertainty of USMLE scheduling amidst social distancing2 may force students to take the exam at inopportune times, thus leading to scores that are not indicative of their true ability.
Dermatology program directors need a reasonably objective metric that can stratify applicants without unfairly disadvantaging students who might be negatively affected by the recent changes described above. The solution is a dermatology shelf exam.
Residency directors could design an exam that tests certain knowledge areas deemed as critical for incoming residents. Developing such an exam would be relatively straightforward, as clinical dermatology questions already appear on other National Board of Medical Examiners (NBME) shelf exams, including internal medicine, surgery, pediatrics, family medicine, and emergency medicine. In order to test basic science, exam designers could use existing USMLE Step 1 questions, or perhaps look at existing dermatology board exam questions to formulate questions that a graduating medical student could reasonably answer.
Such an approach would ensure that studying for the exam would be beneficial in and of itself, and it would help future dermatology residents get a head start on their education. This would also address one of the main objections to the USMLE Step 1: the fact that it tests minutiae rarely relevant to clinical practice.3
The dermatology shelf exam could be administered through medical schools much like other NBME shelf exams, and only students interested in applying for dermatology would need to take it. In addition, allowing medical schools access to their students’ performance would enable them to adjust their curricula accordingly. Further, students could maintain social distancing, whether in the immediate future or beyond as needed, as they would not need to travel to a third-party testing center for exam administration.
Programs need not necessarily use the dermatology shelf exam score in the exact same manner in terms of selecting residents. For example, some programs may use the shelf score as a screening cutoff, while others may weigh the exam as part of a holistic evaluation of the applicant. If such criteria are made known, students can use their exam score to get a better sense of their competitiveness for dermatology residency and tailor their application strategy accordingly. While some argue that USMLE scores already serve this function, students starting medical school in 2021 (the beginning of the pass/fail era of Step 1) will likely take Step 2 CK (clinical knowledge) too late in the application cycle for those results to have any impact. In contrast, students could take the dermatology shelf exam anytime during their clinical rotations, perhaps months before their residency applications are due. Their score could also help them decide whether they want to take a gap year to strengthen other aspects of their application.
An important caveat is that standardized tests are inherently flawed, and they should never become the sole metric used to select residents. Residency programs should continue to use traditional criteria such as letters of recommendation, performance in away rotations, or research output in order to select applicants. However, it is also important to acknowledge that these other criteria are also flawed and heavily favor applicants from prestigious medical schools. This may explain why a large percentage of matched dermatology applicants hail from a select few institutions.4
As dermatology is one of the most competitive residencies, increased transparency in the selection process would benefit both programs and applicants. A well-designed dermatology shelf exam would provide an additional objective data point about an applicant while motivating students to learn knowledge that will be valuable during dermatology residency training.
Dr Hussain is a dermatology resident physician at MedStar Washington Hospital Center in Washington, DC.
Disclosure: The author reports no relevant financial relationships.
1. USMLE program announces upcoming policy changes. United States Medical Licensing Examination. February 12, 2020. Accessed May 11, 2020. https://www.usmle.org/incus/#decision
2. USMLE update on resuming testing. United States Medical Licensing Examination. May 8, 2020. Accessed May 11, 2020. https://www.usmle.org/announcements/default.aspx
3. Crane MA, Chang HA, Azamfirei R. Medical education takes a step in the right direction: where does that leave students? JAMA. Published online March 6, 2020. doi:10.1001/jama.2020.2950
4. Ryan MP, De Jong AL, Wagner RF. Medical school ranking and dermatology match results: an analysis of the 2018 match data. Dermatol Online J. 2019;25(3):13030/qt59p3z80r.