A Closer Look at Medical Education—the role early licensing exams play in constructing a curriculum

Before we really know what law schools could borrow from medical schools and what we can’t, it is critical to understand how very different our two enterprises are.   Medical schools have access to resources of which we can only dream (they are profitable).   Also, medical education is far from flawless—there are issues, especially in the second two years, of bullying and systemic racism that are very troubling.  Finally, the phenomena of medical students not attending class is old news—although some schools have responded with very impressive creative solutions like self-directed learning to making class time more valuable.  Moreover, a focus on U.S. Medical Schools  alone is misleading given how my physicians practicing in the U.S. attended allopathic or foreign medical schools.

 The purpose of these posts, though, continues to be introducing how other disciplines use research data to evaluate and develop curricular innovations—and if you’d like to know about that without further talk of medical education have a look here and here.

Let’s start an issue close to all of our hearts—licensing exams.   Medical students start taking licensing exams while they are in school.  The United States Medical Licensing Examination (USLME) has three parts (steps).

Passage at each step is mandatory for continuation of medical studies.  The first exam comes after two years.  At four years, when they graduate, they must pass a two part second exam after which they are licensed to practice only under supervision and, finally, they must pass a third test before they can be fully licensed. 

Who writes exams?  A company that is owned by the Federation of State Medical Board  (“FSMB).   Like lawyers physicians must be licensed by the state in which they practice but unlike lawyers, these licensing boards have come together in developing a uniform licensing exam.

And it’s not coincidental that the need to pass two licensing exams while in medical school focuses the curriculum towards the more practical aspects of practicing medicine.  Have a look at FSMB’s mission-- “70 Boards. One Mission. FSMB supports America’s state medical boards in licensing, disciplining and regulating physicians and other healthcare professionals. Our end goal: keep patients safe.”   

Because these exams have come during medical school as far back as the living memory of anyone practicing medicine, the idea that the medical school curriculum would ignore them has never had the hold on academic medicine the way it has in the legal academy.  It’s not that anyone believes that the contents of the exam are the most important or certainly most interesting part of practicing medicine (look  here, herehttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC1681601/, and herehttps://www.stfm.org/fmhub/fm2008/September/John574.pdf)—it’s that there can be no practice of medicine without passing them.  And even more so, because failure rates are very low, the score students achieve on these exams (which they can only take once if they pass) are critical to their chances of getting a desirable residency slot.

So, like it or not, Medical Schools have to confront licensure exams while students are in school whereas we legal academics do not have this direct exposure.  The USMLE’s emphasis on patient safety orients the first four years of medical school’s curriculum towards issues that are most likely to come up in practice (with its fair share of “gotchas” to keep things interesting).  Neither the finer points of neurosurgery or heart transplantation are tested in Step https://www.boardvitals.com/blog/9-things-to-know-before-taking-usmle-step-1-exam/1 or Step 2https://www.usmlepro.com/single-post/How-to-Score-a-280-on-Step-2-CK.  Yet the first four years of medical school are hardly one long exam prep session.  Medical school professors also like to teach students about complex problems with no easy answers. (and students often complain there is not enough focus on the boards).

In contrast, law school curriculums, even in first year mandatory courses, often  privilege the most difficult problems that make their way to appellate courts.   We have also designed a curriculum where the most heavily tested subjects are taught years in advance of the exam-and likely never referred to again until the students begin bar preparation after graduation.

As noted in the beginning, the differences between law and medical schools make drawing on the nose analogies or facile comparisons a waste of time and resources.   But by understanding the differences and seeing how medical schools have applied research findings to solving their curricular issues we can benefit from knowing more about what they and indeed what all our colleagues in higher education are doing to enhance the education of their students.

Going forward, I will look more closely at issues like how medical schools prepare students for these licensing exams, how the MCAT has changed with the change in medical school curriculums, and what efforts are being made to reduce the cost (and length) of medical school.