Medical Students' Reflections on the Recent Changes to the USMLE Step Exams

Association of USMLE Step 1 Pass/Fail Reporting with Interview and Match Outcomes

OBJECTIVE

To investigate interview and match outcomes of medical students who received pass/fail USMLE reporting vs medical students with numeric scoring during the same period.

DESIGN

Retrospective analysis of a cross-sectional survey-based study.

SETTING

United States 2023 residency match.

PARTICIPANTS

Medical student applicants in the 2023 residency match cycle who responded to the Texas Seeking Transparency in Application to Residency (STAR) survey.

RESULTS

Among 6756 applicants for the 2023 match, 496 (7.3%) took USMLE Step 1 with pass/fail reporting. Pass/fail reporting was associated with lower USMLE Step 2-CK scores (245.9 vs 250.7), fewer honored clerkships (2.4 vs 3.1), and lower Alpha Omega Alpha membership (12.5% vs 25.2%) (all p < 0.001). Applicants with numeric USMLE Step 1 scores received more interview offers after adjusting for academic performance (beta coefficient 1.04 (95% CI 0.28-1.79); p = 0.007). Numeric USMLE Step 1 scoring was associated with more interview offers in nonsurgical specialties (beta coefficient 1.64 [95% CI 0.74-2.53]; p < 0.001), but not in general surgery (beta coefficient 3.01 [95% CI -0.82 to 6.84]; p = 0.123) or surgical subspecialties (beta coefficient 1.92 [95% CI -0.78 to 4.62]; p = 0.163). Numeric USMLE Step 1 scoring was not associated with match outcome.

CONCLUSIONS

Applicants with numeric USMLE Step 1 scoring had stronger academic profiles than those with pass/fail scoring; however, adjusted analyses found only weak associations with interview or match outcomes. Further research is warranted to assess longitudinal outcomes.

Impact of USMLE Step 1 transition to pass/fail scoring system on medical students' anxiety, sleep quality, and burnout

INTRODUCTION

Originally designed to evaluate the application of foundational scientific knowledge in clinical contexts, the United States Medical License Exam (USMLE) Step 1 evolved into a comparative tool for assessing candidates with similar educational foundations. This transition heightened the pressure on medical students to excel in the exam. In response, collaborative efforts involving the National Board of Medical Examiners prompted a change from reporting scores to a pass/fail system. The true impact of this shift remains insufficiently explored. This study aims to assess the emotional toll - encompassing burnout, anxiety, depression, and sleep quality - experienced prior to taking the Step 1 exam. Additionally, it aims to uncover potential gender-based disparities in perceived anxiety and depression.

METHODS

The study encompasses the entirety of third-year medical students at Drexel University College of Medicine, who were invited to participate in a comprehensive survey. Drawing from retrospection, the survey relies on self-reported data regarding anxiety, depression, sleep quality, and burnout. Data compilation was anonymized and executed via Qualtrics platform.

RESULTS

A total of 102 medical students completed the survey, with a 97% pass rate for the USMLE Step 1. Despite their excellent performance, 75% of students reported inadequate sleep quality, and 68% exhibited mild to moderate anxiety levels. Among them, a higher percentage of females (83%) experienced anxiety compared to their male counterparts (50%). Furthermore, 66% of students felt that their commitment to education exceeded what was reasonable for their well-being.

CONCLUSIONS

The transition from traditional scoring to a pass/fail system was ostensibly intended to enhance the mental well-being of medical students. Nevertheless, our findings underscore that students continue to endure heightened levels of stress, anxiety, and burnout during the pivotal month leading up to the Step 1 examination.

Family Medicine Clerkship Directors' Perspectives on USMLE Pass/Fail Scoring: A CERA Study

INTRODUCTION

Reports on the effects of changing the United States Medical Licensing Exam (USMLE) Step 1 examination scoring to pass/fail are evolving in the medical literature. This Council of Academic Family Medicine Educational Research Alliance family medicine clerkship directors' study seeks to describe family medicine clerkship directors' perceptions on the impact of incorporation of Step 1 pass/fail score reporting on students' family medicine clerkship performance.

METHODS

Ninety-six clerkship directors responded (56.8% response rate). After exclusion of Canadian schools, we analyzed 88 clerkship directors' responses from US schools. We used descriptive statistics for demographics and responses to survey questions. We used ꭓ2 analysis to determine statistically significant associations between survey items.

RESULTS

Clerkship directors did not observe changes in students' overall clinical performance after Step 1 pass/fail scoring (60.8%). Fifty percent of clerkship directors reported changes in Step 1 timing recommendations in the past 3 years. Reasons included curriculum redesign (30.5%), COVID (4.5%), change in Step 1 to pass/fail (11.0%), and other reasons (3.7%). Forty-five percent of these clerkship directors did not observe a change in students' clinical medical knowledge after Step 1 went to pass/fail. Eighty-four percent of these clerkship directors did not compare student performance on clerkship standardized exams before and after Step 1 score changes. We found no significant relationship between Step 1 timing and student performance.

CONCLUSIONS

This study represents an early description of family medicine clerkship directors' perceived observations of the impact of Step 1 scoring changes on student performance. Continued investigation of the effects of USMLE Step 1 pass/fail scoring should occur.

Update on the Selection Criteria of Plastic Surgery Residents: A Survey of Program Directors and Associate Program Directors

BACKGROUND

Plastic and reconstructive surgery (PRS) is recognized as a highly competitive specialty. Since the first assessment of resident selection criteria in 2007, PRS residency programs have adopted holistic review processes and adapted to changes such as a decline in medical schools participating in the Alpha Omega Alpha Honor Medical Society as well as the recent transition to pass/fail grading for the United States Medical Licensing Examination (USMLE) step 1 examination (Schultz et al. Plast Reconstr Surg Glob Open . 2020;8:e2892; Tadisina et al. Plast Reconstr Surg . 2017;139:330e-331e). This study was devised to evaluate current PRS residency criteria in light of these changes.

METHODS

An anonymous, 12-item, electronic survey was generated and distributed using Alchemer. An email was sent to 171 program directors (PDs) and associate program directors (APDs) of PRS residency programs. Survey questions were developed to collect data regarding respondent demographics and their desired criteria when assessing residency applicants. Complete responses were collected and analyzed with summary statistics and multivariate logistic regression using RStudio (version 1.3.109).

RESULTS

In total, 44 (25.7% response rate) of the 171 PDs and APDs completed the survey. Of the 16 programs (36.4%) with a USMLE cutoff score, 7 (43.8%) reported a range of 230 to 239 and 6 (37.5%) reported a range of 240 to 249. Without a score for step 1, the majority (48.8%) of respondents believe that step 2 scores will replace step 1 scores in terms of assessment criteria, and the content of recommendation letters was selected as the criterion with the greatest increase in weight (66.7%). In addition, 27.3% of programs require a step 2 score at the time of interview. The top 3 academic criteria in order of decreasing importance were the content of recommendation letters, clinical grades, and letter writers, whereas the top 3 nonacademic criteria were subinternship performance, maturity, and interview performance.

CONCLUSIONS

Plastic and reconstructive surgery remains a highly competitive specialty for residency applicants. Our findings suggest that Alpha Omega Alpha membership remains diminished in importance, whereas USMLE cutoff scores have increased. With recent changes in the step 1 grading system, PDs and APDs will rely more heavily on step 2 scores and the content of recommendation letters.

Student Perspectives on the Undergraduate Medical Student Research Experience at a Single United States Allopathic Institution

Introduction The purpose of this study was to identify student-reported institutional facilitators and barriers to successful research experiences at a single United States allopathic institution. Residency applications have increasingly become more competitive, and with the United States Medical Licensing Examination (USMLE) Step 1 exam's transition to pass/fail, factors such as research experience and outcomes may become more important to increase residency application competitiveness. This study sought to explore factors that impact successful research experiences leading to tangible outcomes for medical students at our medical school, the Joe R. & Teresa Lozano Long School of Medicine. Methods  A cross-sectional survey was developed and administered via REDCap to 853 students in May 2022. Survey question domains included demographics, past and present research participation, perceived barriers/facilitators to research, tangible outcomes (e.g., publications and posters), and overall satisfaction with research comparing subjectively "best" and "worst" experiences. The Institutional Review Board (IRB) deemed this project as non-regulated research.  Results We had a 24% (n = 204/853) response rate. The responses were distributed equally among the four classes. A big portion of the participants (71%, n = 59/83) identified a tangible outcome as the most important measure of success. Regarding facilitators, students identified having a mentor (89%, n = 165/184) and departmental connections (85%, n = 156/184) as the most important when looking for a project. Barriers included SMART goals (Specific, Measurable, Achievable, Relevant, and Time-Bound) lacking in 31% (n = 24/75) of worst projects, followed by a clear timeline in 29% (n = 22/76) and hours of commitment in 27% (n = 21/78). The best projects were more likely to have resulted in a publication (61% (27/44) vs. 32% (14/44)) or have a poster (64% (28/44) vs. 36% (16/44)). Conclusions Medical students are interested in participating in research, with important facilitators including mentorship and departmental connections. Modifiable variables include lack of clear timelines, well-defined roles and responsibilities, and time commitments. This information may be useful for faculty who mentor medical students or medical schools interested in designing medical student research programs.

The Impact of United States Medical Licensing Examination Step 1 Transitioning To Pass/Fail on Medical Student Perception of Research Needed to Match Into One's Preferred Specialty

Purpose To evaluate how the transition of United States Medical Licensing Examination (USMLE) Step 1 to a pass/fail scoring influenced medical student perceptions of the importance of research required to match into their preferred residency specialty. Methods A 14-item survey was distributed by e-mail to medical students at one medical school in the southeastern United States in November of 2021. Responses were compared between medical students taking USMLE Step 1 pass/fail in the future and medical students taking USMLE Step 1 for a three-digit score. Results A total of 168 medical students responded to the survey with 98 respondents who planned on taking USMLE Step 1 pass/fail (45 first-year medical students (MS1) and 53 MS2) and 70 respondents who took USMLE Step 1 for a numerical score (37 MS3 and 33 MS4). There were no differences in how each cohort scored the level of importance of research in matching into their preferred residency specialty (p=0.10); however, those taking USMLE Step 1 pass/fail believe an average of 4.6 research experiences are necessary to match into their preferred residency, compared to only 3.4 research experiences for those who took it for a numerical score (p=0.04). Conclusion No statistically significant difference in the perceived importance of research in matching into one's preferred residency specialty was found between cohorts. However, the pass/fail cohort believes they will need more research experiences to match their chosen specialty than the numerical score cohort. Results could indicate that students participate in more research and extracurricular activities to be more competitive for residency applications.

Pure Wisdom or Potemkin Villages? A Comparison of ChatGPT 3.5 and ChatGPT 4 on USMLE Step 3 Style Questions: Quantitative Analysis

BACKGROUND

The United States Medical Licensing Examination (USMLE) has been critical in medical education since 1992, testing various aspects of a medical student's knowledge and skills through different steps, based on their training level. Artificial intelligence (AI) tools, including chatbots like ChatGPT, are emerging technologies with potential applications in medicine. However, comprehensive studies analyzing ChatGPT's performance on USMLE Step 3 in large-scale scenarios and comparing different versions of ChatGPT are limited.

OBJECTIVE

This paper aimed to analyze ChatGPT's performance on USMLE Step 3 practice test questions to better elucidate the strengths and weaknesses of AI use in medical education and deduce evidence-based strategies to counteract AI cheating.

METHODS

A total of 2069 USMLE Step 3 practice questions were extracted from the AMBOSS study platform. After including 229 image-based questions, a total of 1840 text-based questions were further categorized and entered into ChatGPT 3.5, while a subset of 229 questions were entered into ChatGPT 4. Responses were recorded, and the accuracy of ChatGPT answers as well as its performance in different test question categories and for different difficulty levels were compared between both versions.

RESULTS

Overall, ChatGPT 4 demonstrated a statistically significant superior performance compared to ChatGPT 3.5, achieving an accuracy of 84.7% (194/229) and 56.9% (1047/1840), respectively. A noteworthy correlation was observed between the length of test questions and the performance of ChatGPT 3.5 (ρ=-0.069; P=.003), which was absent in ChatGPT 4 (P=.87). Additionally, the difficulty of test questions, as categorized by AMBOSS hammer ratings, showed a statistically significant correlation with performance for both ChatGPT versions, with ρ=-0.289 for ChatGPT 3.5 and ρ=-0.344 for ChatGPT 4. ChatGPT 4 surpassed ChatGPT 3.5 in all levels of test question difficulty, except for the 2 highest difficulty tiers (4 and 5 hammers), where statistical significance was not reached.

CONCLUSIONS

In this study, ChatGPT 4 demonstrated remarkable proficiency in taking the USMLE Step 3, with an accuracy rate of 84.7% (194/229), outshining ChatGPT 3.5 with an accuracy rate of 56.9% (1047/1840). Although ChatGPT 4 performed exceptionally, it encountered difficulties in questions requiring the application of theoretical concepts, particularly in cardiology and neurology. These insights are pivotal for the development of examination strategies that are resilient to AI and underline the promising role of AI in the realm of medical education and diagnostics.

Competency-Based Medical Education in a Norm-Referenced World: A Root Cause Analysis of Challenges to the Competency-Based Paradigm in Medical School

Competency-based medical education (CBME) requires a criterion-referenced approach to assessment. However, despite best efforts to advance CBME, there remains an implicit, and at times, explicit, demand for norm-referencing, particularly at the junction of undergraduate medical education (UME) and graduate medical education (GME). In this manuscript, the authors perform a root cause analysis to determine the underlying reasons for continued norm-referencing in the context of the movement toward CBME. The root cause analysis consisted of 2 processes: (1) identification of potential causes and effects organized into a fishbone diagram and (2) identification of the 5 whys. The fishbone diagram identified 2 primary drivers: the false notion that measures such as grades are truly objective and the importance of different incentives for different key constituents. From these drivers, the importance of norm-referencing for residency selection was identified as a critical component. Exploration of the 5 whys further detailed the reasons for continuation of norm-referenced grading to facilitate selection, including the need for efficient screening in residency selection, dependence upon rank-order lists, perception that there is a best outcome to the match, lack of trust between residency programs and medical schools, and inadequate resources to support progression of trainees. Based on these findings, the authors argue that the implied purpose of assessment in UME is primarily stratification for residency selection. Because stratification requires comparison, a norm-referenced approach is needed. To advance CBME, the authors recommend reconsideration of the approach to assessment in UME to maintain the purpose of selection while also advancing the purpose of rendering a competency decision. Changing the approach will require a collaboration between national organizations, accrediting bodies, GME programs, UME programs, students, and patients/societies. Details are provided regarding the specific approaches required of each key constituent group.

The Impact of Changing Step 1 to Pass/Fail Reporting on Anxiety, Learning Approaches, and Curiosity

Purpose

Given the significance of the US Medical Licensing Exam (USMLE) Step 1 score moving from a 3-digit value to pass/fail, the authors investigated the impact of the change on students' anxiety, approach to learning, and curiosity.

Method

Two cohorts of pre-clerkship medical students at three medical schools completed a composite of four instruments: the State-Trait Anxiety Inventory, the revised two-factor Study Process Questionnaire, the Interest/Deprivation Type Epistemic Curiosity Scale, and the Short Grit Scale prior to taking the last 3-digit scored Step 1 in 2021 or taking the first pass/fail scored Step 1 in 2022. Responses of 3-digit and pass/fail exam takers were compared (Mann-Whitney U) and multiple regression path analysis was performed to determine the factors that significantly impacted learning strategies.

Results

There was no difference between 3-digit (n = 86) and pass/fail exam takers (n = 154) in anxiety (STA-I scores, 50 vs. 49, p = 0.85), shallow learning strategies (22 vs. 23, p = 0.84), or interest curiosity scores (median scores 15 vs. 15, p = 0.07). However, pass/fail exam takers had lower deprivation curiosity scores (median 12 vs. 11, p = 0.03) and showed a decline in deep learning strategies (30 vs. 27, p = 0.0012). Path analysis indicated the decline in deep learning strategies was due to the change in exam scoring (β = - 2.0428, p < 0.05).

Conclusions

Counter to the stated hypothesis and intentions, the initial impact of the change to pass/fail grading for USMLE Step 1 failed to reduce learner anxiety, and reduced curiosity and deep learning strategies.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40670-023-01878-w.

The US Residency Selection Process After the United States Medical Licensing Examination Step 1 Pass/Fail Change: Overview for Applicants and Educators

The United States Medical Licensing Examination (USMLE) Step 1, arguably the most significant assessment in the USMLE examination series, changed from a 3-digit score to a pass/fail outcome in January 2022. Given the rapidly evolving body of literature on this subject, this paper aims to provide a comprehensive review of the historical context and impact of this change on various stakeholders involved in residency selection. For this, relevant keyword-based searches were performed in PubMed, Google Scholar, and Scopus to identify relevant literature. Given the unique history of USMLE Step 1 in the US residency selection process and the score's correlation with future performance in board-certifying examinations in different specialties, this scoring change is predicted to significantly impact US Doctor of Medicine students, US Doctor of Osteopathic Medicine students, international medical graduates, and residency program directors, among others. The significance and the rationale of the pass/fail change along with the implications for both residency applicants and educators are also summarized in this paper. Although medical programs, academic institutions, and residency organizing bodies across the United States have swiftly stepped up to ensure a seamless transition and have attempted to ensure equity for all, the conversion process carries considerable uncertainty for residency applicants. For educators, the increasing number of applications conflicts with holistic application screening, leading to the expected greater use of objective measures, with USMLE Step 2 Clinical Knowledge likely becoming the preferred screening tool in lieu of Step 1.

Ethnic and Racial Differences in Ratings in the Medical Student Standardized Letters of Evaluation (SLOE)

BACKGROUND

The Standardized Letter of Evaluation (SLOE) stratifies the assessment of emergency medicine (EM) bound medical applicants. However, bias in SLOE, particularly regarding race and ethnicity, is an underexplored area.

OBJECTIVE

This study aims to assess whether underrepresented in medicine (UIM) and non-UIM applicants are rated differently in SLOE components.

METHODS

This was a cross-section study of EM-bound applicants across 3 geographically distinct US training programs during the 2019-2020 application cycle. Using descriptive and regression analyses, we examine the differences between UIM applicants and non-UIM applicants for each of the SLOE components: 7 qualifications of an EM physician (7QEM), global assessment (GA) rating, and projected rank list (RL) position.

RESULTS

Out of a combined total of 3759, 2002 (53.3%) unique EM-bound applicants were included. UIM applicants had lower ratings for each of the 7QEM questions, GA, and RL positions. Compared to non-UIM applicants, only some of the 7QEM components: "Work ethic and ability to assume responsibility," "Ability to work in a team, and "Ability to communicate a caring nature," were associated with their SLOE. "Commitment to EM" correlated more with GA for UIM than for non-UIM applicants.

CONCLUSIONS

This study shows a difference in SLOE rating, with UIM applicants receiving lower ratings than non-UIM applicants.

Student-Led Initiatives and Advocacy in Academic Medicine: Empowering the Leaders of Tomorrow

Trainees' value as effective leaders within academic medicine has been increasingly recognized. From their perspective as adult learners who enter medical education from diverse backgrounds, trainees offer significant value to the teaching, learning, and practice of medicine. As such, trainees have developed and led various successful initiatives throughout academic medicine. In this Invited Commentary, 2 medical students with national leadership roles provide their perspectives on how student-led initiatives and advocacy can help push academic medicine forward. The authors first provide an overview of the success of student-led initiatives throughout medical education as evidenced by the Trainee-Authored Letters to the Editor in this issue, highlighting the unique contributions and perspectives of trainees in the development and implementation of new initiatives or ways of thinking. Although trainees add value to many areas in academic medicine, here the authors highlight 4 current areas that align with Association of American Medical Colleges priorities: (1) public health emergencies including the COVID-19 pandemic; (2) equity, inclusion, and diversity; (3) wellness and resilience amongst trainees and health care providers; and (4) recent changes to the United States Medical Licensing Examination and the transition to residency. By sharing their experiences with student-led initiatives within each of these domains, the authors provide lessons learned and discuss successes and obstacles encountered along the way. Overall, there is a critical need for increased engagement of trainees in medical education. Empowering trainees now ensures the academic medicine leaders of tomorrow are prepared to face the challenges that await them.

Reported completion of the USMLE Step 1 and match outcomes among senior osteopathic students in 2020

Context

The United States Medical Licensing Examination (USMLE) is not required for osteopathic students to match into postgraduate programs; however, it is unknown if taking the test improves their chances of matching.

Objectives

Our objective was to determine the association between taking the USMLE Step 1 and matching into the applicant’s preferred specialty for senior osteopathic students applying to the 10 specialties to which students applied most in 2020.

Methods

We performed a secondary analysis of the free and publicly available 2020 National Residency Match Program (NRMP) published match report for senior osteopathic students. First, we determined the number of senior osteopathic students that matched into their preferred specialty vs those that did not and stratified them by reported completion of the USMLE Step 1 within each specialty. Next, we calculated odds ratios (ORs) within each specialty for senior osteopathic students matching into their preferred specialty with and without the USMLE Step 1 utilizing the Fisher’s exact test. Finally, we repeated the analysis with only senior osteopathic students who had reported USMLE Step 1 scores in ranges including or below the mean for those who matched in their specialty.

Results

For senior osteopathic students, reported completion of the USMLE Step 1 was associated with matching for those who applied to Internal Medicine (OR 3.3 [95% confidence interval 2.07 to 5.48]), Emergency Medicine (2.1 [1.35 to 3.17]), Pediatrics (4.4 [1.38 to 18.63]), Psychiatry (2.5 [1.34 to 4.98]), Anesthesiology (3.4 [1.57 to 7.32]), and General Surgery (3.1 [1.56 to 6.14]). After repeating the analysis with only senior osteopathic students who reported low USMLE Step 1 scores, the association remained significant for those who applied to Internal Medicine (2.5 [1.49 to 4.28]), Anesthesiology (2.6 [1.17 to 5.54]), and General Surgery (2.5 [1.24 to 5.04]).

Conclusions

In 2020, reported completion of the USMLE Step 1 by senior osteopathic students was associated with matching for those who applied to Internal Medicine, Emergency Medicine, Pediatrics, Psychiatry, Anesthesiology, and General Surgery. In addition, reported completion of the USMLE Step 1 with a low score was associated with matching for those who applied to Internal Medicine, Anesthesiology, and General Surgery.

Current Views on the New United States Medical Licensing Examination Step 1 Pass/Fail Format: A Review of the Literature

INTRODUCTION

Residency programs have historically used numerical Step 1 scores to screen applicants, making it a career-defining, high-stakes examination. Step 1 scores will be reported as pass/fail starting in January 2022, fundamentally reshaping the residency application review process. This review aimed to identify opinions of physicians and medical students about the new format, identify arguments in support of or against the change, and determine the implications of this change on the residency selection process.

METHODS

A comprehensive PubMed review was performed in May 2021 to identify articles that discussed the new Step 1 format. Non-English and duplicate articles were excluded. Data collected from each article included publication year, specialty, subjects, and key findings.

RESULTS

A total of 81 articles were included, 26 of which discussed the impact of the new format within surgical fields (32.1%). Remaining articles discussed the implications within the medical community as a whole (n = 33, 40.7%) and nonsurgical fields (n = 22, 27.2%). Studies suggest Program Directors will rely on Step 2 Clinical Knowledge (CK) scores, medical school reputation, applicant familiarity, Dean's letters, recommendation letters, and research in lieu of numerical Step 1 scores. In addition, concerns have been raised that the new format will disadvantage international, osteopathic, and minority applicants while increasing stress surrounding Step 2 CK.

CONCLUSIONS

Within the medical community, there are concerns that Step 2 CK will be used to substitute Step 1 and that resident diversity will diminish due to the new Step 1 format. Holistic candidate consideration will be increasingly important.

Student well-being during dedicated preparation for USMLE Step 1 and COMLEX Level 1 exams

BACKGROUND

Nearly all U.S. medical students engage in a 4-8 week period of intense preparation for their first-level licensure exams, termed a "dedicated preparation period" (DPP). It is widely assumed that student well-being is harmed during DPPs, but evidence is limited. This study characterized students' physical, intellectual, emotional, and social well-being during DPPs.

METHODS

This was a cross-sectional survey sent electronically to all second-year students at four U.S. medical schools after each school's respective DPP for USMLE Step 1 or COMLEX Level 1 in 2019. Survey items assessed DPP characteristics, cost of resources, and perceived financial strain as predictors for 18 outcomes measured by items with Likert-type response options. Open-ended responses on DPPs' influence underwent thematic analysis.

RESULTS

A total of 314/750 (42%) students completed surveys. DPPs lasted a median of 7 weeks (IQR 6-8 weeks), and students spent 70 h/week (IQR 56-80 h/week) studying. A total of 62 (20%) reported experiencing a significant life event that impacted their ability to study during their DPPs. Most reported 2 outcomes improved: medical knowledge base (95%) and confidence in ability to care for patients (56%). Most reported 9 outcomes worsened, including overall quality of life (72%), feeling burned out (77%), and personal anxiety (81%). A total of 25% reported paying for preparation materials strained their finances. Greater perceived financial strain was associated with worsening 11 outcomes, with reported amount spent associated with worsening 2 outcomes. Themes from student descriptions of how DPPs for first-level exams influenced them included (1) opportunity for synthesis of medical knowledge, (2) exercise of endurance and self-discipline required for professional practice, (3) dissonance among exam preparation resource content, formal curriculum, and professional values, (4) isolation, deprivation, and anguish from competing for the highest possible score, and (5) effects on well-being after DPPs.

CONCLUSIONS

DPPs are currently experienced by many students as a period of personal and social deprivation, which may be worsened by perceived financial stress more than the amount of money they spend on preparation materials. DPPs should be considered as a target for reform as medical educators attempt to prevent student suffering and enhance their well-being.