The in-Training Editors-in-Chief, Nihaal Mehta (NM) and Amelia Mackarey (AM), talked to Dr. Dustyn Williams (DW) and Jamie Fitch (JF), co-founders of OnlineMedEd — one of the most widely-used educational resources by medical students around the world — and two leading figures in shaping medical education. The conversation ranged from OnlineMedEd as a learning platform to Dustyn’s and Jamie’s philosophies on teaching and the future of medical student education.
You can also read parts one, two, and three of this interview. Here, in part four, we talk about how rising USMLE scores will impact residency applications, why medical knowledge is becoming less important for doctors and how the electronic medical record has hurt medical education.
NM: My experience with using multiple resources, if you’re getting First Aid, Pathoma, UWorld, Sketchy — and that’s only for first and second year — you’re talking about thousands of dollars in subscriptions that’s on top of your enormous medical school tuition bill. With Step scores going up every year, just get to that average is harder — is that part of the calculus behind the model of free videos and the idea of bringing it all into one place?
DW: I would love it if everyone got 240. One of my founding principles was more education for more people for less — free videos. The other one was to go after predatory education services that charge thousands of dollars and give you shit — and you know who they are. The last one was, the USMLE exam was always meant to be pass/fail, a litmus test — and it isn’t.
If everyone learns enough so that everyone keeps scoring highly, so that the average is 230 or 240 or above, then it stops becoming about the scores and more about the person. I want people to do well on the test. But I’m ok with the test getting “easy,” or people knowing the licensing exam answers. That means everyone’s better qualified to be a doctor — that’s ok. So, no, it’s not really about trying to help people compete. It’s more about get everyone doing so well that the licensing exam becomes pass/fail regardless of your scores.
NM: Do you worry, though, that if everyone’s scoring a 240, the new standard becomes you have to score a 260 to get into something that, before, a 245 would have been ok? Or do you think that forces a re-evaluation of how we’re using Step 1 and 2 scores?
DW: That’s exactly it. We’re actually working with the White Coat Coaching — Emily Tan is doing a “how to get into residency” series for us. She helps [orthopedic surgery] applicants get into ortho residencies. [At the Baton Rouge General Internal Medicine Residency Program] we’re an IMG [international medical graduate]-friendly residency — most come from the Caribbean or India — so we do use the Step 1 scores as a litmus. If you’re an IMG and you failed, we’re not going to look at you. But if you have over 220 on either Step 1 or Step 2, you’re ruled in. We’d rather have people who wants to be in the program to work with for three years than someone with [high] scores.
If we can get more people thinking like that then I think the Step score becomes less relevant. If people are worried about getting their ophthalmology spot, I really don’t give a shit. You have to get a 280. But you want to be a doctor and get into residency, it should be more about who you are and not your score.
JF: When you talk about Emily, pretty much everyone applying to ortho has the same scores — it’s a very high score. So she’s looking at beyond that. The score doesn’t matter — I guess it matters to be within the cool kids club, to even be able to go for it, but after that it’s all about your personality and what else you bring to the table.
DW: Program directors are old people. People still think the average is 220 and that the second number you get is your percentile. I have to educate people about what’s a good score and bad one. We have DOs that apply with a 490 — is that good? It’s a lot higher than 270! Actually, it’s below average.
I don’t think people are going to be negatively affected by people doing well. I think the person that gets a 220 who wants to do anesthesia is going to have trouble, but the people who get the average — which used to be a standard deviation above the mean — I don’t think it’s going to cause problems. It might cause problems for programs. They’re going to have to find ways to re-evaluate and pick people better, not just based on the Step score.
JF: There’s already been a slight paradigm switch. It used to be if you just killed Step 1 you were good to go. It still kind of is. But it used to be if you didn’t do well on that it’s a complete uphill battle. Over the last decade that’s changed — the Step 2 holds a lot more value than it ever has. People are looking at what you actually do in your sub-is [sub-internships] and electives. There’s already a shift — I don’t want to say completely away from Step 1 — but there’s been a slow change toward understanding the holistic doctor and what makes you up as a person.
DW: As an example, at Tulane for medicine, we have a rating system and if you do well on either Step 1 or Step 2, it doesn’t matter which — you don’t get docked, you get added points. The shift is that it’s not, “do you know the basic sciences?” — Step 1, Step 2, the tests — it’s, “are you a person? Are you a doctor? Do you know how to interact with people?” And, ok, yeah, that test score’s there. You can’t fail, but as long as you perform above a certain level, you’re ruled in. Residencies are always going to rule people out — there’s 5 spots for 5,000 people. They get so many applicants, they’re going to have to do it.
In terms of becoming a physician, it’s going to be better. You’ll be more likely to be paired with people who are like you, who you want to work with, and less with people who scored similarly to you. This is something I want to contribute to Emily’s program: When you pick a residency, the name is irrelevant, where you go is irrelevant, your score is irrelevant. If you don’t like the people, your life will be miserable. It’s far better to find someone you want to work with for 4-5 years, who you want to be on the same team with, than to work with someone who got a great score or to go to a name brand for the sake of going to a name brand.
I hope what we’re doing here has the downstream effect of [making it so that] the USMLE score, especially Step 1, can’t be used as the rule-out tool, and instead what people do to get admitted to residency is more about the humanistic side of things.
NM: We’ve talked about some of the shifts in medical education. Obviously, there have been bigger shifts in medicine as a whole. How have you seen the evolution in medicine — especially in things like EMRs [electronic medical records] and the administrative work doctors have to do — how do you see that impacting medical education?
DW: I don’t like bureaucratic bodies in general, but the ACGME [American College of Graduate Medical Education] Milestone program was exceptional, with LCME [Liaison Committee on Medical Education] following suit. What they’ve said is knowing a bunch of stuff doesn’t make you a good doctor. Being a well-rounded person who can communicate with patients … professional integrity, leadership — all these things are now recognized as part of being a fantastic doctor.
What medical school has done traditionally is teach everything about everything, because in the 1960s we didn’t know that much. Harrison’s has quadrupled in size in the past 40 years. We have people teaching who grew up in that environment, where medicine was anatomy and they could learn everything about everything.
What I hope is by creating a resource like OnlineMedEd, it builds the foundations. You come into class having already done OnlineMedEd, ready to take it to the next level rather than catching up. Since OnlineMedEd is far more efficient and effective at teaching you the things you need to know at the level you need to know them, you have an infinite amount of time left over for something else.
What I’d love to see happen is medical schools use OnlineMedEd to satisfy the medical education portion of the LCME Milestone. And then use the free time that’s left over, instead of eight hours of class, to give earlier exposure to patient care, to let people become humans — so they don’t gain weight and lose all their hobbies — and then go through the things you can’t do online: leadership, communication, teamwork.
Medical schools will have to be creative in how they do that. Not just going to class — going to class is easy. We’re more efficient than they are. Students will learn what they need to learn and they’ll pass their exams. Hopefully, there will be more time left over for being a person — developing the whole, holistic approach — not just the medical knowledge.
The fifth and final part of our interview with Dr. Dustyn Williams and Jamie Fitch, co-founders of OnlineMedEd, will be released next week.