Educational and Personal Opportunity Costs of Medical Student Preparation for the United States Medical Licensing Examination Step 1 Exam: A Single-Center Study

Purpose To assess the degree to which medical students choose to disengage from their regular preclinical curriculum and extracurricular activities in order to focus on United States Medical Licensing Examination (USMLE) Step 1 exam preparation, as well as learner-perceived effects of Step 1 preparation on their physical, social, and mental health. Method Online survey of medical students who have taken the USMLE Step 1 exam at a single large Midwestern academic medical center. Results The response rate was 54%. Students often reported absenteeism from a variety of preclinical curricular activities, including lectures (44%) and didactics focusing on medical ethics (37%), clinical skills (28%), and encounters with actual and standardized patients (9%) in order to study for USMLE Step 1. Many students also forewent extracurricular opportunities including research (53%), elective patient care opportunities (45%), community service (39%), and healthcare advocacy experiences (38%) in order to study for USMLE Step 1. Majorities of students identified Step 1 preparation as a cause of burnout (79%) or significant anxiety or depression (61%), for which nearly a third sought mental healthcare; students also reported Step 1 preparation as a cause of engaging in dangerous behaviors such as illicit prescription stimulant use as well as driving or providing patient care while impaired by fatigue. In narrative comments, students frequently described Step 1 to be a barrier to their development into effective clinicians, the traditional medical school curriculum to be a barrier to performance on Step 1, or both. Conclusions Medical students often prioritize Step 1 exam preparation over engaging with the standard preclinical curriculum, extracurricular opportunities, and activities to promote wellbeing. These findings have implications for the emphasis residency program directors place on single high-stakes standardized exams in the resident recruitment process.