A few separate paragraphs I’ve tied together from Curriculum Development for Medical Education:

The difference between the ideal approach and the current approach represents a general needs assessment.

[A] curriculum can be written, starting with broad or general goals and then moving to specific, measurable objectives. Objectives may include cognitive (knowledge), affective (attitudinal), or psychomotor (skill and behavioral) objectives for the learner; process objectives related to the conduct of the curriculum; or even health, health care, or patient outcome objectives. The development of goals and objectives is critical because they help to determine curricular content and learning methods and help to focus the learner. They enable communication of what the curriculum is about to others and provide a basis for its evaluation. When resources are limited, prioritization of objectives can facilitate the rational allocation of those resources.

The first step in designing a curriculum is to identify and characterize the health care problem that will be addressed by the curriculum, how the problem is currently being addressed, and how it ideally should be addressed.

What percentage of core medical curricula simply exist, and then goals and objectives are grafted on after the fact to link up with the things that are already happening?

When is the last time any medical school went back to first principles? 1910?

Update 2/11/2020: The NBOME cancelled indefinitely postponed COMLEX Level 2-PE. Not sure why they needed the extra shame of waiting two weeks to cave to reality. Here’s the refund waiver link for students who already paid.

On the heels of this week’s USMLE Step 2 CS cancellation and the immediate bold non-cancellation of the COMLEX Level 2-PE (Restarting April 2021? Are you joking?), I thought it’d be worth sharing some information about which states actually require the COMLEX for osteopathic licensure. You see, many DO students already take and pass the more common USMLE exam required for allopathic physicians/MDs.

While schools impose their own graduation requirements and traditionally DO residences may have their preferences, most states don’t care if a DO student passes the COMLEX or the USMLE.

The American Osteopathic Association (AOA) released this licensure summary back in May 2020 (currently unavailable for public consumption save through the magic of the Wayback Machine, h/t Mustafa Basree). The summary is this:

• In 44/50 states, DO students can complete the USMLE exams for licensure.
• 5 more states (CA, MI, OK, WV, and PA) are more complicated. These often have requirements that are clearly in need of an update (such as permitting the substitution of the defunct FLEX exam for older doctors but with no mention of USMLE). MI, OK, and WV may give reciprocity (i.e. get licensed in one of the usual 44 and you may be able to transfer). Pennsylvania also requires a dedicated OMT exam if you haven’t passed Level 2-PE. The language here sometimes says “similar” requirements and sometimes says “equal requirements.” I have no idea what constitutes what here, but certainly wanting to work in these states would be a reason to finish the COMLEX series for now.
• Only Florida actually specifically demands a full suite of COMLEX scores.

Given that Step 2 CS is canceled, the world has changed. SOMA, the largest osteopathic student association, has already called for a single licensure exam, but students are–at best–the bottom of the stakeholder food chain. I encourage physicians to lobby their state medical boards to modernize their rules and legislate away redundant requirements. I encourage the entire DO community to put pressure on the AOA to change the COCA accreditation requirements that require students to take the COMLEX in order to graduate.

I’m not saying that the COMLEX shouldn’t count (of course it should); I’m saying it shouldn’t exist.

If the USMLE is enough for MDs, it should be enough for DOs as well. Let the market decide. I don’t think the NBOME, a broadly despised organization, is doing osteopathy any favors here.

Whenever possible, I hope DO organizations, schools, and students walk away from the offerings of the NBOME and put pressure on the organization to reform itself into nonexistence. A system of two separate but otherwise analogous licensing exams is wasteful and expensive (and profitable). Osteopathic principles and manipulative medicine are not sufficient justification for complete redundancy, and there is no future where COMLEX overtakes the USMLE. Just add in a short dedicated OMM exam and call it day. Practically, I don’t think there’s a future where most traditionally allopathic program directors ever accept COMLEX in place of USMLE without bias until at least Step 2 CK becomes pass/fail. The NBOME might be holding on specifically for that future, at which point no one will care who takes what.

For now, students who are able to graduate without taking COMLEX Level 2-PE due to the pandemic and don’t need to practice in the exception states but who have taken USMLE Step 1 and Step 2 CK can finish out the series with Step 3 and call it a day. I hope folks doing this opens the common sense floodgates, but organized medicine doesn’t change easily.

In the 21st century, I’m not convinced physicians are best served by maintaining distinct osteopathic and allopathic pathways at all. A physician is a physician, and the easiest way to get rid of the unfair DO stigma is not to make it a PR issue–but to make it a non-issue. I understand there’s a lot of history here (though much of it not so positive) and plenty of strong feelings. However, even if one buys the argument that the underlying educational philosophy is sufficiently different to warrant different degrees, that’s no justification for perpetuating a separate-but-equal system for licensure given that post-graduate training has already merged and the vast majority of states don’t care.

The eventual outcome is the same. As we all know, it’s the residency training that really makes the doctor.

The NBME announced yesterday that they’re scrapping plans to relaunch the USMLE Step 2 CS as a virtual telehealth evaluation that pretends to assess clinical skills:

Following the May 2020 suspension of Step 2 CS due to the COVID-19 pandemic, we announced our intention to take 12-18 months to bring back a modified Step 2 CS exam that was appreciably better than the prior assessment. After reviewing current and anticipated progress with the exam and in consideration of the rapidly evolving medical education, practice and technology landscapes, we have decided to discontinue Step 2 CS.

If you want to read somebody pillorying the initial plan, here was my take.

Clinical skills evaluation isn’t dead, it’s just unclear how it will be incorporated in the future. The obvious solution is to offload a formal standardized clinical experience to schools in the form of a universal OSCE, but who knows. If there’s a way for the NBME to profit here without completely looking awful, they’ll find it.

A long time coming

In 2016, there was a grassroots movement to #EndStep2CS, codifying the gripes of generations of medical students angry about an expensive and inconvenient test (read: tax) with a near 100% pass rate. In response, the NBME increased the failure rate. While they couldn’t argue about the expense or the inconvenience, they could pretend that the exam was now really good at catching “deficient” students (even though they had no data that Step 2 CS performance meant anything in the real world).

One of The only benefit of Step 2 CS for US students was that it really forced schools to invest more in (LCME-required) Objective Structured Clinical Examinations (OSCE) and provide more structured instruction in clinical skills. OSCEs aren’t perfect, but there is an undeniable role for simulated medical exams and standardized patients in the medical education toolkit. But the idea that pandemic-affected residents seeing real patients would need to travel around the country to see fake ones in order to do what they’re already doing was silly. And the idea that the NBME could move CS online and somehow have that be more meaningful than what the schools are already required to do in-person was untenable.

And so here we are.

It took a pandemic, but Step 2 CS is canceled.

I’ll admit that wasn’t on my 2021 bingo card, but perhaps in the background, the NBME was looking for a way to save face and cancel the increasingly unpopular CS without admitting the test was garbage.

Now what?

It’s still early days here. Advocate-in-chief Dr. Carmody rapidly turned around a good summary, which I always recommend, including how the news will impact international students (for now, back to taking an English test) and DO students (the NBOME sunk enough money into their version that they really don’t want to cancel it).

The NBOME, the NBME’s osteopathic counterpart, deserves some serious scorn here for continuing to double down on their products (and, really, continuing to exist at all). The preservation of separate parallel licensing exams is a bad look in a world where most states don’t actually require DOs to take DO-specific exams, most residencies prefer the USMLE, and where ACGME has since taken over the accreditation of all residencies. It’s an extra cost for DO students that provides no value.

The continued existence of osteopathic schools as a distinct entity from allopathic schools itself is mostly an anachronism, and the faster the NBME and the copy-cat NBOME can merge the better off students will be. If not, I hope osteopathic schools will increasingly remove any COMLEX-specific board exam graduation requirements and enable the students to vote with their feet (and student loan dollars). Let the market decide.