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.

The AAMC recently released an open letter sounding the alarm bells on how the residency interview season is shaping up this year:

We are seeing students in the highest tier receiving a larger number of interviews per person than in past years, leaving other students – including those in the middle of the class – with fewer interviews than we would anticipate based on their qualifications.

Interestingly, interview software purveyor Thalamus is arguing that this year is like last year. Who is right? I don’t know. Perhaps the AAMC’s data tells a different story. Or maybe they’re crying wolf. They do have a vested interest in programs filling and people matching at high rates to stave off growing criticism of their growing ERAS revenues.

But #ApplicationFever has been very beneficial for one group:
the Association of American Medical Colleges (AAMC), corporate sponsor of ERAS.

Note how ERAS revenue has increased almost three-fold since 2008. pic.twitter.com/RszTxhUWXd

— Bryan Carmody (@jbcarmody) March 3, 2020

They go with this advice to schools:

Discuss any additional steps that students with fewer interview offers than anticipated might take at this point to maximize their likelihood of matching (for example, applying to preliminary positions for which applications are still being accepted).

This could also read: we recommend people give us more money by applying to more programs.

Also, this is terrible advice. There’s a good chance there will be more spots in the SOAP than usual this year. If you’re a typical applicant who would expect to match in years past but are suffering from a dearth of interviews, why would you pass up the chance for a categorical spot in the SOAP for a prelim position that goes nowhere? The kinds of prelims that are accepting new applications in December are probably the kinds of spots that aren’t selling like hotcakes pre-SOAP anyway.

And they offered the following advice for students:

Consider releasing some interviews if you are holding more than needed, allowing your fellow students access to these interview opportunities. If you have fewer interview offers than anticipated, discuss with your student affairs officer or advisor any additional steps you might take at this point to maximize your likelihood of matching (for example, applying to preliminary positions for which applications are still being accepted).

People have largely been going on too many interviews (for years). While some fields have a preponderance of tiny programs, nearly 80% of successful applicants will end up with one of their top 4 and rarely go beyond 7-8.

However, it’s ludicrous to put this back in the students’ hands and argue that they should go against their own interests. Overapplication and–to some extent–interview hoarding are rational choices made to maximize the odds of a successful match. We shouldn’t blame students for playing a poorly designed game as best they can.

The AAMC has the most power to improve this process

This year should serve as a wake-up call because it’s not the n=1 powerless students that have the agency here. It’s the AAMC. The combination of pass/fail Step 1 and increasing graduating medical student numbers was already threatening to send the residency selection process into an application fever death-spiral before the pandemic, and they’re still coming for us.

Though, sure, look at Charting Outcomes and your interview plans. If you’ve been on a bunch of interviews and you have some programs lined up that you aren’t genuinely interested in, you could potentially change a peer’s career by giving up a slot in addition to avoiding another day on Zoom.

But the real take-home point is this:

The AAMC, through its highly-profitable administration of ERAS, is ultimately the entity responsible for the “maldistribution of residency interview invitations.”

The rest of us are just doing the best we can.

From a WaPo article discussing protests at Stanford about a vaccine distribution plan that favored remote-working employees over trainees:

The “residents” — medical school graduates who staff the hospital for several years as they learn specialties such as emergency medicine, internal medicine and family medicine — were furious when it became clear that just seven of the more than 1,300 at the medical center were in the first round for vaccinations. Also affected were “fellows,” who work in the hospital as they train further in sub-specialties, nurses and other staff.
An email to pediatrics residents and fellows obtained by The Washington Post said that “the Stanford vaccine algorithm failed to prioritize house staff,” as the early year doctors are known collectively.

Of course “Medical school graduates” should read doctors or physicians.

Stanford blaming the algorithm in its medical version of Silicon Valley doublespeak is such a hand-wavy 2020 way of passing the buck. An algorithm is just a set of rules for carrying out a task.

The algorithm in this case isn’t some artificial intelligence black box. It represents value judgments made by fallible humans. In this case, the folks in charge forgot that it should be a person’s function in the system more than their benefits package that should determine how quickly they receive a vaccine that may not only protect them but hopefully prevent the spread of a potentially deadly disease to patients.

Those in the front line should be at the front of the line (unless we were to otherwise reasonably implement the age-based vaccination program used in many countries). Within a hospital system stratified by job roles, it’s the environmental and food services staff, nurses, CNAs, techs, transport, and all providers directly facing patients who should get it when supplies are constrained.

The idea that leadership could forget a huge class of people working in the hospital because those people aren’t considered normal employees is just another example of trainees being treated as faceless cog-like cheap labor. It’s an unfairness baked into our training system where the only pathway to independent practice as a physician is to be treated as a second-class citizen, which implicitly supports these sorts of slights.

So, when you make a mistake so blatant that you aren’t sure how to respond, don’t blame the algorithm. Blame yourself.

I’ve done enough Zoom nonsense since March that I thought I’d put down a few thoughts on optimizing your setup during the remaining interview season.

This situation is garbage, and while I’m thrilled that this year’s students won’t have to shoulder the typical fourth-year travel costs, I don’t envy anyone’s decision-making process. Programs can feel more alike than different even when you see them in person, walk the halls, have dinner and lunch and a conference, and talk to tons of people. A breakout session during an informational conference call just isn’t the same.

Let’s start with saying I don’t think anyone would or should consciously judge anyone for their Zoom set up or how they appear on camera. That said, the data on ERAS application photo bias concerns me. How “professional” you look, even outside the usual appropriate dress and grooming that would be true in person, may indeed have an impact.

I personally don’t care if you’re in your closet or at school, if there’s a baby crying (or even a baby in your arms), or if there’s construction just outside. Some landscapers were really going at my neighbor’s yard with the leafblower just this morning. We’re all doing the best we can. Thank you for logging in and making the best of the crazy times we live in.

The vast majority of students I talk to are using their laptop’s crappy webcam (because for some reason all webcams are garbage even though new phones can record 4K video) and sitting in front of blank drywall. So if that’s your jam, I promise that you are in good company.

Without further ado, a few optimizations:

Position & Camera

Raise up your camera. If you set your laptop on your desk or a table, chances are you’re looking down at the screen, which means that the default angle is an upshot of your nostrils or hunting for a double-chin. But more important than the potentially unflattering position is the fact that it’s an unnatural angle for conversation. Unless you’re very tall, you’re probably not used to looking down at people to speak. So get a couple of thick textbooks to prop up your laptop until the camera is at eye level.

If you’re using a separate camera source–like using your phone as a magical webcam with an app like EpocCam or plugging in a fancy camera via an expensive or cheap HDMI capture dongle–try to have it near your screen so that your eyes aren’t constantly looking way down. Lack of eye contact is sad.

Lighting

If you can be in a room with a large enough window to provide decent natural light, that’s a plus (as long as it’s in front of you or to the side, not behind).

If not, try to get some kind of light source, even a table lamp, in front of you. Strictly overhead lighting casts shadows on your face, which isn’t ideal but can be especially problematic on older computers by triggering over-eager automatic brightness correction when you move your head around. For me, the constant brightness shifts on my webcam depending on the proximity of my face to the sensor was the reason why I stopped using my 2013 laptop for Zoom (and started using my phone, which is new).

So try to get some light. I’ve been using a cheap ring light stand I got on Amazon and it solves the problem of low light in my room of choice but anything that can function as a key light will help. If you wear glasses, try to have the light source elevated or off to the side enough that it’s not reflecting.

Background

It seems like most people have determined that the best quiet spot in their abode for interviews places them in front of empty drywall. If that applies to you, again, you are not alone. Just be aware that if it is possible to artfully arrange something in the background, perhaps some greenery or a print or even some dim accent lighting might be nice. Note that if your artwork has a glass frame that any extra lighting should be arranged to the side enough not to reflect in the shot. And, of course, a blank wall is better than a mess. Virtual backgrounds are fine when necessary.

Attitude

I almost feel like virtual interviews are to the normal residency interview process what Step 2 CS is to actual patient care. Everything blurs together more because it feels less real.

I am conducting my interviews from home, so we don’t even have the pretense of meeting in my (shared and barely used) office at the hospital.

The interview season has always been tiring, but I think in some ways it may be even easier to let enthusiasm flag this year. The lack of travel and relative brevity of a typical virtual interview day means that some applicants are able to hoard interviews and “visit” programs they otherwise would have been forced to cancel in prior years. Logistics make it easier to waste your and the program’s time.

So, if you are interested, make sure you look interested.

Likewise, I suspect some programs may be showing even more of a regional bias than usual given the unpredictable nature of this year’s process (others may just be over-interviewing for safety). If your top programs haven’t invited you for an interview and your application doesn’t click in an obvious way, it’s not too late to let them know why you love them.