A. Pock is associate dean for curriculum and associate professor of medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland. M. Daniel is assistant dean of curriculum and associate professor of emergency medicine and learning health sciences, University of Michigan School of Medicine, Ann Arbor, Michigan; ORCID: http://orcid.org/0000-0001-8961-7119. S.A. Santen is senior associate dean of evaluation, assessment, and scholarship of learning and professor of emergency medicine, Virginia Commonwealth University School of Medicine, Richmond, Virginia. A. Swan-Sein is director, Center for Educational Research and Evaluation, and assistant professor of educational assessment, Columbia Vagelos College of Physicians and Surgeons, New York, New York. A. Fleming is associate dean for medical student affairs and professor of pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee. V. Harnik is associate dean of curriculum and associate professor of cell biology, NYU School of Medicine, New York, New York.
Acad Med. 2019 Jun;94(6):775-780. doi: 10.1097/ACM.0000000000002651.
An increasing number of medical schools have moved away from traditional 2 + 2 curricular structures toward curricula that intentionally integrate basic, clinical, and health systems science, with the goal of graduating physicians who consistently apply their foundational knowledge to clinical practice to improve the care of patients and populations. These curricular reforms often include a shortened preclerkship phase with earlier introduction of learners into clinical environments. This has led schools to reconsider the optimal timing of United States Medical Licensing Examination Step 1. A number of schools have shifted the exam to the period immediately after core clerkships. Although this shift can provide pedagogical advantages, there are potential challenges that must be anticipated and proactively addressed. As more institutions consider making this change, key educational leaders from five schools that repositioned the Step 1 exam after core clerkships share strategies for mitigating some of the potential challenges associated with this approach. The authors describe six possible challenges: lack of readiness without consolidation of basic science knowledge prior to clerkships; risk that weaker students will not be identified and provided academic support early; clerkship or clinical shelf exam performance weaknesses; extension of Step 1 study time; an increase in student anxiety about residency specialty choices; and/or a reduced time frame to take and pass board exams. These potential challenges may be addressed using three main strategies: effective communication with all stakeholders; curricular design and assessments that facilitate integration of basic and clinical sciences; and proactive student coaching and advising.
越来越多的医学院校已经不再采用传统的 2+2 课程结构，而是采用旨在整合基础、临床和卫生系统科学的课程，目的是培养能够将基础知识始终应用于临床实践以改善患者和人群护理的医生。这些课程改革通常包括缩短预科阶段，让学习者更早地进入临床环境。这导致学校重新考虑美国医师执照考试（USMLE）第 1 步的最佳考试时间。许多学校已经将考试提前到核心实习之后的阶段。虽然这种转变可以提供教学优势，但也必须预见并积极应对潜在的挑战。随着越来越多的机构考虑进行这一改变，来自五所将第 1 步考试安排在核心实习之后的学校的教育领导分享了一些策略，以缓解这种方法可能带来的一些潜在挑战。作者描述了六种可能的挑战：在实习前没有巩固基础科学知识就缺乏准备；风险是较弱的学生不会被及早识别和提供学术支持；实习或临床架子考试表现薄弱；延长第 1 步学习时间；学生对住院医师专业选择的焦虑增加；以及/或者通过和通过董事会考试的时间框架缩短。通过三种主要策略可以解决这些潜在的挑战：与所有利益相关者进行有效沟通；设计和评估课程，以促进基础和临床科学的整合；以及积极的学生辅导和咨询。
