Should a single test determine your future? Growing up in a rural village in newly independent India in the 1950s and 1960s, my uncle was educated in a system where the results of a single end-of-year exam determined whether students would advance to the next grade. These tests also determined who received scholarships to attend college. In a poor village that had not seen anyone enroll in a tertiary educational institution in years, these scholarships were crucial. When it came time for my uncle to take his test, he did quite well. But he came up 2 points short (out of 1000) and did not earn a scholarship. For weeks, he was devastated. He ended up working in various jobs. By the time he was finally able to go to college, he had lost his passion for physics, his first love. Over five decades later, he still wonders whether his path in life would have been different had he scored just a couple points higher on his exam. When I was studying for Step 1 in medical school, I could not help but think about my uncle's experience. I knew that a few odd questions sprinkled over the course of a grueling, 8-hour exam could dramatically impact my future. I knew that residency program directors consistently cite Step 1 scores as one of the most important factors they use in selecting applicants. I knew that many residency programs employ minimum Step 1 score cutoffs in screening residency applications; I probably would not even be considered for an interview if I did not score highly enough. 'This Has to Stop' Now in residency, I can appreciate just how ludicrous this arrangement actually is. For one, Step 1 is a poor tool to use to select residents: It is not correlated with the acquisition of clinical skills and tests content that is not relevant to modern medical practice. This should not be surprising, given that Step 1 was originally intended to be a competency exam for licensure. It was never meant to be used to stratify medical students. Second, external factors over which I had no control could have easily affected my performance on test day. A poorly timed illness or the receipt of bad news prior to the exam very well could have depressed my overall score. These extenuating circumstances would surely be lost on residency programs considering my application for an interview. In other words, plain bad luck could have barred me from entering entire specialties. Some might argue that these are simply theoretical concerns and that Step 1 is rarely the reason that medical students end up entering specialties that they did not plan to originally. I disagree. In fact, Step 1 may play a much larger role in the specialty decisions of medical students than I had even realized. A recent series of tweets by an astute medical trainee helped alert me to this possibility. Not only are some medical students potentially choosing a path that will not satisfy them most, but the community is possibly missing out on passionate specialists as well. A December 2018 study in Medical Science Educator shed more light on the prevalence of this phenomenon. The authors surveyed 793 medical students at the Albert Einstein College of Medicine who took Step 1 between 2011 and 2015. Among the respondents to questions about specialty choice, more than 1 in 4 (27.5%) reported that they changed their specialty because of their Step 1 scores. Equally concerning were the reasons behind the changes: 39% suddenly developed "new interest in [previously] 'out of reach' fields," 39% "no longer [felt] competitive for some fields," and 10% "did not want to waste [their] score." In other words, a significant number of physicians may not be practicing in the field of medicine that most appealed to them. USMLE Reform Desperately Needed In recent months, medical students, academic institutions, and testing organizations have been engaged in an active debate about the future of Step 1. In particular, the dialogue has focused on whether the current three-digit Step 1 scoring system should be jettisoned in favor of one that simply indicates whether an examinee passed or failed. Proponents of the status quo argue that Step 1 offers an "objective assessment of relevant competencies" and "mitigates the reliability challenges of some medical school assessments." Critics, including me, argue that Step 1 is a poorly designed test with little clinical relevance,and that it jeopardizes the well-being of students and corrupts medical school curriculums. In some ways, however, this debate misses the forest for the trees. Ultimately, the goal of the American medical education system should not be limited solely to training superb, adaptable clinicians who are well equipped to deal with the myriad challenges posed by a fast-changing 21st century. It should also strive to train physicians who are passionate about their patients and their fields of practice. Doctors should be able to practice the type of medicine that most appeals to them. They should be excited to come to work every single day. Unfortunately, the current reality in American medicine could not be further from this ideal. American physicians are in the midst of a devastating moral injury crisis that affects patients, providers, and the medical system as a whole. Findings show that 44% of American physicians feel burned out and 15% report feeling depressed. Every year, 300-400 doctors die by suicide. This is not to suggest that Step 1 scores are the main cause. However, if a med student chooses a specialty for the wrong reasons, it can put them on a path to a lifetime of professional dissatisfaction. This complex national crisis will require fundamental systemic reform. As it stands now, by forcing doctors into specialties they are not necessarily interested in, on the basis of the results of a single exam, we are only making the problem worse. A good way to start fixing the situation is to ensure that a poor metric like Step 1 does not function as a gatekeeper in preventing medical students from pursuing their passions. We should be doing everything we can to allow physicians to practice in their preferred fields of medicine. They should not have to spend the rest of their lives, like my uncle, wondering about what could have been. Kunal Sindhu, MD, is a resident physician in New York City. He has previously written about problems associated with board examination testing for BMJ. The opinions expressed in this perspective are his own. 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