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Should the U.S. Medical Licensing Examination (USMLE) Step 3 be scored? Members of the American Medical Association (AMA) don't think so, and passed policy to that effect during the annual House of Delegates meeting in Chicago on Tuesday.

Members also grappled with the question of how to manage unmatched graduate physicians, ultimately deciding the issue needs more study.

Debating Changes to Step 3

Doug Myers, MD, who spoke on behalf of the American Academy of Otolaryngology-Head and Neck Surgery, opposed the idea of switching from a numerically scored Step 3 exam to a pass/fail exam. He offered an amendment striking a single provision of the version of the policy resolution put forward by the reference committee (that was largely similar to the original), which called for the change.

Step 3 is the final required exam needed to obtain physician licensure, Myers said. While his delegation agreed that the exam should not create "undue burdens of time or expense" for residents, a scored exam would not impact either, he noted.

"No patient will ever ask a doctor [about] the scores, but it does provide additional helpful information for residency and fellowship directors," Myers argued, as well as a "level playing field" within a single specialty.

Dayna Isaacs, MD, MPH, a delegate for the Resident and Fellow Section and primary author of the resolution, opposed the amendment, which she said tests only general medicine concepts in primary care and does not accurately reflect the "complexity of modern medicine."

Isaacs is starting a hematology/oncology fellowship in 3 weeks, and 1 year into her residency, she had to receive scores for obstetrics, surgery, and pediatrics, which had no bearing on her daily practice.

"I had to study for Step 3 while working 80-plus hours a week, and I was forced to use vacation days both to prepare for and to take this exam," she said. "There are no data validating Step 3 scores. They are not correlated with patient outcomes or clinical skills."

Karthik V. Sarma, MD, PhD, a delegate from California and a psychiatrist, who spoke on his own behalf, said he remembered taking Step 3 and being asked to diagnose a pathology slide. Wishing no disrespect for his pathology colleagues, he said, "I'm not sure my inability to diagnose that slide really says anything about my ability to be a physician."

And while Step 3 includes competencies that are important for physicians regardless of specialty, his numerical score is irrelevant to his qualification as a physician, Sarma added.

Kimberly Templeton, MD, a delegate who spoke on behalf of the American Academy of Orthopaedic Surgeons, also opposed the amendment. Of note, she is a member of an orthopedic residency review committee for the Accreditation Council for Graduate Medical Education. (Templeton said her views do not reflect those of the council.)

"As both a program director [of the orthopedic residency review committee] and a state medical board member," with 20 years' and 12 years' experience in each role, respectively, she said, "we saw no advantage of having a specific exam score. All programs need to know, and all state medical boards are interested in is, did a resident pass the exam?"

However, it's impossible to convince residents that Step 3 scores do not matter. They continue to stress out over the exam, Templeton noted, urging the House not to pass the amendment striking the pass/fail provision and to pass the entire resolution for the sake of "residents' well-being."

Ultimately, the amendment was struck down with a vote of 117-476.

The final version of the policy resolution was adopted in a voice vote by the House. This included provisions recommending that Step 3 be made a pass/fail exam; called for a 1-day versus a 2-day exam; recommended medical students have the option to take the exam after passing Step 2 while still in school (as opposed to during their residency); and recommended the same changes be made for the Comprehensive Osteopathic Medical Licensing Examination Level 3.

Unmatched Physician Graduates

Following committee discussions over the weekend, an AMA reference committee recommended against adopting a policy calling on the AMA's Board of Trustees to study the role that unmatched physicians might play in patient care, as well as their potential to mitigate the physician shortage. The draft resolution also called for the AMA's Board to "provide recommendations on how to enroll these graduating physicians with a uniform title, privileges, geographic restrictions, and collaboration choices," and requested a report back to the House.

Edmond Cabbabe, MD, a delegate from Missouri representing the Heart of America Caucus, called for passage of a simplified resolution, asking the Board to study and report back on "how unmatched medical graduates can contribute to lessen the expected shortage of licensed physicians."

In 2014, Missouri passed a law allowing graduating physicians who did not match for residency to work under the title of "assistant physician" in underserved areas in primary care under the supervision of licensed physicians. Roughly 15 states have passed similar laws, he said.

"We want to see if unmatched physicians can play a role in taking care of the patients who need their services, in areas where they are needed. They are definitely more qualified than nurse practitioners and/or physician assistants to do that," Cabbabe argued.

Vicki Norton, MD, speaking on behalf of the Florida delegation, threw her delegation's support behind the proposed amendment.

Florida also recently passed a bill to create a year-long "graduate assistant physician" role, which only applies to U.S. medical graduates, is renewable for 1 year, and requires the individual to practice under a fully licensed physician, Norton explained.

"We view this as a very important pathway for physicians who have graduated from medical school ... under a tremendous amount of debt, to have a way to learn, to earn a living, and have some dignity while they try to rematch," she said.

Some medical school graduates who do not match wind up taking jobs as Uber drivers and Starbucks baristas, Norton added. "Is that what we want for [the] future of medicine?"

Andrew Rudawsky, MD, a delegate for the Ohio State Medical Association, speaking for the Great Lakes States Coalition, argued against the proposed draft policy.

"Our main argument in the scope-of-practice fight with PAs and NPs is that our graduate medical education sets us apart," he said. "And I think that if we create a subclass of physicians that don't have that, we lose a little bit in that argument. In scope of practice, I think our first, second, and third priority should be creating residency spots and ensuring that these physicians are able to complete their training."

After substantial discussion, the policy was ultimately referred to the Board of Trustees for further study.

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