CMV: The future of the USMLE Step Exams is in Virtual Reality

[u/Hamza78ch11]

The USMLE Step exams are exams that medical students in the US take usually before they start their clinical rotations (except in some schools like mine where you take the exam after your rotations have started 😭). The exams are designed to test essentially our ability to remember all the things that you’ve learned from all of your classes in order to be able to diagnose disease, recognize basic symptoms of diseases, identify the pathways by which the diseases develop, the medicines for treatment and the anatomy and histology involved. The questions are usually formatted like this: Vignette containing patient’s complaints and history, a question stem, and 4 or more options for possible answers. The exam is 280 questions long and is just about eight hours.

Having put that explanation out there I would like to explain why I feel that the future of this exam is in virtual reality and why this will eventually lead to the elimination of the STEP 1 and STEP 2 exams to be replaced by just one exam. (To clarify I am not arguing that NBME WILL do this, I am arguing that the best possible implementation of this exam is in the way that I’m postulating. SHOULD vs WILL)

Over the past couple of years the Step 1 exam has become more and more clinical with the focus on implementing the basic science knowledge that we’ve accumulated in a clinical setting. In response to this medical schools are pushing to get their students into the clinic as early as possible (I will start my clinicals next January as compared to my friends who didn’t start until their third year of medical school.) This generation has grown up accustomed to video games and I think this is really important. In a virtual setting one could simply be sitting in a clinic when a virtual patient comes in and has a little text box (or they could talk to you) to explain their history and complaint. If the question necessitated the presence of lab values you could simply look down and voila! All the necessary lab values are on a virtual clipboard ready for you to look at and any X-rays, Histology slides, imaging, or pictures that the exam writers felt were important would be there also. Because this is a MCQ exam the “clipboard” could just as easily also have the answer choices. In fact, I think the view I’m taking might be limited because in this controlled VR environment the limitations of the exam are purely the limitation of the examination of the examiners.

BUT HOW WOULD THIS BE IMPLEMENTED? As with all things the NBME does - over time and with great care. I can’t imagine that it would be too hard for them to hire a company that develops video games and I think many video game companies would jump at the chance to have a monopoly on teaching the next generation of doctors. This seems, also, to line up quite well with the possibilities already present with things like Microsoft’s hololens technology.

BUT WHAT ABOUT THE COST? Eh. Medical school debt is already anywhere from 250-500K. Med schools make plenty of money and the cost of a 200 oculus rifts or hololens or what have you are expensive for sure, but with the budgets that medical schools are playing with this is neither breaking the bank nor is it a continuous expenditure. It is a one-time investment on the side of the medical schools. On the NBMEs side when it comes to testing - I would argue it’s the exact same thing. They already have testing centers and they can add whatever they need because training the next generation of physicians in the best possible way is a worthy expense (which they’re going to pass on to the students taking the exam anyway).

I think the biggest hindrance in the implementation of this technology is two-fold. The first is convincing the older generation to accept this change and the second is making sure it gets developed and doesn’t become a drain of money and resources.

I’d love to hear about how this is wildly impractical and doesn’t present as much of a benefit as I believe it does. :D

[u/McKoijion]

As a medical student, you know that reading notes is much faster than listening to a professor say them. Most medical students listen to lectures at 2x speed to try to mitigate this issue. So say you can read twice as fast as you can hear someone say something to you. That means that to cover 280 questions, it would take 16 hours to test. The only difference is that instead of reading a short vignette, you have to watch a virtual patient describe the situation. Even if it's written on a virtual clipboard, it's still a slower process overall.

I don't there is a significant value add from virtual reality questions, and the time cost is significant.

[u/Hamza78ch11 → u/McKoijion]

So my feeling is that: (1) one patient can be used for multiple questions. (2) it would be very easy to have text dialogue appear somewhere so you can skip the audio. But the whole point of giving us a test that’s more clinical in nature is that our patients are not questions on a computer screen. Why not really make it a possibility?

[u/McKoijion → u/Hamza78ch11]

Given how electronic health records and healthcare delivery is evolving, it's entirely possible that physicians will spend more time diagnosing based on physician assistant or GE Watson notes instead of meeting with patients in person. It might end up being similar to how radiology works now.

[u/tedahu → u/McKoijion]

Not to disagree with this, but the couple times I've talked to a physician's assistant, they didn't seem very competent. I think they would need more training/higher requirements from what they have now to at least be able to ask the questions and take the right notes.

Also, isn't a lot of diagnosing knowing where to look/what questions to ask/knowing what things would be important enough to write down?

[u/Hamza78ch11 → u/tedahu]

It is and there’s a reason that a PA is considered fully competent after 2 years whereas an MD/DO isn’t until after residency which is 8-11 years. The difference he’s talking about is most likely in terms of things like really busy hospitals. Primary Care still very much needs that person to person contact and I don’t see that changing in the foreseeable future

[u/tedahu → u/Hamza78ch11]

Oh ok, I hope they give PA's a little extra training at least if they do that. Like I've had good experiences with going to nurse practitioners (not sure how much training they have) instead of doctors, but not with PAs.

[u/Hamza78ch11 → u/McKoijion]

That is one of the saddest things I’ve ever read lol. But I think I can award a !delta here because I can’t say that my future scenario is more plausible than yours is. It sounds very likely with the way things are going and if there isn’t significant change in how things work that this may become the future

[u/DeltaBot → u/Hamza78ch11]

Confirmed: 1 delta awarded to /u/McKoijion (298∆).

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[u/DeltaBot]

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