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  • Writer's pictureRebekah Bernard

Standardized exams: what it takes to become a physician and the failure of the DNP USMLE experiment

The pathway to becoming a licensed physician in the United States requires nine to eleven years of formal education, and all physicians are required to pass a series of three high stakes standardized examinations called the United States Medical Licensing Examination (USMLE) before they can be licensed as to practice medicine. Most physicians also go on to become board-certified in their specialty field, which requires an additional examination following their residency or fellowship training. Compared to physicians, nurse practitioners and physician assistants have a far shorter course of training, and both are required to pass one standardized examination to be licensed to practice. In 2008, the National Board of Medical Examiners offered down a simpler version of the USMLE Step 3, an examination all physicians take to receive a medical license. The pass rates for DNP candidates ranged from 33%-70%, and the experiment was discontinued in 2014 due to "low utilization."

Roy Stoller DO, an otolaryngologist and board examiner, joins Rebekah Bernard MD and Niran Al-Agba MD in a discussion of the differences between the exams that medical doctors, nurse practitioners, and physicians assistants take.

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Rebekah Bernard MD 0:04

Hello and welcome to 'Patients at Risk,' a discussion of the dangers that patients face when physicians are replaced with nonphysician practitioners. I'm your host, Dr. Rebekah Bernard, and I'm joined by my co-host and the co-author of our book, 'Patients at risk the rise of the nurse practitioner and physician assistant and healthcare.' Dr. Niran Al-Agba.

Niran Al-Agba MD 0:23

Good evening.

Rebekah Bernard MD 0:24

The pathway to becoming a licensed physician in the United States requires nine to 11 years of formal education, and all physicians are required to pass a series of three high-stakes standardized examinations, called the United States Medical Licensing Examination or USLME before they can be licensed to practice medicine. Most physicians also go on to become board certified in their specialty field, which requires an additional examination following their residency or fellowship training. Compared to physicians, nurse practitioners and physician assistants have a far shorter course of training, and both are required to pass one standardized examination to be licensed to practice.

Today we are joined by a very special guest, Dr. Roy Stoller, an otolaryngologist, and a board examiner, who is here to help us understand the differences between the exams that medical doctors and nurse practitioners and physician assistants take. Dr. Stoller, thank you for being with us.

Roy Stoller DO 1:21

Thanks for having me.

Rebekah Bernard MD 1:22

Roy, tell us about your training and how you became a board examiner for physicians certifying as otolaryngologists.

Roy Stoller DO 1:30

As you know, it all starts in university. Most of us who major in science, or don't major in science, take at least up to 60 credits in the hard sciences. I was a psychometric psychology major and as I went through these hardcore sciences, I really developed a sense of deductive reasoning, which I don't believe I would have developed had I not had to take these hard science classes. So all medical students complete th

at regimen. And then we take the MCAT, which is a very comprehensive exam to kind of standardize all the different students from across the country because as you know, medical school is very competitive. Less than, you know, I'd say three out of 10, or four out of 10 eventually get in.

Once I got into medical school, completed four years of medical school - which includes about 2000 and more clinical hours, where we're supervised - we start to take our licensing exams. The second year, we take the USMLE1, as we all know, that is one of the hardest exams to pass. What we all say is 'study for six months and pray.' It's written by PhDs in sciences and they do not let up on us. We have to pass that exam to show we have the basis to continue. At the end of the four years of med school, we take part two of the USMLE, which includes a didactic and a clinical part, most of us now pass at higher rates, because we're getting more into the clinical sense. And then in our first year of internship and residency, which all states require at least one graduate m

edical education year, we take the third part, and we have very high passing rates because we've all been weeded out and studied so much and where we're kind of ready to go out there. So I believe it's between 90 to 98% of us pass that exam.

Rebekah Bernard MD 3:29

Yeah. And I always like to hear what different subjects different physicians majored in. I was a sociology major, although of course, just like you and every physician, I still had to take all the hard sciences, biology, chemistry, organic chemistry, physics, calculus, biochemistry, but I did choose to major in sociology just because I found it really interesting. And you said you were you majored in psychology and psychometrics and ran, what did you major in?

Niran Al-Agba MD 3:57

I was actually physiology with a specialization in history of medicine.

Rebekah Bernard MD 4:02

Oh, that's really an interesting major.

Niran Al-Agba MD 4:04

Yeah, it was a little bit of more of medical ethics. We went through a lot of the different medical cases and of life. Dr. Kevorkian in Michigan was very controversial at that time. And so there was ethics, history of medicine in the United States, other countries, healthcare systems, and what's different. And that was a long ti

me ago. So 1992 to '93 is when I was doing that.

Rebekah Bernard MD 4:26

But what we all had in common is no matter what we chose as a major, we all had to complete the same hard sciences. And of course, many physicians do choose to major in a science as well. I know many of my colleagues majored in biology, or one of the other biological type sciences, zoology, some of them did.

Niran Al-Agba MD 4:42

You know what's interesting, though, if we don't major in a science, it doesn't mean we get out of taking those courses. And I think that's a really important point is that even when you're a philosophy major, for example, you still need to apply to medical school and be approved on the application list or for the prerequisit

es. You still take biochemistry, biology, chemistry, physics, and a lot of those hardcore sciences regardless. So I think that's a really important point, that you have to have a science background to really go get accepted into med school.

Rebekah Bernard MD 5:11

And I think it's one of those things for me, I forget how hard it was and how much I went through. And it's something that's a bit of a bonding experience. I think if you talk to most doctors, you'll ask them, and they'll all remember how awful organic chemistry 2, for example, was. Everyone has that in common.

Roy Stoller DO 5:28

What was amazing is I graduated early, I skipped some grades. And I was one of the youngest in medical school. And they had PhDs in my class, and oh, my God was medical school hard! You know, we're all straight-A students now being put in the same classes. And working with these really intelligent, very accomplished people. It just was so competitive that it forced me to be the best I could be.

Niran Al-Agba MD 5:55

How old were you when you went in? How early did you go into medical school?

Roy Stoller DO 5:59

I started med school when I was 22. But I had finished high school at 16. So I took a year off and started a master's in health science because I really felt I needed to slow down. I didn't think that was a good move that they pushed me through school so fast.

Rebekah Bernard MD 6:19

Yeah, you want to have a better experience and more a little bit of life experience, I guess, can be really helpful when you're going into medical school. And not that you have that much life experience in your early 20s, but at least there's something versus going straight through I think there's something to be said for that.

Niran Al-Agba MD 6:37

I had my 21st birthday, my first year of medical school. I entered at 20. So I completely agree. Looking back, I often think that a few extra years, I shouldn't have been in such a hurry.

Rebekah Bernard MD 6:47

I felt that way, too. I was 21. And when I if I think what is the one or two things I could change in my life, I would have taken a few gap years, as they call it nowadays. It wasn't really an option because nobody was really funding me. But it would have been great to like, backpack Europe or something awesome like some people I knew did instead of going straight through school. But getting back to the competitiveness, as you mentioned, Roy, you're exactly right. The last acceptance rate that I have statistics on says that 39.6% of all applicants to medical school were accepted. And it's quite a contrast to others programs like nurse practitioner schools, some of which boast a 100% acceptance rate. There are only 179 medical schools in the country. And of those medical schools, they accept a little under 40% of all applicants, so they really do have to be at the top and the only people who are applying are people that meet the criteria. In other words, they've already taken those sciences and they've already taken the MCAT. And let's talk about the MCAT. Because that's really the first standardized test that most of us experience. Tell me what you remember about taking the MCAT?

Roy Stoller DO 7:54

Oh, boy, I remember studying really hard because you're going over all those hard sciences that you did in college. And I remember we were tested in chemistry, biochemistry, biology, physics, calculations, mathematics...

Rebekah Bernard MD 8:13

And there was also I think some writing on there and some English and things like that. You just to throw a little, you know, make sure you weren't just focused on science, right?

Roy Stoller DO 8:21

Yeah, I took the MCAT twice, I believe. But man, it was - I guess I blocked it out. It is not a pleasant experience, only to be worsened by USMLE1.

Rebekah Bernard MD 8:23

Yeah, you think, 'Oh, this is just terrible'. And you don't realize at the time that this is just a drop in the bucket to what comes in the next phase.

Niran Al-Agba MD 8:46

To me, that's actually the worst of all the tests, at least as I go back and think about it. I'm sure you guys probably agree, the USMLE 1, t

hey gave us about two months off to study for it. And you know, every day we're hitting the books. And the year I took it, there was some sort of scandal or something where even fingerprinting us wasn't good enough. And so the results were delayed. And I remember just sweating it hoping that I just could pass and you know that that's the hardest part.

Roy Stoller DO 9:12

You know, I read some of the flippant things on social media, like I'm going to be a doctor, oh, I'm going to be a nurse practitioner, I could have gone to medical school. 10% of my class dropped out. And I kind of don't get how people don't really like to speak once you get into medical school, doesn't mean you're going to be able to complete it. It's not a guarantee - a letter of acceptance. I mean, it is that's great to get a letter of acceptance, but the amount of work and dedication that you have to put in to get through, I don't believe anyone really realizes that except us who have completed it.

Rebekah Bernard MD 9:49

You know, that's a really good point. And to me also, Niran, Step 1 was my worst experience aside from Gross Anatomy. My worst memory of my whole training was gross anatomy. And it's because I didn't realize when I took gross anatomy - I studied the human body, the dissection as it was laid out on the table. So the arm in anatomic position, the arms are laid out with the palms up. And then when I went in to take the examination, instead of seeing the body like that, they had taken off the arm, they had flipped it around, inverted it, and stuck a little pin in a structure of the arm. And then on top of that, instead of just saying, 'What is this structure?,' which is kind of what I expected, they said, 'What is the embryologic root of this structure?' So first of all, I had to imagine what did this arm look like put it back in the position that I studied, which was hard

enough, and then also to figure out what it was, and even further what the question was actually asking me, which was really detailed. And of course, that was timed. So as I was sitting there, sweating bullets, and trying to figure out how I was going to come up with this answer, the little bell rang - ding - and we had to move to the next table. And that was just the beginning of my nightmare, which I still relive, where - and I actually failed that examination, it was the only time I ever failed anything, I failed miserably. About half of our class failed that exam. And I remember we were asked everyone - this is medical school, I don't know if it's still like this now - but at the time, they said at the end of our next lecture - and I just found out I failed it, so I was in shock. And they said, 'Everyone who failed the exam, please remain behind.' So half the class gets up and leaves and the rest, the other half of us are sitting there just like mortified, dying. And then we found out, of course, that was it was kind of good to know, we weren't the only ones that failed. And then we got some special tutoring so that we actually knew how to study appropriately. And thank God, I passed the other ones, because if you failed another exam, you failed the entire first year of medical school, you'd have to repeat the year. And potentially you might not even make it at all through med school, as Roy pointed out. So that was a horrible experience.

And then step one was also a horrible experience. And that was a matter of weeks - that we got a month off to study. And I used to go to t

he law library because the medical school library was really bad - well, not bad, but the law library was really nice. And I would get up at eight in the morning and go into the library. And I would stay all day, take 30 minutes for lunch, go back, stay all night, have dinner and go back and did that, you know, like a 12 hour study day for a whole month, even seven days a week.

Roy Stoller DO 12:24

You know, you're reminding me of my final exams. When I had like 18 classes, I would literally start in the evening and just study the whole night through, go in, take the exam, come home, go to sleep, wake up, study the whole day into the night and then take the exam and no one saw me for two weeks. It was like I have to pass my finals. It was crazy.

Niran Al-Agba MD 12:46

Well, I think what you both are talking about is this acquisition of expertise, which I love to talk about. And I actually studied in an area of the University of Washington where Bill Gates had done his middle-of-the-night computer work. So he talks about why he always donates to the UW because there's this area where th

ere aren't a lot of people and it's sort of - it's not really unlocked 24/7, but the lights are on. And it's a very quiet place. It's a certain wing of the University of Washington, and that's where we spent - my study partners and I - we spent all our time and sometimes it was overnight. And again, it's this sort of acquisition heading to the 10,000 hours of experience and learning - engrossing yourself in a subject so that you are literally an expert. And it's amazing. Even still, as much as we laugh about our gross anatomy flipping parts over which was so disconcerting to me in the final exams like you're talking about. I think when we're under the gun, and we're in a situation that's an emergency or something we draw on that I routinely draw on my anatomic stuff I learned on the histology, just so many things during primary care, that I still go back and think, wow, that's why I had to learn that it was worth it. Yeah, it was worth it. We're experts. And I think that's such a critical piece.

Rebekah Bernard MD 13:58

And you have to put in the time to gain that expertise. Unfortunately, there's really no substitute for just logging 10,000 hours and doing it the correct way - as I didn't in my first gross anatomy exam, but I had to learn how to do it correctly. And so Step 1 that we take, just to recap, it's eight hours long. It's 280 questions, and it evaluates the students' mastery of science. And that's the first step exam that we take. Then this is at the end of our second year of medical school, which is typically our sciences, our foundation, although we are gaining clinical experience during that time too. But we re

ally start our clinical years in the third year. And so after we finish our third-year core rotations, which are internal medicine, pediatrics, obstetrics, etc. We then take another exam that's called part two. And that exam measures our clinical knowledge and our clinical skills, and it includes simulated patient encounters. Now, that exam is nine hours and it's 318 questions. And then after we graduate from Medical School and get into our residency training, we then have to take a final step exam in order to be licensed as physicians. And that exam is two days long. The first day is seven hours of testing, and it covers the foundations of independent practice. And then the second day includes nine hours of multiple-choice questions and computer-based simulation.

Niran Al-Agba MD 15:22

First-time pass rates - if we're going to talk about those - you know, the, for U.S. physicians, the most recent data we have would be those trained in the U.S. in 2015. The DO degree which is the doctor of Osteopathic Medicine, 91% of those passed step one for the first time passing rate. And then for MDs, it's 98%. And the pass rate for physicians who were trained outside the United States is closer to 89, a little bit lower, 89%.

Rebekah Bernard MD 15:49

Still, most people pass those standardized examinations, and you must pass them to move on. We learned about something really interesting, which was that the National Board of Examiners did an experiment where they gave

nurse practitioners a version of the USMLE Step 3, can you tell us about that?

Roy Stoller DO 16:07

You have to put that in context. So in this era, it's about 2008, 2006, and Libby Zion, unfortunately, dies in New York City. She's a teenager who ends up having a complication of medical intervention called serotonin syndrome, which at the time, we really didn't know about. But politically, it is investigated and the powers that be come down on the medical education system and say that residents are spending too many hours in the hospital. So they cut our hours by about 20%. So now you have resident physicians who are the backbone of the hospital system working 20 hours a week less. And when you multiply that out by the hundreds of 1000s of doctors that you have, you now have a void.

Mary Mundinger at Columbia University is a PhD in nursing, and she is the mother of modern nurse practitioning. She's on the board of United Healthcare, an insurance company. And they are constantly figuring out how to save money. She sees this as an opportunity to now package her nurse practitioners off

as primary care practitioners. And although they constantly deny it, it was wrapped around so that they could replace family physicians. She hijacks the DNP degree. Not a PhD - it is a doctorate degree that nurses use to educate other nurses and study nursing health care policy. And she now creates a doctorate that she can give her nurse practitioners. But what she's missing is equivalence. So she goes to the USMLE boards and petitions them to give a watered-down version of our part three.

Now, again, in context, USLME3 by itself is not an exam that tests for clinical competency. To get to that point, you first have to graduate medical school, pass all the exams, pass all the courses, and pass USMLE 1 and 2. So she's skipping all that, and cherry-picking questions of our easiest exam. She now cherry-picks the DNP candidates, she's going to give it to their Columbia University cream of the crop, DNP candidates. And when they give this exam to them, they vary between 35% or 40% to 70% passing. And they can't ever get over that hump. Though, instead of stating 'Oh, we need to give them more education' - so if we want to prove equivalence, what do they do? They lower the standards, change the exam, and put forth studies that really don't test equivalence. But they pretend to test equivalence. And they now have this pseudo-manufactured nurse that looks like they can practice primary care.

Rebekah Bernard MD 19:19

It was such an interesting experiment. And I think it didn't go the way they planned it to go. So first of all, let me point out also, we mentio

ned that most of us studied for two months for step one. And there's kind of this adage in medicine about the step exam, they say, 'two months, two days, two number two pencils.' In other words, you study for step one for two months, two days for step two, and you don't even study for step three, because this is what you do every day. So you show up with your number two pencils. So remember that if you ask most physicians which was their easiest exam, they're going to tell you step three. So step three was the one that the nurse practitioner DNP candidates took. They start in 2008, and they had 45 applicants that took this exam and they had a pass rate of 49%. And remember, this isn't even just the USLME 3 that physicians take. This was a, as Roy said, a watered-down version. In fact, the National Board of examiners published a white paper and it stated, quote, 'the DNP certifying examination is not designed to replicate the USMLE assessment for medical licensure. It does not include the in-depth assessments of fundamental science, clinical diagnosis, and clinical skills that are provided through USLME for physicians'. So 2008 was the first time. 2009 they had 19 people test and only 57% passed. In 2010, they tried it again, 31 candidates, 45% pass rate. In 2012, they had a little bit of improvement, 22 people took it and 70% passed, but then in 2013 of the 18, that took it only 33% passed. And keep in mind that the physician p

ass rate is about 98% for the same exam. So guess what happened? In 2014, they discontinued this examination, it was discontinued for, quote, 'low utilization.'

Niran Al-Agba MD 21:15

So limited utility, as if it's not valuable because it can't be passed. So, therefore, we'll just not do it head to head, we'll not compare apples to apples or even try. Because, you know, the educations are completely not comparable.

Roy Stoller DO 21:29

But what's interesting is that these nurse practitioner DNP candidates had already passed some version of their FNP tests. And that's the test that they use to state now that they are equivalent to us. So it's not even this more complex, watered-down version of what we have, they're going back to a master's degree, that that in the beginning, the reason why they wanted to create the DNP was they didn't think the master's degree was enough. And now because they cannot develop this doctorate program to that level, they're going back to the master's degree FNP and trying to pass it off as equivalent.

Rebekah Bernard MD 22:07

You're exactly right. So we've gone through the three steps. And this is what we need to be licensed as physicians, but most doctors don't just stop getting a medical license, almost every physician becomes board certified. And that means that they complete a residency period of training that is credentialed and that follows standardization, and then they have to pass a board examination at the end of that period to be board certified. Roy, you're an otolaryngologist and ENT physician, tell us what the ENT board exam is like.

Roy Stoller DO 22:38

Well, again, you have to qualify for it. So most ENT physicians do five or six years of postgraduate training. And that involves being supervised by countless number of surgeons learning how to do surgery, learning how to do clinical work. And at the end of every year, you take an inservice exam, which compares you to the other residents in the country. And you have to get a score that is respectable or you could lose your residency position. And the test is not easy.

At the end of those five to six years, you take the written exam and ENT is an all-day test. And it's written by specialists in the field like myself. And we focus on three components: knowledge, application, and comprehensio

n. So to the lay public, knowledge is: suppose you have conjunctivitis What is that? It's an eye infection. That's knowledge. Application is, well, what do you do about it? Well, you treat it. Do you treat it with antibiotics? Is it a virus? Is it a bacteria? Comprehension is where we like to test doctors. And that is more deductive reasoning. Does your patient suffer from comorbidities like diabetes? Are they currently pregnant? What would be the complications if you don't treat this or you treat it ineffectively?

And so the when we write the boards for otolaryngology, we have 70% of the questions have to be in comprehension and not just knowledge base. Once you pass that exam, you go out to practice and in the middle of your practice year, you're called back for your oral exams. And you have four stations where you're tested in ear, nose, throat, and facial plastics. And those questions are based on clinical settings. And what we're watching is how well you function under pressure. And of course, we're going to throw complications at you. That's what happens because we want to see what you do when things don't go well. And we fail people because when we put out a product of a Board Certified otolaryngologist in the United States, we want a certain standard.

Rebekah Bernard MD 24:54

And thank goodness you do because I certainly want to know that my ENT physician knows what they're doing. And same as my family physician or my pediatrician. Niran, tell us about your pediatric board exams.

Niran Al-Agba MD 25:07

Well, it's not quite as involved as Roy's describing, but it's two days, and it's eight hours, both days. And, again, it's rigorous, and we have to pass it. And obviously, if we don't pass it, then we don't end up being board certified as a pediatrician. And it's that kind of the second step that you talk about, right? It's not just knowing that you know, 90% of normal children walk by 15 months, right, that's burned into my brain forever. But it is, the child can do this, this, this, and this roughly how old is the child? So it kind of makes you it, you really have to know your knowledge. And so again, I think it's something that we put out a certain standard of excellence and of knowledge, and then application of that knowledge, which is what's so important.

Roy Stoller DO 25:56

And what we don't realize is primary care physicians, such as the two of you, is the extensive base of what knowledge you need to have. And you guys make it look easy. And why that is so is because, honestly, I'd say 80% of the patients you see are pretty straightforward. And you know, it's that 20% that you guys have to pick up on. And that's what your tests test because I write questions for your exams, and I know what I'm writing, I am not writing the standard ENT questions. And that's the difference when you see a physician versus a nurse practitioner or PA in pediatrics or family medicine. And I don't think the medical community or the patients really appreciate the base of knowledge of what primary care has to know.

Rebekah Bernard MD 26:46

Yeah, it's really rigorous. So for family medicine, the boards are nine hours, there are 320 questions. For internal medicine, the exams are 10 hours. For sub specialists, they have to take an additional four hours of questioning. And as Roy mentioned, for some specialties, like psychiatry and surgical fields, there are oral board examinations. And those are really an important part of their testing. Just for contrast, nurse practitioner exams, there are a couple of options that they can choose. And the family nurse practitioner exam is three to four hours long. And it's 200 questions in 2015, the pass rates, they have two different exams, the pass rates were 75% for one exam and 81% for the other exam.

And what's interesting is that Lehman College, their family nurse practitioner program just lost its accreditation, because their graduates were not achieving an adequate pass rate, they had to have at least an 80% pass rate from their college to be accredited. So they went on probation, and then they got their levels up to 78%. But because they still hadn't met that 80%, they did lose their accreditation. I know that they're appealing that. But the point is that, again, consider the nurse practitioner boards kind of like our step three exam in which physicians are about a 98% pass rate. And here we have 75% for one of the board certifications that they have.

Niran Al-Agba MD 28:10

And then we should talk about PA boards, I think as well. I mean, I think that that's a worthwhile thing to add on. There's one certifying exam for them. At the end of school, the physician assistant national certification examination, which is known as the PANCE. It's a five-hour 300 question test, which has to be taken every 10

years to recertify and 93% of test-takers pass. And then after graduating from school and then passing this test, they can apply for a license to practice. And as we're seeing in some states, that means independent practice.

Rebekah Bernard MD 28:41

And they have to take their exam every 10 years. Physicians also must take exams periodically. It's either every seven to 10 years depending. But nurse practitioners don't have to repeat their exams, they only have to take it one time. And then recertification is just them submitting their hours and those hours can be volunteer hours. So there's no additional certification requirements.

Roy Stoller DO 29:04

And you know, I would like to say that the three of us I know that we all agree that nurse practitioners and physician assistants are valued members of our teams. But those teams need to be physician-led. And what we're trying to convey here is the education and testing processes for these auxiliary health care practitioners does not meet our standards for allowing them to see patients independently, but they are valued members of our team, and they do great things, but they need to be supervised by physicians.

Niran Al-Agba MD 29:38

Well, and that goes with what we found. Again, what I've shared with people a lot is it's not an opinion, to say physician-led teams are safe. It's actually what the science has evaluated. So it's evaluated the ability of nurse practitioners and PAs to practice which we absolutely find valuable, but five decades of research shows that they provide safe and very high-quality health care when supervised by physicians. And that's what's been studied. So that's what we know.

Rebekah Bernard MD 30:07

Thank you so much - I appreciate both of you being with us. For our listeners out there, please visit our YouTube channel Patients at Risk, where you can see this discussion and also some additional information, which goes over some sample board questions for nurse practitioners and physicians. And we've included some interesting screenshots that you may want to check out. Please subscribe, wherever you listen to podcasts and to our YouTube channel. Please get our book 'Patients at risk the rise of the nurse practitioner and physician assistant and health care.' It's available at Amazon and Barnes and And if you're a physician and you'd like to learn more about this information, please visit our website posi

tions for patient Thanks so much and we'll see you next time.

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