Democratizing the Dermatology Residency Application Process: Is a Shelf Exam the Solution?

The transition of the US Medical Licensing Examination (USMLE) Step 1 exam to a pass/fail format has brought significant change to how medical students are evaluated, particularly in competitive specialties such as dermatology.¹ Historically, this exam has served as a key metric for assessing a student’s foundational knowledge in the basic sciences, and a high exam score was often an essential ingredient in securing a residency spot in dermatology.¹ With the elimination of a numeric score, there have been concerns that the lack of quantitative metrics to stratify applications leads to an arms race of publications and prestigious letters of recommendation that may ultimately benefit only a small subset of medical students. There is now a pressing need for additional objective metrics to evaluate students who are interested in dermatology.² One possible solution to this conundrum? A dermatology shelf exam.²

In other medical specialties, shelf exams play an important role in assessing students’ knowledge and readiness for clinical practice. For instance, emergency medicine, internal medicine, and pediatrics all have their own shelf exams, which further serve as standardized assessments of a student’s competency in each of those fields.² These exams are widely accepted as essential tools for evaluating whether a student has the necessary knowledge and clinical reasoning skills to excel in each of these specialties. Dermatology, however, lacks a comparable assessment tool, leaving a significant gap in the evaluation process for students pursuing this specialty. If our medical system is going to subject students to taking an exam, we believe the best use of their resources should be based on correlating the exam to their future specialty.

What Is the Need for a Shelf Exam?

The USMLE Step 2 is a scored exam designed to evaluate clinical knowledge across a broad range of medical disciplines. However, given that dermatology content is only 3% to 5% of the exam per the USMLE website, it seems illogical to stratify medical students based on their overall performance on an exam that covers content not directly relevant to dermatology, such as fetal heart tracings and cardiac arrhythmias.

A dermatology shelf exam would provide a more targeted assessment of a student’s knowledge in dermatology. This exam would allow residency programs to evaluate applicants based on their understanding of dermatologic conditions, treatments, and diagnostic approaches, which will be relevant to their future in dermatology residency. Many programs already require an end-of-rotation exam for dermatology rotators; however, these vary based on the individual institution and there is no way to meaningfully compare students across different schools. As a result, residency programs are left without a reliable metric to distinguish between applicants.

The dermatology shelf exam would supplement existing metrics, such as clinical grades (which may be biased), letters of recommendation, and access to research projects. Giving such an exam early in the application cycle would be helpful as those students who score poorly can target their applications accordingly or apply more broadly.

Furthermore, the introduction of a dermatology shelf exam would align with the existing structure of medical education, where other specialties already benefit from dedicated shelf exams. Many of us may recall medical school classmates of ours who chose a dermatology elective not because of any profound interest in the material or applying to dermatology, but because dermatology was considered an “easy” rotation. The addition of a standardized exam would encourage other medical students to take the subject more seriously and gain knowledge that will ultimately help them in any residency program.

What Would a Shelf Exam Entail?

Dermatology education is currently undergoing an overhaul. The new “Exams of the Future,” with BASIC, CORE, and APPLIED exams, are replacing the previous in-service exams and the older board exam, focusing on clinically relevant material in a modern age. Why not begin this education approach at the graduating medical student level?

Developing questions for a dermatology shelf exam would involve a process similar to that of other exams. The process should begin with identifying core competencies and incorporating questions that cover a wide spectrum of dermatology. Sources of questions may include the following: 1) dermatology-oriented questions from existing exams, such as the USMLE Step 2 or shelf exams in pediatrics or internal medicine; 2) simplified versions of questions from the PGY-2 BASIC exam; and 3) new questions developed by dermatologists. After drafting the questions, it is essential to review and refine them with input from medical students, residents, and board-certified dermatologists, as well as other medical specialties. Pilot testing the questions with a small group of medical students and residents allows for assessment of the difficulty level. Finally, regular review and exam updates are necessary to ensure it remains relevant and reflects the latest advances in dermatology.

Standardized tests, while essential, have many flaws. They often emphasize memorization over critical thinking and may not fully assess practical skills. These tests can also be a disadvantage to certain student groups due to factors such as testing anxiety and educational disparities, which in turn can lead to scores that do not accurately reflect a student’s true abilities.³ However, it is these authors’ opinion that a lack of objective numeric metrics is also harmful and contributes to a toxic arms race of publications that also drains resources from clinical education. We view a dermatology shelf exam as a reasonable compromise; this exam can be used as one of many data points in residency selection rather than as a score cutoff. Residency programs can also choose to use the score as they see fit. Some programs may wish to disregard the score entirely, whereas others (perhaps those whose residents have struggled with CORE exams) may seek to stratify students who score highly on standardized exams.

Conclusion

The implementation of a dermatology shelf exam may have a significant upside in democratizing the application process for dermatology residency and help add more objectivity to a fraught and confusing process.

Dr Hussain is a dermatologist at Galaria Plastic Surgery & Dermatology, LLC in Chantilly, VA. Nehaa Sohail is a medical student in the Paul L. Foster School of Medicine at Texas Tech University Health Sciences Center in El Paso, TX. Dr Shalabi is a resident in the department of dermatology at Baylor Scott & White Medical Center in Temple, TX.

Disclosure: The authors report no relevant financial relationships.

References

1. USMLE program announces upcoming policy changes. US Medical Licensing Examination. February 12, 2020. Accessed August 27, 2024. https://www.usmle.org/incus/#decision

2. Hussain A. The need for a dermatology shelf exam. The Dermatologist. 2020;28(7):38-39.

3. Crane MA, Chang HA, Azamfirei R. Medical education takes a step in the right direction: where does that leave students? JAMA. 2020;323(20):2013-2014. doi:10.1001/jama.2020.2950