Every physician hoping to earn a state medical license in the United States is familiar with the United States Medical Licensing Exam (USMLE). Its three-step process is designed to assess a physician’s ability to apply knowledge, concepts, and principles, and to demonstrate fundamental patient-centered skills that are important in health and disease and that constitute the basis of safe and effective patient care. Yet, a recent study completed by ABOM Diplomates and published in the journal “Teaching and Learning in Medicine” found that the most important concepts of obesity prevention and treatment are not represented on the USMLE Step Exams. Exam items, the researchers concluded, primarily addressed the diagnosis and treatment of obesity-related comorbid conditions instead of obesity itself.

Dr. Robert Kushner, former ABOM board chairman, who authored the study along with ABOM Diplomates W. Scott Butsch, Scott Kahan, Sriram Machineni, Stephen Cook and Louis J. Aronne, offers his insights about the study below.

What compelled you to look at this issue?

We know that the science and practice of obesity medicine is insufficiently addressed at the undergraduate and graduate medical education levels. Tackling this challenge will require multiple efforts such as developing competency-based curricula, identifying knowledgeable faculty, and assuring that the national licensing exams adequately assess learners’ knowledge, attitude and behavior regarding obesity. As medical educators, we know that students are incentivized by what is on the exam. So the first step we took was to review the obesity-related content of the three USMLE Step Exams. We are grateful to the National Board of Medical Examiners (NBME) for allowing our 6-member panel to spend 1 ½ days reviewing the examinations.

What surprised you most about the findings?

There were several findings that surprised us. The first was the limited number of items that actually addressed obesity. And of those items, the majority pertained to obesity-related comorbidities (e.g., Type 2 diabetes, obstructive sleep apnea, metabolic syndrome, polycystic ovarian syndrome), rather than addressing the diagnosis and management of obesity itself. In

addition, our findings emphasized that the most important concepts of obesity prevention and treatment, ranging from current basic science to assessment to clinical management, were poorly represented.

What changes to the Step Exams would you recommend in response to the findings?

At the request of the NBME, the panel identified multiple important obesity-related topics that were insufficiently addressed or entirely absent from the examinations. A list of recommended topics to be included in future examinations is provided in the published article. For the Step 1 exam, they include obesity-related content in the disciplines of genetics, physiology, behavioral sciences,epidemiology, pharmacology, and nutrition, among others. For the Step 2 Clinical Knowledge [CK] and Step 3 exams, the recommended topics correspond with the physician competencies of scientific knowledge and concepts, patient care diagnosis and management, and communication and interpersonal skills. The panel also recommended that obesity experts be invited to participate on USMLE item writing item committees. Toward this end, I am currently serving on the Chronic Care Test Material Development Committee (TMDC) writing items that begin to address deficient content areas.