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Step 1 in the Time of COVID

Before medical students embark on their clinical training, they must pass the United States Medical Licensing Examination (USMLE) Step 1. This year, like those before us, we entered our study periods for Step 1 with some trepidation — both about the long hours of studying and the high stakes of the exam. Like those before us, we reassured ourselves that if we put our time in now, we’d be able to move beyond memorizing minutiae to caring for patients in the hospital. And then, unlike those before us, testing centers across the world closed.

The current significance of Step 1 in medical education cannot be overstated. Typically taken between the second and third years of medical school, Step 1 is the first of the many board exams students must pass before entering residency training. A medical student’s Step 1 score is one of the most important factors in their residency application and seriously impacts their future career opportunities. In fact, most medical schools offer a six- or eight-week “dedicated” period during which students solely focus on preparing for this grueling eight-hour test. Between pre-clinical years when students are beholden to lecture content and tightly scheduled clinical years when they are beholden to clinical duties, these weeks are precious.

On March 11, the World Health Organization declared that COVID-19 was a global health crisis. The National Board of Medical Examiners (NBME), which oversees Step 1, and the Prometric Test Centers, which administer Step 1, responded by closing exam centers on March 17, with plans to reopen in mid-April. However, when the United States extended lockdown policies and individual states began operating on different timelines, many of us questioned whether reopening the test centers would be feasible, given the proximity of students to each other while testing. Prometric extended closures twice more, doing so mere days before the test centers were to open. The most recent announcement stated that medical student examinations would begin May 1 but scheduled exams would be subject to random cancellations to comply with state-specific social distancing guidelines.

These delays may seem like a minor ordeal. However, many students were weeks or even days away from taking the biggest exam of their careers when the first round of closures occurred. Some had been in a highly-regimented “dedicated” period and suddenly were floundering. With no guidance directly from the NBME or Prometric, students began obsessively checking local government updates, refreshing testing site websites, calling test centers and scouring through speculative Reddit posts to piece together morsels of information. Even the local testing centers sometimes offered different information than what was presented nationally. The newest wave of cancellations is keeping medical students guessing by potentially cancelling appointments at random less than 24 hours before their exam with no guarantee of later test dates. In tandem with these cancellations, Prometric has also opened new seats at test centers that don’t seem to be open, leaving even students who never received a cancellation notice unsure if their test is valid. To make matters worse, students still have to cope with the personal effects of coronavirus as well. Many students are immunocompromised, have ill family members or families financially impacted by the pandemic. Continuing to study as usual is nearly impossible.

Scheduling adjustments are not only magnifying the stress of “dedicated” study periods for Step 1 but could also mean delays in students entering the hospital, engaging in research projects or contributing to student initiatives to directly address the pandemic. Due to a lack of testing sites and the random cancellations, many students who were slated to complete Step 1 before beginning their time in the hospital are now scrambling for test dates during their clinical rotations through different hospital services. This is inopportune when many students have used up thousands of dollars of practice materials, are already expected to devote substantial time towards rotation-specific exams (pediatrics, surgery, etc.) and may not have study time built into their third year. As a result, some students are searching for testing locations outside of their local centers to find an open seat before they begin rotations. Because Prometric and the NBME have not implemented alternative testing methods, medical students will be driving or even flying across the country to take their exams. Those without the means to travel are left to hope their local center doesn’t close or to reschedule for a date months later — yet another manifestation of how medical school disproportionately favors the financially well-off.

Complying with social distancing guidelines is a responsible action by Prometric and the NBME, but the temporary fixes that they are proposing took too long and do too little to address the impact of the pandemic on students. Delayed test center openings and appointment cancellations precede an inevitable backlog of exams for students who planned to take the exam in March, April and May — the usual test-taking months. Instead of continuing to push back tests in haphazard fashion, Prometric and the NBME could have looked at how other organizations that administer similar standardized exam delays have adjusted. Collegeboard, which oversees Advanced Placement exams, has maintained an active and organized website. They are offering both free AP review lessons and remote administration of the AP exams taken by high schoolers for college credit. For the LSAT, the law school admissions exam, LSAC announced a plan to create a shortened, online-proctored LSAT-flex for students taking the exam in the near future. The MCAT, the medical school admissions exam, will still be offered in-person, but to increase testing capacity, the AAMC is temporarily shortening the length of the exam and adding evening slots.

Prometric could allow medical schools to proctor the USMLE Step 1 exam, or even send a Prometric representative to proctor these exams on campus. The NBME already administers secure national exams during clinical rotations at medical school campuses, which sets a precedent for on-campus testing. Alternatively, the NBME could hasten its pass/fail proposal set to be implemented by 2022 and modify the scoring of the exam during the pandemic. In the absence of pass/fail, for students anticipating how the emotional strain of a pandemic will affect their Step 1 score, perhaps statements from residency program directors would be helpful. For example, a move towards assessing the examination as pass/fail or through a more holistic and less numerical approach would go a long way towards showing humanity to students.

No one expects any organization to have the perfect solution to this crisis. These circumstances are unprecedented, and healthcare students make up a small portion of those affected. The NBME has made a few helpful gestures, such as releasing free practice exams and posting weekly updates (the latter, partially in response to an online petition). They also recently released a statement noting their disappointment with Prometric’s testing centers and added that they “are working hard to accelerate alternate test delivery solutions.” Still, this response comes after 2 months of vague, conflicting responses from the NBME and Prometric. It is imperative that the NBME follows through on this statement in order to tackle the backlog in test-taking and the potential downstream effects for students entering the healthcare force in the next few years. On a more basic level, the current response shows a lack of compassion for how the pandemic has already impacted many students.

As one rising fourth-year medical student put it: “Let it be known that while med students have been told to adjust our expectations accordingly and have done so, nowhere has it been explicitly stated that the expectations of us will be adjusted accordingly.” Today’s medical students will become tomorrow’s physicians, and many are already stepping up to contribute to pandemic relief efforts. We deserve the same respect and transparency from these institutions now as we will when we have “M.D.” after our names. It is imperative that the NBME take this time to seriously reorganize and make big changes in this examination process, starting with prioritizing the primary stakeholders: medical students.

Image credit: final exam (CC BY 2.0) by dcJohn

Apshara Ravichandran Apshara Ravichandran (3 Posts)

Contributing Writer

Saint Louis University School of Medicine

Apshara Ravichandran is a third-year medical student at Saint Louis University School of Medicine in St. Louis, MO. In 2018, she graduated from Williams College with a Bachelor of Arts in anthropology and chemistry. She enjoys reading, running, and going to the local dog park in her free time. After graduating medical school, Apshara would like to pursue a career in a pediatric specialty or child psychiatry.

Paavani Reddy Paavani Reddy (2 Posts)

Contributing Writer

Northwestern University Feinberg School of Medicine

Paavani Reddy is a medical student at Northwestern University Feinberg School of Medicine in Chicago, IL. She graduated from Northwestern University with a Bachelor of Arts in Anthropology, after which she spent a year in South Korea with the Fulbright Program. She is passionate about health equity, education, and the arts.