Students Upset by USMLE Response to COVID-19 Demand Changes

What your doctor is reading on Medscape.com:

MAY 04, 2020 — Students frustrated with changes to the way they will take US Medical Licensing Examination (USMLE) tests during the COVID-19 crisis have published an open letter to the test program’s cosponsor detailing their concerns and offering alternatives.

A tweet on May 1 introduced the letter, coauthored by Leah Pierson, a second-year MD/PhD student at Harvard Medical School in Boston, and Elizabeth Stein, a second-year student at University of Washington School of Medicine in Seattle, who worked with input from other students.

The letter not only describes some of the students’ biggest concerns but also suggests alternatives. It was addressed to the National Board of Medical Examiners (NBME), which cosponsors the USMLE tests with the Federation of State Medical Boards (FSMB).

At the time of this publication, the letter had more than 1600 signatures from students across the country.

Left in Limbo

Chief among the criticisms was a complaint about the reduction in the number of spots available during each exam session. The test facilitator, Prometric, has cut the number of spots in half to allow for social distancing. “Thousands of second- and third-year medical students have been randomly selected to have their test dates canceled, and these cancellations have left students in limbo, studying indefinitely for the most important exams of their careers,” the letter states. “Resident physicians, many of whom are working long hours caring for COVID patients, have been similarly impacted by Step 3 exam cancellations.”

Pierson, who is scheduled to take steps 1 and 2 of the exam this summer, told Medscape Medical News that she has personal concerns for all who need to take any of the USMLE tests. She said that as an MD/PhD student, she is particularly worried because the changes may mean having to take the exams while being a full-time PhD student.

“But what motivated the letter,” she said, “was hearing from friends and a lot of people across the country who have been impacted in much more significant ways.”

Some students will be forced to make difficult choices, such as traveling at considerable expense to take a test in a city that has fewer COVID-19 restrictions and thus more test spots, which could mean breaking stay-at-home orders, Pierson said.

The letter also points out that “[t]he process of studying for Step exams is one of the most stressful periods in medical school. At baseline, rates of mental illness are much higher among medical trainees than they are in the general population. Adding the stress of repeated Step exam cancellations and postponements to the personal and financial stressors of COVID-19 is harmful for the mental health of all affected trainees and risks plunging some into crisis.”

Pierson also said that confusing communications are compounding the problems. On April 25, Medscape Medical News reported on memos that contained seemingly contradictory information provided by the USMLE program and Prometric. The memos sparked a series of questions among students.

Some students cancelled their dates on the basis of information from either USMLE or Prometric. They then found out that they could have kept the spot but that it had been filled, and they couldn’t get another date anywhere near their original date, Pierson explained. Trainees should receive updates at specified intervals from only one centralized source, she said, “so we know when we will get reliable bits of new information.”

Solutions Offered

The letter not only included complaints but also offered solutions, including the following:

• Exams could be proctored online, as is currently being done for the shelf exams. Alternatively, medical schools could administer these exams in campus buildings.

• Trainees should have the option to proactively cancel their test dates and receive full refunds.

• Trainees should be granted indefinite extensions so that they can enroll in other courses during this time, rather than having to continuously study for exams that may be repeatedly delayed.

• Students who will be applying for residency after 2022 should be notified as to whether their exams will be reported to residencies as pass/fail or with numerical scores attached. “This would allow these students to make informed decisions about whether to study indefinitely for their exams or take them at another time.”

The letter also proposes that NBME consider making step 1 pass/fail now, rather than implementing that change in 2022 as planned. When Medscape Medical News recently asked Dave Johnson, chief assessment officer at FSMB, about that option, he said, “There are no plans to accelerate that timeline. We thought it would be even more disruptive.”

When asked for a response to the open letter, NBME spokesperson Barbara Del Duke told Medscape Medical News, “We are working diligently to design and deliver solutions outside of Prometric testing centers.

“We have several efforts underway to deliver supplemental testing, and we have committed to accelerating our publicly stated timeline to provide a solution,” she said.

In terms of the specific recommendations, Del Duke stated, “We are exploring remote proctoring, delivery at alternate sites (including medical schools), and additional solutions to resume testing and to address testing backlog and capacity constraints.”

As the USMLE considers the proposals, the letter urges expedience: “These are unprecedented times that require unique, timely, and innovative solutions. Without flexibility in the timeline or administration of these exams, the next cohort of physicians continues to make challenging personal, financial, and professional decisions that significantly impact their medical training — and their lives.”