To the Editor:
Imagine that a medical student quickly checks his email while studying for his fast-approaching United States Medical Licensing Examination (USMLE) Step 1. He sees the dreaded words informing of his exam cancellation due to the pandemic with no information on rescheduling. To avoid having to cancel his upcoming clinical rotation, he pays for cancelation fees, flights, and accommodations to take his exam 600 miles away. This story exemplifies the experiences of U.S. medical trainees since the COVID-19 pandemic began, with over 17,000 exam cancellations before June 2020 alone. 1
During the height of the pandemic from 2020 to 2021, the process for rescheduling the USMLE Step 1 was haphazard at best, with communications to Prometric testing going unanswered. This compounded the anxiety medical students already experience due to the exam—anxiety that disproportionately affects students underrepresented in medicine, who already score lower than their White and Asian counterparts due to structural racism and financial inequities. 2 Even though USMLE Step 1 scores do not predict residency performance, 3 and there had been plans since February 2020 to convert the exam to pass/fail scoring, 2 there were no adjustments to the exam or score reports for disruptions caused by the pandemic.
At a time when medical students demonstrated flexibility with online classes and exam cancellations, little reciprocal flexibility was offered by NBME and Prometric. Available options could have included monetary compensation for students who incurred cancellation costs, school-proctored exams (which were only offered for a few months in 2020), and remote exam proctoring. An earlier transition of USMLE Step 1 to pass/fail scoring could have used the change driven by the pandemic to focus on an individual’s trajectory rather than standardized measures, 4 allowing students to prioritize clinical electives, research, volunteering, and wellness over studying for the USMLE Step 1.
Overall, NBME’s response is a symptom of a larger issue: a disconnect and lack of transparency between students and decision makers. In the future, if wide-scale USMLE exam cancellations occur again, providing specific data regarding the number of affected students, frequent updates, and concrete steps with the rationale behind NBME’s actions will be essential to reestablishing students’ trust and confidence. We hope that NBME will be more actively engaged with student advocates in decision making and acknowledge and take accountability for the impact of their choices on student well-being.
The authors wish to thank Dr. John Dalrymple and Dr. Sarah Fazio for their insight, comments, and mentorship in the creation of this manuscript.
1. Murphy B. Delays, miscommunications add even more stress to USMLE Step exams. American Medical Association. https://www.ama-assn.org/residents-students/usmle/delays-miscommunications-add-even-more-stress-usmle-step-exams
. Published June 2, 2020. Accessed January 20, 2022.
2. McDade W, Vela MB, Sanchez JP. Anticipating the impact of the USMLE Step 1 pass/fail scoring decision on underrepresented-in-medicine students. Acad Med. 2020;95:1318–1321.
3. Neely D, Feinglass J, Wallace WH. Developing a predictive model to assess applicants to an internal medicine residency. J Grad Med Educ. 2010;2:129–132.
4. Kogan JR, Hauer KE. Sparking change: How a shift to Step 1 pass/fail scoring could promote the educational and catalytic effects of assessment in medical education. Acad Med. 2020;95:1315–1317.