USMLE® Step 1 & 2

COVID-19 and USMLE testing: 4 key questions for students, residents

Brendan Murphy , Senior News Writer

Broken into three parts spanning medical education and training, the United States Medical Licensure Examinations are key assessments for medical trainees.  

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Step 1 is typically taken following a medical student’s foundational science training. Commonly on a medical school calendar, that takes place at the end of a student’s second year. Step 2, which is broken in two parts, is generally taken during either the third or fourth year of medical school. Step 3 is most frequently taken during a resident’s first year, also called intern year.  

For students and residents who were preparing for the Step examinations, the COVID-19 pandemic has brought uncertainty to a process that, in normal circumstances, can be stressful. Prometric, the test delivery vendor for the computer-based assessments in USMLE, has announced those test centers will be closed until at least May 1.  

What should students know about the status of licensing exams during the pandemic? Recent conversations with representatives from the two organizations that oversee the exams—the National Board of Medical Examiners (NBME) and the Federation of State Medical Boards (FSMB)—offered some insight for prospective test takers. Those organizations have also collaborated on an FAQ for potential test-takers. 

Prometric is closed until at least May 1. Facilities controlled by the company administer the USMLE Step 1, Step 2 Clinical Knowledge and Step 3. The other part of Step 2, the USMLE Step 2 Clinical Skills exam, is administered by the NBME and the Educational Commission for Foreign Medical Graduates (ECFMG) at six Clinical Skills Evaluation Collaboration Test Centers in five cities. Those will be closed through the end of May.   

For students who are already registered for an exam, eligibility periods have been extended through year’s end. Any fees to reschedule an exam have also been waived.  

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Most medical schools require students to have taken Step 1 before entering clinical training. Step 2 is generally a requirement for medical school graduation and Step 3 is often required for resident physicians to progress in their training. With exams on hold, what happens to those potential promotions is still up the air. It will be decided on a program-by-program basis, however. 

“One way to think about this is that the many USMLE candidates who are medical students have a need or a strong desire to test from the standpoint of maintaining their preparation, as well as limiting curricular disruption and staying on track toward the next phase of their curriculum, or their progression to residency,” said Michael Barone, MD, MPH, a pediatrician who is vice president of licensure programs at the NBME. “A lot of them have studied for months and are ready to test. That’s completely understandable.  

From a licensure perspective, however, there’s no immediate need for them to test now because their eligibility for a medical license is still a ways away.   

Schools that use Step 1 as a requirement for entry into clinical training do have flexibility to re-examine that approach. The launch of core clerkships is confronting another reality. In the present environment, clinical training is vastly different from what it was a few months ago. Trainee safety is a chief priority, with guidance from the Association of American Medical Colleges calling for a suspension of activities in which medical students have direct patient interaction.  

In some states, residents may be required to have a passing Step 1 or Step 2 result to obtain a resident training license. In those instances, the FSMB reached out to state medical boards and recommended they grant a waiver in instances where a candidate may have been unable to take the exam, according to David Johnson, the FSMB’s chief assessment officer. The organization has also advocated for state medical boards that have requirements related to passing the USMLE Step 3 for licensure to consider granting exceptions or waivers on a case by case basis.  

About two months ago, it was announced that the USMLE Step 1 exam would move from numerical scoring to a pass-fail score reporting. The earliest that change would take effect, according to the organizations overseeing the exam, is January 2022.  

With the pandemic creating disruption for potential test-takers some have asked if that development could be implemented for the current test-taking cycle. That is not under consideration, according to Dr. Barone.  
“That’s a big change and while we understand it could impact some students’ issues around stress and anxiety around the exam, particularly in light of [COVID-19], that would add a lot of disruption to an already disrupted system for transition from medical school to residency,” Dr. Barone said. “The other issue is we’re faced with a lot of operational challenges now. There’s always been a perception that we could flip a switch to make [the exam] pass-fail. Changing Step 1 to pass-fail reporting is actually quite complicated and will take some time.” 

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The organizations behind the USMLE are working with Prometric to add additional capacity for those taking the exam once it returns to availability. As far as preparation is concerned, the NBME has provided a series of free self-assessments for students that can aid in preparation.  
“Students need to be talking with advisers and student affairs deans,” Johnson said. “There are some schools that are taking an approach for backing [the exam requirement up] for the better part of a year. Some of these individuals may be encouraged to defer taking their Step 1 until later in their medical school progression.” 

The Coalition for Physician Accountability has launched work groups to consider downstream implications of educational disruptions related to COVID-19. One of those groups will address whether the timing of the residency application process needs to shift, recognizing challenges students face in compiling typical elements such as exam scores.  

 The AMA has curated a selection of resources to assist residents and medical students during the COVID-19 pandemic to help manage the shifting timelines, cancellations and adjustments to testing, rotations and other events.