With states reopening across the country, medical students are eager to check Step 1 or Step 2 Clinical Knowledge (CK) of the United States Medical Licensing Examination (USMLE) off their to-do list. For many, the process of preparing for the exam during the pandemic has been rife with delays. The preparation period, even in a typical year, can be rigorous.

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A recent webinar hosted by the Association of American Medical Colleges’ Organization of Student Representatives sheds some light on where things stand with the exams, and when and how testing can resume.

All computer-based versions of the USMLE—Step 1, Step 2 CK and Step 3—are administered at Prometric test centers. Those were closed for several weeks as a response to the COVID-19 pandemic. Since May 1, those test centers have reopened for testing for essential clients in some locations.

According to data from the webinar, which was presented by representatives from the National Board of Medical Examiners (NBME)—one of two organizations with oversight of the USMLE—about 17,000 medical students and residents waiting to take their USMLE exams were displaced. Since May 1, about one-fifth of those students and residents have successfully tested.

A brief look at internet forums reveals that the process has been a chaotic one, with many potential examinees reporting late notice of exams getting rescheduled and receiving confirmation for multiple test dates.

“Prometric has acknowledged in a letter to NBME that their communications have been inadequate with examinees,” said Michael Barone, MD, MPH, a pediatrician who is vice president of licensure programs at NBME. “And that the testing experience in many cases has been unacceptable. It’s not acceptable to have an examinee go to a testing center that never opened on May 1. It’s not acceptable to have an examinee find out an exam has been canceled within 12 hours of when they were scheduled to take the exam. We understand fully the level of preparation students have for these exams.”

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To meet the high demand for testing and potential delays, the NBME is working to expand beyond the Prometric network to pilot administration of exams at medical schools. The first pilot site to open was at the Warren Alpert Medical School of Brown University, which began administering exams May 27.

Additional facilities in New England, California, Texas, the Southeast and Midwest have been announced. Each facility is expected to have 20-50 test administrations per day. For students attending a medical school that is included in these regional consortia, NBME advises to wait to hear from their medical school dean’s office before taking any action to schedule or cancel a Prometric test center appointment. The institutions’ dean’s offices, in collaboration with Prometric and the USMLE program, will schedule eligible students for onsite USMLE testing.

“These school-based test centers are limited to certain areas,” Dr. Barone said. “. They are the first step in our multi-tiered effort to help with breaking the log jam in testing.”

NBME is working to provide testing to larger groups of trainees on medical school campuses, via event testing. If event testing were to take place, the USMLE exams could be administered concurrently to thousands of examinees in sittings at medical schools across the country.

It is also looking into the potential for remote proctoring of exams—as it has done with subject matter exams—though that possibility is still in the nascent stages, and the USMLE program has not committed to remote proctoring at this time.

“States value that the USMLE is a highly secure examination,” Dr. Barone said. “This is [because] of their understanding that the USMLE score is a valid one. USMLE has decided that we will explore remote proctoring particularly as a pandemic resource and then determine if it is something that is feasible for USMLE ongoing.”

As far as working through the backlog of test-takers in a timely manner, during the webinar Dr. Barone expressed confidence that it could be done.

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“[The USMLE program] is not meant to be a barrier,” he said. “It’s meant to be a minimum competency assessment. We realize that [students] sequence these examinations in particular times and do an incredible amount of preparation for them. ... I believe that we are on track to deliver these exams.”

School administrators are aware that external limitations on exams affect institutions’ policies for students’ progression toward graduation and transition to residency. Many schools are re-evaluating their historical timing of the Step exams to keep students moving forward. The Liaison Committee on Medical Education does not require the Step exams as part of accreditation and supports appropriate adjustments in timing or administration under the guidance of each school’s curricular oversight process.

The Coalition for Physician Accountability, of which the AMA is a part, has launched workgroups to consider downstream implications of educational disruptions related to COVID-19. One of those workgroups will address how the residency selection process for the class of 2021 needs to adapt, recognizing challenges students face in compiling typical elements, including clinical experiences and Step exam scores.

The AMA has curated a selection of resources to help manage the shifting timelines, cancellations and adjustments to testing, rotations and other events. 

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