Medical students are experiencing a number of unprecedented changes in how their education is delivered. Because of COVID-19, objective structured clinical examinations (OSCEs) and anatomy instruction are now virtual, and exams are being remotely proctored. Leadership at medical schools, following guidance from the Association of American Medical Colleges (AAMC), suspended clinical rotations as of March 17. Since then, medical students have been assisting with COVID-19 efforts by rerouting personal protective equipment to hospitals and clinics, providing childcare for health care workers, translating health material into dozens of languages, and serving patients via telehealth.
It is also the prime testing season for second and third-year medical students. Medical students have been suspended in exam preparation ‘purgatory’ for the duration of this crisis. The Step exams are a series of 3 exams that are required for licensing by state medical boards and progression through medical education. Second-year students have lamented memorizing and rememorizing minutiae in the nearly 700-page Step 1 exam guide, all without having a clear idea of when they can sit the exam. Preparation for the exam is a 6-8 week full-time ordeal because it is a high-stakes exam used to screen applicants for residency selection, although there is a lack of correlation between exam scores and residency performance.
Due to testing site closures, students who began studying in January and February, or even earlier, are attempting to remain at their peak for months as they struggle to find spots at Prometric testing centers. Students and medical school leadership have been strung along by a series of communication gaffes on the part of the Step exam administators, the National Board of Medical Examiners (NBME), and its exam proctor, Prometric. When Prometric suspended all exam proctoring until April 16, and then again until May 1st, the announcements appeared on their website first, without any coordination with the NBME. When Prometric announced it would suspend ‘non-essential’ exams until May 31st, students began to cancel their May exams only to be told later by the NMBE that the Step exams were indeed essential.
But if the exams are considered essential, why were they suspended in the first place? For an organization with a mission of “Protecting the Health of the Public through State of the Art Assessment,” the NBME seems to hold a low bar for its commitment to public health. Students are rightfully concerned about sitting for the 8+ hour exam and potentially exposing themselves, their families, and Prometric employees to infection. Although Prometric requires students to wear a mask during testing, the feasibility of properly wearing the mask for the duration of these high stakes exams is unknown. Furthermore, the desperation of students with the financial means could mean students book hotels and travel to states with more lax social distancing guidelines without stay-at-home orders in place. This desperation is bound to increase now that Prometric is canceling 50 percent or more of scheduled testing appointments in order to limit capacity at their sites.
The answers to all of these issues have been clear to medical schools for some time. Medical school deans have advocated for remote proctoring of the exam. Initially, the NBME was adamant that remote proctoring would not be a solution during the pandemic. As of April 27, the NBME has stated they are considering remote proctoring as an option. However, they have committed to completing an analysis by June 30th, perhaps too late for students stuck in limbo. Another idea has been to expedite the transition of the Step 1 exam to a pass/fail format (currently slated to occur in 2022), but the NBME handwaved and stated, “a move to P/F impacts many individuals and stakeholders.” As students who are essentially being forced to endanger our health and the health of others to take this exam, we are left wondering who these stakeholders are and if they matter more than the public’s health.
Another exam board that is making changes in light of the pandemic is the Association of American Medical Colleges, which has canceled nearly all May administrations of the MCAT, shortened the exam by removing experimental questions, and added additional times so students can take it at staggered times.
The cost of transitioning to remote proctoring would be a minuscule expense in the NBME’s operation budget. It is unconscionable that the NBME, an organization that reported 175.4 million dollars in revenue in 2018, continues to exploit students during a pandemic. Students are shelling out hundreds of dollars for practice exams and question banks, without a clear idea of when they can safely take their exam. The NBME’s executives take in a combined salary of 5.7 million dollars, while students straddled with debt pay thousands of dollars for each of their Step examinations.
The optics of stalling the licensure of medical students during a public health crisis are not great. The NBME is placing financial interests over the wellbeing of students and the public. Without clear guidelines about ensuring student safety that does not revolve around wearing a mask for 8 hours, exams should not be resumed. The most important stakeholders of the exam, medical students, should be prioritized by increasing safe testing opportunities such as remote proctoring, removing experimental questions from the exam, expediting scoring for students who must make residency decisions, and making sure all communication is transparent and timely.
Fatima M. Warsame is a medical student.
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