USMLE Testing Chaos May Harm Current and Future Doctors

Lexi Krupp

June 15, 2020

Somewhere near Kansas, 2 hours into a 17-hour drive on Interstate 70, Geoff Markowitz checked his email. He was on his way to a testing center in Nashville, Tennessee, to take his Step 1 exam the next morning. In his inbox was a message that said his test had been canceled. Again.

Although Markowitz is a student at the University of Colorado School of Medicine, in Aurora, the testing center in Nashville was the only location where he could both secure an appointment and confirm it was open.

Upon reading the email, he called the testing company but was unable to speak with anyone. When he checked the online system, the exam appointment he had originally made was still listed as available. He rescheduled. Then he got another cancellation email. He rescheduled again. That one finally seemed to stick.

He arrived in Nashville in the middle of the night and took the exam early the next morning. "The whole while I was in disbelief that I might be able to take the test," Markowitz said. Since his first Step 1 cancellation, he had rescheduled 15 times.

Others have not been as fortunate. In response to the COVID-19 pandemic, on March 17, the United States Medical Licensing Examination (USMLE) announced that licensing exam testing was suspended for 30 days. On April 17, the private company that administers the exams and runs the testing centers, Prometric, canceled testing once again.

According to medical students, residents, and faculty who spoke with Medscape Medical News, testing has now resumed, although the process has been chaotic, poorly communicated, discriminatory, and outright harmful, largely because of the USMLE's relationship with Prometric.

Step Scores Still Loom Large

It is estimated that cancellations affected 17,000 medical students and residents through mid-May, according to student representatives from the Association of American Medical Colleges. Last-minute cancellations continued through early June, sometimes just hours before exams were to start. Students have arrived at testing centers for exams only to find them closed. Many have called testing centers and Prometric's headquarters to find full voicemail boxes, automated messages, or hours-long waits.

For people with disabilities or who need accommodations for other reasons, such problems are not just annoyances. Those students can't compete for testing dates online and can only schedule appointments by phone, during Prometric's business hours.

Some argue the situation has exposed inherent unfairness in the system. "It's an equity problem to say that this exam [Step 1] is standardized," said Lauren Marcell, a student at the University of Washington School of Medicine, in Seattle. To address inequities and student concerns about the disproportionate influence of Step 1 scores, the USMLE is moving to have tests evaluated on a pass/fail basis. But not until January 2022 at the earliest. Until then, scores will still go a long way in determining specialty choice and residency placement.

"Students are freaking out," said Bryan Carmody, MD, a pediatric nephrologist at the Children's Hospital of the King's Daughters, in Norfolk, Virginia, who has written extensively about medical licensing exams and the financial conflicts of interest involved. The message, Carmody says, has always been, "This is the most important test you'll ever take — it determines your whole future, your whole career."

For years, the USMLE — which is composed of the National Board of Medical Examiners (NBME) and the Federation of State Medical Boards (FSMB) — has contracted with Prometric. That company facilitates the administration of exams and oversees testing centers, many of which are operated by third-party vendors. Those affected say that inconsistent and often conflicting information from Prometric and the USMLE has resulted in confusion and frustration.

Critics allege that the organizations have demonstrated a lack of accountability. "When Prometric says it cannot administer the exam, I put the responsibility squarely on the NBME and the FSMB to make sure there are alternative opportunities, or to advocate for those students," said Senthil Rajasekaran, MD, MMHPE, a senior associate dean at the Wayne State University School of Medicine, in Detroit, Michigan.

Students have spoken out but are ultimately at the mercy of test administrators. The USMLE is "the organization that has legal and moral responsibility for the exam," said Neil Gesundheit, MD, MPH, a professor and senior associate dean at Stanford School of Medicine, in California. "They should really have a backup plan and not delegate all of their testing responsibilities to one organization [Prometric] that has essentially created a monopoly."

Test Takers Left in the Dark

Prometric opened some of its locations for USMLE testing at 50% capacity in May. To accommodate this change, the company randomly selected thousands of appointments for cancellation. Many test takers were given no advanced warning of cancellations or received inaccurate information, according to communications shared with Medscape Medical News.

One medical student who wished to remain anonymous (for fear of backlash from administrators) received a confirmation email on Friday, May 28, indicating that his Step 2 Clinical Knowledge exam was still on. When he arrived at a Chicago testing center the following Monday, June 1, the center was closed. "It's shocking to have no warning and show up ready for your board exam and not take it," he said.

When students have tried to directly confirm timing with Prometric, they often could not. Jordan Rudman, a student at Rush Medical College in Chicago, had no success calling Prometric headquarters. "They shut down their phone line. There was literally no way to speak to somebody," he said. "The communication and transparency has been grossly inadequate."

Test takers have contacted Prometric's corporate offices, individual testing centers, the USMLE, and even government officials. "I sent emails to all of my representatives and called the governor's office, as well," said Rudman. "I ended up calling the Illinois Chamber of Commerce and working with someone there.... He said he's been getting tons of calls from people in healthcare."

Others have looked to social media. "I literally joined Twitter to figure out what's happening," said Marcell. "It's not like Prometric or USMLE are emailing these updates — they're coming from posts on Twitter."

Prometric has acknowledged communications failings but faults the pandemic. In a statement emailed to Medscape, Prometric representative Tom Warren wrote, "Some test centers had to close on short notice or were unable to reopen...due to the evolving situation. Decisions had to be made daily to ensure the safety of our test takers, which is our number one priority." He attributed their limited phone support to an unprecedented volume of cancellations and rescheduling.

Thousands of medical students and residents remain in a state of anxious limbo. "You never know when the next wave of cancellations is going to hit," said Matthew Durst, a MD-PhD student and president of the student council at the University of Illinois College of Medicine, in Chicago, who coauthored a scathing letter to the leaders of the NBME and FSMB in early May. The letter states: "This level of dysfunction, disorganization, and disruption is simply unconscionable given that [these organizations] have had since the suspension of testing on March 17, 2020 to plan for timely and organized resumption."

Accommodation Needs Lead to Greater Disadvantage

Those who require testing accommodations are even further disadvantaged, because they cannot use the online system. People with learning disabilities, mobility impairments, or type 1 diabetes and anyone who is pregnant or breastfeeding must reschedule by phone during business hours and often encounter hours-long waits.

Appointments have become rare commodities, snatched up online in minutes. "People are on this website all day, refreshing, trying to find these testing dates available," said Leah Pierson, a student at Harvard Medical School, who coauthored an open letter to the NBME that had over 2700 signatures.

"If you have some accommodations, then basically you have no chance to compete with other students to get these slots," said Ameet Kini, MD, PhD, a pathology professor at the Loyola University Medical Center in Chicago.

A medical student in Minnesota, who requires testing accommodations and wished to remain anonymous because of concerns about backlash, said he experienced hour-long waits multiple times when he called Prometric. When he finally did reach the company, he received inaccurate information. At one point, a representative rescheduled his exam to a testing center in Bedford, Texas. When he called that Texas location to confirm, he couldn't get through. Desperate, he called a restaurant next door. They told him the building had caught fire weeks before and hadn't reopened.

Organizations such as the Coalition for Disability Access in Health Science Education have pointed out these disparities in letters to the NBME and the FSMB, copies of which have been reviewed by Medscape. The USMLE and Prometric have yet to publicly acknowledge these concerns. "This is unacceptable," Kini said. "This is about equal access and fairness towards students with disabilities. The silence is deafening."

When asked for comment, the USMLE redirected the blame to Prometric. "We requested that Prometric proactively reach out to examinees in need of testing accommodations to facilitate scheduling," communications director Joe Knickrehm wrote in an email.

Solutions Underway, Uncertainty Looms

In mid-May, the USMLE reported that to accommodate the testing bottleneck, it would establish a limited number of regional testing locations at medical schools throughout the country. Since then, it has announced testing sites at Brown University, in Providence, Rhode Island; the University of South Florida, in Tampa; Indiana University, in Bloomington; the University of California, San Francisco; the University of Texas at Austin; and the University of Arizona College of Medicine–Phoenix. Each will serve students from an additional 40 selected medical schools in the surrounding regions and offer 20 to 50 seats a day.

The USMLE has also announced that it will suspend the Step 2 Clinical Skills exams for at least another 12 to 18 months. "It's clear that we're headed in the right direction," said Pierson, of Harvard Medical School.

Still, not all medical students will benefit from these changes, including those who are not at or near schools offering USMLE testing, as well as international medical graduates. "I am concerned that a vast number of students do not have a solution," said Rajasekaran of Wayne State University School of Medicine.

Students whose exams have been postponed fear continued cancellations, worse test scores, and delays in finishing their degrees. "What happens if we get to late August and I get another cancellation?" worried Lexie Hensley, a medical student at the University of South Alabama, in Mobile, whose Step 1 exam, originally scheduled for June, has been rescheduled for September. "What position will I be left in then?"

Testing problems could extend far beyond short-term inconvenience. "It's not just the stress — it's detracting from their medical education," said Stanford's Gesundheit. "By delaying and delaying and postponing when they take the exam, they're essentially shortchanging their clinical training. Either they're going to graduate late, or they're going to graduate with less clinical experience."

Corey Kronman, an MD-PhD student at Penn State College of Medicine, in Hershey, Pennsylvania, summed up how so many feel right now. When it comes to the USMLE and Prometric: "It feels like they failed their students."

Lexi Krupp is a journalist who covers science and health stories for audio and print. Her work has appeared in Science Vs, Popular Science, Audubon Magazine, and elsewhere. Before working as a journalist, she taught ecology in Wisconsin and Maine.

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