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Step 1, COVID-19, and a Marathon Unraced

Studying for the USMLE Step 1 exam has never been an easy feat. From the first day of medical school, students are anxious to sit for the exam which determines, in great part, which specialty they can practice and where they can train. At the end of the preclinical curriculum, students begin anywhere between six–12 weeks of dedicated Step 1 study. Dedicated is like training for a marathon. For months, you plan what your training will look like. How many miles will you run each day? How long will your weekend run be? What shoes will you wear? You meticulously research the exact training — in this case, study — plan months in advance, basing your schedule off of years of data from successful runners: the test-takers. Then, a few days before your race date, after years of working towards your once seemingly insurmountable goal, it’s canceled. You don’t know when you can race, but you know it’s the most important race of your life. You can’t keep running 20 miles every weekend — your legs will give out. You can’t stop training, because you need your body to perform seamlessly when the day comes. When Prometric announced on March 17, 2020, that all locations would be closed due to COVID-19, we did not have time to grieve. It is only after taking the exam that we have had time to reflect on our experiences of:

Denial How did we spend days attempting to contact Prometric and furiously scrolling Twitter for official USMLE updates while also studying for Step 1? It must have been a nightmare induced by sleep deprivation.

Anger For months we were locked into a cycle: exhaustion led to securing a test date, ramping up studying, a canceled test date, and finally, exhaustion. This repeated over five times. 

Bargaining Students and deans signed petitions to advocate for our concerns. Maybe we could accelerate the pass/fail decision? Maybe we could administer tests at medical schools? 

Depression The unsatisfying halt to months of meticulously scheduled practice exams, videos, and flashcards that prepared us for the marathon somehow left us barely able to run around the block. We worried about sick loved ones, missed important milestones, and the feeling of isolation was exacerbated by our grief.

Acceptance Step 1 didn’t feel like a victory with a medal around our necks. It felt like dragging a 200-pound boulder up a hill a dozen times, not knowing when it would stop getting pushed back down. Despite the frustration, we knew that the cancellations were necessary. Now that we have crossed the finish line, we look forward to our future and hearing how Program Directors (PDs) will address our collective challenges during the 2022 application cycle.

Recently, USMLE announced that in 2022, Step 1 will be a pass/fail determination instead of a numerical score. The two-year delay is to give adequate time for residency programs to reestablish their metrics for evaluating applicants. Students are uncertain how PDs plan to address the shift away from Step 1 scores. Originally, new screening parameters were not absolutely necessary until 2023, when the first round of students with pass/fail scores will apply. However, we believe the time for change is now. Step 1 scores are prone to vast variability during the pandemic. In the wake of COVID-19, students are now facing unprecedented challenges: inadequate study locations, children in the household, sick family members, and financial struggles. Medical students are spread particularly thin. Amidst the pandemic, we are trying to perform our civic duty by volunteering and conducting research. All the while, we tried to maintain our Step 1 knowledge. Despite these challenges, we recognize our privilege. Many of our Black and Brown peers are both experiencing the consequences of systemic racism and carrying the burden for change. Though the Step 1 marathon is over for many, we students look forward to PDs listening to our challenges; we encourage transparency of screening methods for the class of 2022. A recent Journal of the American Medical Association (JAMA) letter encourages a holistic review of applicants, residency application timeline adjustments, and an expansion of program information available to students. Outwardly, medical students are filled with hope and passion. Internally, we are fearful and anxious about our education and careers. We know Step 1 scores are a critical tool for PDs; we don’t underestimate the work needed to approach application season without them. We look forward to an outward-facing plan from PDs. We understand Step 1 cannot be definitely made pass/fail now, though we think that there are attainable solutions to these unique circumstances. Realistic solutions given the timeline include modifying algorithms to put less weight on Step 1 scores and lowering cutoffs to screen applicants scoring on the cusp. Medical students, we hear you. Program Directors, hear us out. Grief is a burden best carried together. 

Sophie is a third year medical student at University of Illinois at Chicago College of Medicine (UIC-COM). She is involved in Endocrinology research, serves on the Student Curricular Board Executive board, is leading cross-campus reviews of the curricular response to COVID-19 pandemic at UIC-COM, COVID-19 research, and is heavily involved in MRKH patient advocacy.

Divya is a third year medical student at University of Illinois at Chicago College of Medicine (UIC-COM). She is involved in Obstetrics and Gynecology research, COVID-19 research, serves on the Student Curricular Board, and is a Patient Centered Medicine Scholar. 

Manish is a third year medical student at University of Illinois at Chicago College of Medicine (UIC-COM). He is involved in Otolaryngology research, Bioengineering development, is an Innovation Medicine Scholar, and is an intern for MD Angels.

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