On the morning of Saturday, May 16, 2020, I woke up at 6:00 AM, tried to calm my mind with a ritualistic cup of coffee, and packed snacks for a long day. I left at 7:20 AM and turned around five minutes later, realizing that I forgot to take my wallet. Again, I left at 7:35 AM with wallet in hand and arrived at my testing center 50 miles away a half hour before my 9:00 AM United States Medical Licensing Exam (USMLE) Step 1 appointment, as instructed. The parking lot was empty. Nonetheless, I tried the door to the testing center—it was locked. No one was inside.

The USMLE Step 1 in its current form is arguably the most important test a medical student will take. While intended to be pass/fail for licensing, it reports performance as a 3-digit score, which is the most common factor used by residency programs to select applicants for interviews.¹ Thus, it can impact where a person will complete residency, which specialty to practice, and whether they will be able to practice medicine at all. This emphasis has created a “Step 1 climate” that impacts pre-clinical learning and student wellness thereby putting an extra financial burden on students.² Because of this, it was announced earlier this year that the Step 1 exam would change to pass/fail reporting.³ However, the COVID-19 pandemic has introduced new challenges for current test takers.

When I arrived to find an empty testing center, I was upset, but not entirely surprised. For the last two months, I had heard of my fellow medical trainees experiencing cancellation of their exams and difficulty with the rescheduling process. Prometric, the testing vendor for the USMLE, announced on March 17 that its testing centers in the United States and Canada would be closed until May 1.⁴ Students scheduled to take the exam during that time were forced to reschedule to a later date when they would be able to take their exam. Students needing accommodations had a particularly difficult time since they had to reschedule by phone—during times of high cancellations, Prometric had turned off its phones.⁵

Throughout the spring, I watched with apprehension for word about the status of my exam appointment. Since my third-year clerkships weren’t scheduled to begin until June, I had originally scheduled my exam for May 14 with the hope that I could travel and see family before beginning clerkships. On April 23, it was announced that while certain locations would resume testing on May 1, many cancellations would be inevitable in order to adhere to social distancing at the testing centers.⁴ A large number of these cancellations were announced by e-mail on April 27. While I did not receive an e-mail that day, I grew worried that I would be one of the many who did not receive a cancellation notice and would only find out the exam was cancelled upon arrival at the testing center.

There was still an issue of which exact locations would be opening, and when. While the USMLE is considered an essential program, the opening of each site is based on a number of factors including local, state, and federal regulations. At the time, there was no updated list of when each site was supposed to open. Just three days after avoiding the mass cancellation, I, too, received notice that my exam was cancelled due to my center still being closed that day. I immediately checked for open spots and found none available in my state or in surrounding states for the next three months.

Despite preparing myself for the possibility, it felt like I was approaching the end of a marathon only to be told that the finish line was being moved back but not told how far. I was worn out, but needed to keep the information fresh because I didn’t know if I would to take the exam in a week or a month or a year. My school adjusted its policy so that students could begin the next phase of training without having completed the exam; but, we were at risk of study burnout and worse performance on the exam the longer the delay.

On top of this stress was COVID-19 itself. I began my dedicated study period as my state began its stay-at-home order. I studied flash cards as more cases were announced, more studies published, and more people died. I did practice questions as hospitals became overcapacity and medical professionals begged for more personal protective equipment. I took notes while I worried about my family and if they’d be able to stay safe. Many of my fellow medical students had more worries, some amplified by the killing of George Floyd on May 25 and the subsequent uprisings.

I continued to watch the Prometric website for openings and just four days after the mass cancellation and over 24 hours after my cancellation, many spots suddenly became available late on a Friday afternoon. It seemed too good to be true. After more than an hour of waiting due to high traffic to the site, I was finally able to reschedule my appointment. I managed to get a date only a week later than my original date, but it was in my home state of Minnesota since those sites had been confirmed to open May 1 whereas the sites in Illinois where I attend medical school had not. While I knew I shouldn’t travel states away during a pandemic, it was what I was going to have to do to take the exam.

I did not keep that exam appointment in Minnesota for long. I worried that I would drive all of that way and risk spreading the virus, only show up to the testing center and not be able to take the exam that day. If that was going to happen to me, I’d rather have it in Illinois close to where I live, as it nearly did.

Eventually, Illinois testing centers appeared as opening on the Prometric website. I didn’t truly trust that they were opening until I had assurance in writing from my medical school dean who had been in touch with the owner of a nearby location and was told that they were definitely going to begin testing. Eager to get the exam done, I switched my date to May 16 at that location. I called the location and confirmed the appointment three days prior. I did not receive the confirmation phone call from them the day before my exam that they had told me to expect.

At 9:00 AM on May 16, when I was supposed to be starting my exam, I e-mailed my dean from the parking lot of the empty Prometric location to ask what I should do. I heard from her within minutes. She said that she tried to reach the owner with no luck but was going to keep trying and told me to wait. I waited there with an internal medicine resident who had called to confirm his Step 3 appointment the previous day and had driven from Indiana the night before to take the exam. Neither of us confirmed the time of the appointment when we had called.

Within the hour, my dean was able to reach the owner who then contacted me. It turns out there was a scheduling error—one calendar had exams at 9:00 AM and another had exams at noon that day. Because they were busy training a new employee the previous day, they didn’t double check the schedule. Guess which calendar they saw. He was going to get an employee there as soon as he could. We were still going to be able to take our exams that day.

I tried to calm my mind and prepare myself to take the exam. I laughed, reflecting on how I had thought nearly forgetting my wallet was my last hurdle before taking the exam. Soon, an apologetic employee arrived and let us in. I began my exam at 10:30 AM.