Purpose
During the COVID-19 pandemic in 2020, undergraduate college education switched to online class delivery that affected exams, method of assessment and study methods in multiple ways, including often essentially open-book type of exams during online classes. The purpose of this study was to investigate how this different college education experience subsequently affected academic performance in the first course of a medical school curriculum.

Methods
Academic performance of the 8-week Course 1 “Cancer Biology & Core Principles of Medical Sciences” was assessed between Fall 2021 and 2024. During that time, we used again regular face-to-face in-person class delivery post-COVID-19 pandemic, as before, but still had medical students that had received part of their college education during COVID-19 pandemic-related educational conditions.

Results
The class average for our course remained within the same range between 2021 and 2024 (87.9%, 86.9%, 85.7%, 87.2%) with about 33-34% of students receiving an Honors grade, however we noticed an increasing tail of low-performing students from 2021 (2% F), 2022 (4% F) to 2023 (11% F) with a reversing trend back in 2024 (4% F). No changes to the course lectures or teaching faculty had occurred during this time.

Conclusions
Some of the lower performing students had reported that during the COVID-19 pandemic when they received their previous college education, they often had less rigorous exams with frequently open-book-type of tests or reports replacing exams that provided less opportunities of learning how to memorize material which they now recognized as a new challenge in their medical school curriculum exams. Hence this may in part explain the larger tail of lower-performing students who received part of their previous college education during COVID-19 pandemic-modified education, with a recent reversal of this trend in 2024 three years after the pandemic situation.