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During one particularly grueling year of medical school, cartoons marked the start of every day for Anna Moshkovich. But she wasn't watching "Tom and Jerry" or "Scooby-Doo." Instead, she was watching animated videos about medicine on the subscription-based test-prep website Sketchy.

At least tens of thousands of other medical students learn the same way, thanks to a new wave of online medical education companies like Boards and Beyond, Pathoma, OnlineMedEd, and Sketchy. But while Moshkovich -- now a fourth-year medical student at Rush University in Chicago -- continues to pay for a subscription to Sketchy, many of her peers have been sharing logins or accessing on a shared cloud drive for years.

"Students can basically watch the videos for free without having to pay the subscription for the service," said Jason Ryan, MD, MPH, the founder and CEO of Boards and Beyond, and associate professor at University of Connecticut School of Medicine in Farmington.

Ryan told 麻豆传媒 that video piracy is prevalent among medical students.

Free access to medical education content can be especially tempting during a time of record-high tuition and . A monthly subscription to Sketchy costs paying customers about $33, and Ryan's service ranges from $20 to $89 per month. On social media, some medical students admitted to using illegal content because of financial reasons, but did not respond to 麻豆传媒's multiple requests for comment.

Ryan, who graduated from medical school in 2001, said that piracy of educational content was virtually nonexistent when he was in school. He began Boards and Beyond as a one-man show in 2014, and the company operated at a loss for a long time. He learned that medical students were watching his videos illegally about 1 year into his venture.

The number of medical students who illegally access content is unknown, but he said that unlawful use of his content eats into his profits.

"Starting the company was a lot of work," he said. "I see a lot of students getting benefits from it and that makes me very happy, but I wish everyone would just pay. If any student worked really hard to create something and then saw someone take it for free, they would be upset."

Media and education companies large and small are vulnerable to and unauthorized access. Last year, even video streaming service giant started to clamp down on users who share subscriptions across multiple households.

Arthur Caplan, PhD, a bioethicist at New York University in New York City, told 麻豆传媒 that some may see pirated videos as a justice issue. "It's like, 'I'm poor, you're rich. This is Robin Hood time. I get to sort of take advantage because I'm the one who's disadvantaged.'"

"Every year, it's just exponentially getting more and more expensive to become a physician," Moshkovich lamented. And not having access to study tools "just further creates a divide where privileged students are able to pursue privileged professions, and students that don't have resources are unfortunately barred from even being able to try to serve the communities that they come from."

She said that subscriptions to medical education platforms are a burden for students like herself who already pay large sums of tuition. Although she never used pirated videos, Moshkovich initially viewed the practice as "collaborative."

"The Google Drives were very prevalent and it's definitely something that I think med students found pride in," she said. "When you come from a really competitive pre-med environment to an environment where all of a sudden everyone is sharing their resources, it seems like you're moving in the right direction."

Nevertheless, Caplan maintained that it is unethical to illegally access pirated content. "It's not right," he said. "If you don't want the damn thing, don't use it."

"These creators are saving me hundreds of hours of studying, and they deserve to be compensated," Moshkovich agreed. "It's really easy to look the other way and not think about the damage that you're causing to creators that make this content ... [These subscriptions are] very expensive investments, but I do think that it's important to at least start that conversation."

Though Moshkovich said her thinking is still unorthodox, she highlighted that a growing number of her peers are opting to support medical content creators. Many students now split the costs of subscriptions within a limited group of friends.

Is that the path to sharing study materials more ethically?

Caplan said that account sharing bundles could be a way for education companies to recover profits lost from piracy, and argued that these companies should update their subscription plans to include group plans. The question is who would pay for these bundles.

Tyler Olson, a financial planner for physicians, said that the large price tag for medical school warrants complimentary subscriptions for all students.

"My foundational thought is that it's really stupid the way it's all laid out. Why would a medical school not be adequately providing all the tools?" Olson said in an interview. "I think that it's unfortunate that the students get put into this situation."

Ryan noted that Boards and Beyond partners with over 50 medical schools to offer them group bundles. However, a large portion of schools remain without partnerships.

For now, his team is relying on Boards and Beyond features not accessible when the content is pirated -- such as personalized user experiences and question banks -- to make the paid subscription more attractive for paying customers.

"No matter what you do -- even if you had the most perfect system -- someone can always point a camera at the screen and record it," he acknowledged. "There's really no perfect system that will prevent people from pirating the content."

Though his team does not go after students who illegally access their content, Ryan said that medical schools should reprimand students.

"A lot of students feel like there's no way the school will ever find out, so they're not too worried about punishments," he said. "Violations, though, are taken very seriously because they're thought to indicate the possibility that down the road, that student will become a physician who behaves unethically."

Ryan's bottom line: "I think the more morally responsible you are as a student, the better physician you'll be."

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