On Step 1 Mania, USMLE Score Reporting, and Financial Conflict of Interest at the National Board of Medical Examiners

Abstract

Though intended to inform a binary decision on initial medical licensure, the United States Medical Licensing Examination (USMLE) is frequently used for screening candidates for residency positions. Some have argued that reporting results as pass/fail would honor the test’s purpose while preventing inappropriate use. To date, the USMLE’s sponsor organizations have declined to make such a change. In this Perspective, the authors examine the history and mission of the National Board of Medical Examiners (NBME), trace the rise of “Step 1 mania,” and consider the current financial incentives for the NBME in implementing a pass/fail score-reporting policy. The NBME was founded in 1915 to address the lack of interstate reciprocity in medical licensure examination. With the creation of the USMLE in 1992, a single pathway for licensure was established, and the organization’s original mission was achieved. Yet even after fulfilling its primary purpose, the NBME—classified as a nonprofit organization—has seen its revenues rise dramatically over the past 2 decades. Much of the increased revenue is derived from test products and services not required for medical licensure, with sales driven by the increasing importance of Step 1 scores in residency selection. Revenue from these products and services would likely decline if the NBME reported Step 1 results as pass/fail. A financial conflict of interest occurs when a judgment concerning a primary interest may be influenced by a secondary interest, such as financial gain. The data presented here demonstrate that the NBME has a conflict of interest in its current score-reporting policy. Possible remedies, such as disclosure, recusal, divestiture, and restructuring, are considered.

Implications of Pass/Fail Step 1 Scoring: Plastic Surgery Program Director and Applicant Perspective

“… 6 There has been increasing emphasis on Step 1 preparation in undergraduate medical education, with students purchasing costly resources and dedicating additional time to study for the Step 1 examination. 7 Unfortunately, socioeconomic status disparities in accessing resources may contribute to demographic differences in Step 1 performance by race and gender. 8 – 10 Consequently, Black and Latinx medical students may be disproportionately excluded from surgical careers, as many surgical training programs use minimum Step 1 scores for screening applications.…”

A Comparison of Selected Items Found in Graduation Survey Instruments from MD and DO Schools. What It Reveals About Satisfaction with Career Choice

“…A rising student debt and higher expectations on board exam performance for specialty choice [9][10][11] could be to blame as well. The cost of preparation and examination increases during the clerkships [23,24], and rising debt has been negatively associated with mental well-being and academic outcomes [25]. For both DO and MD students matching into a desired first-choice GME specialty, it has become overwhelmingly dependent specifically on performance in board exams [26,27].…”

Application Fever: Reviewing the Causes, Costs, and Cures for Residency Application Inflation

“…Because United States Medical Licensing Examination (USMLE) scores are the only sortable scaled metric available in ERAS, most programs use specific target scores to limit applications for review [6]. Accordingly, medical students focus on test preparation at the expense of engagement in educational experiences that are more difficult to quantify [7][8][9]. Although the USMLE Step 1 exam will be reported as pass/fail as soon as 2022, 81% of program directors plan to increase emphasis on USMLE Step 2 Clinical Knowledge (CK) scores in selecting applicants [10].…”