On Friday, I’ll be one of thousands of medical students nervously waiting for the results of this year’s Match Day, the moment we learn where we will go after medical school for internships and residencies.
Our destinies are a mystery until the Match. Some students will be invited to join their dream programs; others won’t match at all.
Regardless of their futures, however, all students who get to Match Day have been extorted by the National Board of Medical Examiners (NBME).
This board is responsible for administering a series of mandated exams, dotted throughout medical school and residency, that are necessary for acquiring a medical license in any state. These include Step 1, Step 2CK, Step 2CS, and Step 3. The NBME’s mission is ostensibly to “protect the health of the public.” Its balance sheet, however, suggests the organization might have a different motive. Last year, the NBME made more than $158 million in revenue. It relies mainly on physician volunteers to write the test questions while compensating its executive board with high six-figure salaries.
The board’s revenues are generated mainly through exorbitant registration fees for exams taken by over 44,000 medical students a year, many of whom are already ridden with significant debt (the Association of American Medical Colleges estimates the median debt at $200,000).
A prime example is a test called Step 2CS, which simulates a typical day in an outpatient clinic with patient-actors. This year, the registration fee for the exam jumped to $1,300. The test can be taken in just five cities across the United States, requiring most students to travel, and has a pass rate of more than 96% among American medical graduates. Unsurprisingly, a 2013 study published in the New England Journal of Medicine suggested that the Step 2CS test is likely a poor metric for determining the competence of physicians.
Taken at face value, the mission of the National Board of Medical Examiners is reasonable. There should be standardized tests in place to help guarantee public safety — medicine is, after all, a dangerous business. But it is difficult to justify what the board is doing to medical students today, and its actions have consequences for the public.
The United States Medical Licensing Examination (USMLE) Step 1 is especially responsible for the recent corporatization of medical education, creating an environment in which students are obliged to invest thousands of dollars in test-prep materials early in their medical school careers to obtain the high score — far and above a passing score — needed for placement in a competitive residency. This test has been linked to burnout responsible for depression and suicide among medical students well before they see their first patient.
Performing well on the NBME’s exams often relies heavily on heuristics. As a result, racial stereotypes and disease associations are frequently reinforced without a clear biological basis. A recent study, for example, found that medical students are more likely to believe that black patients are less sensitive to pain than their white counterparts.
The NBME’s tests do little to help resolve the serious diversity problem in medical education, in which American Indian, Black, and rural students remain severely underrepresented. Individuals from these groups often have the most difficulty paying several thousand dollars over the course of their medical school and residency careers for these tests.
When medicine is less diverse, patients ultimately lose. There’s good data out there suggesting that patients tend to trust their doctors more when they share identities with them.
The NBME has made its fortune from two cultural glitches in medicine: a resistance to move from the status quo and the desire to preserve painful rites of passage. I hope that its influence will wane over time.
Last month, the organization announced its intention to make Step 1 a pass/fail exam without a numerical score starting as early as 2022. I believe this is a positive step forward. Yet no changes appear to be on the horizon for its exam registration fees, underscoring that the organization intends to protect its financial bottom line.
Changing this system may require pressure from state medical boards (which require NBME exams today to license physicians), or even Congress. It may involve sustained organized action by medical students and residents building from past efforts, such as those by Harvard med students to eliminate Step 2CS in 2016. It may even come to filing a class-action lawsuit against the NBME for racketeering, as physicians did against the American Board of Internal Medicine in 2018 (a suit that was later dismissed).
As medical students plod along in the physician-trainee pipeline, it’s easy for us to feel helpless in the face of this community-sanctioned extortion. Medicine today deserves a better steward of its profession than the National Board of Medical Examiners.
Vishal Khetpal is a fourth-year medical student at the Warren Alpert Medical School of Brown University.