National Board of Medical Examiners

The National Board of Medical Examiners (NBME), founded in 1915, is a United States operation which sets state recognised examinations for medical students.[1] The NBME is an independent, not-for-profit organization headquartered on and adjacent to the University City Science Center research campus in Philadelphia, Pennsylvania.[2] NBME states that its mission is to "protect the health of the public through state of the art assessment of health professionals." The board emphasizes that "while NBME's mission is centered on assessment of physicians, this mission encompasses the spectrum of health professionals along the continuum of education, training and practice and includes research in evaluation as well as development of assessment instruments".

During COVID-19 pandemic and George Floyd Protests, the medical community criticized the NBME's refusal to revert Step 1 scoring to pass/fail before 2022 and for the gross mishandling of Step examinations during the pandemic, creating "chaos," further "disadvantages," "harm," "bias" and "inequity;" and called for an emergency committee (that included student representatives) who could address these issues in a timely manner without financial or other conflict of interests.[3] [4][5][6]

History

The board rose in prominence in the years after World War II. Prior to the war, states administered their own exams, and operated agreements to license doctors passed by other state exams. After the war, states began to use the results of an NBME exam to decide whether to award a license. This system meant students would sit the same exam.[7]

The United States Medical Licensing Examination (USMLE), introduced in 1992, is a multi-part professional exam sponsored by the Federation of State Medical Boards (FSMB) and the NBME, and must be passed before a Doctor of Medicine can obtain a license to practice medicine in the United States.[8][9]

The NBME creates self-assessment exams for the programs it runs including USMLE Step 1 and USMLE Step 2 CK.[10] As of February 2018, these assessment tests are available only in expanded feedback version costing $60 and displays the incorrectly answered questions in addition to the analytics.[11] The assessments now provide the correct answer to questions in the expanded feedback version. Prior to this, students frequently discussed the questions among themselves on online forums to reach the correct answer. The latest NBME in the series of NBME tests is NBME 22, with three additional tests to be released in late Spring 2019.

Current Leadership (as of 2020)
  • president – Dr. Peter Katsufrakis
  • vice president of Licensure Program – Michael Barone
  • chair – Dr. Alfred Tallia
  • vice chair – Dr. Paul Wallach
  • treasurer – Dr. Latha Chandran
  • Executive Board – Suzanne Anderson, Pat Mastors, Kamili Wilson, Dr. Marie Foley, Dr. David Milling, Dr. Karen Sanders, Dr. Reena Karani[12]


NBME mishandling and inequity created during COVID-19

With the ongoing COVID-19 pandemic, the USMLE and NBME were met with tremendous criticism by the medical community--including their parent organizations AMA and AAMC as well as letters and petitions from physicians and students-- for lack of flexibility and adaptability during COVID and for mishandling testing and refusing to revert step 1 scoring pass/fail before 2022.[13]

A summary of current complaints surrounding the USMLE mishandlings can be found here and include the USMLE's "failure to take responsibility," "lack of communication," "day-of cancellations," and unequal access for test takers that created "inequity," "bias," "chaos" and "harm" to students and "shortchanging their clinical experience."[14]

By not reverting to remote P/F during COVID, the USMLE is "distracting students from their medical education," said a doctor at a Stanford. Because of overemphasize of Step 1, students study for months, often at the expense of classes and clinical training. These further delays will further exacerbate that problem. For the few that were able to test during COVID, many of those students reported taking a day or more off of clinical rotations to fly to their exam, only to find out their exam was cancelled day-of and had to scramble for a new date months later, meaning they would miss more months of their medical education to study for Step 1.

The medical community was upset that despite the chaos, harm, and damages to the integrity of the test created by USMLE, the USME's concern was their stakeholders, not students. Despite numerous letters, petitions on change.org and the medical community's public pleas, Michael Barone, VP of NBME Licensure Programs, said that the USMLE would not consider moving up the anticipated pass/fail Step 1 scoring before 2022 because it would affect their "stakeholders" (implying that their stakeholders were residency programs, not medical students). The medical community was upset that the USMLE prioritized residency programs (who want to keep scores visible) over students and doctors (who believe score reporting should be pass/fail as originally intended). The Step scores were not designed to be used as a residency admissions metric; the scores we intended for medical licensing purposes only and have no meaning beyond pass/fail designation. While it is ultimately the Residency programs fault for misusing the step scores, the USMLE/NBME are aware of and directly enabling the misuse. The overemphasis of Step would not occur if the exam was scored as originally intended. [15]

The resulting "harm and chaos" has created inequity and bias and damaged the integrity of the Step exams, defeating the purpose of a standardized test. To have the most "unbiased and equitable" exam, the medical community has asked the AAMC, ERAS, and USMLE to allow medical students to choose how their score would be reported (scored or P/F) on their ERAS transcript during this transition or retroactively report scores as pass/fail beginning with the class of 2022. To avoid the potential financial conflict of interest of the NBME and USMLE,[16] the Coalition for Physician Accountability launched workgroups to address the downstream implications of COVID-19.[17]

Numerous memes have gone viral regarding these matters.

Controversies

Katsufrakis & Chaudhry comments against Step 1 changes

In Dec 2018, NBME President Peter Katsufrakis and FSMB President Humayun Chaudhry wrote in opposition of USMLE Step 1 changes in from Improving Residency Selection Requires Close Study and Better Understanding of Stakeholder Needs: "If students reduce time and effort devoted to preparing for Step 1, they may indeed devote attention to other activities that will prepare them to be good physicians. This would arguably be an ideal outcome of such a change. However, if students were to devote more time to activities that make them less prepared to provide quality care, such as binge-watching the most recent Netflix series or compulsively updating their Instagram account, this could negatively impact residency performance and ultimately patient safety. We know that assessment drives learning, so another concern resulting from a shift to pass/fail scoring may be a less knowledgeable physician population."[18] [19]

NBME Executive Salary

The NBME executives received public criticism after their salaries were released after increasing costs for students, showing many executives receiving high said to seven figures. "Former NBME President Dr. Melnick's compensation increased from $399,160 in 2001 to over $1.2 million in 2016, almost perfectly in parallel with the tripling of USMLE costs." [20][21] "As of 2016, NBME President also gets free first-class airfare for himself and his travel partner, as well as a membership to a Philadelphia social club. According to the 2017 Form 990, Schedule J, two lower executives received total compensation over $700,000; another two over $600,000; another three receiving over $500,000; and another 6 receiving over $400,000....Yet, the total number of test-takers for the USMLE Step 1 has been essentially unchanged for the past 10-15 years."[22]

Pricing

NBME and USMLE were met with criticism when they announced their raising cost for standardized tests. Kevin MD wrote, "Safeguards are needed to ensure fees for mandatory testing such as the USMLE do not exceed reasonable operating costs, particularly for financially vulnerable medical students."[23]

As of 2020, the USMLE currently charges:

  • $645 for Step 1
  • $645 for Step 2 CK
  • $1300 from Step 2 CS [24]


As of 2020, Student Assessments costs include:

  • $799 for a two year subscription to UWORLD
  • $60 for each NBME Self Assessments (access expires after 90 days)

See also

References
  1. Statistics of Land-grant Colleges and Universities (1921) United States Office of Education
  2. Kostelni, Natalie (2007-11-23). "Medical examiners to expand HQ". Philadelphia Business Journal. Retrieved 2009-05-16.
  3. https://www.ama-assn.org/residents-students/usmle/delays-miscommunications-add-even-more-stress-usmle-step-exams
  4. https://www.medscape.com/viewarticle/932366
  5. https://www.ama-assn.org/residents-students/usmle/delays-miscommunications-add-even-more-stress-usmle-step-exams
  6. https://thesheriffofsodium.com/2019/02/01/a-non-mbas-guide-to-nbme-revenue-in-9-simple-charts
  7. Ludmerer, Kenneth M. Time to heal: American medical education from the turn of the century to the era of managed care (1999), Oxford University Press US, 1999. p. 197-198. ISBN 0-19-511837-5
  8. United States Court of Appeals for the Third Circuit (1999-12-09). "JOHN DOE, v. NATIONAL BOARD OF MEDICAL EXAMINERS, APPELLANT, D.C. Civ. No. 99-cv-04532". AltLaw. Retrieved 2009-05-16.
  9. Melnick, Donald E. (December 2006). "From Defending the Walls to Improving Global Medical Education: Fifty Years of Collaboration between the ECFMG and the NBME". Academic Medicine. Association of American Medical Colleges. 81 (12 Suppl): S30–S35, Volume 81 - Issue 12. doi:10.1097/01.ACM.0000243462.05719.e1. PMID 17086043.
  10. "NBME Self-Assessment Services". nsas.nbme.org. Retrieved 2016-03-02.
  11. NBME. "FAQs about Review | NBME". www.nbme.org. Retrieved 2016-03-02.
  12. https://www.nbme.org/about-nbme/our-people
  13. https://www.medscape.com/viewarticle/929899
  14. https://www.medscape.com/viewarticle/93236
  15. https://www.medscape.com/viewarticle/932366
  16. https://thesheriffofsodium.com/2019/02/01/a-non-mbas-guide-to-nbme-revenue-in-9-simple-charts
  17. https://www.ama-assn.org/residents-students/usmle/delays-miscommunications-add-even-more-stress-usmle-step-exams
  18. https://in-housestaff.org/dear-nbme-and-fsmb-i-watch-hgtv-more-than-netflix-a-response-to-the-invited-commentary-on-usmle-step-1-1274
  19. https://opmed.doximity.com/articles/step-1-vs-netflix-and-instagram?_csrf_attempted=yes
  20. https://forums.studentdoctor.net/threads/step-3-trick-works.1271481/page-32
  21. https://projects.propublica.org/nonprofits/organizations/231352238
  22. https://thesheriffofsodium.com/2019/02/01/a-non-mbas-guide-to-nbme-revenue-in-9-simple-charts/
  23. https://www.kevinmd.com/blog/2016/07/cost-taking-usmle-exams-staggering.html
  24. https://www.nbme.org/taking-assessment/united-states-medical-licensing-examr-usmler
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