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Letters to the Editor

In Reply to Tallia et al

Carmody, J. Bryan MD, MPH; Rajasekaran, Senthil MD

Author Information
doi: 10.1097/ACM.0000000000003546
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We thank Dr. Tallia and his colleagues on the National Board of Medical Examiners (NBME) Executive Board for their response to our Perspective. Though their reply alleges that our article “raise[d] serious allegations intermixed with speculation and anecdote,” we note no material corrections to the facts we presented and continue to stand by our work.

Instead, we challenge some of the assertions made by Dr. Tallia and colleagues. We question whether the self-assessments sold by the NBME “protect the health of the public” any more than practice materials provided by the numerous for-profit entities that operate in this space. Similarly, although it is true that United States Medical Licensing Examination (USMLE) fee increases have approximated the Consumer Price Index (CPI), it remains unclear why any increase in registration fees was necessary when, as we reported, the NBME’s revenue was growing at more than 5 times the CPI.

Some of the information provided by Dr. Tallia and colleagues may be helpful to readers. Yet when considered in full, their response seems to sidestep the key points in our article. We presented data showing how the rise of USMLE Step 1 mania has financially benefitted the NBME and how these benefits have been achieved by offering products and services other than the USMLE. We showed how the NBME’s revenues more than tripled from 2001 to 2017, with salaries for top executives rising in lockstep with the rise in revenue. We emphasized that conflict of interest is a condition, not a behavior, and asserted that the NBME’s current business model and unique market position create conditions sufficient for a problematic financial conflict of interest. Both our article and the associated, independent Invited Commentary by Dr. Gesundheit1 included multiple specific and actionable proposals that could resolve this conflict of interest and restore trust in the NBME—though few of these were addressed in their response.

We appreciate that the NBME is conducting a review of its governance, and we thank the executive board members for their pledge to consider carefully all concerns raised regarding conflict of interest. We continue to hope they will seriously consider those raised in our article.

J. Bryan Carmody, MD, MPH
Assistant professor of pediatrics, Eastern Virginia Medical School, Norfolk, Virginia;; ORCID:
Senthil Rajasekaran, MD
Senior associate dean for curricular affairs and undergraduate medical education, Wayne State University School of Medicine, Detroit, Michigan; ORCID:


1. Gesundheit N. A crisis of trust between U.S. medical education and the National Board of Medical Examiners. Acad Med. 2020;95:1300–1304.
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