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Letters to the Editor

In Reply to Tallia et al

Gesundheit, Neil MD, MPH

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doi: 10.1097/ACM.0000000000003545
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I thank Dr. Tallia and colleagues for their response to my Invited Commentary that accompanied the Perspective by Drs. Carmody and Rajasekaran. Our community of medical educators appreciates the service provided by National Board of Medical Examiners (NBME) Executive Board members and understands that they are committed to the high ideal of assuring physicians are prepared to serve the health needs of the U.S. public. In addition, the decision by the NBME and other stakeholders to convert the United States Medical Licensing Examination (USMLE) Step 1 exam to pass/fail status in 2022 has been generally applauded. This change demonstrates the responsiveness of the NBME and stakeholders to concerns about “Step 1 mania” voiced loudly by medical educators, psychologists, administrators, and students throughout the United States. However, the financial underpinnings of the NBME continue to raise grave concerns.

Although the NBME is a 501(c)3 nonprofit, the organization reported earnings (revenue less expenses) in IRS Form 990 of almost $40 million in 2013–2017 (the most recent interval for which data are available) and has had substantial growth in revenue-enhancing products, as well as a highly compensated management team. Though perhaps most NBME board members do not receive honoraria, the organization enjoys monopolistic control of licensing USMLEs and sets fees with little if any outside oversight. Despite high profitability, Drs. Carmody and Rajasekaran1 found that USMLE fee increases have outpaced inflation as measured by the consumer price index. As an example, the 2004 Step 1 exam fee of $435 is equivalent to $590 in 2020 dollars, yet the current Step 1 fee is $645 for U.S. medical students. Exam fees are even higher for international students. If a student fails an exam, he or she must repay the fee in full. Virtually all of the NBME’s revenues are paid, directly or indirectly, by medical students, who have median debt at graduation of $200,000.2 This lack of regulation and transparency in finances, accompanied by the high profitability of the NBME, undermines the organization’s mission.

I continue to encourage the NBME and Federation of State Medical Boards to allow outside oversight of their finances. Only with independent and transparent oversight, and with renewed commitment to providing service to U.S. medicine without personal or organizational gain, will the noble mission outlined by Dr. Tallia and colleagues be realized.

Neil Gesundheit, MD, MPH
Professor of medicine, senior associate dean for medical education, Stanford University School of Medicine, Stanford, California; [email protected]


1. Carmody JB, Rajasekaran SK. On Step 1 mania, USMLE score reporting, and financial conflict of interest at the National Board of Medical Examiners. Acad Med. 2020;95:1332–1337.
2. Association of American Medical Colleges. Statement for the record submitted by the Association of American Medical Colleges (AAMC) to the House of Representatives Committee on Small Business: “The Doctor is Out. Rising Student Loan Debt and the Decline of the Small Medical Practice.” Published June 11,2019. Accessed June 8, 2020.
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