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Letters to the Editor

The National Board of Medical Examiners on Potential Conflicts of Interest

Tallia, Alfred F. MD, MPH; Wallach, Paul M. MD; Chandran, Latha MD, MPH

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doi: 10.1097/ACM.0000000000003544
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To the Editor:

As officers of the National Board of Medical Examiners (NBME), and as physicians, educators, and citizens, we are deeply concerned about the well-being of students and physicians, the quality of our medical education and training system, and the health of our patients and our society. We remain committed to excellence in assessment, maintaining the highest ethical principles and using the tools at the NBME’s disposal for the betterment of all. Carmody and Rajasekaran1 as well as Gesundheit2 raise serious allegations regarding financial incentives intermixed with speculation and anecdote. We correct information presented and expand on issues raised.

The mission of the NBME is to “protect the health of the public through state of the art assessment.”3 Its 12-member governing board includes diverse individuals with experience in medical education, training, and health care, with one-third representing perspectives of patients. With the exception of the chair and treasurer, no board members receive honoraria, and the former donate these.

The NBME strives to meet educators’ and students’ stated needs. Without exception, subject exams and self-assessments were developed in response to medical education needs. We feel they are well aligned with the NBME’s mission. Medical schools use these high-quality exams for evaluation and as common metrics for purposes, such as curriculum evaluation and accreditation self-study. The NBME also pursues its mission by advancing assessment through empiric research and through development of formative tools aimed at improving the clinical performance of health professionals. The United States Medical Licensing Examination (USMLE) program is jointly governed by the NBME and the Federation of State Medical Boards (FSMB). The NBME’s governing board does not and cannot unilaterally set USMLE fees, which are determined by individuals drawn from the NBME’s volunteer academic and professional health care community membership, balanced equally with representatives of the FSMB. USMLE fee increases have approximated the Consumer Price Index.

USMLEs are the work of over 350 voluntary medical school faculty, state medical board members, and the public drawn from across North America. Examination content thus represents the judgments of dedicated experts not employed by the NBME or the FSMB. Pass/fail standard, or “cut-point,” decisions are based on surveys of thousands of stakeholders, including examinees, and on committee work undertaken by faculty and state board members. Thus, determination of the pass/fail standard relies on individuals without financial ties to the USMLE program.

In 2019, the NBME began a review of its governance. Although we believe that any potential conflicts of interest are already well managed, we will carefully consider all concerns raised, and if needed, modify structures, policies, or procedures to ensure that any potential conflicts of interest are managed appropriately. The NBME remains committed to the highest standards of excellence in assessment, ethics, and service to the public and the health professions.

Alfred F. Tallia, MD, MPH
Professor and chair of family medicine and community health, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, and chair, National Board of Medical Examiners, Philadelphia, Pennsylvania;
Paul M. Wallach, MD
Professor of medicine, Dolores and John Read Senior Professorship in Medical Education, executive associate dean for educational affairs and institutional improvement, Indiana University School of Medicine, Indianapolis, Indiana, and vice chair, National Board of Medical Examiners, Philadelphia, Pennsylvania.
Latha Chandran, MD, MPH
Executive dean and founding chair, Department of Medical Education, Miller School of Medicine, University of Miami, Miami, Florida, and treasurer of the National Board of Medical Examiners, Philadelphia, Pennsylvania.


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. Gesundheit N. A crisis of trust between U.S. medical education and the National Board of Medical Examiners. Acad Med2020;95:1300–1304.
3. National Board of Medical Examiners. About NBME. Accessed June 2, 2020.
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