In Reply to D’Eon and Kleinheksel : Academic Medicine

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Letters to the Editor

In Reply to D’Eon and Kleinheksel

Arnhart, Katie L. PhD1; Cuddy, Monica M. PhD2; Johnson, David MA3; Barone, Michael A. MD, MPH4; Young, Aaron PhD5

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doi: 10.1097/ACM.0000000000004583
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We thank the authors for their critique and for highlighting the important role medical licensing examinations serve in the regulation of physician practice. Our article outlines existing United States Medical Licensing Examination (USMLE) and state medical board attempt limit policies and indicates that our “findings provide some support for the use of attempt limits as suggested by the USMLE program and implemented by state medical boards.” 1 We want to emphasize that although our findings support a relationship between multiple USMLE attempts and increased likelihood of receiving disciplinary actions, the findings in isolation are not sufficient for proposing new policy on how many attempts should be allowed. We view our research as one of many factors for policy makers to consider as part of their broader decision-making process when reviewing minimum standards for medical licensure.

Although we did not discuss specific extenuating circumstances that may cause competent medical students and physicians to take the USMLE multiple times, we did acknowledge the legitimacy for multiple attempts by saying, “Attempt limit policies aim to balance providing individuals sufficient opportunities for demonstrating competence with protecting the integrity of the examination.” 1 Though any of the extenuating circumstances noted in D’Eon and Kleinheksel’s critique might be true (e.g., health issues, personal dilemmas), their cause for necessitating successive repeated attempts would be less likely over time.

D’Eon and Kleinheksel also indicate concern that disciplinary actions were measured dichotomously and failed to pick up nuances of why physicians received actions. In the Discussion of our article, we noted that exploring the number of USMLE attempts in relation to the risk of receiving a disciplinary action by type and severity would be a productive topic for future research. Furthermore, it is important to note we made efforts to focus on actions associated with problematic behavior by omitting administrative and other minor board actions in our analysis.

We understand the caution raised by the authors about a direct substitution of the number of examination attempts and examination scores to predict the likelihood of disciplinary action, as these 2 factors provide different types of information—even though there may be some overlap. Our intention is to consider that the number of USMLE attempts may provide one of several useful measures for understanding physician performance, and our results support the use of existing attempt limit policies as opposed to no limit at all.


1. Arnhart KL, Cuddy MM, Johnson D, Barone MA, Young A. Multiple United States Medical Licensing Examination attempts and the estimated risk of disciplinary actions among graduates of U.S. and Canadian medical schools. Acad Med. 2021;96:1319–1323.
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