Opinion Column: A fundamental flaw in the USMLE exams

Last Updated on June 27, 2022 by Laura Turner

There exists a fundamental flaw in the USMLE exams – applicants who pass the exam cannot retake the exam. This means that applicants who score poorly in the exams are prevented from applying to competitive specialties and in some cases even from practicing as a doctor in the US. Why does the USMLE not allow candidates to rewrite exams to improve scores? To understand this, we have to delve into the purpose of USMLE.
The United States Medical Licensing Examination or USMLE as it is popularly known, is a critical set of exams that medical students and graduates must pass before they can practice medicine in the US. The USMLE is a multi-part exhaustive evaluation of a physician’s ability to apply knowledge, concepts, and principles, and to determine fundamental patient-centered skills that are important in health and disease and that constitute the basis of safe and effective patient care. It is highly regarded not just in the US, but also in various other countries around the world. So much so that one can use the USMLE in lieu of that country’s exams.
Every year thousands of medical students and graduates from around the world attempt these exams as the necessary prerequisite prior to applying to a US medical residency program, the next step on the arduous path to become a practicing physician. Once an applicant has passed the USMLE, they are granted an initial license to practice medicine in the US. The applicants are also given scores, as a byproduct, that shows how well they have performed in the exams. These scores have now completely changed the meaning and purpose of the USMLE process.
The USMLE defines its role mainly as the agency that provides a common evaluation system for applicants for the initial medical license. The scores used to be incidental, but the main crux of the exam used to be whether the applicants passed the exam or not. You can retake the exam up to six times if you fail, but once you pass the exam, you have succeeded as per the USMLE. The score that you got incidentally is your final score. As per the USMLE, you don’t have any need to improve it neither are you afforded an opportunity to do so, because the important thing is you got the license and the scores are just a byproduct and inconsequential in terms of licensure.
This would have been an acceptable argument, but the reality today is that the USMLE scores have become the primary determinant for which specialties a candidate can apply to and in some tragic cases, whether a physician should even consider applying to any residency, or give up on their dreams to get trained and practice medicine in the US. What had begun as a straightforward licensing exam has now morphed into a formidable screening tool for residency programs.
Most residency programs sort candidates based on the test scores. An average residency program now receives on average at least 100 applicants per position they have. The number is even higher for a competitive specialty. Given how short-handed and stressed these residency programs are, it’s only natural that they use the USMLE scores to screen out applicants because they simply do not have the time or the resources to look at each candidate in depth. This means that applicants might have impressive credentials and experience, but if they have a poor score, their application would not even merit further consideration beyond that first score. They have been screened out!
Can one score be this important to determine a physicians future? According to a survey of residency program directors conducted by NRMP in 2014, the single most important factor to rank a candidate is their USMLE Step 1 score. Simply put, if a candidate scores poorly in this exam, they can kiss their medical dreams goodbye.
But this is fair, one could argue. After all a student already has to give numerous standardized exams such as SAT for college, GMAT or GRE for graduate school, and MCAT for medical school. Even if the objective of the USMLE exams was just to grant a license to practise medicine, there should not be any objections as to why it should not be used a selection or ranking tool by residency programs.
This should be true, but for the obvious glaring flaw in the USMLE exams. The USMLE generously allow candidates upto six attempts to pass the exams, but if a candidate has passed the exam, then the candidate cannot retake the exam until seven years after passing the exam. This is a travesty of justice, especially if one is the unfortunate candidate who passed the exam but just secured a mere passing score. Such a situation becomes a veritable death knell to that doctor’s chance of cracking a residency spot let alone even think of trying for a competitive specialty.
One of the several reasons that the USMLE cites for not changing this policy is the security and risk of exposure to items that can happen if multiple attempts are allowed. But this risk still remains since people who fail the exam are allowed to rewrite the exams six times. Therein lies the irony, because the candidate who passes the exam but does not secure a high enough score is penalized whereas the candidate who fails the exam is still justly allowed the opportunity to retake the exam and improve their performance.
Its scary to think that one bad day writing an exam can ruin an entire lifetime’s effort to pursue a passion, a dream. But the real cruelty is that if the doctor had performed worse and failed, there still would have been a chance to salvage the dream.
The USMLE is a difficult, challenging and an uncompromising process, as it should be, because the granting of a license to practice medicine is an important responsibility. But if the process has determined that a doctor is good enough to be granted that license, how important is it that the doctor has scored 192 – the passing score- or 240 – the screening score that some residency programs publish on their websites. A cursory review of residency websites will tell you that if a doctor scores less than 220, they don’t stand a chance at most programs, even though they have passed the exams.
Most recognized tests such as the SAT, GMAT, GRE etc. allow candidates to improve upon their performance by retaking the exam. It allows for the fact that the candidates could have a bad day affecting their performance, but is still given an opportunity to improve their performance – even if they were not fortunate enough to fail. The USMLE scores are now similarly important for all physicians applying to residency programs. They should not deprive candidates the chance to improve their performance and condemn them to their fate because of one day’s poor result.
Only the truly committed can invest the years of education, struggle, hard work and debt to pursue a lifelong passion like medicine. The profession demands such character. It’s a profession where a doctor becomes better after learning from their many failures rebounding each time to greater successes. A partial failure at USMLE should not be an insurmountable challenge for the thousands of applicants pursuing this difficult and challenging path. The USMLE must rectify this flaw in their policy to keep in line with the principle and philosophy of this great profession.