A few numbers and some thoughts on the medical licensing exam

graph photo  Few of us spend much time thinking about numbers; yet they’re immersed in our daily lives. Most of the numbers we think about are mundane—shoe sizes, bank statements, calendar dates. Others reflect serious matters such as the 2.0 degree Farenheit increase in the earth’s average surface temperature since the late 19th century.

We’ve all heard that “numbers don’t lie.” This is true in a manner of speaking as the scoundrel is really their author rather than the number itself. Take, for example, the recent national dialogue concerning wealth and income distribution in the United States. A writer’s decision to report mean rather than median household income may reflect an attempt to minimize such concerns using a valid though misleading number.

We also understand that numbers in the form of data can inform our decision-making in positive ways—including some that are not necessarily intuitive. Michael Lewis’ Moneyball spawned not just a great accompanying movie but a partial reversal of baseball culture as the gut-instinct decisions of scouts, managers and other ‘experts’ and traditional statistics (ERA, batting average) are now tempered by data-driven metrics that reconsider the value of some of these same statistical categories.

Numbers offer a linguistic shorthand. Most of us could list English language idioms featuring numbers: the impossible conundrum is a “catch 22,” to “deep six” a negative report is to metaphorically bury it, the shoplifter’s “five finger discount.”

I say all this to preface a few numbers—and some accompanying thoughts—on the medical licensing exam.

953,000 nine hundred fifty-three thousand 953k

According to the Federation of State Medical Boards, at the end of 2016 there were 953,695 physicians in the United States with an active medical license. It is a diverse group. The majority of these 953k are men (64%) but that figure is sloping slowly downward based upon the enrollment figures showing more women than men in US medical schools. Most of these physicians hold the MD degree but a growing number (8%) are osteopathic physicians holding the DO degree. Many of these licensed physicians are early in their career (22% aged 30-39) though a much larger group is at the backend of their practicing career (29% aged 60-79). In addition, twenty-three percent of this 953k are international medical graduates (IMGs) who graduated from a medical school outside the US. One could dedicate an entire book to exploring the ramifications of these numbers and the trends behind them.

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Despite this diversity, there is one thing all 953,000 of these physicians have in common—all of them took a medical licensing examination. Osteopathic physicians generally take the Comprehensive Osteopathic Licensing Examination (COMLEX-USA). However, the vast majority of America’s physicians—including every MD and IMG—took the United States Medical Licensing Examination (USMLE) or one of its predecessor exams.

We’ve made great progress in getting down to just two exams (see below). I can’t help wondering if ultimately we will end up with a single examination pathway for medical licensure.

50 fifty 50 funfzig 50

Though the USMLE has only been in existence a little over a quarter of century, already 50% of this nation’s physicians with an active medical license have taken all or part of the USMLE sequence. While the testing culture in the United States has come under scrutiny and criticism for some time, one fact remains—the examination required by state medical boards for licensure represents a de facto independent audit of the education and training of these prospective physicians.

This is a far cry from the late 19th century origins of medical regulation when every state developed and administered its own examination for licensure. One of the predictable outcomes was obvious: Every state had a high degree of satisfaction with their exam while casting a skeptical eye toward just about every other state’s exam. The result being a duplicative approach to licensing that discouraged license portability by usually requiring even the experienced practicing physician to retake a licensing examination.

140,000 one hundred forty thousand 140,000  140k

Collectively, the USMLE administers 140,000 tests each year. This large number may surprise. Now think for a moment about the resources (technical, financial, manpower) required to develop, maintain, administer and oversee a national examination program like this. These demands are significant and well beyond the resources available to individual state medical boards to conduct such a stream of work on their own.

This is the biggest reason why state medical boards got out of the business of developing their own examinations back in the 1960s and 70s. Even Puerto Rico—the only remaining state or territory in the US developing its own medical licensing exam—has finally halted its exam (at least temporarily) under the mounting financial pressures facing that island.

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In 2016, IMGs accounted for 39% of all USMLE test administrations. A portion of these physicians are seeking to gain certification from the Educational Commission for Foreign Medical Graduates in order to secure residency training in the US before returning to their home country.

However, many, if not most, have aspirations for becoming fully licensed, practicing physicians in the US. This reflects a significant, long-term trend dating back to the massive dislocations arising from World War II and the subsequent influx of émigré and refugee physicians by the late 1940s and early 1950s. Most Americans are blithely ignorant that this country has met, and continues to meet, its physician workforce needs by relying (in part) upon practitioners educated and trained by other countries. Depending on your perspective this is either an unconscionable “brain drain” depriving the host countries of a valuable medical resource or evidence of the continued real and perceived economic opportunities attracting individual physicians to America.

5 cinco 5 five 5

The fail rate for medical students and graduates of US medical school program issuing the M.D. degree and taking the USMLE for the first time is roughly 5%. Non-physicians and those unfamiliar with medical regulation are probably surprised by this number. They wonder, “Shouldn’t it be higher?”  To them, 21st century medical knowledge is so daunting in its depth, breadth and unfamiliar terminology that achieving anything close to mastery in the field must feel like a Sisyphean task.

But step back for a moment and think about it. Medicine in the United States attracts academic star performers, classic over-achievers and those who excel on standardized tests. Schools already winnow the field of incoming matriculants through a set of criteria demanding academic excellence at the undergraduate level and a strong performance on the Medical College Admission Test (MCAT). Once on campus, educational support systems kick-in to assure success among an already strong talent pool of highly motivated erstwhile physicians.

Of course, we could shade the discussion differently by presenting this figure in a reverse fashion. Instead of sharing a fail rate, we could present this as a 95% pass rate—an approach likely to trigger an opposite reaction, “Why is the pass rate so high?” Uh oh. I seem to have returned to the territory of that “numbers don’t lie” assertion. I’ll stop here…for now.

The opinions expressed here reflect the views of the author and do not represent those of the FSMB.

Sources

Young, Chaudhry, Pei, Arnhardt, et. al. A Census of Actively Licensed Physicians in the United States, 2016 (Washington DC: Federation of State Medical Boards, 2017)

Donald E. Melnick, Licensing Examinations in North America: Is External Audit Valuable? Medical Teacher 2009; 31:212-14

USMLE aggregate performance data available at http://www.usmle.org/performance-data/

DA Johnson, HJ Chaudhry, Medical Licensing and Discipline in America: A History of the Federation of State Medical Boards (Lanham, MD: Lexington Books, 2012)

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