Legitimacy of the USMLE and COMLEX Exams

What did precipitate exponential growth of the USMLE and COMLEX prep industry?

COMLEX and USMLE examinations are so much interwoven into the fabric of our system for evaluating eligibility of practicing medicine in the US that we hardly question the legitimacy of their existence. It is unfortunate to see that the American Medical Schools that have long prided themselves on providing quality training to their students have progressively become trapped in this grand-scheme and have become covert sanctioning advocates for these examinations.  

There is a high likelihood that those tiny islands that can hardly be seen on the globe may each harbor at least one medical school!

How it all began? It is astounding to appreciate the extent that the medical board prep industry has grown from its infancy in early 1980’s to its current level. It has now turned into a global mega industry with the USMLE and COMLEX examinations at its core. The fuel for this exponential growth was originally piped by the mushroom-like proliferation of offshore Caribbean medical schools that were designed to serve only one purpose, to tap into the American medical market. Most of these island-based entities placed their utmost stress on the USMLE passing rates of their students as means of justifying their sub-optimal curricula. As a result, it comes as no surprise to see that the entire first two years of some of these offshore medical schools are devoted to USMLE Step 1 preparation. We should bear in mind that the original concept of having offshore Caribbean medical schools has now propagated exponentially throughout the entire globe, both on various islands and on the lands. As such it would not be inappropriate to categorize most of these entities as “USMLE prep schools” instead of “medical schools”.

By far the most attractive feature of the Caribbean schools is the promise of life on a beautiful Caribbean Island!

Are the American medical schools Covert advocates of the USMLE and COMLEX examinations?

It is unfortunate to see the US medical schools being dragged into this swamp, and increasingly using USMLE and/or COMLEX scores of their students as means for justifying the quality of their curricula. It is noteworthy to mention that alongside sprouting offshore schools, there has been a parallel increase in the number of American medical schools since 1980s. For example, there was only one DO degree offering and four MD offering medical schools in the 80’s in Michigan. Now there are seven allopathic and three osteopathic schools in Michigan. Moreover, the original medical schools of Michigan used to only accept about 100 students each. Since then they have almost tripled the number of their incoming classes.

Interestingly, the unchecked growth of the USMLE- and COMLEX-related industry has also encouraged the outburst of many US-based private medical schools that have practically employed the Caribbean model as means of exploiting the American market of medical practice. Isn’t it shameful to see that the graduates of Harvard, University of Michigan, Stanford, and many other outstanding American medical schools have to take the very same qualifying exams that were originally intended to only evaluate the quality of education that non-American medical schools were offering to their students?

Should American medical students and graduates no longer be required to take USMLE and COMLEX examinations?

The Liaison Committee on Medical Education (LCME) is the U.S. Department of Education recognized accrediting body M.D. programs in the United States. It also accredits M.D. programs in Canada, in cooperation with the Committee on Accreditation of Canadian Medical Schools (CACMS).  On the other hand, osteopathic medical schools that grant the Doctor of Osteopathic Medicine (D.O.) degree are accredited by the Commission on Osteopathic College Accreditation of the American Osteopathic Association (COCA). The US Department of Education lists the COCA as the accreditor of the American medical schools. It is understandable that all the American medical schools are accredited by these agencies to perform their primary duties of training medical professionals for optimally performing their duties in the American job market. It is also understandable that these agencies act as watchdogs to ensure compliance with their established blueprints.

If so, then, is it necessary to subject American medical students to the add-on cost and agony of preparing for and taking these exams? Would it be enough to make accredited American medical schools accountable for the proficiency of their graduates for practicing medicine in the US? If international medical graduates (IMGs) and the American medical graduates (AMGs) are all required to take the very same qualifying set of examinations what would be the advantage of an American medical student who goes through rigorous MCAT (Medical College Admission Test), and completes their degree in the US over another American medical student who circumvents this path and obtains their degree from an offshore medical school? COMLEX and USMLE examinations have become so interwoven into the fabric of our system for evaluating eligibility of practicing medicine in the US that we no longer question the legitimacy of their existence. It is unfortunate to see that the American Medical Schools that have long prided themselves on providing quality training for their students have progressively become trapped in this grand-scheme and have become covert sanctioning advocates for these examinations.

Should American medical students be required to only take Step/Level 3 exam?

It’s astounding to appreciate the extent of hidden symbiotic relationship that has progressively sparked among LCME, AOA accredited American medical schools, and the USMLE and COMLEX examinations. Almost all US medical schools currently use these exams along other products of the NBME and NBOME organizations, as tools for evaluating mastery of their own curricula. In other words, the curricula that these colleges evaluate with the USMLE and COMLEX exams, are the ones that are already approved and legitimized, at least in part, by the very same organizations that are inherently associated with the USMLE and COMLEX exams.

The symbiotic relationship of the American and offshore medical schools with the USMLE and COMLEX examination has also generated a worldwide market of para-board exam services and products.  It is astounding to realize that since 2010 a countless number of Youtube-channel-operated and cellphone-run, one-person entities, have sprouted like mushrooms across the globe, and every single of them has entered into a symbiotic relationship with the USMLE and COMLEX examinations. If you add these to the USMLE- and COMLEX-relevant internet-based forums, electronic sources of information, and traditional hardcopy books and study materials, you will better appreciate the magnitude of this worldwide web of para-medical-licensure-exam prep industry.

Looking from the island to the mainland!


I would like to leave my readers with these three questions:

(1)  Is it fair or even legal to force American medical students on taking all levels/steps of COMLEX and USMLE examinations, or just taking one of the four, namely Step/Level 3 exam is sufficient?

(2) Would it be reasonable to allow all fully accredited American medical schools to have the sole authority to qualify their own graduates for practicing medicine in the US without the COMLEX and/or USMLE requirements?

(3) What policy changes should be made to accommodate international medical graduates of schools that are solely developed to tap into the American medical market, and how should they qualify for practicing medicine in the US?

Dr. E

By

Also known as "Dr. Testbuster", Dr. Eftekar (Dr. E) is the founder, head coach and lead lecturer of the medical board training programs at Northwestern Medical Review. A unique attribute of Dr. E is his well-rounded academic background that, in addition to the science of medicine, extends over several other disciplines such as physiology of aging and longevity, philosophy of science and medicine, and integrated kinesiology.

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