A Guide to the National Board of Medical Examiners

If you're on the path to being a doctor—whether you're in medical school, a recent graduate, or just a pre-med undergraduate—you know it's a tough road. You have to ace courses like organic chemistry. There are the MCATs to worry about, medical school itself, state licensing requirements.

One of the more daunting obstacles in your way is the NBME—the National Board of Medical Examiners. The NBME's U.S. Medical Licensing Exam is used by states around the country to determine whether or not a medical school graduate should be granted a license to practice as a doctor. The exam itself is a grueling assessment of a medical student's ability to apply what they've learned in real clinical settings. In simplest terms, it demonstrates you know what you're doing.

As you might expect, things can and do go wrong during this exam. Of course, the most obvious problem is finding a way to pass it. The test is difficult, and the NBME limits the number of times you're allowed to take it. In addition, though, the NBME is hyper-vigilant when it comes to testing “irregularities,” and many students find themselves accused of infractions both large and small. Those kinds of accusations can put an end to any hope of a medical career.

You don't have to accept that outcome, though. There are many ways to respond to a cheating allegation, and you shouldn't allow anyone to tarnish your good reputation without a fight. This guide offers some basic information about the NBME and other important obstacles to becoming an M.D. In addition, though, it suggests ways you can work to overcome these obstacles and achieve your goals.

The National Board of Medical Examiners

Founded in 1915, the National Board of Medical Examiners (NBME) is a non-profit organization whose stated mission is to

“protect the health of the public through state of the art assessment of health professionals.”

That is, the NBME was designed to ensure that every person who enters the medical profession is fully qualified and well-prepared to enter their field. It does this primarily by developing examination materials, including the U.S. Medical Licensing Exam, one of the chief tools used by state licensing boards to determine an individual's eligibility for a medical license.

In addition to administering the USMLE, though, the NBME works in a number of other important areas to improve medical assessment.

  • Research: The NBME itself conducts extensive research into assessment techniques, evaluating the effectiveness of current testing methods but also looking for new, cutting-edge ways to measure medical learning and competence.
  • Data sharing and collaboration: The organization also maintains an extensive database with information on medical students and testing. Qualified researchers can gain access to this data to use in a wide range of assessment-oriented research projects.
  • Medical school collaborations: The NBME provides testing resources for medical school courses, helping instructors better assess their students. In addition, the organization puts on regular workshops teaching test writers how to create better assessment tools.
  • Global partnerships: The NBME works with a number of organizations around the world, including several national governments, to improve global medical care through better assessments.


For all of the other work NBME does, though, the organization is most well known for administering the U.S. Medical Licensing Exam. In fact, the USMLE isn't one exam, but rather a series, or “program” of three exams, the purpose of which is to:

“assesses a physician's ability to apply knowledge, concepts, and principles, and to demonstrate fundamental patient-centered skills, that are important in health and disease and that constitute the basis of safe and effective patient care.”

Students take three separate “Step” exams at different points in their graduate and post-graduate training. Steps One and Two may be taken in any order, but both must be completed before students are eligible to take the Step Three Exam. Typically, students take the Step One Exam after their first year of medical school and the Step Two Exam after completing their fourth year. Step Three is taken after some post-graduate work.

  • Step 1 Exam: This exam takes place over a single, 8-hour day divided into 7, 60-minute blocks. Questions are multiple-choice and assess a student's knowledge of basic science in areas such as “respiratory and renal/ urinary systems,” “reproductive and endocrine systems,” and “the cardiovascular system.”
  • Step 2 Clinical Knowledge Exam: The Step 2 exam also takes place over a single day. In this case, the test lasts a total of 9 hours. These are divided into 8, 60-minute blocks. This exam emphasizes “health promotion and disease prevention” and is meant to assess the examinee's ability to provide patient care under supervision. Again, questions are multiple-choice.
  • Step 3 Exam: The Step 3 Exam assesses whether a student is competent to practice general medicine in an unsupervised setting. It is meant to be the final test of a medical student's knowledge and ability before licensing. This exam takes place over two days. The first day includes multiple-choice questions. During the second day, examinees answer more multiple questions but also respond to thirteen case simulations.

What Can Go Wrong?

If becoming a doctor was easy, anyone could do it. The truth is, we want medical students to go through rigorous training, to take difficult, exhausting exams such as the USMLE, to prove beyond a shadow of a doubt that they are ready to be doctors. Doctors sometimes literally determine whether people live or die, and we don't take that lightly. We want to know that whoever is working on us has the training and the experience to keep us healthy.

That means, though, that not everyone will get into medical school. Not everyone who goes to medical school will graduate. It means not everyone who sits for board exams will pass.

Maybe when you take the exam the first time, you aren't as prepared as you thought you were. Maybe you simply weren't ready for the pressure of the test, and even though you knew the answers, you just couldn't come up with them quickly enough. Whatever the reasons, students do fail the exam. According to the most recent data, some 4,000 students fail Step One each year.

If you should fail, all is not lost. You can retake each step up to four times. That doesn't mean there aren't consequences for failing. According to a 2020 study by the American Association of Medical Colleges, 72% of students who failed Step One on their first attempt went on to medical residencies. That's not bad, but it's not as good as the 94% rate for those who passed the first time.

A failed test is one thing. You have the power to overcome a mistake like this on your own. Study harder, practice more, work a little extra.

If you should find yourself accused of “test irregularities” for one of the exams, you're facing a much bigger problem. The USMLE takes such irregularities seriously, so seriously, in fact, that it has a long list of examples of what not to do. These include items such as:

  • Seeking unauthorized access to testing materials
  • Asking someone else to take an exam for you
  • Talking with others about questions during the exam

Of course, it's reasonable to expect students not to cheat on a medical licensing exam. However, it's certainly possible to make innocent mistakes without intending to. For example, one stricture prohibits test takers from:

“possessing any unauthorized materials, including, but not limited to, photographic equipment, communication or recording devices, fitness and tracking monitors, and cell phones in the secure testing areas.”

In other words, if you forget to take off your Apple Watch or your Fitbit, you could find yourself accused of cheating.

Other rules prohibit examinees from making notes of any kind except on paper provided by USMLE or even from reconstructing questions from memory after the exam. Most of us, at one time or another, have been guilty of telling someone else which questions we struggled with on an exam. Apparently, that, too, is a testing violation.

Another example notes that examinees can be investigated for “failing to adhere to any USMLE policy, procedure, or rule, or instructions of the test center staff.” While instructions like that shouldn't pose problems under normal circumstances, surely disputes must come up occasionally. The question is whether an argument over a procedure should ruin a person's chances of becoming a doctor.

That's just what an accusation of irregular behavior can mean. The USMLE bulletin explains that every accusation will be fully investigated. It doesn't specify exactly how investigations proceed, but what is clear is that the organization expects accused examinees to cooperate fully and treats any refusal to cooperate as yet another example of irregular behavior. In fact, the bulletin notes that accused testers must sign release forms allowing the USMLE to obtain information and records from all their past educational institutions.

The penalties for “irregular behavior” aren't minor. The USMLE notes that it can bar individuals from taking future tests. That in itself could effectively end a student's medical career. Even if that doesn't happen, the USMLE also promises to include a notation about cheating on the scores of anyone found guilty of irregular behavior. Even for students who go on to pass the exam, this could have serious consequences for their ability to obtain a medical license.

Why the NBME Matters

Why does the NBME matter, and what difference does it make whether you pass the USMLE? The answer is simple. No one in the U.S. can obtain a medical license without passing the exam. The USMLE serves as the stamp of approval, verifying you are qualified and capable of working as a physician.

To be clear, the NBME itself doesn't decide whether or not you can be licensed as a doctor. Simply passing the USMLE doesn't automatically make you a doctor. Rather it is one necessary component required by licensing boards.

Medical licensing is actually left up to the states. Each state has its own board that makes independent decisions about applicants. The process works differently depending on the state, and any given state may ask applicants to fulfill their own individual qualifications before granting licenses. Georgia, for instance, requires all applicants to complete a “Malpractice Questionnaire.” Other states, such as California, don't.

In addition, a state can set any conditions it likes for applicants. Most, for instance, require doctors to abide by a strict ethical code of conduct and will reject applicants who have a criminal record. The one thing every state requires, though, is a degree from an accredited medical school and board certification via the USMLE.

What Else Can Sidetrack Your Quest to be a Doctor?

Of course, the NBME isn't the only place your career can get sidetracked. Problems can arise at any point along the way, from the first day of your first semester in college to the day you finally get your license. What are some of the more common problems that can occur?

  • Academic misconduct at the undergraduate level: If you're found responsible for cheating or plagiarism as an undergraduate, this could have serious implications for your ability to get into medical school. Generally speaking, most graduate schools aren't anxious to admit students who've proven they can't abide by academic rules. While schools differ in how they respond to academic misconduct, most colleges and universities include reports of misconduct in a student's permanent record, and some provide a transcript notation about the offense. Negative academic reports can hurt a graduate school application.
  • Student misconduct at the undergraduate level: Student misconduct can include anything from a dorm room noise violation to a sexual misconduct allegation. Here again, if you're found responsible under Title IX or your school's own conduct policies, it may be difficult to find a medical school that will admit you. Sometimes, in fact, even an accusation can cause problems. While you may ultimately be found “not responsible,” a date rape accusation that winds up in the media or on the internet can follow you throughout your career.
  • Medical school infractions: Penalties for academic or student misconduct don't go away when you start medical school, of course. Instead, the penalties become more severe. Instead of a note in your file, cheating on an exam one time will likely get you expelled.

Any one of these has the power to prevent you from moving forward or, eventually, from obtaining your medical license. In fact, once you have your license, you're not immune from having it revoked. Insurance fraud, patient abuse, and malpractice can all put your license in jeopardy. So too can sexual misconduct and lesser offenses such as DUIs. Ultimately, your personal history can have an enormous impact on your ability to practice medicine.

What Can an Attorney Do for You?

None of us is perfect. We all make mistakes, even future doctors. The question isn't whether or not you will make mistakes but rather whether or not you will allow those mistakes to define you.

If you've been accused of a serious mistake—academic misconduct, sexual misconduct, irregular behavior while taking the USMLE exam—it might still be possible to get your medical career back on track.

In most cases, though, you can't do it alone. It's not easy to battle academic institutions and organizations. It can be even harder to take on state licensing boards. You need someone who knows the law in your corner, someone with experience negotiating settlements, who can make sure you aren't mistreated. You need an attorney.

What can an attorney do for you? It depends on the situation.

Ideally, you want an attorney to keep you from being convicted of a crime in the first place. The same applies to college accusations. It is far easier to defend yourself during an investigation or hearing than to try to go back after the fact and resolve an issue that was already decided. That means the time to hire an attorney is as soon as you're charged with a violation.

What specifically a lawyer will be able to do will vary depending on the particular circumstances. However, often they can:

  • Accompany you to meetings with officials. If you've been accused of violating school policy, you can expect you'll be asked to stand before an investigator or other school administrator and defend yourself. Often lawyers can attend these meetings with you and speak on your behalf. Even when they aren't allowed to do this, they can still help you prepare what you're going to say.
  • Help you uncover evidence and find witnesses. An attorney knows how to find evidence and how to use it effectively to defend clients. Too often, students accused of one policy violation or another try to get rid of evidence they think makes them look guilty when a seasoned attorney might know how to use it in their favor.
  • Represent you in formal hearings. Title IX cases always involve a hearing. Many schools use formal hearings to decide other cases. A lawyer can represent you at these hearings. They can help you develop a winning defense strategy and explain how to implement it. They can ask questions of witnesses, present evidence, and raise objections on your behalf.
  • Negotiate a settlement. Just because you've broken a rule doesn't mean you have to suffer forever. In today's political climate, schools often treat policy violations severely. An attorney can help negotiate a reasonable sanction, one that doesn't go on your permanent record and won't prevent you from going to graduate school or getting a future job.
  • Deal with the media. It's an unfortunate fact that the media is always looking for another story, and they don't mind muckraking on campus if they must. An attorney can make sure you're treated fairly, can answer questions on your behalf, and in some cases can even get gag orders issued to stop the coverage altogether.
  • File suit again the school if necessary. Over the last decade, an increasing number of students have filed suit in federal courts against schools that have violated their due process rights. An attorney can assist you in filing such a complaint or in negotiating a settlement with the school.

Of course, lawyers can also help if you're trying to undo a past indiscretion. They can talk directly to schools and administrators about expunging your record. They can negotiate new settlements. They can argue that you weren't treated fairly the first time around.

Likewise, lawyers can deal with medical schools or with the NBME. Here again, a qualified attorney can ensure the USMLE can't violate your due process rights during investigations and can't treat you unfairly. In fact, a lawyer who understands licensing and the medical profession can even help experienced physicians hold on to their licenses when they're facing accusations and scandal.

Let Attorney Joseph D. Lento Help

Why choose attorney Joseph D. Lento to help you deal with challenges like these? Joseph D. Lento built his career on student legal matters, and he has helped many medical students overcome issues with the NBME and the USMLE specifically. Attorney Lento and his team at the Lento Law Firm have years of experience dealing with NBME and USMLE concerns, and also of course, colleges, universities, and graduate schools. Through dedicated efforts, Attorney Lento and his team have make sure students' rights are protected. Attorney Lento knows how to negotiate for reasonable settlements that won't tarnish your academic reputation. He's practiced at defending students from unfounded charges of academic misconduct. He's won hundreds of Title IX cases. And most importantly, he has achieved countless successful resolutions when dealing with the NBME and related medical school concerns. Whatever the problem, attorney Joseph D. Lento knows how to get students the very best resolutions to their cases.

If you're a medical student who has run into problems on your path to becoming a doctor, don't wait. Whether you're dealing with the USMLE, a medical school, or your undergraduate college while working you way towards a career in medicine, contact the Lento Law Firm today at 888-555-3686, or use our automated online form. You have important goals; we can help you get there.

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If you, or your student, are facing any kind of disciplinary action, or other negative academic sanction, and are having feelings of uncertainty and anxiety for what the future may hold, contact the Lento Law Firm today, and let us help secure your academic career.

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