Maryland NBME and USMLE Defense

With its proximity to the Capitol Area, Maryland boasts a robust economy, with defense and aerospace, biotechnology, and healthcare research sectors employing a significant portion of the population. Excellent career opportunities make any of its cities and towns, from Baltimore and Bethesda to Ellicott City and Silver Spring, an ideal place to build a life-long foundation. Maryland's wealth of colleges and universities, too, presents a world of opportunities for medical students living in or moving to the Mid-Atlantic region.

To become a licensed physician in Maryland, one of the most essential tenets in starting a practice is passing the United States Medical Licensing Examination (USMLE). The three-part exam sequence is a challenge for anyone. It requires years of studying, immense focus, and dedication to following the strict guidelines the National Board of Medical Examiners (NBME) maintains.

Rule violations as minor as an examinee's scheduling permit not exactly matching their official identification can lead to test cancellations that end their medical career before it begins. Even though states allow medical students to sit for an exam multiple times, any incident or allegation of misconduct can become a barrier to achieving a passing score, such as:

• Test center officials alleging "irregular behavior" that leads to punitive action.
• Disputes over scores that hold students back from preferential residencies.
• Unfair testing conditions caused by a lack of reasonable accommodations.

Any problems arising before, during, or after test day threaten an examinee's academic and career progression. Even mistakes or false accusations on the first attempt can have long-term implications for career longevity in the healthcare field. The Lento Law Firm Student Defense Team stands ready to assist Maryland USMLE examinees and protect their rights and opportunities to become licensed physicians. Call the Lento Law Firm at 888-535-3686 now or visit our confidential consultation form, and we will reach out to you.

NBME Standards Guide USMLE Assessments

The NBME is an independent, non-profit organization that oversees the creation and administration of the USMLE. Its responsibilities also include defining exam competencies to ensure the sequence aligns with prevailing medical education and practice. The NBME works with the Federation of State Medical Boards (FSMB) to guarantee the USMLE meets state licensing requirements nationwide for medical doctors and osteopathic physicians.

Examinees will sit for the USMLE in three separate parts over several years. The first and second steps are typically taken in the first years of medical school, and the final step is taken after students graduate and have secured a residency. Steps will assess the following information:

• Step 1: Assessing a student's knowledge of foundational sciences (anatomy, biochemistry, microbiology, pharmacology) and relating them to the practice of medicine, treatment, and patient care.
• Step 2 Clinical Knowledge (CK): Evaluating the ability to use competence in scientific knowledge and medical skills to assess and treat patients in a supervised setting.
• Step 3: Judging the capacity to use medical knowledge and clinical science to carry out official duties on patients in an unsupervised setting.

The NBME limits the number of attempts per step to four. However, exceptions can be made at the direction of a state's licensing authority. Yet, neither the NBME nor the FSMB maintains a timeline for completing the stages. Individual state boards, such as the Maryland Board of Physicians (MBP), set their own standards. While many states hold a seven to ten-year limit to pass all three steps of the USMLE, Maryland does not. Nevertheless, some NBME regulations prohibit test takers from hastening through the process.

Individuals may only take the Step 1 exam three times within one calendar year. Any further attempts must be at least one year after the first attempt and at least six months after the most recent.

Maryland Exceptions

The USMLE has limited the number of attempts a candidate can take the same step to four, but the USMLE Composite Committee will allow the examinee additional attempts at the request of the MBP. The examinee must show a "reasonable nexus with Maryland" and be eligible for a medical license in Maryland.

Examinees are required to provide the following information before the board provides sponsorship:

• A completed initial medical licensure application with supporting credentials for a Maryland medical license.
• Proof of Maryland residency.
• Proof the examinee was educated in Maryland.

While the MBP provides a pathway for students to gain the credentials they need to practice medicine in Maryland, some may need program alterations to ensure a better testing environment. Not everyone is eligible for accommodations, but medical students sitting for the USMLE could be surprised to learn that not seeking them may have caused allegations of misconduct or subsequent violations.

USMLE Testing Accommodations

The NBME is not a college or university; however, since its educational apparatus receives public funding, it must provide reasonable accommodations for test takers with disabilities. Title II of the Americans with Disabilities Act (ADA) and Section 504 of the Rehabilitation Act mandate program alterations for individuals with qualifying disabilities to promote equal opportunity outcomes.

The ADA asserts that a qualifying disability (physical and mental) is an impairment that "substantially limits a person's ability to perform one or more major life activities as compared to most people in the general population." USMLE authorities state that examples of activities include, but are not limited to, the following:

• Concentrating
• Hearing
• Reading
• Seeing
• Thinking

Determination of whether an individual's normal functioning is substantially limited as compared to most is based on an individualized assessment. Test takers seeking accommodation must fill out an official request form that includes the following:

• Relevant background information about the history of the impairment, such as an initial diagnosis, functional limitations impacting daily life, any previous accommodations implemented, and rationale for seeking USMLE accommodations.
• Clinical documentation from the treating or evaluating professional, including diagnostic criteria, personalized description of current symptoms, current functional limitations due to the disability, and a recommendation for accommodations in the context of standard testing conditions.
• Supporting documentation that includes written feedback from teachers or supervisors, academic records, performance evaluations from training programs, or official records verifying approved accommodations like Section 504 plans or Individualized Education Programs.

Upon submission, NBME Disability Services will acknowledge the receipt of the request by email within a few business days. The USMLE Management Committee reviews all requests and submits decisions within approximately 60 days.

Any accommodations granted by the Management Committee must match the permit the examinee is given. If denied, individuals may request a reconsideration review. Examinees only have one chance of appeals per test registration period, and only new and substantive evidence is accepted. If a test taker's eligibility expires during the review or if they test before the review is complete, Disability Services will discontinue the reconsideration process.

Individuals without qualifying disabilities may also receive some changes to the USMLE structure. Examinees with medical conditions, such as nursing mothers and those with diabetes, may apply for additional breaks through a separate request form. Personal items outside normal accommodation requests are also approved on a case-by-case basis. Any changes to the normal testing schedule must be noted in an accommodated permit.

USMLE Rules of Conduct

Maryland medical students and first-year residents are likely aware that passing the USMLE is one of the biggest tasks they will face during their careers. However, they may not realize how easy it is to derail the opportunity to become licensed physicians.

The NBME has strict administrative and behavioral guidelines called Rules of Conduct. All examinees must follow the rules precisely, and any deviation is subject to discipline. Violations can quickly snowball into severe consequences, including canceled test attempts, score invalidation, and adverse action from schools or state licensing authorities.

Among the Rules of Conduct are the following guidelines:

• Examinees must match the identity of the person on the scheduling permit.
• Test takers cannot seek, provide, or obtain unauthorized assistance.
• Formulas, notes, papers, and electronic devices are prohibited in testing areas.
• All personal belongings must be placed in a locker or cubicle before entering the testing room.
• Examinees can only leave their testing station when the break screen is visible on the monitor.
• Cell phone use is limited to outside the testing center during an authorized break.
• All exam content (notes on materials provided) must remain in the testing center.
• Individuals must uphold test confidentially outside of the testing center.
• Examinees may only write on the laminated note boards provided.

If testing center officials or proctors believe any of the Rules of Conduct are violated during the exam, an individual may be directed to leave immediately no matter how much or how little progress they've made. Such is true regardless of whether the allegations are false or not.

Test center staff will notify the USMLE Management Committee following the incident. Officials may pursue misconduct charges, cancel the examinee's score, and potentially ban them from taking future USMLE exams.

USMLE Violations

Within the context of preparing for and taking the USMLE, violations of the Rules of Conduct are referred to as "irregular behavior." Although Maryland medical students are educated on the testing procedures and standards before exam day, consequences can happen as early as applying for the first exam.

Before taking any step of the USMLE, individuals can get in trouble for:

• Registering or attempting to sit for an exam that one is ineligible to take.
• Attempting to secure a scheduling permit with false or misleading information.
• Taking someone else's exam or soliciting someone to take an exam for which they are not scheduled.

While taking any of the USMLE's three steps, examinees risk violating the Rules of Conduct if they:

• Communicate with other test takers in the test center's secure areas.
• Make notes without using the test center materials.
• Bring any unauthorized materials into testing areas.
• Engage in forms of disruptive or unprofessional behavior.

After the exam, test takers still risk punishment for:

• Changing or misrepresenting scores on any official documents.
• Failing to cooperate while under investigation.

While enforcement spearheads effort to mitigate cheating and dishonesty, there are some things that may not be as straightforward. Some acts or behaviors can be considered violations without the applicant or examinee knowing.

If a medical student is eager to apply for their second attempt at Step 1 and accidentally applies five months after their first attempt, it could be flagged as irregular behavior. Moreover, since the sequence takes years to complete while a student is transitioning from medical school into a residency program, if students relocate for their continuing education or careers and do not change that on official documentation, there is a chance the scheduling permit may not match, and testing officials may flag the matter as irregular behavior.

Outside of applying for and taking the USMLE, individuals can also be caught up in the unethical behavior of others. For instance, preparation courses are available from outlets not associated with the USMLE. As well, the organization prohibits using, distributing, or soliciting content from recent test takers or actual examinations. However, if someone used a test preparation program or service that did, an examinee's registration and scores may be canceled.

Unanticipated Conditions for Maryland Examinees

There's no doubt the risk of punishment for acting or behaving outside of the Rules of Conduct is high. Yet, the USMLE does provide some flexibility in certain circumstances. Examinees can contest unanticipated situations that may affect their abilities on exam day.

Officials do not list every potential issue and how they may decide on an individual matter, but some common examples include:

• Computer or network issues at the test center
• Building or test center errors or malfunctions
• Unexpected personal conditions

The USMLE Management Committee has sole discretion concerning what situation, if any, is eligible for review. Nevertheless, students must take advantage of every chance of redress to protect their best outcome. To pursue a review of unanticipated conditions, individuals must:

1. Report any interruption that may negatively affect performance to test center staff immediately.
2. Email the USMLE program within ten calendar days.

In their correspondence to the USMLE, examinees must include the name on the scheduling permit, USMLE ID number, exam step and date taken, and a detailed description of what occurred. Those who fail to complete the above two steps waive the right to review.

The USMLE Management Committee has 15 business days to investigate the matter and render a decision in writing. The notice will include whether the exam attempt is scored in full or scored by removing the impact the unanticipated conditions had on the score.

Examinees may believe that some things are worth reporting. However, an unreported issue can come back to harm a student's score. Unanticipated conditions can be grounds for a proctor's allegations of irregular behavior. Therefore, reporting doesn't just work for one's potential benefit; it can be the first line of defense. False accusations or not, students will endure the program's grievance process.

USMLE Investigation and Hearing Process

Maryland examinees come under heavy scrutiny on test day. Exam proctors are trained to detect any small activity or behavior outside the rules, and high-tech surveillance systems will catch anything center staff don't. Afterward, exam responses are checked with computer programs to detect patterns indicative of cheating.

Allegations of irregular behavior from USMLE officials aside, misconduct claims can also come from anonymous sources. When complaints arise, the Committee for Individualized Review (CIR) convenes and employs the following approach:

1. The examinee receives a written notice from the CIR explaining the nature of the allegation and the reason for the investigation.
2. The CIR requests examinees to provide a written explanation regarding the incident, including any additional information.
3. CIR personnel conduct a thorough investigation of previous test attempts, proctor reports, surveillance video, and other relevant evidence.
4. Test center staff and other witnesses are interviewed by the CIR, which may also interview the examinee in some cases.
5. The CIR sends examinees a notice whether the matter is closed or it will pursue formal charges.

During an investigation, the USMLE prohibits individuals from registering for other exams. Moreover, any scheduled attempts are canceled, and unreleased scores may be withheld until the grievance process closes. Wherein the CIR conducts a formal hearing, examinees are granted the opportunity for a hearing at the NBME headquarters at 3750 Market Street in Philadelphia, Pennsylvania. A crucial right for examinees is that they may be helped by a legal professional during official proceedings.

At the outset of the hearing, the committee and the individual (or their legal representative) may make an opening statement and present an overview of their case. Both may submit mitigating or supporting evidence, and the accused has the opportunity to provide explanations or refute the allegations, call witnesses, and clarify misunderstandings. Committee members may ask questions to probe inconsistencies, as can the accused, to address points raised by the committee. After the hearing, the CIR deliberates privately to evaluate whether the alleged violation is substantiated or not.

Consequences of Violations

All outcomes of CIR hearing are sent to individuals in a written response. If the CIR substantiates the charges, the test attempt may be canceled, with the hearing details becoming part of their USMLE transcript. If the exam was scored, transcripts also notes the CIR's findings. Officials may even ban those sanctioned from ever sitting for the sequences again.

For medical students taking Step 1 and Step 2 CK, the CIR may notify their school, which may urge further action like:

• Probation
• Suspension
• Expulsion
• Degree revocation

Medical residents also face repercussions from the MBP because it will enforce its rules barring license application because of misconduct. With their reputation in medical programs and licensing boards tarnished, career opportunities are greatly diminished . Since Maryland is a signatory of the Interstate Medical Licensure Compact (IMLC), licensure outside of the state will be challenging.

Over three dozen states are part of IMLC to simplify the physician licensing process and thus share information across a nationwide database. Therefore, most other state medical and licensing boards will know if a candidate was sanctioned, making employment as a physician in Maryland and elsewhere next to impossible.

Maryland USMLE Examinees Need the Lento Law Firm Student Defense Team

While it may not seem like it before test day, just a single, minor mistake on the USMLE can end a medical career before it even begins. Unfortunately, it's common for examinees not to realize the severity of violating the Rules of Conduct, and the following could derail attempts and scores before, during, and after test day:

• Using unethically-sourced exam prep services or material.
• Forgetting to leave a cell phone in the test center locker or cubicle.
• Submitting a report of unanticipated testing conditions after ten days.
• Telling a friend about some of the questions on the USMLE.

Examinees may want to seek a reconsideration review, score appeals, and represent themselves alone to the CIR and USMLE officials. However, exam attempts are nothing to waste, and anyone seeking accommodations or working on a defense strategy will have the best outcome with the Lento Law Firm Student Defense Team. We are an invaluable asset during the program's grievance process and will ensure test takers exercise every opportunity to defend their actions or push back against allegations.

We also provide robust representation and guidance to ensure students have the accommodations they need (and the USMLE is legally required to give) to promote the best performance for any exam of the three-part series. Call the Lento Law Firm at 888-535-3686 today or visit the confidential online consultation form.