Based on recent data, medical students pay approximately $136 million dollars each year in registration fees for the U.S. Medical Licensing Examination (USMLE) Step 1, Step 2 CK, Step 2 CS and Step 3 exams.
Current registration fees to take the four USMLE exams are $3,320 per U.S. medical student and $4,125 per international medical graduate (IMG). Estimated annual registration fees for the USMLE exams are $69.6 million dollars from U.S. students and $66.8 million dollars from IMGs. These cost estimates are based on 2015 USMLE data for total U.S. medical student test takers and 2015 Educational Commission for Foreign Medical Graduates (ECFMG) data for total number of IMG exam registrants. Net annual registration fees per exam are as follows:
Step 1: $35.6 million dollars (24,333 U.S. students at a $605 registration fee and 23,730 IMGs at $880)
Step 2 CK: $29.5 million dollars (23,317 U.S. students at $605 and 17,499 IMGs at $880)
Step 2 CS: $48.9 million dollars (20,252 U.S. students at $1,280 and 15,024 IMGs at $1,535)
Step 3: $22.3 million dollars (17,887 U.S. students at $830 and 8,981 IMGs at $830).
(Data includes MD and DO test takers and repeat examinations. Calculations for Step 1 and Step 2 exams are based on the number of U.S. test takers and number of IMG registrants. Step 3 data is based on the number of U.S. and IMG test takers.)
USMLE test takers also pay tens of millions of dollars in travel and test preparation expenses. Many U.S. and IMG medical students must travel significant distances to take Step 2 CS as this exam is only offered in five U.S. cities. IMGs are also not allowed to take Step 3 in their home countries. Medical students typically fund these costs, including registration fees, with student loans that accrue interest adding to the total expense. Of note, the USMLE also takes in $2.7 million dollars annually from IMGs with J-1 visas (9,575 IMGs last year) that must pay a $285 annual fee during post-graduate training. Additionally, the USMLE charges physicians a minimum $70 fee to deliver official transcripts to employers and licensing bodies.
The aggregate cost of registering for and taking the USMLE exams is staggering. The USMLE program is owned by the Federation of State Medical Boards (FSMB) and the National Board of Medical Examiners (NBME). The USMLE also has oversight from a governing committee that includes members from the FSMB, NBME, ECFMG and the public. The USMLE program does not readily disclose how registration fees are utilized, how leadership is designated or compensated, or what the operating costs are for producing and administering USMLE exams.
The USMLE program provides a standardized measure of physician knowledge and clinical performance that is a key component of professional certification. However, data demonstrating the benefit of requiring four separate USMLE exams is limited, particularly when excluding studies funded by the USMLE and affiliate organizations. The necessity of the Step 2 CS exam is particularly controversial and an ongoing campaign to eliminate Step 2 CS as a requirement for licensure has gained support of more than 15,000 medical students.
Medical students cannot afford to pay the USMLE $136.4 million dollars each year without adding to already burdensome student loan debt. The USMLE’s lack of cost transparency makes it difficult to determine whether physician constituents should feel confident that mandatory fees are reasonable. Safeguards are needed to ensure fees for mandatory testing such as the USMLE do not exceed reasonable operating costs, particularly for financially vulnerable medical students.
Physicians and health care organizations are increasingly accountable to cost transparency and outcome measures. It is time to hold the USMLE program and other medical licensing bodies to a similar standard.
Matthew F. Covington is a radiologist.
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