LAUSR

Though intended to inform a binary decision on initial medical licensure, the United States Medical Licensing Exam (USMLE) is frequently used for screening candidates for residency positions. Some have argued that reporting results as pass/fail would honor the test's purpose while preventing inappropriate use. To date, the USMLE's sponsor organizations have declined to make such a change. In this Perspective, the authors examine the history and mission of the National Board of Medical Examiners (NBME), trace the rise of "Step 1 mania," and consider the current financial incentives for the NBME in implementing a pass/fail score reporting policy.The NBME was founded in 1915 to address the lack of interstate reciprocity in medical licensure examination. With the creation of the USMLE in 1992, a single pathway for licensure was established, and the organization's original mission was achieved. Yet even after fulfilling its primary purpose, the NBME-classified as a nonprofit organization-has seen its revenues rise dramatically over the past two decades. Much of the increased revenue is derived from test products and services not required for medical licensure, with sales driven by the increasing importance of Step 1 scores in residency selection. Revenue from these products and services would likely decline if the NBME reported Step 1 results as pass/fail.A financial conflict of interest occurs when a judgment concerning a primary interest may be influenced by a secondary interest, such as financial gain. The data presented here demonstrate that the NBME has a conflict of interest in its current score reporting policy. Possible remedies, such as disclosure, recusal, divestiture, and restructuring, are considered.