The Long History of Misconduct on the Medical Licensing Examination in the United States

A written examination for medical licensure developed in nearly every state in the late nineteenth century. Cheating behaviors (e.g., copying, test proxies, attempted pre-access) emerged soon after. State medical boards adopted mechanisms to deter and detect such behaviors. The twentieth-century shift to nationally administered exams (NBME Parts, FLEX, USMLE) saw a continuation of exam misconduct despite the application of greater controls and data forensic analyses. Two features characterize historical and contemporary misconduct on the medical licensing examination: infrequency and persistence. Though exam misconduct appears modest in scope (national data exists only for the last 30 years), its impact extends beyond infrequency to include risk to the broader medical licensing system and even patient outcomes. Evidence presented here makes clear that the soft underbelly of historical and contemporary exam security was the human element: lapses in following procedures designed to protect the licensing and examination systems but also a general belief that a security breach happens elsewhere. The infrequency of the behavior is remembered but the documented persistence of cheating behaviors is forgotten.