The United States Medical Licensing Examination (USMLE), a standardized testing pathway required for physician licensure in the United States, had been at the centre of a significant cheating scandal involving Nepali international medical graduates (IMGs). In January 2024, the USMLE and its administrative bodies invalidated scores for a group of examinees after detecting "anomalous performance patterns" that suggested prior access to secure exam content.
One test taker filed a lawsuit against the National Board of Medical Examiners (NBME) challenging the invalidation, but a U.S. federal court denied the motion.
The USMLE is a multi-step, standardized examination designed to assess whether a medical graduate possesses the knowledge and clinical reasoning required to practise medicine safely and effectively in the U.S. Passing Step 1 and Step 2 Clinical Knowledge (CK) is also a core requirement for ECFMG (Educational Commission for Foreign Medical Graduates) Certification, which is required for IMGs to enter U.S. residency and licensure pathways.
To protect exam integrity, the USMLE program and the NBME implement strict anti-cheating measures, including:
Statistical analysis of answer patterns
Monitoring for unusually high performance correlated with rapid answer times
Detection of patterns inconsistent with normal exam behaviour
Data analytics to identify clustered irregularities
Examinees agree to these conditions as part of the testing terms.
At the beginning of 2024, the USMLE and NBME identified a pattern of anomalous exam performance associated with a subset of test takers linked to Nepal, in which large numbers of examinees exhibited matching answer choices, including incorrect answers at the same points and steps, and disproportionately high scores. These patterns were statistically unlikely to occur by chance, described as having “less than a 1 in one hundred million” probability, which raised concerns of prior unauthorized access to exam content.
The investigation pointed toward the possible use of unauthorized “recalls”, which are illicit reconstructions of exam questions by examinees who had previously seen them and later sell or share these question banks. Recall use is strictly prohibited, as USMLE policies state that reproducing and distributing any exam content, including by memorizing and reconstructing questions, violates the exam’s copyright and security provisions.
Based on the investigation, the USMLE program invalidated the exam scores of approximately 832 examinees tied to the irregular patterns. The ECFMG stated that invalidated scores no longer meet requirements for certification and that ECFMG certificates issued based on these results were also invalidated, meaning those individuals are no longer considered ECFMG certified.
Individuals with invalidated scores were offered limited options:
Request NBME reconsider the decision (a process that could take up to 10 weeks)
Retake the affected exam(s)
Do nothing, leaving the scores invalid and making them ineligible for certification or residency programmes
Steps 1 &2 generally require waiving the right to sue NBME as part of the process.
A Nepali IMG, identified in legal filings as Dr. Latika Giri, filed a federal lawsuit in the U.S. District Court for the District of Columbia on behalf of herself and other examinees whose scores were invalidated. She argued that:
NBME acted in violation of its own published procedures
The decision discriminated against examinees “on the explicit basis that they were associated with Nepal,” which she alleged contravened the Civil Rights Act of 1964’s prohibitions on discrimination based on national origin
The complaint sought to block NBME from invalidating the scores and restore the original results.
However, in February 2024, U.S. District Judge Christopher R. Cooper denied the emergency motion to restore scores, noting that USMLE and NBME had a “good faith basis for questioning the validity of the scores” and that public safety interests outweighed the request. The ruling stated that NBME’s actions were taken based on evidence suggesting compromised exam content, not discriminatory animus. The judge also declined to certify the lawsuit as a class action at that time.
Invalidated USMLE scores have significant implications for affected examinees:
Scores no longer fulfil ECFMG Certification requirements, which disqualify candidates from entering U.S. residency matches and licensure pathways until valid scores are obtained.
Prior invalid scores remain on official transcripts, which may influence future evaluations by programme directors and licensing boards.
Unsanctioned recall question use, even outside organized groups has been a concern; widespread sharing of recalled questions in online WhatsApp messaging groups was understood to contribute to the anomalous patterns that triggered the investigation.
The USMLE program emphasises exam integrity as essential for public safety, ensuring that licensed physicians have the necessary competencies. To maintain validity and fairness, the program uses:
Continuous performance monitoring
Statistical flags for anomalous response patterns
Requirements that examinees adhere to strict confidentiality and content security agreements
Data comparison between suspected compromised items and neutral item performance
If irregularities are detected, secure exam questions can be rotated or withdrawn from scoring pools to preserve overall fairness.
These protocols are designed to protect both examinees who adhere to exam rules and the medical community and patients who rely on physicians to meet established competency standards.
The USMLE cheating scandal associated with Nepali examinees stems from irregular performance patterns detected in exam results, leading to invalidated scores for hundreds of individuals. A lawsuit challenging this action was rejected by U.S. courts, with judges finding that the invalidation was supported by evidence and necessary in the interest of public safety.
USMLE Program. “USMLE Program Statement on Notification of Invalidated Exam Scores.” USMLE.org. https://www.usmle.org/usmle-program-statement-notification-invalidated-exam-scores.
Medscape. “Nepali IMG Sues NBME After Invalidating USMLE Scores Over Cheating.” Medscape, 2024. https://www.medscape.com/viewarticle/nepali-img-sues-nbme-invalidating-usmle-scores-cheating-2024a10003ap?form=fpf.
