Cheated out of the American Dream

The United States Medical Licensing Examination (USMLE) is a test that those who want to practice medicine in America have to pass. A growing number of Nepalis have been taking the test to emigrate to the US. 

Last week, USMLE invalidated test results of some 800 Nepali doctors because of ‘unusual score patterns or variations’.

‘The USMLE program has identified a pattern of anomalous exam performance associated with Nepal, which challenges the validity of test results for a group of examinees,’ its statement said. 

Essentially, USMLE was accusing Nepali doctors of having prior knowledge of questions. This sparked outrage among Nepalis in the United States who say it tainted the country's image, and besides there is no way the test questions can be ‘leaked’. 

Ramu Kharel is an emergency medicine physician and assistant professor at Brown University. He told us, "We care for the integrity of the program, and do not condone cheating in any form but the decision is not backed by strong evidence and creates biases when there is already a lot of brewing anti-immigrant sentiment.”

Kharel reached out to the USMLE director who told him it was ‘an ongoing investigation’.

“And yet they put out a blanket statement that has tarnished an entire country’s image as well as the credibility of practicing Nepali doctors who have done a lot of good work in the US.”

Several international doctors in the United States back this up, saying irregularities should have been addressed individually instead of singling out a whole country.

‘Some folks are using incidents of what they call “unusual USMLE Scores" to vilify the whole immigrant community who are resilient, hardworking, and knowledgeable as local doctors are. Let's not generalize the acts of a few to whole country and to emigrants,” X'ed Sadiq Naveed, psychiatrist in Hartford, Connecticut.

 Ahmad Rehan Khan, psychiatrist based in Virginia also tweeted: ‘In my opinion mistakes of some mustn't lead to singling out of an entire country. ECFMG & USMLE could have handled the situation better by a making a more generalized statement rather than naming a particular country.’

Kharel started a petition calling on USMLE to redact or change the statement, and has over 2,500 signatories already. He has approached the Nepali physicians' group in the US as well as the America Nepal Medical Foundation seeking legal counsel.

“The damage is already done, but USMLE at the very least needs to immediately revise its statement and issue a formal apology,” says Kharel. “The truth is that Nepalis are generally well-liked here." 

A week before the USMLE statement, Nepali Times published a report about doctors emigrating to the US, UK, Canada, Australia and the Gulf, leading to a shortage of specialists in Nepal and weakening an already fragile medical system.

Nepal has an annual turnover of nearly 2,500 MBBS graduates, yet the country faces a severe shortage of doctors. The Nepal Medical Council says 36% of doctors have emigrated, but that seems to be an undercount.  

Between April-December 2023, 1,025 physicians left Nepal. Since 2020, 1,578 doctors have emigrated to the UK, and 888 to the US. 

There are many push factors, but the lack of professional fulfilment in Nepal is the biggest. Equally strong is the pull of the American dream, with even unskilled Nepalis paying up to Rs6 million to human traffickers to take the illegal backdoor to the US.

Emigrating doctors may earn more than in Nepal, but international medical graduates in the US often do not get to practice specialised medicine of their choice, and are relegated to long hours as general physicians. 

“Nepali doctors are emigrating essentially for thankless, blue-collar jobs,” says Bishal Dhakal, cardiac surgeon and founder of Health At Home in Kathmandu. “They do not make a lot of money by American standards and are doing jobs that American doctors do not want to do. Which is why Nepalis being accused of cheating is so tragic.”

Even so, the Medscape medical news website on 1 February states that selling and buying USMLE questions online have become rampant with test questions selling for anywhere from $300 to $2,000.

An Indian doctor Ahmad Ozair at Johns Hopkins says his suspicions were aroused when he saw several students from one medical school in Nepal, posting on social media about scoring up to 280-plus.

‘The statistical probability that you would have three or more candidates in the same year, scoring in the 99th percentile worldwide, from a small geographical area is extremely low,’ Ozair said to Medscape. 

Others say the USMLE recall of Nepali test takers was not an ordinary one, and there is photographic evidence of questions leaked at exam centres. 

The fact that Nepal’s university exams have regular scandals of ‘question outs’ gave credence to accusations of Nepali cheaters. 

J. Bryan Carmody, nephrologist based in Virginia, also took to Twitter to write: ‘This isn’t the usual low-quality “USMLE recalls” - and instead involves screenshots/photos of real questions, taken at test centers by proctors (or after the proctors were paid to look away).’

Medical educator Conrad Fisher of MedQuest Test Prep questioned in an X post the high performance of Nepalis: ‘Of 138 with >275 applying to my program, 86% are Nepali. Of the top 100 applicant scores 92% are Nepali.’

But Bishal Dhakal says Nepalis are used to practicing for exams based on past tests, and it is unfair for USMLE to call it cheating just because of high scores. “If there is an issue with exam centres, that should be dealt with separately without dragging the whole country into it," he adds.

An increasing number of Nepali doctors passing USMLE tests with high marks seems to be making some international graduates in America insecure. He adds, "We are sending our smartest doctors to America, and that didn’t sit well with those benefiting from the Subcontinent quota. A small country is being singled out."