832 examinees, a 240 Step 1 average at the Nepal centre: how the USMLE invalidated scores in 2024 and a federal judge upheld it

Every year hundreds of doctors from South Asia sit the United States Medical Licensing Examination (USMLE) hoping for an American residency. A pass is a condition of certification by the Educational Commission for Foreign Medical Graduates (ECFMG), and the exam is run by the National Board of Medical Examiners (NBME). In early 2024 the programme did something it rarely does: it voided the passing scores of a whole group of examinees linked to one country.

According to the Kathmandu Post of 2 February 2024, the USMLE programme said it had identified a pattern of anomalous exam performance associated with Nepal and invalidated the scores of the examinees concerned, who were told their Step results were void and that they must sit a validation exam. The number affected was not known at the time. The statement quoted by the paper said that 'highly irregular patterns can be indicative of prior unauthorised access to secure exam content' and that invalidated scores no longer meet ECFMG requirements. The Nepal Medical Council's registrar, Dr Bishwa Raj Dawadi, told the paper the decision was the USMLE's and the council could not act on it; the council had issued more than 2,400 letters of good standing in 2023, most of them for the United States.

One affected graduate, Dr Latika Giri of Kathmandu, sued the NBME in federal court in Washington, alleging discrimination against Nepali graduates. The Hospitalist reported that Judge Christopher R. Cooper refused an emergency injunction on 23 February 2024 in a 32-page order and denied class certification without prejudice. Court filings cited there put the number of examinees whose passing results were questioned at 832: 618 with one Step flagged, 202 with two and 12 with all three. The NBME's data, the court heard, showed the Nepal test centre averaging 240 on the 2022 Step 1 when no other centre exceeded 227; the centre also had the highest Step 1 averages worldwide in 2021 and 2022 and the highest Step 2 CK average in 2022. The judge found nothing in the record to suggest the NBME 'went looking for a problem in Nepal' out of ethnic or national-origin suspicion, and called public safety 'the overriding interest' in a case about the credentials of doctors applying to residency programmes.

The mechanism alleged was not a forged certificate but leaked content: prior access to live questions, detected afterwards by statistical screening of test centres. That is why the sanction fell on scores rather than on a school, and why, as the Kathmandu Post reported, doctors who had already reached the United States were affected alongside those still preparing to go.

For a student the lesson is that exam security is enforced retrospectively and collectively. Anyone selling 'recalls', question banks said to contain live items or guaranteed scores is selling a route to invalidation, not to a licence. Prepare only with material the exam programme permits, and check the USMLE and ECFMG websites directly for any notice affecting your test centre.