Med Ed Is 'Rotten,' Says Outspoken Doc on a Quest for Reform

Benjamin Mazer, MD, MBA


June 04, 2021

Bryan Carmody is fed up with licensing examinations. He thinks that the National Board of Medical Examiners (NBME) has unacceptable financial conflicts of interest. He doesn't believe that osteopathic licensing exams should even exist. In Carmody's view, the Association of American Medical Colleges (AAMC) uses its crash-prone residency application website as a cash cow. He has no interest in working his way up through formal medical education committees just to "sit at a table where I could have a polite discussion with the CEOs of these organizations."

Instead, he has taken on these organizations as an outsider. In just a little over 2 years he has become a nationally recognized expert, one whom even the very organizations he routinely criticizes now acknowledge as an influential voice in medical education policy.

Revisiting Medical School

Improbably, Carmody's scorched-earth campaign against the medical education establishment all started simply because he wanted to teach medical students about the kidney.

Carmody, a pediatric nephrologist in Virginia, recalls heading back to medical school for the first time since graduating. It was 2017 and he was participating in the school's nephrology course. He had signed up to teach with the hope of innovating the curriculum.

Bryan Carmody

"I had this idea about how the content should really be reorganized," he said. "I could break down nephrology into the clinical syndromes and then introduce that syndrome and teach the basic principles to help understand it."

He quickly realized, however, that what students learned had to be tailored toward achieving a high score on their licensing exams.

"It was different, man," Carmody told me. "I quickly got to see how the Step 1 exam loomed large over everything, and how residency selection had become this outsized beast since I'd done it just 10 years before." Without a high score, competitive residencies would be out of reach. "I couldn't impose this new schema on students because if I did, it would hurt them. It would limit their career opportunities."

Instead, he started teaching toward the test — a painful experience for him. But it got him thinking that if there was less emphasis on achieving high exam scores, medical education could be more innovative and useful.

'The Sheriff of Sodium'

Carmody kept his thoughts to himself until one day in 2018, when he came across what he refers to as the "regrettable paragraph."

Peter Katsufrakis, president and CEO of the NBME, and Humayun Chaudhry, president and CEO of the Federation of State Medical Boards, had published a commentary in Academic Medicine responding to student complaints that Step 1 scores had become too important in resident selection. In their commentary, Katsufrakis and Chaudhry argued that if medical students spent less time preparing for the high-stakes exam, they might instead end up simply wasting time by "binge-watching the most recent Netflix series or compulsively updating their Instagram account." The line was ultimately removed from the piece.

"That really rubbed me the wrong way," Carmody said. He wrote his first blog post in response to their condescending statement. "The more I've looked into things, like the financial conflicts of interest for those most vocal about maintaining the status quo," he wrote, "the more deeply convinced I've become that the whole system is rotten and we have to do more." He called his site "The Sheriff of Sodium" because he is "salty about medical education."

After publishing this incendiary blog post, Carmody was surprised to find that he had an audience. He now has more than 15,000 followers on Twitter, having ballooned from about 1800 in February 2019. His more popular blog posts garner about 10,000 readers. Media outlets like The New York Times cite him as an expert.

Carmody has a unique ability to connect medical education's present structure to its history. "I try to understand things before I go popping off about them," he said. In his blog posts, instead of simply sharing how he thinks medical licensing or residency selection should change, he puts these views in context through detailed histories of how an exam or the Match process came to be. Carmody's blog does the "hard and underrated work of encapsulating the history of changes in the training process," said Tito Joe Thomas, a medical student who follows Carmody's work.

In his short time as a public advocate, Carmody has taken a number of controversial stances on medical education. What's shocking is how quickly many have come to fruition. Throughout 2019, Carmody wrote a series of blog posts criticizing residency programs' reliance on Step 1 scores to select applicants, going as far as to call it idolatry. By February 2020, it was announced that the exam would move to pass/fail. He also used his blog to dissect the history and deficiencies of the USMLE Step 2 Clinical Skills exam. Last January, the medical community was stunned again when that exam was permanently canceled.

Carmody may not have been the first to criticize the exams, but his well-timed stances have repeatedly put him on the right side of history.

Confronting Conflicts of Interest

Perhaps his most controversial position is that the financial interests of the large, nonprofit organizations that control medical education are harming future doctors. He believes that the significant revenue that the NBME draws from ancillary products, like practice tests sold to students and schools, is incentive to continue pushing an unhealthy obsession with exam scores.

For example, the NBME takes questions "that volunteers write that appear on the USMLE, and then when those questions go cold, sells them back to students," Carmody said. "I think they perceive correctly that there's a huge market for that. The schools don't like to be the bad guy. They don't like to get into the messy business of assessment when they can outsource that."

Once I started to talk about these things, I would frequently get messages. The gist of it was sort of 'back off.

He similarly feels that the AAMC has little incentive to limit "application fever" — the ever-increasing number of applications that students must submit to obtain a residency position in the Match. As applications increase, the AAMC's revenue from its Electronic Residency Application Service (ERAS) only grows. Carmody has a habit of tweeting out a chart he's made of the AAMC's ever-increasing earnings from ERAS — now at more than $94 million per year.

A representative from the NBME says that "Bryan Carmody and others who represent the student experience have contributed to the ongoing conversation. We appreciate and value the broad dialog fueling improvement in our community and hope that it continues." The AAMC declined to comment for this story.

Despite his outsider status, Carmody knows that he has the ear of the people he wants to reach. Using tools available through his website, he can see that his articles are being emailed to these national organizations.

Not surprisingly, this speaking-truth-to-power approach has won him the hearts of many medical students. Carmody's "work in student advocacy helped put what felt like an impossible task into perspective. I no longer felt like it was me against my institution," said one medical student who wished to remain anonymous.

This is because Carmody isn't just a political rabble-rouser. He's also an approachable presence for many struggling students. He was "kind enough to take his time to personally respond to all my questions," international medical graduate Raza Syed told me.

About 15 trainees every week message Carmody from around the world. In addition to responding to personal messages, Carmody answers readers' questions on his blog. "That's been one fun thing about this," he said. "I hear about all sorts of stuff." Perhaps this open dialogue is what gives him a perspective that some other medical educators lack.

He has even garnered some fans within the establishment. Travis Smith, DO, an associate dean at the Lake Erie College of Osteopathic Medicine, said, "He's been ahead of the game." Smith shares Carmody's work with his medical education colleagues. "His opinion is validated by not only myself and my colleagues that I work with, but also students."

Still, his strategy has limits to some. "My personal feeling is that he is tilting at windmills," said Bruce Morgenstern, MD, a senior executive dean at Roseman University College of Medicine. As Carmody himself has pointed out, medical education and licensing are a big business. A persuasive argument rarely speaks louder than a pile of cash. This combination of public duty and easy money can insulate national medical organizations from calls for change.

Taking on Osteopathic Med Ed Organizations

Among his many "windmills," Carmody has demonstrated open disdain for osteopathic medical organizations like the National Board of Osteopathic Medical Examiners (NBOME).

He expresses little loyalty to the system that enabled his own career. "I don't think that the NBOME at this point in history serves a useful purpose," said Carmody. "DOs no longer need that protection." Students now compete for the same residency slots; they work side by side with MDs; they should take the same licensing exams, he reasons.

He thinks osteopathic medical schools have been charging exorbitant tuition for an often inferior educational experience. "There are schools that are over $70,000," he said. "Yet some of these same schools do very little to arrange rotations for their students. The students are sort of on their own to find their own rotations and to get the experiences that they need to match. In general, they have less access to career advising and other things that we sort of take for granted when you go to an MD school."

I raised these concerns with Jeanne Sandella, DO, a vice president at the NBOME. "The curriculum of every osteopathic medical school incorporates distinctive osteopathic principles and prepares students for medical practice as osteopathic physicians," she said. "The COMLEX-USA examination program incorporates these distinctive osteopathic principles, and it is constructed and validated based on practice patterns that are unique to DOs."

Even if the NBOME continues to assert its relevance, Carmody believes that time is not on their side. "Eventually, the people who are frustrated and angry and feel wronged by them are going to rise into power where things will change." He has tweeted that his inbox is flooded with messages from fed-up osteopathic medical students.

'Black Sheep'

"I don't think he's said anything crazy. A lot of it is reasonable," said Smith, the Lake Erie College dean. "Some people just don't want to hear it. That's the problem."

That may be the most important reason more physicians don't speak out on behalf of their students: It poses risks to their career. "Once I started to talk about these things, I would frequently get messages. The gist of it was sort of 'back off,'" said Carmody. "You're not going to get promoted. You're going to be a black sheep." He believes that he is better insulated from political blowback due to the private structure of his practice, in contrast to many academics.

Would Carmody ever join the establishment and work for change from within? "The only thing that I've applied for — and was rejected — was this Coalition for Physician Accountability workgroup," he said. "You had to write a little essay, and I was pretty frank in my essay, [such as] 'I say things that are often provocative, but I will bring diversity of opinion to the group, which otherwise may be lacking.' And naturally, I didn't expect that they would take me."

He doesn't rule out applying for more formal positions in the future, but he's happy with the impact he's having through less traditional routes. Online communication has enabled motivated outsiders like Carmody to have a voice in policy discussions.

Advocacy for students has become even more important during the COVID-19 pandemic. Social-distancing requirements upended traditional medical education, leaving trainees to navigate a new world of modified clinical rotations, canceled exams, and virtual residency interviews. In the end, the pandemic may actually accelerate the kind of innovation for which Carmody has been pushing.

"So much changed all at once in this application cycle, and [while] outcomes are not quite as good, they're very similar to previous years," he told me. "The reality is you shouldn't be afraid to innovate. You shouldn't be afraid to make changes."

Bryan Carmody, at least, remains fearless.

Benjamin Mazer, MD, MBA, is a pathologist at Johns Hopkins Hospital with interests in diagnostic surgical pathology, laboratory management, and evidence-based medicine.

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