Medical Licensing Part 1: The Case for COMLEX — Why Two Licensing Sequences Are Better Than One

healthcare futurism Jan 23, 2024

There’s been a lot of discussion lately in the DO community about COMLEX. On one side, some physicians and students argue that there’s no need for a separate DO licensure examination series. It’s time, they say, to let COMLEX and the NBOME fade into history and rely on the USMLE testing series to determine whether all physicians are competent to practice.


 On the other side of the debate, many DOs insist our approach to medicine is distinct from how MDs practice. They believe strongly that the NBOME and COMLEX serve an important purpose in our profession and should be maintained separately from the USMLE favored by MDs.


 I’m passionate about both medical education and the unique value of osteopathic medicine, so you can bet I’ve followed this debate pretty closely. I’ve spent a lot of time thinking about both sides of the argument and figuring out where I stand. To be honest, I think both sides are partially correct.


 COMLEX in its current form isn’t working well for a minority cohort of DO students, but that doesn’t mean it doesn’t serve an important purpose. In the end, I come down firmly on the side of keeping COMLEX and implementing some major changes to overhaul the testing series and turn it into something useful for all physicians.




Keep reading to find out why I believe we still need COMLEX and how we can overhaul it to best serve future DOs and, for that matter, all physicians.


What is COMLEX? A Quick Refresher




I realize some of you may have either been out of school too long to remember much about COMLEX or are too early in your medical education to be familiar with it, so I’d like to start with a quick overview. I won’t spend too much time here — just long enough to cover the key points.


 The COMLEX-USA Examination Series — or just COMLEX for short - is a series of tests designed to test the minimum competence of medical students who wish to practice osteopathic medicine in the US.


 According to the NBOME website, it’s “designed to assess osteopathic medical knowledge, knowledge fluency, clinical skills, and other competencies essential for practice as an osteopathic generalist physician.” You also have to pass the following series of four COMLEX assessments to graduate from medical school and enter residency:

  1. COMLEX-USA Level 1 — computer-based exam taken after the 2nd year of medical school

  2. COMLEX-USA Level 2 — computer-based exam taken after the 3rd year of medical school

  3. COMLEX-USA Level 2 PE — clinical skills assessment taken after the 3rd year of medical school

  4. COMLEX-USA Level 3 — computer-based exam taken during the first year of residency




That’s COMLEX in a nutshell — a rigorous series of tests that must be passed to become a practicing osteopathic physician.


Regulatory Monopolies Are Bad for Everyone — Why We Need USMLE & COMLEX




DO students must pass COMLEX to become licensed, while MD students must pass a very similar testing series known as USMLE. Both testing series have been around in their current form since the 1990s, but people have begun questioning whether there’s really a need for both in today’s medical landscape.


 Dr. Bryan Carmody, a popular critic of medical education processes also known as the “sheriff of sodium” has written extensively in favor of abandoning COMLEX in favor of USMLE for everyone. He included this interesting statement in a recent blog post:


 The NBOME has served an important purpose. But DOs should now critically consider whether this is an organization that has largely outlived its usefulness.”


 I understand where Dr. Carmody is coming from and I enjoy reading his work, but I think he’s just plain wrong on this point.


 It’s true that the original purpose of the NBOME and COMLEX was to provide a way to evaluate and license DOs in a way that’s just as valid and rigorous as the process used for MDs. This was necessary to help DOs gain respect and acceptance as “real” practicing physicians in the medical world. It’s also true that today DOs and MDs have equal practice rights and access to patients in all 50 states, so, in a sense, COMLEX has done its job and achieved its original purpose.


 The part I take issue with is the idea that the NBOME and COMLEX are no longer useful. I believe they are extremely useful and even necessary to maintain the integrity of medical education in this country. Currently, MDs must take the USMLE and DOs must take COMLEX. If COMLEX is eliminated, there will only be one path to becoming a licensed physician in the United States.


 When one entity controls an entire industry, there’s a monopoly, and regulatory monopolies are always bad for everyone. Monopolies crush competition and innovation and lead to stagnation and corruption. Just look at how ridiculous the NRMP process is, and how bloated ERAS has become!


 We don’t need that sort of thing in our medical education system. Instead, medical students should have multiple valid paths to licensure. The best way to do that is to keep both USMLE and COMLEX and make the current system better by offering both testing series as valid options to all students studying to become physicians.


Why is COMLEX vs USMLE an Issue? The Problem Isn’t the Tests — It’s the Way They’re Used




I’ve made it clear that I’m not convinced by the arguments in favor of eliminating COMLEX and the NBOME, but why do so many people feel differently? How did we get to the point where frustrated DO students are filling Reddit threads and student forums with bitter complaints about the NBOME and many practicing physicians are calling for the end of COMLEX?


 I believe the heart of the issue isn’t the fact that there are two tests — it’s how the tests are being used in ways that go far beyond their stated intent to assess the minimum competence of students studying to become physicians. The most egregious example is the way COMLEX and USMLE scores are used to determine who gets accepted into residency programs.


 Many residency programs use COMLEX and USMLE percentile scores as a way to compare and screen candidates. Here’s the first problem: the test scores were never meant to represent a student’s aptitude for a particular specialty. 


A student’s biochemistry score has very little relation to his or her ability to be an outstanding orthopedic surgeon or pediatrician. Students know this and are understandably frustrated by the disproportionate weight placed on test scores by residency programs.


 The second problem is that some residency programs will only accept USMLE scores. They say they need to compare all students on the same basis (i.e. test scores), but I say it’s laziness on the part of the admissions team to write off candidates just because they took a different test. As a result of this practice, any DO students who want to apply must spend extra time and money to take both the USMLE and COMLEX. This is one of the main frustrations expressed by DO students and their major reason for wanting to get rid of COMLEX.


 And who can blame them? They have every right to be frustrated at the misuse of both COMLEX & USMLE test results, but eliminating one test won’t solve the current problems and will almost certainly lead to new ones.




4 Suggestions to Overhaul COMLEX & Make it Work Better for All Physicians




Just because I think we should keep COMLEX doesn’t mean I think we should keep doing things the way we’ve always done them. Nope. Not at all. In fact, I think the only way to save COMLEX is to give it a major overhaul. Ultimately, I believe the entire medical education system – all the way from medical school admissions processes to board certification and licensure – needs a major overhaul. But in the context of our current topic and system, here’s what I propose:


1. Make all licensing exams pass/fail


Minimum competence is a pass/fail issue — no percentiles required. This eliminates the misuse of percentile scores and aligns the tests with their original purpose. Pass/fail scoring has already been implemented for some tests — including USMLE tests. I hope the trend will continue and pass/fail will become the standard for all licensure exams.




2. Develop specialty-specific aptitude tests for use in residency admissions


Residency programs need an objective way to determine who is the best fit. Because the characteristics and skills needed to succeed are different for each specialty, the best way to do this is to develop specialty-specific aptitude tests to measure how well people score when tested on the skill and knowledge most critical to their chosen specialty.




3. Restructure the COMLEX exam sequence


I propose NBOME should restructure the COMLEX sequence as follows:

  • Keep Level 1, Level 2 as is

  • Reform Level 2 PE (check out Part 2 of this series for details)

  • Eliminate Level 3 as it’s very similar to Level 2 and is no longer needed since almost all grads now complete at least three years of GME in the form of a full residency program

  • Develop specialty-specific aptitude tests to determine residency admissions

  • Require a separate OMM (osteopathic manipulative medicine) exam to complete medical school with a DO degree


4. Open the redesigned COMLEX series to DOs, MDs & foreign grads


I believe all tests in the new series — even the OMM exam — should be open to any medical student who wants to take it. By opening the sequence to DOs, MDs, and foreign grads, you create two valid pathways for licensure for all physicians. This increases the pool of qualified physicians and prevents a regulatory monopoly — and that’s good for everyone.




Like what you read? Have questions? Disagree? Either way, I want to hear from you. Continue the conversation by leaving a comment below or sending me a message.




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