The Comprehensive Osteopathic Medical Licensing Exam (COMLEX)

COMLEX is a series of four exams one must pass in order to be licensed as an osteopathic physician, or doctor of osteopathic medicine, which is abbreviated as DO. COMLEX is divided into three levels. Level two has two exams, and levels one and three each have one exam. Osteopathic medical students take the COMLEX level one and level two exams, and recent graduates of osteopathic medical schools take the COMLEX level three exam.

Osteopathic medicine differs from other fields of medicine in that it strongly emphasizes the patient-physician relationship. In osteopathic medicine, patients are seen as integral parts of their own healing process and health promotion. Doctors are required and encouraged to get to know their patients and relate to them on a more intimate, yet still professional level. Because the patient-physician relationship is so important to osteopathic medicine, medical students are tested on their interactions with simulated patients in the level two performance evaluation section of COMLEX. If a student does not pass a humanistic domain of the exam based on their interactions with patients, they must take the exam again in order to become a DO.

Many go on to become primary care physicians. Osteopathic medical schools emphasize working as primary care physicians because this is a field of medicine in which doctors have a greater opportunity to get to know their patients. Doctors who see patients on a regular basis throughout the course of their patients’ lives have a better perspective on how their patients’ lifestyles and habits can affect health than doctors who only see their patients for a shorter period of time. Although osteopaths do work in all medical specializations, the majority are still employed as primary care physicians.

Osteopaths account for less than one out of ten of the doctors practicing in the United States. However, they make up a greater than proportional percentage of doctors working in communities that lack adequate access to medical care. This is likely due to osteopathy’s emphasis on serving the greater public health.

Osteopathic medicine focuses strongly on preventing illness and injury and promoting good health rather than on treating disease. However, DOs possess the same skill sets as other medical doctors and are capable of performing necessary medical exams and tests to diagnose their patients. There are osteopathic surgeons and osteopathic physicians trained in nearly all facets of medicine.

Osteopaths also focus on eliminating factors that could contribute to poor health. This includes helping patients assess their lifestyles and make positive health choices. This also includes identifying issues faced by a community that could have a negative impact on health and finding ways to lessen or circumnavigate obstacles to good health.

Another tenet of osteopathic medicine is that the body’s structure is essential to its function. If there is a problem with part of the body’s structure, either internal or external, this problem will have a negative effect on the body’s function, which in turn negatively impacts a person’s health. Osteopathic physicians often implement hands-on treatment with the belief that this helps maintain the body’s proper structure.

While they do not shun traditional methods of treatment, osteopathic physicians also believe that the body is capable of healing itself. They focus on treatment techniques that aid and enhance the body’s natural ability to heal itself.

COMLEX is designed to incorporate these principles of medicine into its questions. The written exams in levels one, two, and three will test the application of osteopathic medical principles, and the performance evaluation section of level two will literally test how you implement the principles of osteopathic medicine in your interactions with patients.

Levels of COMLEX

COMLEX is divided into three levels of exams.You are eligible to take the level one exam after completing your first year of osteopathic medical school, you are eligible to take the level two exams after completing your second year of osteopathic medical school, and you are eligible to take your level three exam after you graduate from osteopathic medical school. Levels one and three are each composed of one exam, and level two is composed of two exams, the cognitive evaluation and the performance evaluation.

Levels of COMLEX: The level one exam, the level two cognitive evaluation exam, and the level three exam are each composed of two four-hour sections that make up one whole day of testing. The content of these three exams falls within two dimensions, clinical presentation and physician tasks. The majority of the level one exam falls under the physical tasks dimension and encompasses concepts relating to a general knowledge base of afflictions of the human body. Level one focuses on chemistry, biology, physiology, anatomy, and the principles of osteopathic medicine.

The content of the level two cognitive evaluation exam is similar to the content on the level one exam. However, the level two exam has a greater focus on using the information tested in level one to diagnose disease. In that sense, the level two cognitive evaluation exam is focused more heavily on problem solving than merely understanding information.

COMLEX level three takes critical thinking one step further. Examinees taking the level three exam will utilize their knowledge of osteopathic medicine to focus not only on patient diagnosis but also on hypothetical patients’ long-term health. Level three tests how well osteopathic doctors can relate a patient’s diagnosis to their overall past, present, and future health. Level three also delves into more specialized areas of medicine, such as gynecology, pediatrics, and psychiatry.

The level two performance evaluation exam has a much different format than the other segments of COMLEX. While the level one, level two cognitive evaluation, and level three exams are administered in many test centers located throughout the United States and on many dates, you must travel to the National Board of Osteopathic Medical Examiners’ facility in Pennsylvania to complete the level two performance evaluation.

During the level two performance evaluation, you will see twelve patients over the course of seven hours. You will have fourteen minutes to interact with each patient. While the other segments of COMLEX are scored on a numbered scale, you will receive either a pass or fail on the level two performance evaluation exam. Whether or not you pass this exam is based both on how well you evaluate the medical conditions and necessary treatment for each patient as well as on how well you interact with your patients.

The seven patients you see will purposely represent a diverse group. They will be of different ages, ethnicities, genders, and educational backgrounds. The patients will also have a diverse range of symptoms which you must diagnose. Some of these symptoms will represent chronic conditions, and others will represent acute conditions. In order to represent a realistic demographic of patients who seek osteopathic care, your twelve patients will represent those with cardiovascular disorders, gastrointestinal disorders, musculoskeletal disorders, respiratory disorders, and more.

Correctly diagnosing and designing treatment for these patients is necessary to do well on the level two performance evaluation, and so is your professionalism when you interact with them. Be sure to be polite with your patients but to also maintain your professional boundaries.

Administrative procedures for the performance evaluation section of COMLEX also differ slightly from the administrative procedures for the other segments. You can register for your performance evaluation exam up to a year in advance, whereas you can only register for the other exams up to six months in advance. You also have to wait a few weeks longer to receive your scores from the performance evaluation section.

Registration for COMLEX

COMLEX is a series of exams divided into three levels that someone must pass in order to become licensed as a doctor of osteopathic medicine. The second level is composed of two separate exams, a cognitive evaluation and a performance evaluation. COMLEX is administered by the National Board of Osteopathic Medical Examiners (NBOME). Many students take the first two levels of the exam while they are still enrolled in an osteopathic medical school. You cannot take the third level of the exam until after you have completed your degree in osteopathic medicine.

You can register for each level of COMLEX through the National Board of Osteopathic Medical Examiners website. For levels one and two, the dean of your osteopathic medical school will have to validate that you have completed the necessary amount of schooling and are currently in good academic standing. Once NBOME has received verification from the dean, you can create an online account and register for an exam date.

All three levels of COMLEX are offered frequently in over three hundred testing locations throughout the United States. However, in order to ensure that you are able to register for the exam date of your preference, register at least three months in advance. If you want to get an even earlier start, you can register up to six months in advance for the level one, level two cognitive evaluation, and level three exams. You can register up to a year in advance for the level two performance evaluation exam. The level two performance evaluation exam is only offered at one NCOME facility in Pennsylvania, so if you do not live in the area, you will need to travel to complete this section of COMLEX. Some osteopathic medical schools require that you pass COMLEX level two in order to graduate. If you need to receive your scores before graduation, it is recommended that you take the COMLEX level two performance evaluation segment of the exam before February of your graduation year (if you are scheduled to graduate in the spring).

If your test date for the level one, level two cognitive evaluation, or level three exam is more than a month away, you can cancel or reschedule your exam without penalty. However, if you reschedule your exam less than a month before you are scheduled to take the test, you will have to forfeit a portion of your exam fee. This portion increases if you reschedule your exam less than five days before you are supposed to take the test, and increases again within twenty-four hours of your test date. To reschedule the performance evaluation segment of COMLEX level two, you must do so at least three months prior to your test date in order to avoid a fee. This fee also increases within one month of your test date, and increases again two days before your scheduled exam. If you do not show up for your exam without rescheduling, you will forfeit your entire test fee.

You can only retake a segment of COMLEX if you fail that segment. There is no lifetime maximum for how many times you can take any section of COMLEX, but you can only take the level one, level two cognitive evaluation, and level three segments four times per year. You can take the level two performance evaluation segment three times per year. If you have failed any portion of COMLEX three or more times, you should demonstrate areas in which you have improved your skill set and knowledge base when you register to take the test again.

While there is some leeway in when you need to complete the various segments of COMLEX, you should complete all three levels of COMLEX within a seven year period. However, some osteopathic residency programs take COMLEX scores into consideration, so you may want to complete your levels two or three COMLEX before applying to residency programs.

Scoring COMLEX

You will receive a scaled score for COMLEX level one, the cognitive evaluation section of level two, and level three. Your score report will include a two-digit and a three-digit scaled score. Neither of these numbers reflect the amount of questions you answered correctly on the exam or a percentage of the questions you answered correctly on the exam. The three-digit scores are reported on a scale of 200 to 800. You must receive a score of at least 400 to pass levels one and two, and a score of at least 350 to pass level three. Your two digit scaled score on each level of the exam must be a 75 or higher in order to pass.

All three levels of COMLEX are scored on a curve. However, this does not mean that some examinees will automatically fail and that those who score the highest will receive a perfect score. Rather, the requirements for correct answers are based off of previous examinees’ performances. The lowest acceptable passing score is set to represent a general competency in the field of osteopathic medicine commensurate with your level of experience. For example, you will be expected to have a greater depth of knowledge to pass the level three exam than you will need to pass the level one exam.

Your score reports should be available within four to six weeks after you take the exams for level one, level two cognitive evaluation, and level three. Your scores will be mailed to you, but you can also access your scores through the account you created on the National Board of Osteopathic Medical Examiners’ website when you registered for your exam. These are the only ways you can access your test results they will not be available via email or telephone. Your score reports for levels one and two of COMLEX will also be sent to your osteopathic medical school, and your score report for level three of COMLEX will be sent to your residency program.

Your score report will include information on which content areas in the exam you did well and on which content areas you did poorly. That way, you will know where to concentrate if you did not pass the exam and need to study in order to take the exam again. You can receive one additional score report by mail free of charge if you request one within a month of receiving your scores; however, if you wish for more than one additional score report or a copy of your COMLEX transcript, you will need to pay an administrative fee.

If you wish to confirm your scores because you believe there may be an error in your score report, you can do so for a fee of $50 as long as you request the score confirmation within one month of when you received your score report.

The performance evaluation section of level two of COMLEX is scored differently. You will only receive a pass or fail for your score for the level two performance evaluation. Your score on the level two performance evaluation is based on two factors, the biomedical and humanistic facets of the exam. The biomedical facet encompasses your knowledge and ability to diagnose patients’ ailments, and the humanistic facet is based on your ability to interact with patients politely and professionally. If you fail the performance evaluation section of level two COMLEX, you will receive some feedback on what you can improve in order to pass this exam in the future. Score reports for the performance evaluation section also take a little longer to process than score reports for the other segments of COMLEX. You should expect to receive your performance evaluation score between eight and ten weeks after you complete the exam. You can also confirm your score on the level two performance evaluation section of COMLEX for a fee of $50.

Who Takes COMLEX

How to Succeed at the Level 2 Performance Evaluation of COMLEX: The level two performance evaluation of COMLEX differs from the other segments of COMLEX in that you will be evaluated on how you interact with patients rather than on how you perform on a written exam. Unlike the other segments of the COMLEX, the level two performance evaluation is only offered in one setting, and you can choose your test date up to a year in advance in order to begin making travel plans. Most osteopathic medical students take the COMLEX level two performance evaluation before they graduate from osteopathic medical school, and some schools require students to pass the COMLEX performance evaluation in order to graduate.

The COMLEX level two performance evaluation takes seven hours. You should arrive at the test site at least half an hour before your evaluation is set to begin in order to check-in properly. Make sure to bring a valid, government-issued piece of identification that includes your name, signature, and a recent photo. When you arrive, your identity will also be confirmed with a biometric screening, which validates your identity with your fingerprint. You will be photographed as well. You will also need to bring your own stethoscope. Do not bring any valuable personal items or electronics, as you will not have anywhere to store them at the NBOME facility during your examination. You should wear a white lab coat and dress underneath the lab coat should be business casual.

You will have a fifty minute orientation session before you see your patients for the COMLEX level two performance evaluation. Throughout the course of the day, you will see twelve patients for a total of fourteen minutes each. If you feel that you have adequately completed your assessment of the patient before fourteen minutes are up, you can leave your session early, but you cannot return to your patient after you have left the room. After each session with each patient, you will have nine minutes to write your SOAP notes, which will account for a portion of your evaluation. The nine minute time slot for writing notes is strictly enforced; you will receive a pre-recorded warning when you have only two minutes left, and another pre-recorded statement to stop writing once you have reached nine minutes. If you continue to write after you have been told to stop, your notes will be marked with a warning that could have a negative impact on your ability to pass the exam.

After you see your first four patients, there will be a half hour break for lunch, which will be provided on site. (However, if you wish to bring your own lunch, you can.) There will be another fifteen minute break after your next four patients after lunch.

Your score on the level two performance evaluation exam will be based on your patients’ assessments of the encounters, your SOAP notes, and a video recording of your interaction with your patients. Your score is divided into two domains, humanistic and biomedical. The humanistic domain is how you interact with your patients, and the biomedical domain is your assessment of your patients’ health, diagnosis, and recommendations for treatment. In order to pass the COMLEX level two performance evaluation, you need to pass both of these domains.

You will receive your scores within eight to ten weeks after completing the COMLEX level two performance evaluation. Your scores will be mailed to you and to your osteopathic medical school. Your scores will also be accessible online via the account you created on the NBOME website to register for your COMLEX exams.

Because the COMLEX level two performance evaluation is a different form of assessment than the other three COMLEX exams, do not be discouraged if you do not pass the performance evaluation even though you passed the other exams and have a good academic record. Many students find they have to adjust to applying their skills outside of academia.

How to Succeed at the Level 2 Performance Evaluation of COMLEX

During the performance evaluation section of level two of COMLEX, you will interact with twelve patients over the course of a seven hour day. Each patient is a trained actor familiar with all aspects of the COMLEX level two performance evaluation. However, even though the clinical experience is a simulation, you should interact with your patients as though you are a practicing osteopathic doctor and they are your real patients.

Outside of each examination room you will find a doorway information sheet, which is paper that lists information about your patient. This information includes the patient’s vital signs and the symptoms he or she is experiencing. You should ask each patient about his or her medical history, and choose probing questions that relate to the symptoms listed on the doorway information sheet. Also ask the patient to elaborate on the symptoms. You will then perform a brief physical exam on the patient. Perform the physical exam as you would with a real patient; be sure to execute all of the procedures correctly in order to demonstrate your competence. However, a few physical examination procedures are not to be used during the performance evaluation. These include procedures that invade privacy such as rectal exams, breast exams, internal pelvic exams, or other genital exams. Corneal reflex exams are also prohibited during the performance evaluation.

Because the patients you encounter are trained to simulate real patients, they may react to the procedures you execute. For example, a patient may express that something is painful and ask you to ease up, or a patient may ask questions about the procedure for a particular physical exam. Respond to your patients as professionally and courteously as possible, as your bedside manor is an important part of your performance evaluation. Remember to be specific in your recommendations. If you a offer vague or confusing diagnosis and treatment to your patients, they are trained not to respond. Your patients will not present situations that necessitate cardiac life support or invasive procedures, although you may encounter a diagnosis that requires emergency intervention.

Your patients are trained to represent a diverse group of people that mirrors the diversity of the demographic seeking osteopathic medical treatment in the real world. This means that you will see patients of various ages, genders, and ethnic backgrounds during your level two performance evaluation exam. Remember to obtain parental consent if one of your patients is under eighteen years of age. Your patients will also represent a diverse sampling of ailments commonly encountered by osteopathic doctors. These include cardiac, respiratory, gastrointestinal, musculoskeletal, and other ailments.

You will have fourteen minutes to interact with each patient, and nine minutes to create your SOAP notes afterwards. Your pass or fail score will be based on both biomedical and humanistic components. The biomedical components represent how well you diagnose and recommend treatment for your patients, and the humanistic components represent how well you interact with your patients. You must pass both the humanistic and biomedical segments in order to pass the COMLEX level two performance evaluation.

You will be recorded on video when you interact with your twelve patients, and this video will be reviewed by the National Board of Osteopathic Medical Examiners. Your patients are also trained to report on how well your interactions with them went. They, too, are evaluating you to determine whether or not you will pass the performance evaluation. The other component of your score is your SOAP notes. Make sure your prepare them well and coherently. Your SOAP notes are a way to measure your communication skills as well as a way to measure your ability to accurately listen to your patients, record data, make a diagnosis, and recommend treatment. Since you only have nine minutes to compile your SOAP notes, be sure you use your time wisely and plan ahead on how to maximize your efficiency during those nine minutes.

Your SOAP notes are an important factor in whether you pass or fail the COMLEX level two performance evaluation. You have nine minutes to complete your SOAP notes after each patient encounter. The nine minute limit is strictly enforced. You will receive a pre-recorded audio warning when you only have two minutes left, and will hear another recording instructing you to stop writing once you have reached nine minutes. If you continue to write after you have been told to stop, you may be penalized. A warning could be affixed to the SOAP note that you spent additional time writing, and this warning could cause you to receive a bad score for that particular SOAP note. Because the time limit is so strongly enforced, you should be prepared to use your nine minutes efficiently. Before the day of your exam, think about what you need to include in your SOAP notes and how you want to portray the information. You may wish to practice making notes about prospective patients in order to best understand how you can quickly go through this procedure.

Writing Quality SOAP Notes for the Level Two Performance Evaluation of COMLEX

SOAP is an acronym that stands for Subjective Objective Assessment Plan. Each of these words represents one of four sections in a SOAP note. The subjective section is where you record your patient’s medical history. The information you include in the subjective section will include the details of any information your patient gave you about his or her health and symptoms.

The objective section of a SOAP note is where you record all of the findings you discovered during your physical exam of the patient. Be as accurate and specific as possible. List quantitative data where appropriate. The objective section of a SOAP note is only intended to include information backed up by your clinical tests of each patient, so do not use this section to expound or infer anything on the data you collected during the patient’s physical examination. Instead, simply state the facts as coherently and concisely as you can. The following sections of a SOAP note allow you to express your own opinions and ideas.

The assessment portion of a SOAP note is where you diagnose your patient. You should list the most likely diagnosis for your patient’s condition as well as two other potential diagnoses. List the most likely diagnosis first. Some patients may seek your advice in terms of promoting health and preventing disease rather than seeking treatment. On a SOAP note for a patient merely seeking to lead a healthier life, you can include potential risk factors or other concerns in the assessment portion.

The plan portion of a SOAP note is where you write your recommendations for treatment. You can also include additional testing that you would recommend. If you wanted to perform a specific exam on your patient but ran out of time, you can mention that exam in the plan portion of the patient’s SOAP note. You do not need to record medications or dosages in the plan portion of a SOAP note, but any details of your patient’s exam that back up your treatment recommendations should be included.

You will receive a specific form on which to record your SOAP notes. The form is divided into the four sections that comprise a SOAP note: subjective, objective, assessment, and plan. You cannot write outside of the boxes provided for each section of the SOAP note. Each SOAP note form will be accompanied by directions that restate the SOAP acronym and explain how to fill in the form. Both prose and bulleted lists are acceptable means to convey information on a SOAP note; just be sure that the information you list will be clear to someone who is not familiar with your patient. You may use abbreviations from an approved list, but do not include other abbreviations as they may not make sense to the person evaluating your SOAP notes.