Taking both USMLE and COMLEX? What DO medical students must know

For many osteopathic medical students, the path to residency comes with an added layer of standardized testing.

A 2022 study published in the Journal of Graduate Medical Education found that 60% of DO students took at least one portion of the United States Medical Licensing Examination (USMLE) in addition to the Comprehensive Osteopathic Medical Licensing Examination (COMLEX-USA).

The rationale is straightforward. The COMLEX is necessary for graduation, while USMLE scores—AMA policy advocates for the exams to be viewed equally—are more commonly used as a metric in the residency selection process. 

Victoria Gordon, DO, says that is not necessarily fair to osteopathic medical students. As an osteopathic medical student, she took both exams. 

“It's another step,” Dr. Gordon said. “It's an extra thing to prepare for, but I knew I was always going to take both, just so I didn't limit my options for residency."

As medical students come up on high season in studying for both exams, Dr. Gordon—now a third-year emergency medicine resident in Houston—offered this advice. 

The subjects covered in both exams are very similar. The COMLEX contains extra material related to osteopathic manipulative medicine (OMM). For that reason, Dr. Gordon recommends taking the USMLE exam first and following it up in close order with the COMLEX exam. 

For both the first and second series of each exam (USMLE Steps 1 and 2, and COMLEX Levels 1 and 2, respectively), Dr. Gordon took them within a week of each other. She started with the USMLE each time. 

“Most people do it the way I did, which is that you spend your six weeks of dedicated study time preparing for the USMLE. Then you take it,” said Dr. Gordon, an AMA member. “I had something like three days in between when [I] focused on the OMM portion of COMLEX. You’ve really already covered all the material in studying for USMLE.” 

The AMA Succeeding in Medical School series offers tips and other guidance on a wide range of critical topics, including preparing for the USMLE and COMLEX exams, navigating clinical rotations, publishing scientific research, and maintaining optimal health and wellness.

Dive deeper:

• 7 timeless tips for USMLE Step 1 study time
• USMLE Step 1 FAQ: How, what to study to pass the exam
• When picking study resources, go with what works
• “Meet Your Match”: Residency application tips for DOs

Dr. Gordon found that question banks such as those offered by UWorld and other test-prep vendors can, along with practice tests, be the most helpful methods of exam preparation. She advised integrating daily practice into your schedule. This will allow for the creation of a strong foundation well ahead of your dedicated study period.

"Something I wish I had learned earlier in my medical education is to start earlier, even if it's just like 20 questions a day,” she said. “If you just did 20 random questions a day, four days a week for all the weeks leading up to your dedicated, you would be halfway through studying before you even started. And you'd be able to really hit harder on places that you're not quite as good at.”

Dr. Gordon said that with either exam, and the USMLE in particular, it is easy to overthink questions.  

“Always look what they're asking for,” she said. “Don't assume information if they haven't given it to you. Don't go searching for things that aren't there, which is hard because as you learn more, you know about the whole picture. And so when the test asks you what you do next for your patient, and you would do 15 things for your patient—all the same time—you really need to focus on: What’s the next best thing?”

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Dr. Gordon took Level 1 and Step 1 before both exams went pass-fail. In the current landscape, Step 2 and Level 2 remain scored, and those scores may be viewed by residency programs. In the case of both series of exams, students must authorize the release of their transcripts. 

For DO applicants, the COMLEX-USA transcript is required by many American Osteopathic Association (AOA)-accredited and Accreditation Council for Graduate Medical Education (ACGME)-accredited residency programs as part of their application. However, applicants must authorize the release of their COMLEX-USA transcript before it can be sent to designated programs. Residency programs that receive this transcript will see all COMLEX Level 1 and Level 2 CE attempts, including any failed attempts. Even if a failed Level 1 score is later passed on a retake, it will still be visible to program directors.

For USMLE exams, DO applicants are not required to submit scores unless a residency program specifically requires a USMLE transcript. While applicants can choose whether to include USMLE scores, many ACGME-accredited programs require this transcript, which is issued by the National Board of Medical Examiners (NBME) and includes all attempts at every exam level. If a program requests a USMLE transcript, a Step 1 passing score is crucial, and a strong Step 2 CK score can significantly impact competitiveness—especially in certain specialties.

For many residency programs, “the odds are they are going to care about your USMLE score more than COMLEX,” Dr. Gordon said. “But to me, I wanted to do as well or better on my COMLEX. I didn’t want it to look like a strong USMLE performance was some sort of accident.”

Dive deeper:

• USMLE high-yield topics—in the eye of the beholder?
• 4 keys to maintaining personal wellness during exam prep
• Why failing Step 1 shouldn’t end your dream of being a doctor
• COMLEX Level 1’s move to pass-fail: What it means for DO students

Taking the USMLE series is elective for a DO student. In certain primary care specialties, a USMLE score is not necessary. That also can be true if you are focusing your residency search to certain geographic regions. Ohio, for instance, is a state with a large number of DO schools and one in which the COMLEX series is more commonly accepted. Before you plan your standardized test path, it’s best to speak to a member of your office of student affairs to understand your options. 

In Dr. Gordon’s experience, taking both exams helps a student keep their options open. 

“I want to send my support out to all the DO students paying for and taking two exams,” Dr. Gordon said. “I've been there. I know it stinks in the short term, but in the grand scheme of things it was definitely worth it for me. You never know if you are going to change plans and might need a USMLE score. 

 “Take it while you're fresh. Take it while you're ready. It’s just a few more days of studying and it gives you a lot more flexibility on residency applications."