Clinical Decision-Making

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What is CDM?

The COMLEX-USA Level 3 Examination you will be taking includes a new section containing Clinical Decision-Making (CDM) cases. The NBOME's CDM cases assess the ability to make appropriate patient management decisions as an independently practicing osteopathic generalist physician. The cases are not meant to simply assess factual knowledge, but rather to assess the ability to apply knowledge and skills in caring for patients, which are especially important in the COMLEX-USA Level 3 examination because it is the pathway to licensure for osteopathic physicians for practicing in an unsupervised setting.

The test questions relate to data acquisition (e.g., obtaining history or physical exam findings, ordering tests), data interpretation (e.g., generating a diagnosis), and treatment (e.g., prescribing medication, counseling, or planning follow-up care). This part of the examination contains a series of clinical scenarios, each typically followed by two or three questions. The cases focus on key, critical decisions or challenges related to patient care that are routinely faced by osteopathic generalist physicians.

Online Practice Exam

The Clinical Decision-Making Practice Exam is primarily designed to assist the candidate in navigating through the examination, and it is provided to facilitate the actual testing experience. It is NOT designed to give the candidate a score or provide information about how a candidate might actually perform on the examination. When an answer choice is selected, it will not be recorded for scoring and the selection will not be saved once another item is viewed. If you wish to track your answer choices, you must record them on your own. A special function is provided that allows you to view the correct answer for each item by clicking on the "Answer Key" button located at the bottom of the page. The "Answer Key" button will NOT appear on the actual examination.

Click here to start the practice exam

Clinical Decision-Making (CDM) Cases - FAQs

  1. Why have CDM cases been added to the Level 3 exam?
    The NBOME's Blue Ribbon Panel on Enhancing COMLEX-USA, a prestigious group of academic subject matter experts, practicing physicians, and psychometric experts, recommended the development and implementation of novel test items that evaluate clinical decision-making performance beyond the scope of standard multiple-choice questions. CDM cases offer an opportunity to test critical steps that enable candidates to show their abilities over a wider range of clinical challenges.1,2 Research indicates that these item types have a greater capacity to discriminate candidate performance than more traditional multiple-choice questions.3,4

  2. What are the benefits of CDM cases?
    The CDM examination was first developed by the Medical Council of Canada in 1992 and has been adopted by countries across the world, including Australia and Germany. CDM cases assess the ability to make appropriate patient management decisions as an independently practicing osteopathic generalist physician. The cases are not meant to simply assess factual knowledge, but rather to assess the ability to apply knowledge at specific decision points in patient care, a special emphasis for the COMLEX-USA Level 3 examination.

  3. How are CDM cases constructed?
    The CDM cases focus on critical decisions and key challenges related to patient care that are routinely faced by osteopathic generalist physicians. A typical CDM case consists of a clinical scenario followed by two to four questions. CDM cases feature two new question types: short-answer and extended multiple-choice (one or more correct) questions. Test questions involve data acquisition (e.g., obtaining history or physical exam findings, ordering tests); data interpretation (e.g., generating a diagnosis); and, treatment (e.g., prescribing medication, counseling, or planning follow-up care). For more information on CDM cases, please follow the link above to the demo examination.

  4. What content is being assessed in the CDM cases?
    CDM cases follow the same content blueprints as COMLEX-USA, which can be accessed on the NBOME website.

  5. How many CDM cases are included in the Level 3 exam?
    The exam consists of 350 multiple-choice questions and 8 to 9 CDM cases. CDM cases typically contain from 2 to 4 questions, in both extended multiple-choice and short-answer formats. All CDM cases will be in one section.

  6. How should I respond to short-answer questions?
    Responses should be concise and limited to specific diagnoses, examination steps, diagnostic studies, or treatments. It is unnecessary to answer short-answer questions with full sentences. Do not include reasoning or justifications for your responses. The short-answer text boxes will only allow you to type up to 100 characters per box

  7. Can I use abbreviations in my answers?
    It is generally advisable to avoid or limit abbreviations due to the lack of standardization. Use of abbreviations when completing short-answer questions runs the risk of misinterpretation in scoring and should be used with caution. It is therefore recommended that you spell out names and terms rather than abbreviate.

  8. Will I be penalized for misspellings?
    The examination does not include a spell-check feature; however, misspellings in answers are acceptable when the meaning and interpretation are still clear. There is technically no penalty for misspelling answers unless the meaning is ambiguous or incorrect.

  9. Can I use protocols in my answers?
    Use of protocols as answers will NOT be accepted as correct because they are not universal. The necessary steps or components of protocols must be listed individually in separate boxes. For example, the answer “ACLS protocol” would not be accepted as correct when “synchronized cardioversion” is the next step.

  10. How should I write an order as an answer?
    Write the order just as you would on a hospital or urgent care order record, in specific terms that a technician, nurse, or other health care professional could understand and carry out. However, medication dosages are not required in answers.

  11. Can I answer a question with a laboratory test that is not included on the list of approved lab panels?
    Yes, you can answer with any specific test. The approved lab panels are the only panels that are acceptable as answers. If the panel you have in mind is not listed in the approved lab panels list, please enter the specific test(s) that you want to order. Separate tests should each be entered in a separate text box.

  12. Should I repeat an answer that I already provided on a previous question within a case?
    Each question will be scored separately. Your previous answers will not be taken into account in the scoring of each individual question. If you feel that the option is the appropriate answer to the question, select it again.

  13. How will I know which medical resources are available to me in each case?
    For each case, assume all necessary resources are available to you as a generalist physician in the setting described, and answer accordingly.

  14. Can a referral be an appropriate answer to a question?
    If the correct plan of action requires a specialty referral and/or consultation, you must specify the appropriate procedure or management steps.


  1. Farmer EA, Hinchy J. Assessing general practice clinical-decision making skills: The key features approach. Aust Fam Physician. 2005; 34: 1059-61.
  2. Page G, Bordage G. Allen T. Developing key-feature problems and examinations to assess clinical-decision-making skills. Ac Med: 1995; 70: 194-201.
  3. Page G, Bordage G. The Medical Council of Canada's Key Feature Project: A more valid written exam of clinical decision-making skills. Ac Med. 1995; 70: 104-110.
  4. Trudel JL, Bordage G, Downing SM. Reliability and validity of key feature cases for the self-assessment of colon and rectal surgeons. An Surg. 2008; 248: 252-8.