Enhancing COMLEX-USA

FAQ for Students & Residents

Why is the COMLEX-USA Level 3 examination changing to a two-day format?

The Level 3 exam is changing to a two-day format as part of the overall enhancement of the COMLEX-USA examination series, aligning with the new Master Blueprint that will be implemented in September 2018. This is in response to substantive changes in the evolution of osteopathic medical practice and to ensure COMLEX-USA remains current in meeting the needs of state licensing boards. To learn more about the enhanced COMLEX-USA, you can review the COMLEX-USA Master Blueprint.


What is the new attestation requirement for the Level 3 examination?
Your residency program director will need to attest to the fact that you are in good academic and professional standing and are approved to take the Level 3 examination. It is recommended but not required, that you take the examination after a minimum of six months in residency. Please see the COMLEX-USA Bulletin of Information for a comprehensive list of Level 3 eligibility requirements.
Why do I need to have attestation now?
Attestation is an important step to ensure residency program directors agree a candidate is ready to take the final examination in the COMLEX-USA series and prepare for licensure.
Can my program director attest prior to my school releasing my graduation status?
No, the school must release graduation status prior to attestation.
I graduated from my college of osteopathic medicine last year, but haven’t taken the Level 3 examination yet, is an attestation required?
Yes, all registrations effective after March 15, 2018 for Level 3 will be required to have an attestation. We have provided advance notice of the new attestation requirement during 2017 including in the COMLEX-USA Bulletin of Information and will continue to provide this notice.
I graduated from my college of osteopathic medicine, but am not in a residency program, how do I obtain attestation?
A residency program director must provide an attestation that you are a resident in good standing in their program.
I have graduated from a residency program, how can I obtain attestation?
If you have graduated from a residency program, your program director can provide an attestation after you have graduated from the residency program. If you are within six months of completing your residency program, your program director can provide your attestation. Once you receive an attestation, you will have a total of six attempts to complete Level 3 with a maximum of four attempts in any 12 month period unless your program director rescinds the attestation (no other time limit).
If I cannot find my residency program on the list, what can I do?
Contact the NBOME Client Services via email clientservices@nbome.org or call 866-479-6828 for assistance.
When will I know I have been approved?
You will be notified immediately by email from the NBOME when your program director completes the attestation.
I sent my attestation request a week ago, but I have not heard back, what can I do?
If your program director has not provided an attestation ten days after you submit a request, we will send you a reminder indicating you should follow-up with your residency program director to confirm that he/she received the email in response to your request. If your program director did not receive the email, the reminder sent to you contains instructions to confirm the email address in the NBOME system.
Will my program director receive a reminder six months after I start my residency if they have not attested?
It is your responsibility to request attestation. Once you have submitted a request, the NBOME sends reminder emails to the program director until the attestation is completed.
Can I purchase the exam before I have received an attestation to take the Level 3 examination?
No, in order to avoid potential problems with exam cancellations and reschedules, attestation is required in order to register for, purchase and schedule the Level 3 examination.

Attestation Guidelines

Do I need to wait for the full six months to be approved to take Level 3?
We recommend program directors wait six months to attest and approve candidates to take the Level 3 examination, but this is not a requirement. The final determination is made by the program director.
I am taking a leave of absence from my residency program, am I eligible to take Level 3?
You are eligible to take Level 3 if you have an attestation from your program director which has not been rescinded. If you are enrolled in a residency program or within six months of leaving or graduating from your residency program, your program director can provide an attestation.
I am currently transitioning from one residency program to another, how does this affect the attestation process?
If your previous program director provided an attestation for you and it has not been rescinded, you are eligible to take the Level 3 examination up to a total of six attempts with a maximum of four attempts in any 12 month period (no other time limits apply). You may obtain this attestation from a program director during the residency program or up to six months after leaving or graduating from the previous residency.
If my residency program rescinds approval after I took the examination, what is my status with the examination?
If you completed the examination prior to your program director rescinding your attestation, and the Level 3 score was not yet reported, the NBOME would not report a score. If a score had been reported, a special review would occur and a score annotation and other actions may be required. If you were notified by your RPD that your attestation was being rescinded prior to the administration of the examination, you should not take the examination as your score could be voided.
Must the attestation come from only the current residency program director? Is there a grace period?
Yes, the attestation should come from your current program director but the attestation is valid after the resident leaves or graduates from the residency program for up to a total of six attempts to complete Level 3 with a maximum of four attempts in any 12 month period (no other time limit) as long as the program director has not rescinded the attestation. If the resident has left or graduated from a residency program there is a six month period after graduation (extension of eligibility period) to obtain an attestation from their previous RPD.
Is there a transition period when the program director is leaving a program?
Yes, if a program director has provided an attestation for a candidate and has not rescinded the attestation, the candidate would remain eligible for up to a total of six attempts to complete Level 3 with a maximum of four attempts in any 12 month period (no other time limit).
If an intern completes a transitional rotating internship and doesn’t have a PGY2 position, can the director from the transitional rotating internship provide an attestation? If so, must it be completed before the program ends? If not, within how many days after must the attestation be completed?
The director of the transitional rotating internship program can provide an attestation for the intern. Once this attestation is provided to the intern to take the Level 3 examination it does not expire. The intern would have up to a total of six attempts to complete Level 3 with a maximum of four attempts in any 12 month period (no other time limit) as long as the attestation is not rescinded. If the intern has graduated from the program the intern will have a six month period after graduation (extension of eligibility period) to obtain an attestation from their program director.
If I failed the one day Level 3 examination, do I need attestation to retake the two day exam?
Yes, if you take the exam after Sept 1, 2018 an attestation will be required.

Registration & Scheduling

When will administration of the two-day COMLEX-USA Level 3 examination begin?
The new two-day exam format begins in September 2018. Candidates may register for the two-day Level 3 exam beginning on March 16, 2018.
What is the last day I can register for the one-day COMLEX-USA Level 3 examination?
The last day to register for the one-day Level 3 exam is March 15, 2018.
Can I register for the one-day Level 3 examination after March 15, 2018?
Please contact Client Services (clientservices@nbome.org or 866-479-6828) with questions.
What is the last day I can take the one-day COMLEX-USA Level 3 examination?
The last day to take the one-day Level 3 exam is April 28, 2018. Administration of the two-day Level 3 exam will begin on September 10, 2018.
Are there any restrictions for scheduling the two-day Level 3 examination?
Yes, you are required to successfully complete each of the two days in a 14-day window. Day 1 must be completed before Day 2.
Why is the Level 3 exam not being administered between April and September 2018?
This timing coincides with the conclusion of the Level 3 exam as a one-day examination format, ending in April 2018. From May through August, the NBOME will be preparing for the administration of the new two-day examination format.
What is the cost of the new two-day COMLEX-USA Level 3 examination?
The cost of the new two-day Level 3 exam is $875. This is the same cost as the current one-day Level 3 exam.

Clinical Decision-Making

What is a Clinical Decision-Making (CDM) case?
CDM cases focus on critical decisions and key challenges related to patient care that osteopathic generalist physicians routinely face. A typical CDM case consists of a clinical scenario followed by two to four questions. CDM cases feature two question types: short answer and extended multiple choice (one or more correct). 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 see the practice examination.
Why does the COMLEX-USA Level 3 examination include CDM cases?
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 item types 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 candidates' performance over more traditional multiple-choice questions.3, 4 References
  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. Acad 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. Acad 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. Ann Surg. 2008; 248: 252-8.
What are the benefits of CDM cases?
The Medical Council of Canada first developed the CDM exam in 1992, and countries across the world, including Australia and Germany, have adopted it. 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 Level 3 exam.
What content is being assessed in the CDM cases?
CDM cases follow the same content blueprint as COMLEX-USA, which can be accessed on the NBOME website.
How many CDM cases are included in the two-day COMLEX-USA Level 3 examination?
The morning session of the second day of the exam will comprise CDM cases, with a quarter of the total exam time spent on CDM.
How should I respond to short-answer questions?
Short-answer responses should be concise and limited to a specific diagnosis, examination step, diagnostic study, or treatment. 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 allow up to 100 characters per box. Each text box should contain only one response. If a candidate enters what is deemed to be two responses in a single text box, the candidate’s responses in that box will be counted as two responses and be applied toward the question’s response limit as such.
Can I use abbreviations in my answers?
It is generally advisable to avoid or limit abbreviations due to lack of standardization. Use of abbreviations when completing short-answer questions runs the risk of misinterpretation in scoring and should be done with caution. It is therefore recommended that you spell out names and terms rather than abbreviate.
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.
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.
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.
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.
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. For example, if you think that an answer is correct for question 3 of the case even though you already responded with the same answer to question 1, you should respond with that answer for question 3 to receive the point for question 3.
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 an osteopathic generalist physician in the setting described, and answer accordingly.
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. However, if the next step in management is one that an osteopathic generalist physician could perform, you may respond with simply the management step.