Myths and Misconceptions: The Value of the COMLEX-USA Credential

The NBOME’s vision is to be the global leader in assessment of osteopathic medicine and related health care professions. DOs and DO students are generally able to provide the COMLEX-USA licensure series as a credential that is recognized across the continuum by stakeholders to help them to realize their professional goals.

While its primary and intended purpose is for use in applying for medical licensure for DOs, COMLEX-USA is widely regarded as the valid and reliable assessment for other secondary uses for osteopathic students and physicians. So it’s disappointing when we occasionally hear students or others say or write, “COMLEX isn’t as good of an exam as USMLE,” or “We should only take the USMLE.”

The more than 100,000 professionals who choose to study and practice osteopathic medicine are unique; they are more likely to choose career paths in primary care (roughly 56 percent of DO graduates practice in specialties that comprise primary care) and historically tend to practice in areas of greatest need. Not only that, global recognition of osteopathic medicine continues to grow.

DO students learn to integrate the unique osteopathic principles and practice of medicine. DOs assess each patient through their osteopathic lens, which is developed through mentoring, assessment, practice, and an integrated curricular program leading to the DO degree.

Unique individuals learning a traditionally unique way to provide care for patients should have a unique way to measure those skills.

Nursing students are shaped and assessed by the nursing examinations, law students take the bar exams, and optometry students sit for national board exams in their unique field. So too are MD students, in part, credentialed by the USMLE exam, and DO students by COMLEX-USA.

And this is why numerous authorities across the medical profession recognize the substantial body of evidence for the validity, reliability and quality of COMLEX-USA. For example:

The Federation of State Medical Board’s House of Delegates’ official policy is that the evidence for the validity of COMLEX-USA is exemplary, and every state licensure board uses (and a number require) COMLEX-USA for medical licensure of DOs.  The editor-In-chief of the FSMB’s Journal of Medical Regulation, complements the NBOME in her forward (October 1, 2018): “COMLEX-USA…provides a good example of how medical examiners can update their assessment systems to stay ahead of the curve of change [and] help medical regulators make sound, balanced decisions as they continue their work in protecting the public and ensuring quality in medical practice, keeping our patients safe.”

In November 2018, the American Medical Association’s House of Delegates adopted a new policy to promote equal acceptance of the USMLE and COMLEX at all US residency programs. The AMA also called for education of residency directors to better understand and use COMLEX scores.

The Graduate Medical Education community also endorses COMLEX-USA, as the ACGME accepts COMLEX-USA and USMLE equivalently. In August, the Undergraduate Medical Education to Graduate Medical Education Review Committee (UGRC) of the Coalition for Physician Accountability released a series of recommendations for improving the transition to residency, and calling for the mitigation of bias in all forms—specifically against DO students and their COMLEX-USA credential, which the committee called a “comparable examination with a different scale.”

Kenneth B. Simons, MD, senior associate dean for GME and accreditation at the Medical College of Wisconsin, is another passionate advocate for DO students and for COMLEX-USA. Dr. Simons serves as chair of the Federation of State Medical Boards and is a former leader of the National Resident Matching Program and the ACGME.

“The AMA says [COMLEX] is equivalent, the ACGME says it’s equivalent, the FSMB says it’s equivalent,” he says in this video from 2019.

“I would tell program directors who are uncomfortable with DO students or with COMLEX that they need to get comfortable with both. These young men and women are under tremendous debt and they don’t need additional debt placed on them because a program director doesn’t know how to interpret COMLEX.”

Internationally, the COMLEX-USA series is also highly regarded. Most recently, in September 2020 the Medical Board of Australia established a new competent authority pathway for licensure in that country, which includes COMLEX-USA for US-trained DOs. This decision was based on a recommendation from the Australian Medical Council, its accreditation authority, who performed a comprehensive, two-year review of the COMLEX-USA program and found the exam series to be a valid and reliable assessment for licensure/registration to practice medicine in Australia.

While most international jurisdictions require their own country’s national standardized assessments for physician licensure, COMLEX-USA was the first such physician licensure assessment program in over 15 years to receive this designation in Australia, another seal of approval for U.S. DOs and COMLEX-USA.

Leaders across the house of medicine endorse COMLEX-USA as a valid, rigorous, and trustworthy method of assessing competencies for osteopathic medical practice. What’s more, our profession and its distinctiveness continue to gain popularity; the number of practicing DOs has grown by more than 80 percent over the past decade, and roughly 25 percent of current medical students in the US are enrolled at a college of osteopathic medicine.

Patients like the osteopathic approach to care; a 2019 study found that osteopathic physicians were perceived significantly more favorably by their patients on the measures of interpersonal manner and empathy. An aligned assessment program, linked to this unique education pathway and practice, contributes to high-quality osteopathic medical care for patients and communities.

Robert Frost’s famous poem, “The Road Not Taken,” celebrates seeing things from a different perspective. Today, highlighting the value of different paths traveled and different viewpoints is more important and perhaps more relevant than ever.

While some both inside and external to the profession may struggle to reconcile the uniqueness, spirit, and competencies of osteopathic medicine with their need to assimilate in a number of ways, the fact is that DOs, MDs and IMGs each have their own rigorous and valid pathways to becoming a physician in the U.S.

In diversity there is strength—and a diversity of pathways interacting together helps to broaden the educational milieu in the GME learning environment–and ultimately strengthen health care in the U.S.

For our part, the NBOME, along with the AOA and AACOM, continues to work to educate program directors and other stakeholders to increase their understanding of COMLEX-USA, what is measures, how to interpret its scores. We will continue to advocate for the inclusion of the COMLEX-USA credential when assessment for DOs is considered. We also support the U.S. Department of Education-recognition of COCA accreditation of US DO-granting medical schools, and almost universal acceptance of AOA board certification in 27 different medical and surgical specialties.

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