The 4 tenets of osteopathic medicine underlie the osteopathic philosophy of health and medical care. The body, mind, and spirit approach; the connectedness of the body’s structure and function; and consideration of other factors, such as social determinants of health and partnership with patients in overall wellness all contribute to this approach. DOs are trained to integrate these osteopathic principles and osteopathic manipulative treatment (OMT) into patient care.

If you look at an assessment as a milestone for what has been learned and a framework for what is required, then the assessment tools used should align both with the curricular program (what is taught and learned) and what is practiced (what patients expect). If that assessment is further used as part of a profession’s responsibility for self-regulation (i.e. licensure exam), then it is all the more important.

Examinations are developed by a profession, or entity (think driver’s tests or teacher certification) to assess whether a candidate has the knowledge, skills, and attitudes to perform in that profession. The COMLEX-USA licensure examination series is designed to assess the competencies required for the practice of osteopathic medicine. It reflects how DOs approach a patient, and the foundational abilities needed to provide osteopathic medical care, which remain distinctive for DOs.

COMLEX-USA is the only licensing examination that is aligned with the practice of osteopathic medicine, and it is gaining recognition across the globe. It is the only licensing exam accepted in all 50 states and other US licensing jurisdictions for osteopathic physicians. In 2020, the Medical Board of Australia recognized the NBOME/COMLEX-USA as a competent authority pathway for registration (licensure) for comprehensive medical practice in Australia!

Specifically, then, how is COMLEX-USA osteopathically distinctive?

1. Examination series: The COMLEX-USA series is aligned to be taken at certain developmental times in the osteopathic medical student and residents’ progression toward licensure. Content is designed to be developmentally appropriate and aligned with the osteopathic medical educational programs. COMLEX-USA is endorsed by the AOA’s Commission on Osteopathic College Accreditation (COCA) with graduation standards that include COMLEX-USA examinations. COCA is the recognized accreditation authority by the US Department of Education for osteopathic medical schools.

2. Blueprint design: The COMLEX-USA examination blueprint includes two integrated dimensions: osteopathic competency domains and clinical presentations. The competency domains define the unique knowledge, skills, experience, attitudes, values, behaviors, and established professional standards of osteopathic medicine. The clinical presentations represent the manner in which a particular patient, group of patients, or a community presents for osteopathic medical care. These are both informed by an evidence-based design for the practice of osteopathic medicine, including the review of national databases of what DOs do and see in practice. ^1-2

3. Inclusion of the Competency Domain “Osteopathic Principles, Practice and Manipulative Treatment”: COMLEX-USA includes this as a competency domain, and it is important to osteopathic medical education and practice. However, osteopathic principles are also integrated with the other competencies in the assessment. For example, questions classified or “coded” to this competency domain may also be assessing another competency domain or skill. This aligns with practice—osteopathic physicians bring all of their competencies to the care of a patient, at the same time.

4. Examination construction: Once the blueprint has been designed and the items written, the test is assembled according to specifications for each level (as in, how many of each kind of question goes into an examination, among other considerations). This provides an assessment form that is fair, valid, and aligned with the practice of osteopathic medicine. Because the specifications are so aligned, changing a few items will necessarily change the whole examination. The test specifications are based on DO practice data including that from the National Ambulatory Health Care Surveys, which is actually distinctive from practice data for other physicians. ³

5. Test question and case construction: Down to the item level, the NBOME uses an osteopathically distinctive approach to developing multiple-choice questions and clinical cases. Interdisciplinary groups of DOs and other professional colleagues collaborate to develop patient scenarios and associated questions based on high-frequency, high-impact clinical presentations. This results in items that address whole patient care—not just assessment of basic recall of scientific facts. COMLEX-USA test items and cases are built to assess the application of knowledge and other competencies—not just knowledge itself. The unique clinical decision-making (CDM) cases in the Level 3 examination are designed to assess a candidate’s ability to think beyond multiple-choice questions. CDM forces candidates to think holistically about the patient’s scenario—whether that means determining the diagnosis based on the available findings or selecting management steps for a patient in an extended multiple-choice question. CDM items are particularly relevant to patient safety and differentiation at the minimal competency threshold.

   To help ensure alignment across national standards taught at all of the colleges of osteopathic medicine, the NBOME collaborates with Educational Council on Osteopathic Principles (ECOP) to establish testable concepts and standardized nomenclature related to osteopathic manipulative medicine (OMM). In the Level 2-PE, before that exam was suspended in the pandemic, candidates had the opportunity to perform hands-on diagnostic physical exam maneuvers, and perform OMT as appropriate to the diagnosis and within certain parameters.

On the residency program/GME front, we work at the grassroots-level to help provide information to elective clinical rotation sites and program directors about COMLEX-USA, helping to contribute to the steady increase in DOs being accepted with their own distinctive credentials into ACGME-accredited residency programs.

• We have worked with the American Association of Medical Colleges (AAMC) to provide data for the Report on Residents, which for the first time in 2020 included COMLEX-USA scores.

• Our partnership with the Electronic Residency Application Service (ERAS^®) assists residency program directors by demonstrating parity in the application dashboard for DO and MD applicants, including a COMLEX-USA percentile score converter and similar transcript presentations and notations to those available for licensing exams for MD applicants.

• We serve on the National Resident Matching Program^®’s (NRMP^®) Research Advisory Committee to ensure that the osteopathic voice is represented and that inclusive nomenclature is used for DO stakeholders in NRMP® publications, presentations, and other Match^® initiatives.

Even those less familiar with DOs and COMLEX-USA prior to the Single GME Accreditation System (2015-2020) have learned that DOs take COMLEX-USA. The NBOME has historically advocated for DO students and their credentials, including the DO degree, COMLEX-USA, and AOA board certification both nationally and internationally.

Other examples of osteopathically distinctive assessments deemed to be valid for their purposes include COMAT examinations used by almost every DO medical school campus in the US, AOA board certification assessments in 16 specialties, and numerous residency in-training/in-service assessments designed by osteopathic specialty societies and used by hundreds of residency programs in specialties such as family medicine (ACOFP), internal medicine (ACOI) and surgery (ACOS).

Assessments should be aligned with the educational programs, outcomes, and practice of the profession. A profession must self-regulate and set standards to continue to earn public trust. COMLEX-USA is targeted to the distinct practice of osteopathic medicine to protect that trust. This, along with rigorous standards and continuous quality improvement, has helped COMLEX-USA to be the gold standard licensure examination for osteopathic physicians since the NBOME was founded in 1934. Having a robust, distinctive portfolio of assessments will help DOs to be well positioned to continue to grow and thrive across the United States and the world.

1. Gimpel JR, Horber D, Sandella JM, Knebl JA, Thornburg JE. Evidence-based redesign of the COMLEX-USA series. Journal of the American Osteopathic Association. 2017;117(4): 253-261.
2. Horber D, Gimpel JR. Enhancing COMLEX-USA: Evidence-based redesign of the osteopathic medical licensure examination program. Journal of Medical Regulation. 2018;104(3):11-18.
3. Boulet JR, Gimpel JR, Errichetti AM, Meoli FG. Using National Medical Care Survey data to validate examination content on a performance-based clinical skills assessment for osteopathic physicians. JAOA: 2003; 103(5):225-31.