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The Road to COMLEX-USA

June 26, 2019

In 1989, the NBOME embarked on a journey to convert the NBOME Part I, Part II, Part II Examinations to the new Comprehensive Osteopathic Medical Licensing Examination for the United States – what we all know today as COMLEX-USA.   The journey continues.

The Catalyst.  Our intent was to move away from conventional content groupings and “basic sciences” that were common with national physician licensing exams of the time.  These exams typically organized test content around disciplines, but evidence from the learning sciences had emerged that regrouping content around patient presentations would likely be more relevant to clinical practice, and ultimately produce a more valid test for licensure.

As part of the development process, members of the NBOME Board studied osteopathic physician practice patterns with an eye to create alignment between what was tested, and what occurred in actual practice.  Research demonstrated differences in patient presentations to DOs as compared to those to MDs, further necessitating the need for a separate and valid licensure assessment. This new, unique testing paradigm looked at both the manner in which patients presented to DOs, as well as what physician tasks were employed to care for the patients, with enhanced focus on high-frequency, high-impact clinical presentations, important for patient safety and quality osteopathic medical practice.

This new and novel approach to examination design remains as valid today as it did when it was first implemented in 1995.

The Hallmarks.  While Level 1 focused on basic science concepts and osteopathic principles related to patient presentations and physician tasks, you’ll notice these foundational biomedical science and osteopathic concepts – the “basic sciences” – thread through all three levels to varying degrees.

COMLEX-USA was designed to directly align to the educational program leading to the DO degree, with developmentally appropriate content and physician tasks assessed at each Level.  It also adopted a stage-gate, developmental approach, requiring Level 1 be passed before eligibility was granted for Level 2, and Level 2 passed before Level 3 was attempted.

This garnered considerable attention in the osteopathic medical education and accreditation circles such that the AOA-Commission on Osteopathic College Accreditation expanded their graduation requirements for the DO degree to mandate passing COMLEX-USA Levels 1 and 2.

The Milestones.  COMLEX-USA Level 3, the first of the new series, launched in 1995 and was followed closely by the debut of Level 2 in 1997, and Level 1 in 1998.

In the decade that followed, a national, standardized patient-based, clinical skills examination for COMLEX-USA Level 2-PE was added in 2004.  And the transition to computer-based testing and one-day administration at professional test centers began in 2005.

Computer-based testing enabled us to expand from two administrations per year, per exam level to eventually more than 60 administrations per year now for Level 1, for example. It also enabled enhancements to score reporting, test security and integrity, as well as novel test items featuring multimedia to enhance authenticity, which were introduced in 2006.

While test blueprints are modified regularly to reflect the evolving practice of osteopathic medicine, the most major enhancement of the COMLEX-USA Master Blueprint came in 2018-2019, spearheaded by the Blue Ribbon Panel on Enhancing COMLEX-USA 2010-2016. This expanded the Level 3 to two days, with increased number of clinical decision-making, key features scenarios that focus on patient safety.  Attestation by residency program directors that Level 3 candidates were in good academic and professional standing was added in 2018. It also introduced the new competency-based blueprint, converting physician tasks to competency domains with required elements and measured outcomes, while expanding the detail provided about the clinical presentations likely to be assessed.

The COMLEX-USA examination program continues to evolve to align with the practice of osteopathic medicine as we work to lead the way in valid, reliable, defensible and fair assessment for osteopathic physician licensure, helping to keep our patients safe.  The COMLEX-USA journey continues.


Contributed by John R. Gimpel, DO, MEd | President & CEO  |  NBOME