Understanding COMLEX-USA
About
COMLEX-USA
The Comprehensive Osteopathic Medical Licensing Examination of the United States of America (COMLEX-USA) is an evidence-based assessment series designed specifically for osteopathic medical students and residents. It measures competencies required to provide safe and effective osteopathic medical care to the public.
This guide is intended to help graduate medical education (GME) leaders, program directors, faculty, and staff understand what COMLEX-USA measures, how standards are set, what candidate performance means, and how COMLEX-USA results can be considered as part of a holistic residency application process.
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Pathway to Licensure
COMLEX-USA is used by all medical licensing authorities to make licensing decisions for osteopathic physicians. It is accepted in all 50 United States and recognized by the International Association of Medical Regulatory Authorities (IAMRA), as well as by other international jurisdictions1,2.
The COMLEX-USA program assesses osteopathic medical knowledge, fundamental clinical skills, and other foundational competencies considered essential for the practice of osteopathic medicine.
All osteopathic medical students must pass COMLEX-USA Level 1 and Level 2-CE to graduate with a DO degree3.
DO candidates are not required to take or pass the United States Medical Licensing Examination (USMLE®) to be eligible to apply to ACGME-accredited residency or fellowship programs. The American Medical Association (AMA), the Accreditation Council for Graduate Medical Education (ACGME), and the Federation of State Medical Boards (FSMB) all recognize equivalent uses for COMLEX-USA and USMLE.
Competency & Evidence-based Design
COMLEX-USA is based on a contemporary, two decision-point, competency-based blueprint and evidence-based design informed by extensive research on osteopathic physician practice, expert consensus, and stakeholder input4. The enhanced COMLEX-USA Blueprint assesses measurable outcomes across the Fundamental Osteopathic Medical Competency Domains and focuses on high-frequency, high-impact clinical presentations5,6.
Recognized Validity Evidence
COMLEX-USA is developed through a rigorous scientific process to support the quality, validity, and reliability of the examination series. The FSMB conducted a comprehensive review of COMLEX-USA and USMLE and found both were valid and reliable for their intended purposes, concluding that support for the validity of COMLEX-USA is exemplary.
As part of its research program, the NBOME conducts studies designed to help residency program directors understand validity evidence for using COMLEX-USA results as one component of holistic residency application decisions.
A 2025 study in partnership with the American Board of Surgery (ABS) found strong correlations between performance on COMLEX-USA and performance on the ABS in-training (ABSITE) and board certification examinations.
A 2020 study published by the NBOME and FSMB found a relationship between successful completion of COMLEX-USA and a lower likelihood of state licensing disciplinary action. Multiple studies have reported strong associations between COMLEX-USA and USMLE scores7,8.
Resident Recruitment & Holistic Review
The NBOME advocates for holistic residency screening processes that consider examination performance as just one factor of many in determining whether an applicant is prepared for residency training. When examination scores are used, COMLEX-USA should be the standard for DO applicants.
Holistic review considers the whole applicant and avoids disproportionate focus on a single factor. This approach can support broader consideration of applicant experiences, attributes, and readiness to meet the needs of patients and communities.
The NBOME also supports efforts to reduce the perceived need for DO students to take redundant examinations and supports application systems that more readily allow programs to compare licensing examination information equitably.
Equality for COMLEX-USA in ACGME Programs
The ACGME has aligned accreditation standards for residency programs across the US, allowing all graduates of DO- and MD-granting medical schools to complete residency and fellowship training regardless of which licensing examination pathway they pursued.
The NBOME works with undergraduate and graduate medical programs and other osteopathic organizations to support fair consideration of DO applicants. Many academic institutions, programs, and professional organizations have adopted or updated policies that demonstrate mutual recognition of the unique qualifications and philosophies of both DO and MD graduates.
Multiple specialties have consensus statements recognizing DO applicants and their COMLEX-USA credentials as part of a holistic residency application process.
DO applicants should not be required to undergo licensing examinations other than the COMLEX-USA and consider DO applicants within context of COMLEX-USA.
CAFM
October 2022
Residency programs should not require osteopathic trainees to undergo other licensing examinations in addition to COMLEX-USA.
AACPD
May 2023
Programs [should] accept COMLEX-USA when considering DO applicants to their training programs.
AADPRT
May 2023
Recommends programs accept COMLEX-USA when considering DO applicants.
AAPM&R, AAP, AOCPMR
May 2023
Residency programs should accept COMLEX-USA and not require or pressure applicants with DO degrees to take additional licensing exams
ACOG
September 2023
Osteopathic applicants to residency programs should not be required – nor made to feel like they are required – to undergo licensing examinations other than the osteopathic (COMLEX-USA) licensure exam.
APPD, CMSEP, AMSPDC, FuturePedsRes, NextGenPediatricians
September 2023
Encourages all programs to accept COMLEX-USA results as equivalent to ensure equitable consideration for osteopathic applicants.
CORD
October 2023
Encourages all programs and subspecialty fellowship programs, in their holistic review of applicants, to accept that the COMLEX-USA results are equivalent.
AAIM
March 2024
The 2026 National Resident Matching Program® (NRMP®) Main Residency Match resulted in a 98.5 percent match rate for DO seniors, reflecting the continued success of osteopathic medical graduates in securing residency positions.
For more information on specialties supporting osteopathic applicants and accepting COMLEX-USA as equivalent to the USMLE:
Interpreting COMLEX-USA Scores
The NBOME Percentile Score Converter is available here as well as through the ERAS® Program Director Workstation. Percentile information is also available on the Thalamus Cortex dashboard. This tool converts an applicant’s three-digit COMLEX-USA score to a percentile rank to help programs understand relative performance within a testing cycle and interpret scores appropriately when reviewing applications.
For candidates who took COMLEX-USA Level 1 before the transition to pass/fail score reporting, the Percentile Score Converter provides a percentile rank for the three-digit Level 1 scores.
Eligibility Pathways
COMLEX-USA Level 1
Eligibility for Level 1 is generally based on completion of the first year of study at an accredited college of osteopathic medicine and good academic and professional standing attestation by the osteopathic medical school dean.
COMLEX-USA Level 2-CE
Eligibility for Level 2-CE generally requires passing Level 1, completion of the second year of study at an accredited college of osteopathic medicine, and good academic and professional standing attestation by the osteopathic medical school dean.
COMLEX-USA Level 3
A candidate must meet all requirements for Level 3, including passing Levels 1 and 2-CE, graduating from an accredited osteopathic medical school, and receiving a good academic and professional standing attestation from the residency program director.
New Clinical Skills Pathways Beginning with the Class of 2029
Beginning with the Class of 2029, osteopathic medical students will demonstrate clinical skills competency through either the Core Competency Capstone for DOs (C3DO) or Comprehensive Competency Verification (CCV). Both pathways satisfy the clinical skills requirement for COMLEX-USA Level 3 eligibility and are designed to ensure assessment of core osteopathic clinical skills through direct observation of patient encounters.
Learn more about C3DO and CCV
The NBOME recommends that COMLEX-USA Level 3 be taken after a minimum of six months in residency.
For more on COMLEX-USA eligibility, view the Bulletin of Information.
References
- Federation of State Medical Boards of the United States. U.S. Medical Regulatory Trends and Actions.
- International Association of Medical Regulatory Authorities: Resolution 23-1
- American Osteopathic Association. Commission on Osteopathic College Accreditation, Accreditation of Colleges of Osteopathic Medicine: COM Continuing Accreditation Standards.
- Horber D, Gimpel JR. Enhancing COMLEX-USA: Evidence-based redesign of the osteopathic medical licensure examination program. Journal of Medical Regulation. October 2018, 104(3):11-18.
- National Board of Osteopathic Medical Examiners. COMLEX-USA Blueprint effective beginning September 2018.
- National Board of Osteopathic Medical Examiners. Fundamental Osteopathic Medical Competency Domains 2016: Guidelines for Assessment for Osteopathic Medical Licensure and the Practice of Osteopathic Medicine, Chicago, IL, 2016.
- Barnum S, Craig B, Wang X, Sandella JM, Tsai TH, Boulet JR, Wang Y. A Concordance Study: COMLEX-USA and USMLE Scores. Journal of Graduate Medical Education. February 2022, 13(1): 53-59.
- Sandella JM, Gimpel JR, Smith LL, Boulet JR. The use of COMLEX-USA and USMLE for residency applicant selection. Journal of Graduate Medical Education. 2016;8(3):358-363.
- Coalition for Physician Accountability. The Coalition for Physician Accountability’s Undergraduate Medical Education-Graduate Medical Education Review Committee (UGRC): Recommendations for Comprehensive Improvement of the UME-GME Transition. August 2021.