Should I take USMLE Step 1?

What is the USMLE? COMLEX?

All United States medical students are required to pass a three-step examination for medical licensure. Allopathic (MD) students are required to take the United States Medical Licensing Examination (USMLE) whereas Osteopathic (DO) students are required to take the Comprehensive Osteopathic Medical Licensing Examination (COMLEX). The purpose of these exams is to assess a future physician’s ability to apply the knowledge learned during  medical school to the practice of medicine. Although a passing score is required for each of the 3 steps of the exam, the score from the first exam has the biggest influence on how competitive a candidate is for residency. Students take the first exam between their 2nd and 3rd year of medical school, and typically schools require a student to pass this exam before they are able to start clinical rotations. The second exam is taken shortly after finishing the 3rd year of medical school and the third exam is usually taken within 1 year of graduation from medical school. Although DO students are only required to take the COMLEX, students are given the opportunity to take the USMLE in addition to the COMLEX.

Argument for taking both the USMLE + COMLEX

The main argument for taking both exams is it provides more flexibility and an increased number of residency options for a DO student. Before understanding why taking the USMLE may be beneficial to students, it’s important to discuss the match process for US residencies. Currently residencies are accredited either under the American Osteopathic Association (AOA) or the Accreditation Council for Graduate Medical Education (ACGME). DO students are able to apply to both AOA and ACGME residency programs but MD students are only able to apply to ACGME programs. Since there are two separate systems, DO candidates use their COMLEX score to apply to AOA sponsored residencies, whereas MD candidates use their USMLE score to apply to ACGME sponsored residencies. As of February 2014 the AOA and ACGME agreed to a single accreditation system for graduate medical education by 2020. This merger will eventually lead to a single common match, in which DO and MD students will be able to apply to all residency programs with either their COMLEX or their USMLE scores respectively.  

A 2012 survey found that approximately 77% of ACGME residency programs now accept COMLEX scores, with this number expected to rise over the next few years gearing up for the common match. Since COMLEX scores are not accepted by a small percentage of residency programs, not taking the USMLE automatically disqualifies DO candidates from these programs. Even if an ACGME residency program may accept COMLEX scores, many encourage their DO applicants to take the USMLE. The scoring for the USMLE and COMLEX are very different, with an average score for the USMLE Step 1 being in the high 220s and the average for COMLEX Level 1 being around 500. Because the scores are so different, if an ACGME program receives 50 applicants who took the USMLE and only 1 student who took the COMLEX, it is next to impossible for this program to determine how the student who took the COMLEX did in relation to the other 50 students who took the USMLE.

Argument against taking both the USMLE + COMLEX

The major risk in taking the USMLE is a failing or below average score can negatively impact a residency application. Even though the USMLE is not required for DO students, one cannot hide the score from residency programs.  On ERAS (Electronic-Residency Application Service) students are asked if they took the USMLE. If a student checks “no” but did in fact take the USMLE, that is considered falsifying the application. If a student checks “yes” but does not authorize the NBME (National Board of Medical Examiners) to release their USMLE score, this may make the student look like they are trying to hide something. Either way, taking the USMLE and not reporting the score reflects poorly on the candidate. Regardless of how one scores, taking the USMLE may reflect negatively on a candidate interviewing at an AOA sponsored residency because it may make the program question the candidate’s commitment to the osteopathic profession.

Another disadvantage to taking the USMLE is that it is a completely different exam with a very different emphasis than that of the COMLEX. Although both exams assess a student’s basic medical knowledge in subjects such as physiology, pathology, pharmacology, microbiology, and immunology, the two tests are very different in formatting and content. USMLE has a higher percentage of biochemistry, embryology, histology and genetics. The USMLE also incorporates basic lab techniques into question stems such as gel electrophoresis and karyotype interpretation.  The question style is vastly different between the two tests. COMLEX tends towards pathognomonic “classic” findings whereas the USMLE provides an extreme amount of detail in the question stem for a student to be able to eliminate the incorrect answers. COMLEX questions tend to be shorter and many have an osteopathic component whereas USMLE questions can have long question stems with multiple answer choices (Example A-K instead of A-E which is typical of COMLEX).

Lastly, logistically there are many considerations to taking both the USMLE and COMLEX. Two exams means added time, stress and costs. Both exams take approximately 8 hours to complete and it is not advisable to take the exams in two successive days. Both COMLEX Level 1 and USMLE Step 1 cost about $600 each. Additionally many of my classmates also had to purchase a hotel room for the night before their exams due to not being able to schedule the exam at a nearby Prometric site.

So why didn’t I take the USMLE?

For me the decision to not take the USMLE was a no brainer. I have never been a strong standardized test taker and I didn’t want to risk doing poorly on two exams, when I could commit all my study time and effort into doing well on one exam. Another major consideration for me was being a member of the Armed Forces Health Promotions Scholarship Program (HPSP). The military is extremely DO friendly, with several DOs serving in high ranking positions for their respective branches (Ronald R. Blanck – 39th Surgeon General of the Army, Ronald A. Maul – command surgeon of the U.S. Central Command, Joyce Johnson – U.S. Coast Guard’s Chief Medical Officer just to name a few). Additionally the Association of Military Osteopathic Physicians and Surgeons  was established in 1977 to represent and advocate for osteopathic physicians in the Armed Forces. It is now estimated that DOs make up between 10-20% of all military physicians. Given the military’s friendliness towards DOs, all military residency sites accept COMLEX scores and DO candidates are just as competitive as their MD counterparts without having taken the USMLE. Additionally only one board exam is reimbursed by HPSP, so deciding to take the USMLE would have meant paying $600 out of pocket (not a huge amount of money in the long run, but enough to seriously throw off a medical student budget!) Lastly, I didn’t want to take the USMLE because I am proud to be an Osteopathic student. I want to apply to residency sites that respect my degree and doesn’t require me to take additional testing so I can be compared apples-to-apples with an MD applicant.

At the end of the day, taking the USMLE will not make or break your residency application. For every DO student who feels they missed a residency opportunity due to not taking the USMLE, there has been a DO student who successfully matched into a competitive specialty with just a COMLEX score. The decision to take the USMLE is a personal one, and it shouldn’t be influenced by what your classmates decide to do. If you’re still on the fence ask yourself these questions:

  • Do you want to apply to an ACGME residency program?
  • Are you applying to competitive residency specialties (Derm, Orthopedics, Plastics)?
  • Are you a strong test-taker?
  • Do you want to go to a residency in a state that does not have a DO medical school?
  • Have no idea what or where you want to do residency?

If you answered yes to one (or all) of these questions, taking the USMLE may not be a bad idea. Either way, study hard! The months leading up to COMLEX Level 1 were some of the most mentally exhausting and stressful times I have experienced. If you ever get discouraged, just remember everything you have learned during your first two years of medical school has prepared you for this exam. Getting into medical school is an accomplishment in itself and clearly you have to be one smart cookie to have survived this far into your graduate medical education 🙂


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