What is COMLEX 2 Performance Evaluation (PE)? It is a 1 day exam in which each student encounters 12 standardized patients. For each patient you encounter, you have 14 minutes to complete a history and physical and 9 minutes to type a SOAP note. The day is divided into 3 sets of 4 cases, with lunch after the 4^th and a short break after the 8^th case.

Who takes the PE? All osteopathic medical students are required to pass the PE to graduate from medical school. This is the DO equivalent of the USMLE CS exam.

When should I take the PE? This varies by school. My school gave us approval to take the test after a certain date. For some students that meant they were permitted to take the PE in October of their 3^rd year, whereas I had to wait until May of my 3^rd year. For students at other schools I have heard they are encouraged to wait until their 4^th year before they take the exam, so they schedule the test June-October of their 4^th year. I would encourage students to take the exam as soon as possible for several reasons. While most students are successful in passing their PE on their first attempt, there is a slight chance that you could fail. With spots filling up so quickly, if a student is unsuccessful during their first PE, it may take several months for a spot to open. Some residencies prefer to interview candidates who have already taken their exam which could affect your ability to match and could result in a delay in the start of residency.

Where do I take the PE? Students have the option of taking the exam in Chicago, IL or Conshohocken, PA which is about 30 minutes outside of Philadelphia.

How is this exam graded? Good news and bad news. The test is pass/fail. This is good news because it is slightly lower stakes than Level 1 or Level 2 where how well you do is reflected in a numerical value. This is bad news because if you fail by 1 case or by 8 cases all a residency will see is “Fail”. The scoring is broken down into two categories: biomedical/biomechanical domain and humanistic domain. The biomedical/biomechanical domain is assessing your skills as a doctor. This includes eliciting a history, performing a physical exam, performing OMT, and writing a SOAP note. The humanistic domain assesses your communication and interpersonal skills. This includes treating the patient with respect, showing compassion, and being able to communicate with the patient in a way they understand. The standardized patient will grade each candidate on history taking and physical exam immediately after the encounter. The video recordings of the encounters and the SOAP note is graded by an osteopathic physician. You must pass both the humanistic and biomedical domains to pass the exam.

How should I prepare for the PE? I was fortunate in that my school organizes a 2 day PE review, which was beneficial in being able to practice with a standardized patient during a timed encounter. I highly recommend reviewing the textbook you used for your H&P course. I also used the COMLEX Level 2-PE Review Guide. The review guide gives a brief overview of the exam, and then has 50 cases that simulate chief complaints you may encounter at your PE. I would time myself, and review each case writing down the review of systems questions I would ask, the differential diagnosis, and any OMT I would consider using on the patient. I would then jot down a possible plan. After I reviewed the case, I would then log on to the NBOME website and use the E-SOAP Note Practice which has an interface exactly like what you will encounter on test day.

Help! I haven’t done OMM in a year! Okay, first breathe. You’ll be okay. Quite honestly, aside from treating friends and family members for fun, I have not utilized OMT outside of my OMM lab during my first two years of medical school. Thankfully you are not expected to do OMT on all the patients. There are 3-5 cases which are OMT rated, and the standardized patients make it obvious that you are expected to do OMM. I used NYIT College of Osteopathic Medicine’s videos as a quick review of OMT for each area of the body. I also reviewed the notes I took when I read Savarese’s OMT Review preparing for my Level 1 exam.  Note: students are not permitted to use any High-Velocity, Low-Amplitude or thrust techniques.

Top 10 Tips for Crushing the PE

1. Schedule your PE as soon as possible. I scheduled my PE the day I got my result for Level 1 and I was surprised to see some days were completely booked more than 11 months ahead of time.
2. Take 30 seconds to review the chart prior to entering the room. There is no “Magic EHR” waiting for you outside of your encounter with the patient. If you don’t ask the patient about their family history, tobacco use, review of systems, etc. you will not have access to that information when writing the SOAP note. Take some time to write down whatever acronym you use to remember to ask all the questions, I used CODIERS SMASH FM. I also took this time to make a mental note of a differential diagnosis, potential OMT I could use, and whether there were any vitals I needed to repeat. Also, be sure to make a mental note of the setting in which you are seeing the patient. You don’t want to tell the patient who is experiencing a heart attack that you are sending them to the ED when you are already in the ED.
3. Wash your hands, wash your hands, wash your hands. When you enter the room introduce yourself, excuse yourself to wash your hands, set your chart down, wash your hands (or use sanitizer), and only then shake the patient’s hand and begin the interview. Be cognizant of contamination. If you touch your face or hair, or drop your pen on the floor, pause before beginning the physical exam to rewash your hands. If you do any exam maneuver where you touch the patient’s foot or socks, after finishing that portion of the exam rewash your hands before continuing the remainder of the physical.
4. Show compassion. These encounters are scripted. If you ask all the right questions you will uncover bits and pieces of the patient’s history that any reasonable person should stop to show compassion. If a patient tells you a family member has been diagnosed with a condition or has passed away, they’ve lost their job, they are getting a divorce or anything remotely related stop and ask them how they are handling the situation. Try to be genuine, although these are actors if you are obviously faking your empathy the evaluators will notice.
5. Do a heart and lung exam on every Even if a patient is coming in for a sprained ankle, just take the 2 minutes to do a heart and lung exam to show the evaluators that you are a competent physician who is thinking of overall health and wellness and not just seeking a quick fix for a simple problem.
6. Don’t do a full physical exam. For each patient do heart, lungs, and an exam of the area related to the chief complaint. If a patient is coming in for a cardiac related chief complaint, examine the extremities to assess for pulses, and evidence of peripheral vascular disease and assess the neck for carotid bruits and JVD. If a patient is coming in for a respiratory related chief complaint do a HEENT exam and check the finger nails for clubbing.
7. Expose and drape the patient appropriately. Heart and lung exams must be performed on bare skin. Ask your patient to untie the gown and lower it so you have access to listen to the heart and all lung fields. If you are going to have the person lie in the supine position, allow them to retie their gown, and cover their legs with the drape so you can lift their gown to expose their abdomen while keeping them covered. If you need more area exposed, ask the patient to move their gown themselves or ask for permission to move the gown, take off socks, lower the drape, etc.
8. Don’t forget to give your patient an impression and plan. On my 3^rd year rotations, I was not allowed to give patient’s an impression or plan without consulting my attending physician first. When practicing for the PE I noticed it was a difficult habit to break in getting used to formulating an impression and plan while on the spot without consulting a resident or attending first. You don’t have to tell patient’s every detail of your plan but give the patient a general overview. For example, if you are concerned for a cardiac event, tell them you will return to do an EKG and then you would like to run some labs.
9. Always finish the encounter. A warning announcement plays overhead when there are 2 minutes left in the encounter. Try using this announcement as a benchmark to finish your physical exam and tell the patient your impression and plan and ask if they have any questions. If time runs away from you and the announcement to leave the room is played, quickly tell the patient what your impression and plan is, thank them for their time and shake their hand. Never leave the room without thanking the patient or finishing your thought process.
10. Don’t lie on your SOAP note. It seems obvious, but after 12 encounters you may begin to blur what one patient said to you with another. If you cannot remember if your patient admits to nausea, don’t document it. Only document things you know occurred in the subjective and objective section. If you cannot recall if you asked a question, make a note in your plan to reenter the room and ask the patient the questions or repeat the physical exam that you forgot to do.