You’ve made the difficult decision between DO vs MD and now find yourself facing the first of your comprehensive Osteopathic exams: the COMLEX Level 1. Like each of the other COMLEX exams, the Level 1 is a challenging and intricate exam that tests scientific, theoretical, and clinical knowledge. In this guide, we’ll cover the topics, structure, and logistics of the COMLEX, and offer some tips on optimal preparation and study schedules.
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What is the COMLEX Level 1?
The Comprehensive Osteopathic Medical Licensing Examination (COMLEX) is a series of exams taken by osteopathic medicine (OM) students in the United States throughout their DO program and as capstone for the DO degree and licensure. It’s designed and administered by the NBOME or National Board of Osteopathic Medicine Examiners and is structured into three levels and four parts:
COMLEX-USA Level 1
Assessment of Foundational Biomedical Sciences and Osteopathic Principle and Practice
COMLEX-USA Level 2-CE
Assessment of Fundamental Clinical Sciences for Osteopathic Medical Practice
COMLEX-USA Level 2-PE*
Assessment of Fundamental Clinical Skills for Osteopathic Medical Practice
[*This exam is now indefinitely on hold]
COMLEX Level 3
Assessment of Competencies for Osteopathic Medical Practice
COMLEX Level 1, the focus of this guide, is typically taken by DO students near the end or just after the second year of their DO program Most DO schools schedule COMLEX Level 1 between April and June of the second year, but students typically begin studying and taking practice exams during their first year. Unlike one-time comprehensive exams like the MCAT, the four exams making up the COMLEX series are progressive, meant to assess DO students’ understanding and abilities at multiple points in their development. The Level 1 exam is therefore an incredibly important and enlightening experience for most DO students, exposing their strengths and weaknesses in basic sciences before heading into the applied, clinically-based material of the Levels 2-3 exams.
What’s on the COMLEX Level 1?
As COMLEX Level 1 is taken midway through DO programs, about two years after you submit your DO school application and get accepted, its questions assess your knowledge of foundational biomedical sciences and principles of osteopathy using clinical and patient presentations. In other words, only your theoretical knowledge is being tested in this COMLEX level. It is a one-day, computer-based assessment broken into two four-hour test sessions for a total of 8 hours exam time with a 40-minute lunch break between the morning and afternoon sessions, and two optional 10-minute breaks at the midpoint of each session.
The exam is comprised of 8 sections totaling 352 questions on the following topics:
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The 352 questions testing your knowledge in these subjects are single-best answer in the standard multiple-choice format. Test questions also include audio and visual components, such as heart sounds, images of symptoms, or other relevant aspects of patient presentations. Lastly, these 352 questions are structures around two dimensions of osteopathic development.
COMLEX Level 1 Questions: Two Distinct Dimensions
The types of clinical problem-solving involved in the COMLEX Level 1 exam are organized around two dimensions: Competency Domains and Clinical Presentations. Additionally, both dimensions integrate five central aspects of osteopathic medical care:
- Osteopathic philosophy of whole person healthcare
- Underlying structure-function relationships
- Interdependence of body systems
- Self-healing and self-regulatory mechanisms
- Osteopathic approach to patient care including manipulative medicine and treatment
Dimension 1: Competency Domains
Dimension 1 contains questions that test your knowledge of seven Competency Domains, each of which makes up a specific minimum percentage of the dimension’s questions. The domains tested in Dimension 1 questions correspond to sets of foundational abilities needed to meet established professional standards in Osteopathy. They are:
Dimension 2: Clinical Presentations
Dimension 2 focuses on Clinical Presentations that represent the ways in which a particular patient or community presents for Osteopathic Medical Care. Similar to Dimension 1, each category of Clinical Presentation makes up a specific minimum percentage of questions. They are:
Structure of COMLEX Level 1 Questions
Both Dimensions are well represented throughout the 8 sections of the test, making the question-to-question experience of the COMLEX somewhat unpredictable. The two testing sessions for the COMLEX are specifically not organized into categories, keeping in line with the holistic and integrated praxis of Osteopathy. In short, any two questions within a section of the exam may cover quite different domains or dimensions.
If this all seems a bit confusing, don’t worry. One of the advantages of COMLEX Level 1 being so fundamentally integrative, while also reliant on the domains included in the Foundational Sciences Knowledge Base, is that focusing your studying on these “big percentage” categories will serve you well throughout the test. Likewise, if you’re likely to struggle with a specific domain or type of presentation, you won’t have to grind through an entire section dedicated to that specific domain or presentation.
Another bright side to this structure is that question types don’t really vary. Unlike the MCCQE Part 1 which utilizes 5 distinct question types, the COMLEX Level 1 uses single-answer multiple-choice questions for its entirety. This uniformity of structure can be a big help in studying for the exam and developing comfort and confidence in your ability to navigate the test on exam day.
Scores on the COMLEX Level 1 traditionally utilize a converted 3-digit standard score, ranging from 9-999, with a mean of 500-550. The minimum score to pass the exam is a 400, and most candidates score between 250 and 800.
However, as more medical licensure exams move to Pass/Fail scoring, soon the COMLEX will also. The NBOME made this decision in part to mirror the scoring of the USMLE Step 1, but also to "support wellness across the continuum." Further details on this change have not yet been released. Scores are made available approximately 1 month after taking the exam, and you’ll be notified via email when yours is available.
Here's a quick reminder of what the COMLEX exam consists of:
Registration and Accommodations
Students are eligible to register to take the COMLEX Level 1 when they have completed the first year of a DO program and are considered in good academic standing by their College of Osteopathic Medicine.
The process begins in November of a student’s first year, when they’re invited to create a profile in the NBOME’s Client Registration System (CRS). In this CRS, students can check their eligibility status, register for approved examinations, and pay for whatever services they’ve registered for or received. Additionally, if you want to change the date of an existing exam appointment, you can do so through this CRS portal.
NBOME provides reasonable and appropriate additional accommodations for test-takers in accordance with the Americans with Disabilities Act. Students requiring accommodation on test day should submit a Request for Test Accommodations via the process elaborated on the NBOME’s test accommodations page at least 75 days ahead of their test date. However, such requests may require additional documentation, so we recommend that you submit this form, if necessary, as far ahead of your test date as possible to account for any back-and-forth in sorting out details. Additionally, Prometric offers an extensive array of available accommodations, from sign language interpreters to specialized computer peripherals.
Preparing for the COMLEX: WelCOM and COMSAE
Practice tests and questions are the backbone of any study program, and NBOME has done a tremendous job of offering DO students two excellent practice exam series with which to assess and improve their knowledge of COMLEX material: the WelCOM and COMSAE. Although both exam series are aimed at helping students prepare for the COMLEX tests, there are some notable differences.
# of questions – 75
Available for purchase by – Students
Questions Interval – Self-determined
Scoring – Correct/Incorrect provided in real time
Answer rationales offered – Yes
Reference/Resource Material – Yes
Performance Dashboard – Yes
Cost - $60
# of questions – 176
Available for purchase by – Colleges of Osteopathic Medicine (COMs) or Students
Questions Interval – Single-sitting
Scoring – Numerical Score provided at end of exam
Answer rationales offered – No
Reference/Resource Material – No
Performance Dashboard – No
Cost - $60
WelCOM: Self-Assessment with Lots of Feedback
The NBOME’s WelCOM exams have been designed to help DO students prepare for each level of COMLEX exams. WelCOM exams utilize the Catalyst app and can be taken at any time, with no time limit per question and no set number of questions to be answered per session. Best of all, the WelCOM series utilizes the Catalyst app structure and so offers immediate feedback on responses that includes not only an indication of correct/incorrect, but also rationales and resources for each answer. It’s highly detailed and user-friendly prep tool designed, written, and offered by NBOME, the same organization that makes the COMLEX series, and so is a reliable (albeit somewhat short) resource for practice questions.
The feedback and answer rationale are huge parts of the benefit to using WelCOM exams, even if the total number of questions is somewhat limited. You can utilize the data in WelCOM’s review panel to help guide your studying for up to 90 days afterward, which likely covers the interval before you take another practice exam and establish a new baseline. Consider the WelCOM a fantastic initial or one-off practice exam with a review utility that remains helpful for weeks afterward as you curate and execute the ensuing phase of your study plan.
COMSAE Phase 1: Traditional Practice Test
The COMSAE series is much more traditional in structure. Like the WelCOM, the COMSAE is a series of self-assessment exams that covers 3 levels corresponding to the three levels of COMLEX exams. COMSAE Phase 1, the Assessment of Foundational Biomedical Sciences and Osteopathic Principles and Practice exam, mirrors the topics and content of the COMLEX Level 1.
Recently updated to 176 questions from its prior 200, the COMSAE Phase 1 covers the same 2 Dimensions and 17 categories of Osteopathic knowledge as the corresponding COMLEX, and is designed to give students a sense of their knowledge base and ability specifically to better prepare for the COMLEX Level 1. Although the NBOME cautions students not to view the COMSAE as a linear predictor of subsequent COMLEX performance, it’s similar enough to warrant taking and studying the results thereof while preparing for the COMLEX.
The COMSAE can be taken either timed or untimed, and is purchasable within the NBOME Account page under the “Register & Schedule Exams” section. We advise that students choose to time themselves though, in order to best simulate actual testing conditions. Scoring on the COMSAE is a standard 3-digit numerical score and comes with a Performance Profile that gives students a graphic presentation of their performance on the test’s various content areas.
Lastly, while the WelCOM is purely handled by the student, COMSAE exams are sometimes purchased and invigilated by DO programs, so check with your school before arranging to take the COMSAE on your own to see if it may be a part of your coursework or program.
Learn more about what DO stands for in our video:
What to Expect on Exam Day
Once you’ve registered and plowed through your practice exams and study program, the big day shouldn’t feel too terrifying. Nonetheless, it’s always good to know what you’re in for.
As the COMLEX Level 1 is a Prometric-hosted exam, you’ll want to arrive at your designated testing center at least 30 minutes ahead of your scheduled testing time. However, if it’s your first time visiting that location, we recommend giving yourself a bit more than that, to make sure you’re not rushing to park and navigate a wholly new building. Prometric testing centers are often part of an office suite or park, and so doing some advanced scouting in the days prior to your testing date, to make sure you know the exact location of your testing room ahead of time, will be massively helpful in alleviating stress on test day.
Items to bring to the exam:
- A current/non-expired government ID that includes your picture and signature. Examples of this include driver’s license, passport, or military ID.
- A medical or cloth face mask to be worn throughout the entirety of your time within the testing center.
- Ear plugs if so desired. These may be inspected by a testing center associate (TCA) prior to use.
- Any personal belongings you’d like to access during breaks, such as food, water, and medication. However, you cannot bring these items into the actual testing room, but you will be given access to a storage locker in which you may store these items. The only items allowed into the testing room itself will be your mask, ID, locker key, and ear plugs.
Items provided by testing center:
- Noise-cancelling headphones
Taking the WelCOM and COMSAE exams will help guide your preparation to a significant degree, but there are some important considerations and extra strategies that can help you maximize your COMLEX performance.
In addition to the WelCOM and COMSAE self-assessments, the NBOME also offers the Comprehensive Osteopathic Medical Achievement Test (COMAT) series to COMs for formal proctored assessment on the subjects and knowledge bases tested on the various COMLEX levels. The COMAT relevant to the COMLEX Level 1 is the COMAT Foundational Biomedical Sciences (FBS) test. As you can see in the Dimension 1 breakdown above, FBS material makes up nearly half of the COMLEX Level 1, so if you have the ability to take a COMAT, we highly recommend it. Most COMs that offer the COMAT do so throughout the year, with some typical break periods or holidays excepted. The NBOME offers further details on scheduling and administration on their site, but in general you should simply speak with your COM’s administration to find out when you should take the COMAT.
As it’s a formal exam, COMAT FBS is likely to be an incredibly helpful experience not just for helping you assess your study needs but to simulate the formal testing experience of the COMLEX as well—an aspect of preparation unfortunately not truly provided by the self-assessed WelCOM and COMSAE exams.
Make Coursework a Priority
Managing your time leading up to the exam is the hardest part of preparation. With the COMLEX Level 1, you should give yourself as much time to prepare as possible, but should always make coursework a priority. The reason for this is twofold. Obviously testing well but bombing your courses is a mistake, and so balance, as ever, should be your guiding principle. But the other side of this is that your courses will be covering much of the same material that the COMLEX and related exams will test, so treat your first- and second-year courses like formal test prep sessions. They are!
Incorporate as much relevant material from your courses as you can into your studying, and coordinate study blocks between your courses and sections of the COMLEX. For instance, if you have a course in Medical Immunology or Microbiology, be sure to take good notes and study extensively for tests—this effectively doubles as COMLEX prep, as these subjects are heavily utilized on the exam. Additionally, many schools have noted a correlation between how well students do in their Problem Based Learning course (where they learn all their basic sciences) and how well they do on board exams like the COMLEX. All effort needs to put into being successful in medical school courses during their first year, and fall semester of second year, before starting dedicated exam study.
Of course, while this is all true, students will inevitably need a thorough study schedule to review course material in the second half of Year 2 prior to taking the Level 1.. A good study schedule will help you keep track of which content areas have already been covered and what still needs to be reviewed. It should also include detailed study strategies that utilize the texts and notes you created during your courses, with specific volumes of notes or numbers of chapters per study session. The point here is that treating courses as preparation periods is vital, but so is creating and sticking to a good plan later on when you need to review this course material for the COMLEX.
Effective Time Management Will Reduce Stress
As we just noted, time management is essential to effectively balancing your responsibilities as a new DO student, but it’s also crucial in crafting and carrying out an effective study plan. It’s important to be honest with yourself in this regard: if you have a hard time studying in the evening, make sure you block extra time during weekend days. Find your limit with study questions—if your brain starts to feel fuzzy after the 50th sample question, maybe structure your sessions to end at 40, and so on. It’s important to push yourself but it’s equally important to understand that the point of diminishing returns is real, and that understanding your limit is vital. Be realistic with what you’re capable of and how you function best in this regard—utilize the osteopathic maxim of holistic analysis and make your plans based on the many factors that steer your behavior and functioning throughout the weeks and months leading up to your testing day.
Additionally, consider the notion of periodization or organizing your study phases to accommodate fluctuations in your stress/energy levels throughout the year. For instance, if you have a ton of work for courses in November, maybe structure October to focus more on COMLEX review and practice testing and switch this ratio once midterms or course projects start demanding more of your time. In the 6 months or so prior to your exam date, decrease the volume of studying and prep work in the final weeks to ensure that you’re rested and not trying to cram new information in right up to the last minute. It’s important to approach the final days of prep with an eye toward maximizing your ability to recall what you already know—provided you’ve been studying—rather than a frenzy of covering perceived weak or blind spots. A well-rested and focused mind will be far more effective on exam day than one that’s been running at max voltage for weeks on end.
Study Resources: Quality over Quantity
One of the first things most students notice when searching for study tips is the vastness of study guides, test-specific guidebooks, and other resources that would take even the most gifted student years to churn through. Pick high-quality resources and work with them in detail. You should also seek resources that suit your studying style best. If you love practice questions, then of course seek out high quality question banks and work with them religiously. If you prefer reading and note-taking, opt for more time spent with high-quality study guides like First Aid for COMLEX. Spread your time around to ensure you’re testing and studying with a range of approaches, but don’t privilege variety for its own sake. Work in depth with quality material rather than doing cursory or incomplete work with dozens of resources.
Although the COMLEX Level 1 is a challenging exam, you’ll be learning the content in great detail during the first two years of your DO program. Utilizing smart study strategies and making sure you’ve spent time with each Dimension and Domain will carry you far, and with the right time management, taking the COMLEX can feel like an almost perfunctory repetition of work you’ve already done and mastered. And remember, the Level 1 is merely the first in a series of exams, so while you should strive to score as highly as possible, keep in mind that becoming a skilled osteopathic medical practitioner is a long-term, even lifelong, process. The COMLEX Level 1 is simply the first of many milestones you’ll encounter in your academic career, but it’s important to give yourself a positive experience that will carry you forward to Levels 2, 3, and into residency.
1. Do DO students need to take both the COMLEX Level 1 and USMLE Step 1?
In many cases no, but some schools—such as the Lake Eerie College of Osteopathic Medicine—and many residency programs will require both. If this is the case for you, the good news is that both exams cover quite similar material, at least with regard to foundational scientific knowledge—obviously osteopathic theory and technique aren’t part of the allopathic focus of the USMLE series.Should you elect to take the USMLE if it isn't required? With the COMLEX Level 1 and USMLE Step 1 transitioning to Pass/Fail, it is thought that residency programs will heavily use Step2/Level2 and more extracurricular activities & research when considering applicants. We therefore recommend all DO students take the USMLE if they are not at risk of failing. A lot of allopathic residencies do not understand the scoring of the COMLEX and want to see the USMLE score. Given that DO and MD residencies are now merged into a single program, it is very important to have both scores if the student plans to apply to a historically allopathic program. Also, a lot of programs will not consider applicants without a Step 1 (now maybe Step 2) score.
2. When should I take the COMLEX Level 1?
This will largely be determined by your specific College, but in general students take the exam between the months of April and June, i.e. sometime between the end of your second year or beginning of your third. More to the point, try to take the Level 1 before starting clinical rotations. Once rotations start, the amount of time you can dedicate to studying for the Level 1 decreases, all the while new material is being learned. If you have flexibility in when you take it, we recommend doing so not long after the completion of your second semester of the second year, to optimize your ability to recall information covered in courses while avoiding overlapping with them.
3. Can I take the COMAT exam to prepare for the COMLEX Level 1?
Absolutely! We recommend it even, but not at the cost of overloading your plate. If the COMAT FBS is a mandatory part of your program then simply go with the flow, but if you’re electing to take it independently, then make sure preparing for it won’t interfere with or overburden your surely already-busy second year in DO school. In general though, the COMAT can be a thorough index of how you’re faring in your COMLEX preparation so far, more so than the WelCOM or COMSAE even.
4. Are COMLEX scores used in evaluating medical residency applications?
In some cases yes, but this is to a great extent uncommon. Following the merger of osteopathic and allopathic residency program matching, most residencies want or even prefer a USMLE score. Moreover, typically only historically osteopathic programs—i.e., were a part of the American Osteopathic Association (AOA)—or very DO-friendly residency programs understand COMLEX scoring, and so the USMLE is considered more important for residency.
5. Can I retake the COMLEX Level 1?
You cannot retake any COMLEX exam if you’ve passed it, regardless of how close your score is to failure. However, if you have failed an attempt, you’re allowed to retake the exam up to 4 times per 12 month period.
6. When will I receive my COMLEX Level 1 score?
Typically within 4-6 weeks from the day you took the test, although the first score release in each testing cycle is sometimes briefly delayed.
7. What is a good COMLEX Level 1 score?
A passing score for COMLEX Level 1 is 400, with the mean score being approximately 520, and a truly outstanding and competitive score will be over 600. However, with COMLEX moving to Pass/Fail, this question will become moot, and only a passing score will matter. Residency programs will likely focus on Level 2 scores following this change.
8. Are certain questions on the COMLEX Level 1 weighted differently than others?
Nope! As the structure of each question remains consistent throughout, so does its value. So: every question is equally important, but this also means you shouldn’t panic if something totally stumps you.
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