You’ve finished the second—and possibly third—year of your DO program and now the Comprehensive Osteopathic Medical Licensing Examination Level 2 Cognitive Exam (COMLEX 2-CE) stands between you and beginning work on your ERAS or CaRMS applications for residency. Like the COMLEX Level 1, the COMLEX Level 2-CE is a challenging comprehensive exam, but fortunately its focus lies mainly in the material you’ve recently covered during your 2nd and 3rd year coursework and rotations. In this guide, we’ll cover the topics, structure, and logistics of the COMLEX Level 2-CE, and offer some tips on optimal preparation and study schedules.
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What is the COMLEX Level 2-CE?
The COMLEX Level 2-CE is the second in a series of 4 comprehensive licensing exams administered by the National Board of Osteopathic Medicine Examiners (NBOME). The 4 exams of the COMLEX are structured into 3 parts and 4 exams total:
What’s on the COMLEX Level 2-CE?
While the COMLEX Level 1 is taken after the second year of most DO programs, the Level 2-CE is taken after year 3 or even well into year 4. DO students experience a significant shift in their program from year 2 to 3: at the start of year 3, coursework recedes somewhat as students begin their core rotations in family medicine, general surgery, internal medicine, pediatrics, Obstetrics/Gynecology, psychiatry, and emergency medicine. As a result, the Level 2 focuses more on assessing knowledge and application of these Clinical Sciences, rather Foundational Biomedical Sciences—although, to be clear, FBS knowledge still plays a role on the COMLEX Level 2-CE.
The exam is comprised of 8 sections totaling 352 questions on the following Clinical Science Disciplines:
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. The use of A/V aids in the COMLEX Level 2-CE is significantly greater than that of the Level 1, as the Level 2 assesses a larger variety of physician competencies. Lastly, these 352 questions are structured around two dimensions of osteopathic development.
COMLEX Level 2-CE: Two Dimensions
Similar to the Level 1, the types of clinical problem-solving involved in the COMLEX Level 2-CE exam are organized around two dimensions: Competency Domains and Clinical Presentations. 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:
- Osteopathic Principles, Practice, and Manipulative Treatment — 10%
- Osteopathic Patient Care and Procedural Skills — 30%
- Application of Knowledge for Osteopathic Medical Practice — 26%
- Foundational Biomedical Sciences base —25% of the Application of Knowledge for Osteopathic Medical Practice section (6.5% of the overall test)
- Practice-Based Learning and Improvement in Osteopathic Medical Practice — 5%
- Interpersonal and Communication Skills in the Practice of Osteopathic Medicine — 5%
- Professionalism in the Practice of Osteopathic Medicine — 7%
- Systems-Based Practice in Osteopathic Medicine — 5%
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:
- Community Health and Patient Presentations Related to Wellness — 12%
- Human Development, Reproduction, and Sexuality — 5%
- Endocrine System and Metabolism — 5%
- Nervous System and Mental Health — 10%
- Musculoskeletal System — 13%
- Genitourinary/Renal System and Breasts — 5%
- Gastrointestinal System and Nutritional Health — 10%
- Circulatory and Hematologic Systems — 10%
- Respiratory System — 10%
- Integumentary System — 5%
Structure of COMLEX Level 2-CE Questions
Both Dimensions are well represented throughout the 8 sections of the test, making the question-to-question experience of the exam 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.
Like the Level 1, the COMLEX Level 2-CE utilizes the same multiple-choice structure throughout, so while the balance of Dimensions and Domains is different than the previous COMLEX, the overall test-taking experience is somewhat the same in terms of uniformity of structure. Additionally, each question is weighted exactly the same—no question is any more or less important than another.
Unlike the Level 1, the COMLEX Level 2-CE really stresses physician competencies in fundamental clinical skills, and so the most prevalent domains tested are related to patient care, procedural skills, and applied knowledge. This is a significant change from the Level 1 which, as we’ve noted, is much more geared around testing academic knowledge in the FBS, while utilizing clinical application as a kind of medium for this assessment. In this sense, expect questions to test the knowledge you’ve gained in your clinical rotations, including subjects like ethics and law to a much greater degree than the preceding test.
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Scores on the COMLEX Level 2-CE 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. Lastly, it’s important to note that while the COMLEX Level 1 is moving to Pass/Fail, this does not seem to be the case for Level 2-CE. This means that your exact numerical score will likely be used in consideration by residency programs, making it extra important to score as well as possible.
Registration and Accommodations
Students are eligible to register to take the COMLEX Level 2-CE when they have passed the COMLEX Level 1, completed the second year of their DO program, and are considered in good academic standing by their College of Osteopathic Medicine (COM).
Since you’ll have already registered in the NBOME Client Registration System (CRS) back in year 1 for the COMLEX Level 1, registering for the Level 2-CE is fairly simple. Once you’ve made sure your name and other important information in the NBOME CRS is correct, you need only confirm your eligibility and then register for the testing date you desire. 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.
Here's quick reminder of what the OMLEX exam consists of:
Preparing for the COMLEX Level 2-CE
Official preparation materials for the COMLEX Level 2-CE are to an extent similar to those of the Level 1, though with changes to reflect the Level 2-CE’s augmented dimensions and domains. NBOME offers both WelCOM and COMSAE self-assessment tests geared toward the COMLEX Level 2-CE, and although both exam series are aimed at helping students prepare for the COMLEX tests, there are some notable differences.
WelCOM Phase 2
The WelCOM series is designed to help students assess their knowledge while also providing detailed answer rationales and suggestions for further study. WelCOM exams can be taken at any time, with no time limit per question and no set number of questions to be answered per session. 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.
WelCOM Phase 2 questions differ from Phase 1 in two central ways: obviously, their content skews toward that of the COMLEX Level 2-CE, and so adds more coverage for clinical science and related competencies. Secondly, while WelCOM Phase 1 offers 2 forms of 75 questions each, the Phase 2 offers 4 forms, for a total of 300 available questions.
COMSAE Phase 2
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 2, the Assessment of Fundamental Clinical Sciences for Osteopathic Medical Practice exam, mirrors the topics and content of the COMLEX Level 2-CE.
Comprised of 176 questions, the COMSAE Phase 2 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 2. Additionally, the COMSAE Phase 2 classifies its items by 8 medical disciplines that correspond to the COMLEX Level 2-CE’s 8 clinical disciplines mentioned above: Emergency Medicine, Family Medicine, Internal Medicine, OB/GYN, Osteopathic Principles and Practice, Pediatrics, Psychiatry, and Surgery. 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 Phase 2 can be taken either timed or untimed, and is purchasable within the NBOME Account page under the “Register & Schedule Exams” section. If you choose to use COMSAE, we advise you to time yourself 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.
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 2-CE 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.
Taking the WelCOM and COMSAE Phase 2 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 Level 2-CE 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. There are a few COMATs relevant to the COMLEX Level 2-CE, including both the Comprehensive and Targeted FBS tests, but the most helpful for the Level 2 are the Clinical Subject Exams (CSE) which cover the 8 clinical disciplines included in both the COMLEX Level 2-CE and COMSAE Phase 2.
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.
Although simulating the formal testing experience of the COMLEX Level 2-CE is less of a concern since you’ll have already taken the Level 1, we nonetheless recommend taking the relevant COMAT exams if possible. Additional assessment is almost always a good thing, and at least one study has found “statistically significant, positive associations between COMAT and COMLEX Level 2-CE scores.”
Resources: Quality Over Quantity
As is clear by this point, there is a variety of options for practice assessment and study resources. Between the NBOME exams, third-party question banks, and hundreds of books, there is a real danger of utilizing too many resources to prep for board exams like the COMLEX and USMLE. These resources can be helpful when used as practice materials but should not be the primary source of information for students at any phase in their DO program.
For books, First Aid for the COMLEX remains the gold standard for secondary study guides, and is a must for every level of COMLEX study. Written by former fellows of the Chicago College of Osteopathic Medicine, First Aid compiles a vast amount of information related to OMM theory and technique, with illustrations, study strategies, and mnemonics. However, with First Aid being the exception, for the most part you’ll want to treat course materials as your primary sources of information.
We asserted in our guide to COMLEX Level 1 that students should prioritize doing well in coursework in order to effectively prepare for the heavy FBS focus of that first exam, and while that remains true for the Level 2-CE, the focus of years 3 and 4 of DO programs shifts away from coursework and into clinical rotations, thus making review even more important. For example, your Problem Based Learning course will be at least 1 year in the past by the time you begin studying for the COMLEX Level 2-CE, so making use of your previous course materials as study guides is even more crucial. Prioritize studying and reviewing the specifics of your first and second year courses, and make sure that your notes and other materials from this period are as well-crafted as possible. As test time approaches, you’ll also be busy beginning work on your residency CV and arranging who will write your letters of recommendation, so plan on having far less unstructured study time than you did for the Level 1. Having to re-read textbooks to make notes is essentially out of the question—you should strive to have ready-to-go study materials made from your primary sources by the time of the COMLEX Level 1, and be able to simply review them and work with them once again as the Level 2-CE approaches.
Additionally, as you move into the clinical portion of your DO program, you'll want to ensure that your rotation notes are also clear and annotated with your supervisor's comments on your performance. Taking detailed notes during this period is just as key for performing well on the COMLEX Level 2-CE as it was during your coursework-heavy first two years. One of the challenges of the Level 2-CE is that it assesses how you would react to certain patient presentations as a physician, so having a good knowledge base on patient cases and diagnoses—via your notes, comments, etc.—is especially important.
With the above caution against overloading yourself with resources in mind, we unequivocally recommend a UWorld subscription. The UWorld question bank is structured around the USMLE, but there’s so much shared material between the USMLE and COMLEX—nearly everything but osteopathy-specific material—that it remains a vital and extremely helpful resource. For the COMLEX Level 2-CE, we recommend starting to do UWorld questions by January of the 3rd year, although obviously you’ll want to spend some time with these during your prep for the Level 1 as well. Our experts are adamant that if students are academically strong enough—i.e., they’ve done well enough in coursework to not need an extensive period of review or re-learning FBS material—to finish the bank twice during their Spring semester, they’ll stand a very good chance at performing highly on the COMLEX Level 2-CE. Additionally, use Tutor mode for the first pass and really focus on the explanations provided.
A block of 40 questions may take between 2-3 hours with this additional review protocol, but it’s vital to carefully and completely assess where and how you go wrong in these initial rounds of practice questions. Take notes in First Aid during review as well. After this initial review round, probably the first month or so of study, shift over into random blocks and timed. TrueLearn is another popular option for questions as it has COMLEX-specific blocks, but the questions and explanations are nowhere near as challenging and thorough, respectively, as those of UWorld. Small blocks of TrueLearn may be useful, especially since they cover Osteopathy-specific material and mimic the structure of COMLEX questions to a greater degree, but UWorld remains the greater resource, and deserves more of your time.
A carefully crafted study plan is essential, and even more with the COMLEX Level 2-CE than the Level 1. With rotations replacing coursework as your major daily demands, the ability to study will be tested even further. We recommend blocking out most of your Spring semester of year 3 to studying for the Level 2-CE, beginning of course with one or two practice exams in January to establish your initial weaknesses. In addition to the NBOME practice exams, UWorld’s second self-assessment is great for this.
From here, figure out how many questions you’ll need to answer per day in order to complete the UWorld bank twice before your exam date, and commit to this plan. It’s vital to stay on course and not fall behind, but especially with test prep—trying to cram practice work will greatly decrease your ability to focus and take in necessary information. Additionally, our resident COMLEX expert recommends unbinding your copy of First Aid and placing it in a 3-ring notebook with additional blank paper added as needed for easier note-taking and review. The same advice goes for any other subject-specific study books you may utilize like Pathoma—the point is to make the actual physical process as easy and streamlined as possible.
Topics of Special Focus: Osteopathic Manual Medicine (OMM), Viserosomatic Levels, and Biostats
OMM is a significant component in each of the COMLEX exams, but especially so in the clinical knowledge-heavy Level 2-CE. Fortunately, the OMM material covered in each level of COMLEX is essentially the same, so the better you learn and integrate this material early on, the better you’ll do on each of the COMLEX exams. The viscerosomatic levels (VLs) are also a must to have memorized before your exam, and we greatly recommend dedicating at least a portion of your review time each week to making a chart with each of the levels and making sure you’ve completely memorized it heading into your test day. When you begin the test, spend a moment writing down your now well-memorized VLs chart on your Prometric-provided paper/notebook for reference throughout the exam.
Biostats also makes up a significant part of the COMLEX Level 2-CE as well, so purchasing and working through the Biostats questions on UWorld should be a part of your study program. Similar to the VLs, write down common Biostats equations (sensitivity, specificity, NPV, etc.) on your provided notepad on test day to reference throughout the exam.
COMLEX Level 2-CE and USMLE Step-2 Timing
As the COMLEX Level 2-CE is the last COMLEX you’ll take before applying to residency programs, you’ll need to pay close attention to its timing in relation to the USMLE Step-2. Almost all DO students will take both exams, and we recommend taking the USMLE first then the COMLEX about 2-3 days later. Both exams are exhausting, and taking an additional week or more between them simply isn’t worth it unless you absolutely must. During the few days between each exam, spend time reviewing the COMLEX-specific material like OMM. Go hard during these days—10-12 hour study sessions are ideal, so try to clear your schedule as completely as possible during this period and ideally the week or two prior to taking the USMLE as well. And, perhaps most importantly, make sure the day before each exam is truly, totally off. Rest and reducing anxiety at that point is far more important than blasting through tons of practice questions, so give yourself a rest day to ensure you’re fresh and fiery the day of.
The COMLEX Level 2-CE should feel, by test day, like a largely familiar and unintimidating exam. The Level 1 has prepared you for its structure, and has likewise strengthened your understanding of your weaknesses, giving you a good initial basis to begin studying. Spend time going over your rotation notes throughout Year 3, and discuss points of concern with your advisors and supervisors. Make a careful study plan, stick to it, and be kind to yourself in the days before the exam.
1. When should I take the COMLEX Level 2-CE?
Most students take the Level 2-CE sometime after the end of their 3rd year in DO school, with the most popular months being May, June, or July. Additionally, we also recommend taking it shortly after the USMLE, approximately 2-3 days later. Enough time to rest, refocus, and review OMM material.
2. What are the main differences between the COMLEX Level 1 and COMLEX Level 2-CE?
Both exams share the same structure and overall dimensions and domains, but differ in the ratios of these dimensions on the exam, and scientific disciplines tested. That is, the Level 2-CE moves away from the heavy FBS focus of the Level 1, and instead focuses much more heavily on clinical disciplines. Additionally, there is a greater emphasis on non-science material like ethics and communication.
3. What books do I need to study for the COMLEX Level 2-CE?
Your textbooks from years 1-2 of your DO program are of the utmost importance, paired with your related notes. First Aid for the COMLEX is a must, and Pathoma’s Fundamentals of Pathology can be helpful as well. Otherwise, keep it simple! There are so very many study books that it’s far better to pick a couple good ones and study them in depth, rather than sampling dozens of different books.
4. Is the USMLE Step-2 more important than the COMLEX Level 2-CE?
As a factor in residency decisions yes, but for graduating from your DO program absolutely not. You’re almost assuredly going to take both, so just treat them as equally important, and study accordingly.
5. How is the COMLEX Level 2-CE scored?
Scores on the COMLEX Level 1 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. The historical mean of the COMLEX Level 2-CE ranges from 500-550.
6. What’s a good COMLEX Level 2-CE score?
The historical mean of the COMLEX Level 2-CE ranges from 500-550. Anything over 600 is seen as competitive for most residencies, with scores over 700 putting you in the 90th percentile. That said, in the eternal debate between DO vs MD students, DO students often do stand a slightly lower chance for historically allopathic residencies, so you want to score as highly as possible on both the COMLEX Level 2-CE and the USMLE Step-2. The unfortunate reality is that, as a DO student, you have more tests to take than MD students—but since the Level 2-CE and Step-2 test fairly similar material, your studying for each will benefit both.
7. When are scores released for the COMLEX Level 2-CE?
Scores are typically released approximately 2 weeks after the end of a given testing cycle. For instance, if you took your COMLEX Level 2-CE during the April 16th - May 14th 2021 period, your scores would likely be released between May 25-26th 2021.
8. When should I start studying for the COMLEX Level 2-CE?
Studying ultimately begins on your first day of DO school, as your years 1-2 coursework is the central method of building required knowledge. In the short term, you should begin taking practice assessments in January of year 3 and then begin working with question banks like UWorld thereafter. Do your best to periodize—maximize study sessions during lighter rotation weeks or breaks—but you really have to treat that whole second semester as a study period and be as thorough and consistent as possible throughout.
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