For better or worse, the COMLEX Level 2-PE is unlike any of the other exams in the COMLEX series. While COMLEX Level 1, COMLEX Level 2-CE, and Level 3 are straightforward multiple-choice tests, the COMLEX Level 2-PE is an in-person, active clinical assessment series that asks students to navigate standardized patient (SP) encounters. Those of you familiar with MCCQE Part 2 or USMLE Step 2 CS should have an idea of what these types of assessments look like. No more relaxing into the rhythm of hundreds of single-answer questions on a computer screen in near-silence—the Level 2-PE is a true “out of the frying pan and into the fire” assessment that will test every aspect of your abilities as a 3rd or 4th year DO student.
But all this intensity doesn’t need to feel overwhelming! With the right understanding of the exam and optimal study plans, the COMLEX Level 2-PE can be an exciting and massively confidence-building experience. In our guide, we’ll help you score well and have a positive experience.
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What is the COMLEX Level 2-PE?
The COMLEX Level 2-PE is the 3rd 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:
Two-day computer-based, application of osteopathic medical knowledge concepts related to clinical sciences, patient safety and independent practice, foundational competency domains and clinical presentations
The COMLEX Level 2-PE is an OSCE exam, typically taken shortly after the Level 2-CE, at the start of a DO student’s 4th year. It’s the last COMLEX exam to be taken before residency, and so will likely happen in the midst of your ERAS or CaRMS application prep. Unlike the Prometric-invigilated COMLEX exams, however, the COMLEX Level 2-PE is taken at one of the NBOME’s National Centers for Clinical Skills Testing, either in Philadelphia or Chicago. We’ll get into the structure of the COMLEX Level 2-PE in just a moment, but it’s important to stress from the outset that the experience of the Level 2-PE relies on “standardized patients,” i.e., actors who stimulate various patient presentations. Students perform normal clinical interviews, assessments, and differential diagnoses, and write out treatment plans on e-SOAP notes.
Reminder of what the entire COMLEX exam consists of:
What’s on the COMLEX Level 2-PE?
The COMLEX Leve 2-PE is a one-day assessment structured around 12 standardized patient encounters in one of the NBOME’s two National Centers for Clinical Skills testing—either in Conshohocken, Pennsylvania or Chicago, Illinois. The day is organized into the following blocks:
In one sense, the structure of the Level 2-PE is far simpler than the Level 2-CE. Rather than navigating hundreds of questions that touch on dozens of different dimensions and domains, the Level 2-PE puts you into only 12 standardized patient encounters, greatly decreasing the total variety covered by the exam. However, the obverse of this is that each patient encounter will carry tremendous weight, and will nonetheless pack in a considerable amount of complexity.
Being part of the overall COMLEX series, the Level 2-PE still focuses on assessing students in specific domains—2, in this case—relevant to Osteopathic proficiency. These are:
Of course, these are simply the general domains of assessment criteria. Your knowledge of all other domains will be tested by each examination and diagnosis, including Foundational Biomedical Sciences (FBS) and the various system-specific domains tested in the COMLEX Level 2-CE. There may not be discrete questions on organic chemistry on the COMLEX Level 2-PE, but you still need to understand the role of homocysteine testing in order to diagnose certain kinds of lymphoma.
Lastly, the NBOME’s orientation specifically lists certain Osteopathic Manipulative Treatments (OMT or OMM) that will likely be relevant to your testing session’s standardized patient presentations. These include:
In addition to the OMT and sophisticated clinical skills listed above, there are specific basic skills that should be followed in each patient encounter:
- Introduce yourself formally
- Shake the patient’s hand
- Ask the patient how they want to be addressed – preferred gender pronouns etc.
- Sit at or below the level of the patient
- Maintain good eye contact
- Assure the patient of your attention with eye contact and qualifying why you need to look away when you take notes, etc.
- Be as empathetic as possible
- Convey confidence in your understanding and technical proficiency
- Wash/sanitize your hands before beginning each exam
- Place your stethoscope on skin
- Drape your patient – if you uncover an area, remember to cover it back up
- Clarify transitions between the different components of the exam
- Close the encounter as smoothly as possible – try to end every encounter with some version of “Did you understand what we talked about” or “Do you have any further questions?” before ending with “Thank you very much, I hope that you feel better soon.”
- Be sure to explain what you’re doing at each stage of the exam
- Make your moves and maneuvers explicit – strive to act as realistically as possible in spite of the simulated nature of the patient’s presentation
- Don’t break role – similar to the prior point, always treat the encounter as a real patient encounter.
While these basic protocols can all be memorized and mastered quite easily beforehand, it’s important to remember that you’ll be hitting each of these points of etiquette and procedure while thinking about a great deal of information in order to examine, diagnose, and treat within the time limit. Making sure these basic skills flow automatically and with as little additional self-checking as possible will be key to ensuring smooth and effective patient encounters.
Since the Doorway Information Sheet or Patient Chart is the first thing you’ll examine, your reading and analysis skills are vital throughout the Level 2-PE, not just to perform an accurate SP exam but to keep things on track timewise. These are structured identically to a normal nurse’s note or patient chart, containing a brief statement of the reason for the patient’s visit, their vitals, lab results, and so on. Any relevant radiographic imagery like x-rays will be noted on the chart but available to view on a tablet within the exam room. The SP chart will also include scrap paper for any notes you want to make, though these will not be a part of the grading process and will be shredded after you complete the exam.
Lastly, it’s important to understand from the outset that there are no additional physician examiners or chaperones with you while you’re in an SP encounter. This is in part to best approximate the examination experience of an independent—and so unsupervised—osteopathic physician. Your SP will not respond or react to simulated maneuvers, imaginary medication, paperwork, and so on. It cannot be stressed enough that one of the central keys to doing well on the COMLEX Level 2-PE is treating your SP as a real patient at all times.
Are you wondering how to prepare for an OSCE exam? Check out our video:
Scoring
While you may suspect that scoring the COMLEX Level 2-PE would be a simple correct or incorrect verdict on your examination and diagnosis, it’s actually quite a bit more complicated than that. The Level 2-PE doesn’t utilize a 3-digit numerical score in the way the other COMLEX exams do, but is simply Pass/Fail based on your overall performance. Scoring for the Level 2-PE is conjunctive, meaning you must receive a passing grade in both domains. Your performance is assessed according to the biomedical/biochemical and humanistic domains mentioned above in the following ways:
Biomedical/Biochemical Domain
Assessing skills in this domain includes measuring aspects of data-gathering, OMT, and documentation i.e. SOAP notes. The specific criteria are:
Humanistic Domain
Assessing this communication-based domain includes measuring your ability to
In grading, the standardized patient will assess your skills in history taking and performance of the physical exam, while video recordings of each encounter and your SOAP note will be graded by a separate Osteopathic Physician.
Following your exam, you may request a score confirmation that reviews the accuracy of the data collected and scoring procedure, but the NBOME will not review the video-recorded encounters with test-takers. To a great extent, you must simply hit all of these points well and confidently, and be as accurate in your assessments and diagnoses as possible, in order to pass.
Finally, the NBOME provides the overall Pass/Fail grade on both domains individually. This means that if you Pass, you’ll have passed both domains, but if you fail, you’ll receive an explanation as to whether you failed just one or both domains. Additional descriptive performance information is provided only in the case of an overall Fail. Scores are made available within 8-10 weeks after completion of the test.
Registration and Accommodations
Students become eligible to register for and take the COMLEX Level 2-PE when they have passed the Level 1, completed the second year of their DO program, and have received attestation by their College of Osteopathic Medicine (COM) that they are in good academic and professional standing. For this last criterion, students can request attestation from their COM on the “My Account” page of their NBOME profile, under the “Register or Schedule Level 2-PE Exam” tab.
It’s important to note here that students don’t need to pass the Level 2-CE prior to the Level 2-PE, although in practice, the PE is almost always taken after the CE. This is typically because studying for the CE is more laborious and structured, and touches on much of the material tested “in vivo” in the PE. In other words, taking the COMLEX Level 2-CE first greatly assists the student in preparing for the clinical assessments of the Level 2-PE, but for the most part the reverse is not the case.
As with the other COMLEX exams, special accommodations based on ability or medical need can be requested from NBOME directly. Simply review and follow their Instructions to Request Test Accommodations and submit a request via email or physical mail.
Retaking the COMLEX Level 2-PE follows the same guidelines as other COMLEX exams. You may not retake the exam to improve a passing score, but if you fail you may retake the exam up to 4 times in a year in order to achieve a Pass.
Check out some additional tips that will help you ace any OSCE exam!
Preparing for the COMLEX Level 2-PE
Keeping with the trend that the COMLEX Level 2-PE is distinctly different from its sibling exams, preparation for the Level 2-PE will be quite unlike the methods used to study for the computer-based exams.
Standardized Patient Encounters
Perhaps the biggest predictor of success on the COMLEX Level 2-PE is experience with standardized patient encounters before the exam. A study published in The Journal of the American Osteopathic Association noted that likelihood of passing the exam increased significantly when students have had SP encounters during their first three years in DO school. Specifically, the biggest indicator of success was having undergone a formal SP examination prior to the exam. The majority of students who reported failing the Level 2-PE in the AOA survey reported not having had a formal SP exam, while the majority who passed reported having undertaken at least one formal SP exam. If your COM offers any kind of SP encounters it’s in your best interest to utilize them, and the more formal they are the better.
There are, of course, some important points to focus on during these SP encounters, whether they’re in a formal exam context or purely practice. The first is to always treat them like actual patient encounters. As noted above, your ability to present what you would do in an actual patient assessment is the central focus of the COMLEX Level 2-PE, and the only way to do that is to do exactly that. Be professional and engaged, and try to “be in the moment.” Try to focus in on exactly what the patient is saying and explaining, and for the most part let go of your awareness of the exam timeline—the 2-minute warning is there for a reason, so provided you’ve practiced with time limits and have internalized a sense of how long each encounter should take, you can just remain focused on the patient before you and not worry too much about what comes next.
WelCOM and COMSAE Exams
In our guides to the COMLEX Level 1 and Level 2-CE, we strongly recommended taking the corresponding WelCOM and COMSAE Phase 2 self-assessment tests during your studying. However, since the COMLEX Level 2-PE differs so much in its focus and context, are these practice assessments worth your time during your preparation for the Level 2-PE?
The short answer is “it depends.” If for some reason you’re taking the Level 2-PE before the Level 2-CE—not unheard of but fairly uncommon—and you have plenty of time to study during residency, then the WelCOM and COMSAE Phase 2 exams can be helpful diagnostics to make sure you have grasp on the fundamental clinical science material both Level 2 exams cover. The COMSAE Phase 2 is especially helpful in this regard, as it contains many questions covering the 10 clinical science disciplines covered in both the Level 2-CE and Level 2-PE.
That said, spending your time on multiple choice practice exams before the Level 2-PE probably won’t improve your results much. Instead, the bulk of your studying should focus on.
Course and Rotation Notes
In reality, preparing for the COMLEX Level 2-PE starts as early as your first year, when you begin coursework in Osteopathic Principles and Practice (OPP), Physical Diagnosis, and Medical Procedures (MP). This information should of course already be well-memorized and a part of your understanding of Osteopathic treatment, but when preparing for the Level 2-PE it will likely benefit you to at least review this information.
More time should be spent going over your notes from second year MP courses, and, most of all, your notes from core clinical rotations in your third year, especially those in Internal Medicine and Family Medicine. You should also consult any notes or evaluations provided by your supervising physicians during these rotations, and reviewing any subject or diagnostic areas in which you experienced uncertainty or mistaken diagnosis.
Many schools will offer a PE review day sometime during the second or third year, in which students undertake timed SP encounters. If you have the ability to participate in this kind of exam, by all means do it, and if possible, ask for your supervising physicians or instructors to go over your SOAP notes with you for additional feedback. As you probably suspect, studying your clinical performance thus far as a DO student—both to review what you did well and to identify any potential blind spots or weaknesses—will help you tremendously when exam day comes.
What to Expect on Exam Day
Exam day for the COMLEX Level 2-PE will be very unlike those of the Level 1 and 2-CE. As noted, you’ll have travelled to one of the NBOME’s national testing centers, either in Chicago or Philadelphia. Unless you already live in either of these cities, you’ll need to plan your travel and hotel accommodations ahead of time, but that shouldn’t be much of a problem: because of the limited testing capacity for the Level 2-PE, you’ll need to register well ahead of your exam date—sometimes nearly a year—thus giving yourself ample time to plan and budget for your travel. When you plan your budget for medical school, remember that your medical school costs should anticipate these expenses.
On the morning of your testing date, you’ll wake up and head to the testing center well ahead of your scheduled session. The NBOME recommends arriving at the testing center at least 30 minutes ahead of time, but we also recommend a kind of scouting mission the day prior if possible, so you know exactly where you’re going on test day. As NBOME notes, the complexity of scheduling and organizing the Level 2-PE means that there’s very little wiggle room if you’re running late, and you may be given a No Show. Making sure you’re on time is incredibly important.
Dress professionally and bring a standard, unmarked stethoscope if possible, though the NBOME will provide a loaner if you do not. When you arrive, be sure to have 1 government-issued photo ID and your confirmation page/email readily accessible to verify your scheduled examination. Although the NBOME provides both lunch and a snack, you’ll also want to bring any food you prefer if you have strict dietary needs.
The exam itself is approximately 6 hours long, with 12 14-minute SP encounters followed by 9 minutes to compose your e-SOAP note.
Study Tips
Studying for a performance-based exam can seem difficult or even impossible, but fortunately there are some basic guidelines that can ensure your COMLEX Level 2-PE goes well.
NBOME Orientation Materials
While the NBOME- and AACOM-designed practice assessment series—COMSAE, COMAT, and WelCOM—aren’t especially helpful for preparing for the performance-based Level 2-PE, the NBOME has provided a number of detailed documents and guides for the exam. Specifically, you’ll want to carefully study their eSOAP Note resources, which include a tutorial video, completed eSOAP Note sample, and practice form so you can get used to the format. You’ll also want to watch and take notes on their Sample Patient Encounter video, which will further illuminate best practices regarding the eSOAP note.
The NBOME has also provided two fairly lengthy orientation packages to help you get a clear sense of how the COMLEX Level 2-PE will go. One of these resources is the COMLEX Level 2-PE Orientation video series. Organized into 13 chapters, the orientation video series will cover the basics of each step of the exam, from registration and travel, to SP encounters, to OMT and SOAP note guidelines. Reviewing these videos throughout your study (and especially the night before the exam) will greatly alleviate any uncertainty you may feel heading into exam day.
Virtually every aspect of the exam is covered in detail throughout the NBOME’s COMLEX Level 2-PE Orientation Guide. Updated each year, this is in every way the central organizing document for your review. It covers every element of the exam, including registration requirements, exam design, item-specific guides covering SPs, Doorway Sheets/Patient Charts, eSOAP notes, common abbreviations, and overviews of expected conduct and professionalism.
One of the best ways to study this information is to utilize it during your clinical rotations, making sure that you can successfully and efficiently hit every point of assessment in your encounters. Obviously, this will vary somewhat by patient and/or rotation, but the assessment criteria for the Level 2-PE will, of course, at least approximate what you’re expected to do by your COM. Treating Level 2-PE prep and optimal clinical performance as one and the same is key to understanding the holistic nature of this phase of licensure exam.
SOAP Notes & Practice Cases
The e-SOAP note comprises a major component to your score on the Level 2-PE, and so great care should be taken to ensure yours will be as clear and detailed as possible. The NBOME materials above will help, but you should also spend time practicing assessment protocols like reviewing door notes, writing down questions you would then ask the patient, and finally noting your differential diagnosis, possible OMT, and treatment plan. There are some books with suitable practice cases that can help you do this, such as Jones and Bartlett’s Comlex Level 2-PE Review Guide which includes 50 practice case encounters that you can use to practice all of the aforementioned aspects. Treat each of these practice cases as real encounters: time yourself, even audibly asking the questions you would pose to the patient. If possible, do this with a study partner and take turns acting as the patient for one another to the best of your ability. Review each other’s SOAP notes after the simulated patient encounter, and utilize the criteria listed in the NBOME’s official guides to make sure your notes are sufficiently detailed and clear.
When you go through practice cases, keep in mind that you won’t have time for a full physical exam during the Level 2-PE. Although you shouldn’t feel rushed during the exam, you do need to make some choices about what not to attempt or include, and the reigning consensus is that heart and lung exams should be done in every SP encounter, followed by an exam of the affected areas. This isn’t an ironclad rule, of course, but in general, it makes for a good default format. When you work through practice cases or review your rotation notes, think about how you would best use this structure to address each case, and make sure to note instances where it would’ve been insufficient. This is unlikely, but understanding the potential for exceptions is just as important as internalizing the rules.
Prep Courses
As you may expect, COMLEX Level 2-PE prep courses will be extremely helpful if they are of good quality. There aren’t many that cater to this specific exam, but if you have the time and money to utilize one, they can offer a greater volume of practice cases and, if the course is truly good, individualized feedback on your SOAP notes and differentials in order to help you determine your weaknesses as a clinician or diagnostician.
Conclusion
Although the COMLEX Level 2-PE is a very different beast compared to the other COMLEX exams, in many ways it’s simply a kind of deployment of the material covered in the Level 2-CE, as well as your 3rd year rotations. Studying to perform well within the structure and scoring metrics of the test will then be of slightly greater importance than cramming for biomedical science information, but heading into the Level 2-PE with a balance of both is the best route to success. Seek out as many patient encounters as you can obtain in the months prior to the exam, and really hone your ability to produce quality diagnoses, notes, and treatment plans under a time limit. Lastly, try to enjoy the experience to some extent. If you’ve never been to Chicago or Philadelphia, maybe schedule an extra day or two to tour the city a bit—if you’re in Philadelphia, be sure to check out The Mütter Museum, possibly the greatest medical oddity museum in the world. The COMLEX Level 2-PE is the last COMLEX exam you’ll take as a DO student before residency, so try to savor and reflect on the experience so far.
FAQ
1. When should I take the COMLEX Level 2-PE?
Students become eligible to take the Level 2-PE as soon as they’ve passed the Level 1, but we recommend taking it sometime shortly after taking the Level 2-CE. This allows you to benefit from the studying on Clinical Sciences you’ll have undertaken for the Level 2-CE, while also having one less “big thing” looming on the horizon as you prepare for the 2-PE.
2. How is the COMLEX Level 2-PE scored?
The Level 2-PE is scored conjunctively Pass/Fail. This means that in order to receive a passing score, you must receive a Pass in both the Biomedical/Biochemical Domain and the Humanistic Domain.
3. When are scores released for the Level 2-PE?
Scores for the 2-PE take longer to report than the other COMLEX exams—approximately 8-10 weeks after your test.
4. What happens if I fail the COMLEX Level 2-PE?
The NBOME allows students to retake any of the COMLEX exams a maximum of 4 times within a 12-month period. However, you may only retake a COMLEX exam to pass a previously failed exam, not to improve your score. In the case of the Level 2-PE, then, you can retake it up to 4 times in a year if you fail.
5. Is the COMLEX Level 2-PE difficult?
This is a relative question, but in general the Level 2-PE isn’t seen as especially difficult for most students. In recent years, over 92% of first-time test-takers received a Pass, as did 91% of second-time test-takers. These numbers shouldn’t justify being lazy in the months before the exam, but provided you’ve been performing well in your courses and rotations you should have a pretty solid handle on how to pass the Level 2-PE.
6. If I get behind on time, can I move on to writing my SOAP note without finishing the exam?
You should rely on the 2-minute warning to indicate when you need to wrap up your exam. If you’ve fallen behind during the first part of the exam, try to at least inform the patient of your impression and treatment plan before thanking them, shaking their hand, and leaving the exam room. Remember, a correct diagnosis and thorough SOAP note is only part of the exam—you need to make sure your examination is as complete as possible
7. How many differentials should I include in my assessment?
You should list at least 3 differentials on your SOAP note, ranked from most likely to least likely.
8. Should I try to perform a complete physical exam on each patient?
No, you simply won’t have time for full physical exams in most cases. Rather, focus on heart and lung exams, followed by examining the specific affected areas as described by the SP.
9. Will I receive any directions on what to do in each examination room?
The Doorway Information Sheet or Patient Chart will give you all of the relevant information, as well as mention any radiographic imagery available on the tablet within the exam room. As the SP encounters are meant to simulate actual patient examinations, you won’t have any instruction beyond nurse’s notes on this material, but since you’ll have quite a few clinical rotations under your belt by this time, it shouldn’t feel especially challenging or new.
10. What’s the best way to study for the COMLEX Level 2-PE?
Given the nature of the exam, working through question banks and reviewing textbooks won’t be your best strategy. Rather, focus on attending any and all simulated patient examinations or assessments offered by your COM, and utilize practice cases in material designed for this exam specifically, like the Level 2-PE books and NBOME material listed above. Likewise, to best utilize this material, try to study with another student preparing for the exam, taking turns acting as the patient and trying to simulate an actual exam to the best of your abilities. Lastly, your rotation notes and any comments from attending physicians will be immensely helpful to review, and these can also be used as scripts for partnered study and exam simulation.
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