Study Tips

Should DO Students Take Both USMLE and COMLEX?

Kyle Montgomery
Published on Jan 7, 2020. Updated on Jul 11, 2023.

As a DO student, is taking two sets of board exams worth the stress? An Osmosis Medical Education Fellow and DO student investigates.  

Graduate medical education has undergone some significant changes over the last several years, most notably with the merging of the American Osteopathic Association (AOA) and the Accreditation Council for Graduate Medical Education (ACGME).

Historically, osteopathic medical students (DOs) had the option of applying to both AOA (or DO-specific) residency programs, in which MD candidates were ineligible to apply. They also had the option to apply for ACGME (MD if you will) residency programs without being required to take the USMLE® Step 1, etc. exams that ACGME programs require. They must complete their mandatory COMLEX-USA® licensing exams (Levels 1, 2, and 3) to be eligible, however.

Nowadays there are no longer any residency programs accredited by the American Osteopathic Association. DO candidates are not required to pass the USMLE to be eligible to apply to ACGME-accredited programs. The ACGME does not require DO students to take the USMLE exams.

How will this merger impact DO students?

Many are wondering how this merger will affect DO students. Will there still be adequate residency spots? Will the merger place DO students at a competitive disadvantage compared with MD students now that we are all competing for the same residencies?  

According to the data from the College of Osteopathic Medicine, DO seniors achieved a 90.7% match rate in 2020 which is an increase compared to the number of DOs matching to ACGME programs in 2019 (80.2%). However, there has been a decrease in DO graduates for highly sought-after programs like Neurosurgery and Orthopedic surgery.

Data show that 99.29% of Spring 2020 graduates seeking GME were able to be successfully placed in graduate medical education. In addition, the number of program directors that report accepting COMLEX-USA scores from DO applicants continues to rise.

The reality is that only time will tell how this tectonic shift in graduate medical education will affect DO students. So far the early data seems promising for DO students but we might not see the whole picture yet. My guess is some programs will remain less open to DO students (as they have historically), while others will look upon them more favorably, with the vast majority falling somewhere in the middle. 

Should you take both sets of licensing exams?

The big question for most osteopathic medical students at this juncture is whether or not they should take BOTH the COMLEX and USMLE licensing exams, or if simply taking the COMLEX (Levels 1, 2, and 3) is sufficient. 

A large part of this answer will depend on the individual, their area of interest, funds available for licensing fees and board preparation materials, and the ability to adequately prepare for two licensing exams instead of one. Ultimately, the goal is to perform well and to be a competitive candidate for residency. However, after discussions with classmates, professors, residents, and physicians, taking both the COMLEX and USMLE licensing exams is going to be the right move for most DO students. 

Trade-offs to keep in mind

The basic trade-offs to consider are performance and freedom. Taking USMLE Step 1 is a tremendously stressful and challenging undertaking, made worse by the reality that DO students also have to take the COMLEX Level 1, which is longer, more expensive, and contains 30% more questions than Step 1 at the same time. 

Performing well on Step 1 will give DO students the ability (i.e. freedom) to apply to a wide variety of residency programs in their chosen specialty, as ACGME programs that are historically more attuned to MD candidates have an objective metric with which to compare DO students. Conversely, a poor score on Step 1 has the potential to close doors and leave students (both DO and MD) less competitive for certain specialties. 

Generally speaking, the more competitive residencies/specialties are the ones with fewer available spots (Orthopedics, Neurosurgery, Plastic surgery, ENT, Urology) and tend to place greater weight on high Step 1 scores. Less competitive residencies, in terms of board scores at least, include family medicine, pediatrics, and internal medicine to name a few.

The challenge for first and second-year osteopathic medical students is to figure out what specialty/residency they want to pursue and how competitive it will be to match. Given that most don’t yet know (and shouldn’t) what they’re interested in pursuing, the decision to take the USMLE exam is essentially one of hedging your bets; maybe you get through third-year clinical rotations and decide that Orthopedic surgery really speaks to you. Well, you’ll need an impressive Step 1 score to be competitive, and if you choose not to take Step 1, it’s going to be next to impossible to match into Orthopedic surgery. Conversely, maybe you decide on family medicine; a great Step 1 score can certainly help, but plenty of DO applicants who didn’t take Step 1 still match into family medicine every year.

Final thoughts

While brief, this article provides a basic framework for DO students to consider the merits of taking the USMLE licensing exams in addition to their mandatory COMLEX exams. In general, I encourage my fellow DO students to take both—assuming proper preparation—with the idea that more ACGME programs are familiar with and place more emphasis on Step 1 scores than Level 1 scores. 

Ultimately, this decision will come down to the individual and their unique situation and areas of interest. I recommend speaking with fellow classmates who have gone through the process, professors with experience in this area, and personal research (utilizing NRMP® matching data for example) on the importance of Step 1 scores in the residency selection process. 

About Kyle

Kyle Montgomery is a third-year osteopathic medical student at Pacific Northwest University of Health Sciences-COM. He is originally from Seattle, Washington. Kyle is interested in pursuing gastroenterology. When he isn’t studying, Kyle enjoys playing soccer, hiking, camping, playing the guitar, reading, and wine!