A Medical Student Series: On the Road to Graduation

Congratulations! You have been accepted to medical school and are busy juggling a hectic schedule between life and work as a student. All your steps on this arduous journey to residency count. By pursuing medicine, you have made the investment in yourself so that you may serve others. I hope my monthly series of articles provides you with valuable information and tips that I have learned along the way. 

Hey there! I am a fourth-year medical student who grew up in central Missouri. I attend A.T. Still University – Kirksville College of Osteopathic Medicine and am applying to residency in Emergency Medicine.

Board Examinations as an Osteopathic Medical Student: Preparation and Review

The Comprehensive Osteopathic Medical Licensing Examination of the United States (COMLEX-USA) is divided into three levels throughout medical school and training. These exams are required for licensure to practice osteopathic medicine. COMLEX Level 1 and Level 2-CE are comprised of 352 questions divided into two 4-hour sessions, generally taken after your second and third years of medical school, respectively. The National Board of Osteopathic Medical Examiners (NBOME) began utilizing Pearson Vue testing facilities in 2023 to administer COMLEX exams. COMLEX Level 1 and Level 2-CE currently cost $715 per exam. (https://www.nbome.org/assessments/comlex-usa/)

The United States Medical Licensing Examination (USMLE) is required for students in allopathic medical schools. It is divided into a series of three steps, usually taken in the same time frames as COMLEX exams. USMLE Step 1 is divided into seven 60-minute blocks and will not exceed 280 test questions. Step 2-CK has eight 60-minute blocks and will not exceed 318 questions. Prometric testing centers are utilized by the National Board of Medical Examiners (NBME) to administer the USMLE. Steps 1 and 2-CK cost $670 per exam in 2024. (https://www.usmle.org/)

The final examinations, Level 3 and Step 3, are completed during residency training. Eligibility to sit for these exams partially includes graduation from medical school and successful completion of Levels 1 and 2-CE or Steps 1 and 2-CK. Each state has specific requirements for medical licensure (https://www.fsmb.org/step-3/state-licensure/). Osteopathic physicians primarily take (and need) only Level 3, even if they took Steps 1 and 2. While you should be aware of this content, please do not stress about it now. Medical school is a marathon and best completed one task at a time.

In 2020, both Level 1 and Step 1 examinations were announced to transition from a scored system to pass/fail beginning in 2022. I was one of the first cohorts to take pass/fail medical boards. I would advise students that even though boards are now pass/fail, studying for them should still be taken seriously. While pass/fail scoring does alleviate some stress, it puts more emphasis on the Level 2 and Step 2 scores, which remain numeric. Of note, for those who are considering taking USMLE so they might present the test score to residency programs, you do not have to take Step 1 to be eligible to take Step 2.

While there can be pressure for students to take both COMLEX and USMLE, advocacy efforts have been publicized in 2023 from specialty organizations such as the American College of Obstetrics and Gynecology (ACOG) and the Council of Residency Directors in Emergency Medicine (CORD) to encourage residency programs to accept both osteopathic and allopathic examinations without bias. The NBOME has created a concordance table for residency program directors to give context to COMLEX-USA scores in comparison to USMLE. (https://www.nbome.org/news/concordance-comlex-and-usmle-scores/)   

Ultimately, like many other osteopathic medical students, I found myself asking the question, “Should I take USMLE along with COMLEX?” While osteopathic medical students are NOT required to complete the USMLE, the number of those choosing to sit for both examinations has risen in past decades to improve residency selection candidacy. I will admit this was my primary motivation for completing both COMLEX Levels 1 and 2 as well as the USMLE Steps 1 and 2. I scheduled Step before Level and took them within 7-12 days of each other. I recommend that, if taking both, you schedule them within 5-10 days apart to keep content fresh in your mind and avoid burnout with an extended study period. After finishing my second-year courses, I created a dedicated study schedule for boards (it was a large, colorful Excel spreadsheet). Each day, I would complete a goal number of practice questions, readings, and flashcards. I used UWorld, TrueLearn, First Aid text, and handwritten flashcards. Other students have had success with Amboss, Boards and Beyond, OnlineMedEd (which now requires a subscription), Anki, and other platforms. You have likely identified your study style after two years. Keep up with what best helps you learn and retain content with the board exam in focus.

I used the exact same strategy to study for Level 2 and Step 2 at the end of my third-year, however I had to plan a dedicated four-week period of elective time amongst my clinical rotations to focus solely on boards right before I took the exams. Another tool I found useful in studying for boards were practice tests distributed by the NBME and NBOME. The NBME has several questions at no cost, known as “free 120,” and other practice exams for purchase. I found these helpful in both covering content and simulating test day. The NBOME also has practice exams for purchase, however they offer no exam review or explanation of best choice answers which I found disappointing and unhelpful. Other question bank platforms will have partial or full-length practice tests. Use them! I think a simulation of test day is one of the best things you can do to prepare.

With all of that said, I truly wish you luck. You have done an excellent job thus far entering medical school and preparing for exams. Keep up the hard work until you have crushed your boards! While I do not intend this to be a fully comprehensive guide, I do hope that you find this content from my experience helpful. Read next month’s MAOPS Prognosis for more articles!

Hannah Bisoglio, OMS IV