COMLEX Level 2 vs. USMLE Step 2: What Are The Differences?

Beginning your journey of medical licensing exams can be a tough experience. As a recent DO graduate, I know the challenge of combining studying for the USMLE and COMLEX. For many, the dichotomy between the USMLE Step 2 and COMLEX Level 2 poses a unique set of hurdles—one that goes beyond the usual rigors of medical examination. In this blog post, we will uncover the intricacies of these two exams. We will explore the main disparities in question stems and shed light on the often-mystifying world of scoring. 

To explore question formulation, let’s compare USMLE Step 2 question stems with those found in COMLEX Level 2. What distinguishes these question stems, and how should students adapt their approach accordingly? Should there be a tailored focus on distinct content for each exam, or can students effectively prepare for both simultaneously? 

As we move through this exam terrain, we’ll explore scoring differences. From the supposed equal weight given to all questions in COMLEX to the intricacies of the scoring process in Step 2, we’ll address these issues and discuss how they impact the final assessment. 

Overview of USMLE and COMLEX: History and Purpose

Licensing exams like the USMLE and COMLEX are essential milestones in medical education, serving as standardized tools for assessing the clinical knowledge needed for licensure. The USMLE was introduced to measure MD students’ ability to apply medical knowledge in real-world clinical settings. It is widely recognized across the U.S. and plays a key role in the residency matching process, particularly when students are applying for competitive programs. Over time, the USMLE has shifted its focus toward clinical decision-making, moving away from rote memorization to better assess how candidates apply their knowledge in real-world patient care scenarios. 

In contrast, the COMLEX was developed to meet the specific needs of osteopathic students. This exam emphasizes Osteopathic Manipulative Medicine (OMM) alongside clinical knowledge. The exam not only tests clinical skills but also underscores hands-on treatment techniques central to osteopathic practice. With the AMA now recognizing the COMLEX as equivalent to the USMLE, DO students are better positioned for licensure and residency applications. This development means that osteopathic graduates can compete for the same residency opportunities as their MD counterparts. That being said, many osteopathic students take the USMLE in addition to the COMLEX exams, allowing programs to objectively compare them to allopathic applicants. 

Although the USMLE and COMLEX have distinct focuses, they are vital for obtaining a medical license in the U.S. They share a common goal: assessing future physicians’ readiness to apply medical knowledge in clinical environments, making them major components of the medical licensure process.

USMLE Step 2 vs. COMLEX Level 2 Question Stem Differences

Comparing the question stems of COMLEX Level 2 and USMLE Step 2 highlights distinct challenges in medical licensing exams. Drawing from my personal experiences having studied for these exams, it’s clear that they approach questioning in unique ways. 

In my experience with COMLEX, the questions are not as clear and detailed as those in the USMLE. Unlike Step 2, COMLEX Level 2 doesn’t delve into biochemistry intricacies but emphasizes Osteopathic Principles and Practice (OPP). This requires interpreting OPP findings to understand disease processes, which can sometimes be frustrating and seem illogical. For instance, questions related to acute myocardial infarction presentations might inquire about the appropriate OPP treatment despite emergency cath lab procedures being the norm. Although both exams are moving away from “buzzword” phrases, USMLE will tend to give the classic presentation of disease processes while COMLEX can present atypical demographic features. For example, an autoimmune disease will usually present in a 20s-30s-year-old female on USMLE, while COMLEX may ask about the same disease state in a 40-year-old male. 

Moreover, COMLEX often necessitates assumptions due to information gaps in stems. A noteworthy trend is COMLEX’s emphasis on preventive medicine and risk factors of disease. In contrast, while USMLE Step 2 demands a deeper understanding of pathophysiologic details, its questions are perceived as fair and free from the trickery associated with COMLEX. 

My colleague, Dr. Janet Tam, shared insights on these differences, drawing from her experience as a former DO student and a specialized tutor for Osteopathic students. 

Dr. Tam’s Insights on the Differences Between COMLEX and USMLE 

In my correspondence with Dr. Tam, she agrees that COMLEX Level 2 questions tend to be vague compared to Step 2. She emphasizes that Step 2 provides all the necessary details to piece together a diagnosis, making it clearer what it intends to test. However, she notes that doing well on Level 2 questions often relies on a “gut feeling” cultivated from practice with similarly vague questions. She added that COMLEX prioritizes its own set of topics, such as ethics, pediatrics, and OB-GYN, over intricate biochemistry details tested in Step 2. Furthermore, she mentions a unique aspect of COMLEX, where it will ask multiple questions on the same topic across different question blocks, reinforcing understanding through repetition.

Comparing COMLEX Level 2 vs. USMLE Step 2: Structures and Strategies

Understanding the structure of both COMLEX Level 2 vs. USMLE Step 2 is crucial for medical students preparing for these challenging exams. Although both exams assess clinical knowledge, their formats, time allocation, and focus areas differ, requiring tailored strategies for success.

Total Testing Time:

How long is COMLEX Level 2? COMLEX Level 2 spans approximately 9 hours, including scheduled breaks. In comparison, USMLE Step 2 lasts about 8 hours. These differences in duration make stamina and break planning vital for both exams – especially for COMLEX – which demands more time overall.

Number of Questions:

How many questions are on COMLEX Level 2? COMLEX Level 2-CE consists of 400 questions across 8 blocks, while USMLE Step 2 CK includes around 318 questions divided into 7 blocks. The increased number of questions on COMLEX makes time management essential for success. While USMLE has fewer questions, they often require more in-depth clinical reasoning, making pacing equally important.

Time Per Question:

On average, USMLE Step 2 CK provides more time per question compared to COMLEX. USMLE questions demand a focus on detailed clinical reasoning, whereas COMLEX emphasizes broader preventive medicine topics and risk factors. These question-type differences mean that students must develop unique time management strategies for each exam.

Block and Session Structure: 

USMLE Step 2 CK consists of fixed blocks with a set number of questions, which students must complete within a specific time frame. Conversely, COMLEX Level 2 offers a similar block format but with more flexibility in how students can approach pacing and time management.

Break Time Allocation: 

Break times are an important part of exam day strategy, as they directly impact a student’s focus and stamina. USMLE Step 2 CK provides structured, preset break times, limiting student control over when breaks occur. COMLEX Level 2, however, gives students more freedom to decide when to take breaks, allowing them to adjust their schedule based on personal energy levels.

For students taking both exams, understanding the COMLEX Level 2 to USMLE Step 2 conversion is critical. Despite the scoring scales being different, many residency programs treat the exams equivalently, allowing students to apply more broadly. Being aware of the Level 2 to Step 2 conversion helps students plan their residency applications more strategically.

Scoring Differences Between COMLEX Level 2 and USMLE Step 2 

As we explore the intricacies of COMLEX Level 2 and USMLE Step 2, it’s crucial to grasp the distinctions in their scoring systems. Both exams underwent revisions in 2021, transitioning into one-part assessments with a specific focus on clinical decision-making and medical knowledge. However, their scoring structures differ significantly. 

COMLEX Level 2 Scoring

The COMLEX Level 2 Cognitive Evaluation (CE) has evolved into a unified one-part exam, assessing clinical decision-making and medical knowledge in osteopathic medical students. Level 1 is now pass/fail while Level 2 and 3 are still scored. Scores are reported as three-digit numbers, ranging from 9 to 999, with a passing threshold set at 400 (approximately the 5th percentile). This passing score is a graduation requirement for osteopathic students and is generally accepted by many residency programs. However, the preference for a USMLE score by certain residency programs introduces an added layer of complexity for DO students.

USMLE Step 2 CK Scoring 

Similarly, USMLE Step 2 changed in 2021, consolidating into a one-part exam—the Clinical Knowledge (CK) section. Scores for Step 2 CK are reported as three-digit numbers, ranging from 1 to 300, with a passing threshold that has progressively increased over the past 15 years. As of this blog post, the passing score is 214. The USMLE is widely accepted by US residency programs, regardless of whether the student is a DO or MD. 

Understanding these scoring structures sets the stage for tailoring study strategies. While both exams evaluate clinical knowledge and decision-making, the conversion from COMLEX to USMLE scores introduces an additional layer of consideration for those navigating both exams simultaneously. 

In general, many students feel that preparing for Step 2 instills confidence that carries over to the actual exam day. Step 2 practice tests typically mirror the actual exam, and feeling satisfied with the test experience often correlates with actual performance. In contrast, the COMLEX Level 2 does not offer the same level of reassurance. Despite thorough preparation, students often think of their performance on the exam negatively, even when their final scores are quite high. 

When I asked Dr. Jim Devanney, a fellow EMP tutor and current fellow in Neuro ICU in the Harvard University hospital system, he recounted his experience, stating, “When I took Step and Level 1/2, I could predict within 10 points what my score would be for Step and thought I outright failed on COMLEX despite scoring very well. When working with DO students I prep them with the knowledge that COMLEX will always feel bad no matter how well you did.” 

Differences in Study Strategies for Each Exam 

While there is significant overlap between COMLEX and USMLE, their question styles differ, as discussed above. Therefore, it’s a good idea to practice both styles to the highest scores possible. Engaging with COMLEX-style questions through COMLEX-based question banks is invaluable for learning to utilize limited information in the question stem to arrive at a diagnosis. It also helps in understanding the incorporation of Osteopathic Manipulative Medicine (OMM) into questions. 

I found ComQuest to be highly effective and very predictive of my scores for Levels 1 through 3. Another popular question bank is ComBank/TrueLearn. If you’re preparing for both the USMLE and COMLEX exams, consider using ComQuest or Combank in addition to UWorld. While managing two question banks may seem overwhelming, starting early and utilizing study schedules can make it manageable. This approach provides practice in mastering the small details necessary for success in Step exams while also tackling the unusual and vague questions that COMLEX is notorious for. 

Conclusion

My advice to the students I work with is to prepare thoroughly regardless of the exam. It’s important to focus on some of the finer details when preparing for the USMLE. However, it’s important to note that some of the orientation toward disease-specific details may be less crucial when taking COMLEX. 

For those taking COMLEX, getting in some practice with osteopathic QBanks such as ComQuest and ComBank can foster comfort with the vague presentations often encountered on test day. In my experience with COMLEX Level 2 and Step 2, completing both UWorld and ComQuest proved most helpful. This approach allowed me to experience the differences in question style while reinforcing all the key topics tested in both exams. If you feel like you need more guidance, please reach out to us so we can set you up with 1-on-1 tutoring to help guide your journey