COMLEX Level 3 Changes in 2027: What to Expect and How to Prepare

For many medical students, COMLEX Level 3 can feel so far away. Much must come before then, including scheduling away rotations, securing letters of recommendation, applying to residency, interviewing, matching, and finding time along the way to celebrate how far they have come. Then residency begins, and another licensing exam suddenly joins your schedule, already loaded with patient care, documentation responsibilities, and learning how to function as a new physician. But don’t let it scare you! Recently, the National Board of Osteopathic Medical Examiners (NBOME) has announced some exciting changes to the exam format. 

What’s new?

Effective January 13th 2027, the NBOME is transitioning COMLEX Level 3 from a two-day exam into a one-day exam. The new exam will have fewer multiple-choice questions and clinical cases, but the overall exam topics blueprint will remain the same. This will likely make it easier for incoming PGY1s, who already have a lot to navigate scheduling-wise. Of note, however, just because the exam is shorter does not mean the required preparation is any less. Level 3 will still require adequate studying to build the necessary clinical judgment- just adapted to a one-day exam now. This is how I would approach preparing for this exciting transition! 

In 2024, the NBOME made this announcement, but explicitly stated that the Level 3 exam would retain a very similar proportion of content and cases. Originally, the total testing time was 14 hours, which has now become eight. The previous version of the exam had 420 questions, 26 clinical decision-making cases, and four 3.5-hour sessions. The new exam has 240 questions, 16 clinical decision-making cases, and four 2-hour sessions. When planning test day, however, remember to consider tutorials, authorized breaks, and check-in times. So far, this change is being well received by PGY1s who have yet to sit for the exam and by current fourth-year medical students as they consider coverage arrangements, transportation, and time away from work. Personally, I too believe that removing the second testing day is a meaningful logistical change that works in favor of residents. 

Let’s break it down…

For the new version of the exam, sessions A, B, and C will each contain two sets of 40 multiple-choice questions. Session D will contain two sections of eight clinical cases, preceded by a clinical case tutorial. As with Level 1 and Level 2, the resident physician has a 60-minute authorized break allowance, which they may divide as they see fit. Timing-wise, roughly 90 seconds are allocated to each multiple-choice question, based on the 120-minute time limit for two 40-question sessions.

As for the clinical case section, you have 120 minutes for 16 clinical cases, averaging roughly 7.5 minutes per case. These are not individual time limits, but pacing parameters to consider when you begin practicing for the exam. If you tend to spend too long on the first half of a session, remember that overthinking another answer choice is unlikely to change your answer. Make your most logical guess and move on so you can answer every question. If time permits, you can always return to a flagged question. Also, don’t expect every question to take the same amount of time; that depends on your strengths and weaknesses, the stem length, and your familiarity with the topic being tested! 

How should I study? 

Level 3 assesses readiness for unsupervised, general medical practice, as the target exam demographic is the newest generation of resident physicians. The relevant competencies include patient care, medical knowledge, osteopathic principles, communication, professionalism, ethics, and systems-based practice. A reduction in question count, as seen on the new version of the exam, is not a reason to assume that an entire subject has been removed from the test. Nor should this change imply the exam will be easier or require less preparation.

My recommendation is to use the exam blueprint as a checklist to ensure you are still covering all the foundations that the NBOME expects of you at this point in training. Compare the checklist with your everyday experience in residency and take note of experiences that you may not encounter as often on the hospital wards but are still fair test topics. An internal medicine resident may feel comfortable managing hospitalized adults, but will likely need to review pediatric presentations, reproductive care, or surgical techniques. Familiarity with your own service is surely valuable, but it should not be the boundary of your preparation for the purposes of Level 3 or Step 3! 

My thoughts

I believe that a productive way to study is to move beyond just being able to name a diagnosis. After each practice question, even if the stem does not ask it, ask what the physician should be doing next and why that takes immediate priority. For example, ensure you are able to distinguish between an immediate stabilization step and a diagnostic study. Be able to explain why a reasonable test may be unnecessary. To integrate systems more comprehensively, ask whether your proposed management would change if the patient were pregnant, clinically unstable, or unable to return for follow-up!

This framework will ensure you know more about the topic, which will ultimately benefit you in your clinical practice as well. To track weak topics, I would make an error-log spreadsheet around decisions you are making on practice questions. Be specific when completing this log; instead of writing “missed a cardiology question,” write “selected definitive treatment before stabilizing the patient.” A short, actionable phrase will not only help the material stick better, but will make your studying more efficient. Ultimately, this approach connects studying to the clinical work you’ll see for the rest of your career. 

OMM on Level 3

Osteopathic content remains tested on the new version of Level 3. The published NBOME blueprint lists osteopathic principles, practice, and manipulative treatment as comprising 10% of the exam items. I would interpret this percentage as a ballpark estimate, not an absolute. I would recommend doing the EMP OMM Anki deck as a refresher on topics you may not have encountered since Level 2. Rotate through these topics, including viscerosomatics, sacral and spinal mechanics, autonomics, and OMT indications and contraindications. The goal is to explain how the finding fits the patient. If you memorize a technique but can’t apply it clinically, you’re likely to get the question wrong. Recognizing that you are a full-time resident physician, ensure to keep the workload manageable. Doing 30-50 Anki cards before bed for a few weeks can help refresh the OMM material while ensuring you still have time to accomplish other checklist items. 

An Unfamiliar Section: Clinical Cases 

Unlike Level 1 and Level 2, Level 3 has a specific clinical decision-making section composed of clinical cases to work through. I recommend adding a separate study block into your schedule for this new section. The NBOME tutorial explains that these cases can use extended multiple-choice and short-answer question styles. They also state that each question will have a response limit, and answers that are harmful or unnecessarily costly may reduce the points you receive. Of note, once you move on in this section, you cannot return to fix your answer! I recommend practicing the task as it will be presented. Avoid writing an entire management plan, but ensure you are considering several competing possibilities. I’m sure with more experience throughout your PGY1 year, some of these decisions will become easier to make. 

The NBOME emphasizes the importance of specificity: imaging requires you to dictate the anatomical site, medications require drug name and route of administration, and OMT questions require techniques and specific locations. One useful exercise is to explain the answer out loud, then tweak it to be as concise as possible while staying thorough. 

The Clinical Decision-making Section

The clinical decision-making section is after the three multiple-choice sessions. That could help some test takers if certain multiple-choice questions clarify the best management steps for a condition or system. When preparing for the exam, I would definitely practice the clinical case questions after timed practice questions to build test-taking endurance and help cognitively switch between question styles. You don’t need to do a full practice exam every weekend; that is unlikely to be feasible with a PGY1 schedule. Start with a workload you can actually review properly, then build towards longer sessions, schedule-permitting. I also recommend treating breaks as part of the testing simulation. Plan food, hydration, and brief resets that work for you. 

How to Build a Plan as a Resident Physician

Residency, especially intern year, is no secret: it’s extremely challenging and takes a lot of time. When preparing for Level or Step 3, no single calendar will fit every resident’s schedule. Your baseline knowledge, previous exam experience, residency work schedule, and available study time should guide the study plan. I recommend starting with a baseline assessment, including mixed questions and a few clinical cases. Identify whether the main difficulty is content, pacing, or question interpretation.

Review your mistakes honestly and then craft how you want to approach practice questions from there. I would think that you should save your residency service for last. For example, a general surgery resident may want to focus on internal medicine, psychiatry, family medicine, and OBGYN before spending time on general surgery practice questions. Being exposed to these more familiar concepts daily at work is studying in its own right. If a demanding rotation disrupts your schedule, revise the workload. A smaller plan that you can follow is more useful than an ambitious calendar that leaves you permanently behind.

Resources to Use

Before buying or renewing any resources or question banks, I would ask your residency program director what is provided to you. Many programs still provide residents with UWorld or TrueLearn access, which could save you some money on an already-tight residency budget. For the new format of the exam- timed and mixed questions, system-specific questions, explanations that address management priorities, and clinical case-based multi-part questions- these would all be helpful to use in your preparation.

When crafting practice question banks, follow the new format when adjusting your test settings to accurately reflect test-day experiences. As with Level 1, Step 1, and Level 2, Step 2, I would not recommend using more than one or two resources to study for Level 3/Step 3. Fantastic resources are available, but indecision about which one to use will do a disservice to you and your limited time frame. As with the preceding board licensing exams, I believe practice questions are key and should remain at the forefront of your study plan. You learn by example! 

The Transition

A one-day exam likely does sound better, but it should not be the sole reason to move your test from November or December 2026 into 2027. Discuss the timing with your program director/ chief residents, and consider your clinical schedule, readiness, and relevant deadlines based on your individual situation, specialty, and program. 

In order to register for Level 3, you must have successfully completed Level 1, Level 2-CE, and graduated from an accredited osteopathic medical school in the United States. The NBOME generally recommends about six months of residency training before sitting for Level 3. Everyone’s testing year, circumstances, and program may influence their testing experience, so take others’ advice with a grain of salt and ultimately do what is right for you. When using NBOME resources and practice banks, make sure the page says “2027” at the top to ensure you are using the newly updated practice resources based on the new format. The old materials are surely still clinically relevant, but it may be better to use the new resources to better understand the format. 

Before you sit for Level 3, review the NBOME Bulletin of Information and scheduling instructions so you know what to expect on exam day. Build a plan that gives you time to practice clinical decision-making, work on your pacing, and review the topics you see less often on rotation. If you’d like help building that plan around your residency schedule, explore Elite Medical Prep’s one-on-one COMLEX Level 3 tutoring. You’ve got this, Doctor. Good luck on Level 3!