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COMLEX Level 1 Exam Blueprint and the AOA ACGME Merger

A group of medical students studying for the COMLEX Level 1 exam.


COMLEX Level 1 Exam Blueprint and the AOA ACGME Merger: A Walk Through

If you are a D.O. student, you will inevitably take the Comprehensive Osteopathic Medical Licensing Examination (COMLEX) of the United States in route to fulfilling your dream of becoming a doctor. Additionally, after graduating, you will begin even more rigorous training during residency in a discipline of your choosing. However, things can feel confusing especially with the major updates on the COMLEX and the process of applying to residency that began in May of 2019.

We here at Elite Medical Prep want to make sure you know about these changes and how they will affect you and your journey to becoming a physician.


COMLEX – Update of the Blueprint

Briefly, the COMLEX Level 1 is an 8 section examination designed to evaluate the osteopathic essential medical knowledge and clinical skills needed to practice osteopathic medicine. All osteopathic students must complete the COMLEX to receive their licensure as a D.O. A few years ago, the National Board of Osteopathic Examiners (NBOME) announced that fundamental changes regarding the content on the COMLEX Level One would go into effect in May of 2019.

The most significant change is the release of a New Examination Blueprint. Previously, the NBOME used a two-dimensional blueprint for the exam, where Dimension 1 focused on Patient Presentations, with nine focus domains, while Dimension 2 focused on Physician Tasks, with six focus domains. The new examination blueprint also uses a two-dimensional approach; however, Dimension 1 is now renamed as “Competency Domains” with seven competency domains, while Dimension 2 is now “Clinical Presentations” with ten focus domains (see figure)

The Competency Domains are sets of abilities representing the knowledge, skills, experience, attitudes that govern Osteopathic professional standards and the practice of medicine while Clinical Presentations are sets of focus areas which represent that manner in which a patient or group of patients present to Osteopathic physicians.

What does this mean for you?

Fortunately, the new Blueprint should not significantly impact how you prepare for this examination. Many resources that students use to prepare for the COMLEX (question banks, tutors, textbooks, etc.) have already adjusted their content and approach to fit the new NBOME Blueprint. Continue using the resources that you have already selected. While the Blueprint has changed, the core scientific and clinical principles of Osteopathic medicine have not, and these same principles will be tested on the new COMLEX Level 1.



Currently, there are two major residency accreditation systems: the American Osteopathic Association (AOA) and the Accreditation Council for Graduate Medical Education (ACGME).

As a D.O. student, you can currently apply to both AOA and ACGME residency programs while M.D. students are only eligible to apply to ACGME programs. In 2020, the AOA and ACGME will formally merge into one governing body underneath the ACGME in the United States, all residency programs will be required to receive ACGME accreditation, and M.D., International Medical Graduate (IMG), and D.O. students will be able to apply to all residency programs. Additionally, there will no longer be separate match processes; rather, there will be one match process for all students into all residency programs.

So, what does this all mean for you?

Well, first off, D.O. students do NOT have to take the USMLE examinations in order to be eligible to apply to ACGME accredited residency programs after the merger – the COMLEX will technically suffice. In the past, those D.O. students who wanted to apply to competitive ACGME programs would take both the COMLEX and USMLE Exams as not all ACGME programs recognized the COMLEX. After the merger, all residency programs will recognize the COMLEX as comparable to the USMLE, on paper that is. While the American Medical Association recently voted to promote equal acceptance of the COMLEX and USMLE exams by all residency programs, it is unlikely that program directors, who previously only used the USMLE examinations as part of the applicant evaluation process, will immediately adopt this suggestion. It is difficult to directly compare scores from the COMLEX and USMLE, and it is unclear if residency programs will fully adopt the AMA recommendation.

For D.O. students, the merger means that the process of applying to residency programs will be streamlined and more efficient. Additionally, these students may not need to take the USMLE in order to be a competitive applicant for previously M.D. only programs. However, we currently believe that it is in the best interest of D.O. students who wish to apply to competitive residency programs to continue to take both the COMLEX and USMLE examinations. While this recommendation may change in the future, it is unlikely that most ACGME programs will immediately adopt the AMA recommendation.

For M.D. and IMG students, the process of applying to residency will not change very much, in fact, one could argue that this merger seems to benefit these students as they now have access to approximately 3000 previously D.O. only residency programs. It is also not unreasonable to argue that this merger potentially hurts D.O. students as they are now competing with M.D. and IMG students for these traditionally D.O. training positions. The AOA states that, approximately 50% of osteopathic graduates are already training in ACGME residency programs and, “neither the AOA nor ACGME controls which applicants are chosen for specific programs…and [the AOA has] every confidence that D.O. graduates are well qualified and will continue to have opportunities in competitive residency training positions.” It is difficult to predict if the proportion of M.D., IMG, and D.O. students who match will change as a result of this merger. 

For D.O. students, this change could mean that you need to strengthen your residency application to compete with the M.D. and IMG students by taking the USMLE examinations or other means. However, as this time, it is too early to tell if this is true. So, in summary:

  • M.D. and IMG students will not be greatly impacted by this merger and will have more residency options starting in 2020.
  • D.O. students will not need to take the USMLE to be eligible to apply to residency programs after the merger; however, it is unclear how many programs will fully adopt an AMA recommendation to treat the COMLEX and USMLE as equivalent. We currently recommend that D.O. students continue to take the USMLE after the merger if they are hoping to join a competitive residency program.


If any part of this walk-through is unclear, do not hesitate us to contact us with questions.

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