To Take or Not to Take

This post will pertain mostly to osteopathic students, as only DO students have the options to take both the USMLE and COMLEX. Despite that, I would urge MD students to give it a read as well only because you may find yourself in a position where a DO student would ask you what you think about this situation and the more you know the more you can help.

Welcome to boards season. A time in every medical student’s life that fills them with dread and anxiety. As a DO student, you may have just a bit more stress, knowing not only must you take your own exam, the COMLEX, but you also have the choice to take the MD one as well, the USMLE. You’ll hear the “yes you need to take both!” or the “don’t even bother!” arguments over and over while trying to figure what you should do. While both have valid points, I think the most fair thing is to let the student hear as many pros and cons as possible to make their own choice on what’s best for them. I’m going to attempt to do that.

First some quantifications;

USMLE: approx. 280 questions with seven 60-minute blocks, 28 to 40 questions a block. Each block may be followed by a break. You have 45 minutes (or 60 if you skip the tutorial) to disperse however you like over each break. Generally considered hard, but fair.

COMLEX: exactly 400 questions with 8, 60 minute blocks, 50 questions a block. There are only two 10-minute breaks between the 2nd and 3rd sections and the 6th and 7th sections, plus lunch. Generally considered random.

I made sure to ask as many of my classmates as possible to get a good idea of what they felt as a whole and to make sure I wasn’t being weirdly biased, since I only took the one (though I originally was going to take both). Basically, the USMLE is a better written and more organized test over all, doing a better job of testing the “high yield” topics often associated with boards. COMLEX, though still having some very consistent testing topics, will have many point-and-shoot questions, vague stems and answers and super random questions on things you’ve never seen in your life or will ever see again. Long story short, there’s a bit of a skew when it comes to the standardized testing.

That being said, as a DO student we don’t have a choice in taking the COMLEX. That’s our test.

Hopefully, this will help you find a clear direction you want to take in this whole crazy process.

Let’s start with some fun stuff.


  • ACGME programs don’t understand COMLEX scores.

This is probably the biggest argument to take both exams I’ve heard, and also one of the most poorly thought out ones. Think about it for a second. Yes, the program may have older doctors who don’t “get it”, but if you’re looking at an MD program many times you’ll check to see if it has any DO residents. Thus someone on staff knows what your score means, so if you tank your COMLEX and do well on the USMLE it actually does matter and you won’t be able to escape it. Plus, ACGME programs are now highly encouraged take the extra time to understand COMLEX scores past the poorly made algorithm to compare to USMLE scores. This isn’t to say there is no bias, because it does still exist, but you can’t assume they’re ignorant either.

  • AOA programs aren’t as good as ACGME ones.

Maybe once upon a time this was sort of true, but not really anymore (especially since the merger plans to weed out programs not up to par, both AOA and ACGME). There are amazing programs on both ends, and crap programs on both ends. Just do your research, check Frieda and AOA opportunities. Be smart about it.

  • Studying for the USMLE is studying for the COMLEX.

Eh. Kind of. There is some truth to this, the overall material you need to know is basically the same for both test. But as I mentioned earlier, the tests are not the same. The question styles are pretty different. You would probably be okay if you only studied for one, but you probably wouldn’t do as amazing on the one you didn’t do prep for. It’s easily remedied by just doing questions from multiple banks.

General considerations:

  • So much money.

These tests are expensive AF. And while an extra $600 may seem like another “drop in the bucket,” remember the tests after this one are even more outrageously expensive. Plus you might be moving and dealing with all the other life crap. It’s not a huge consideration, but for some it’s important.

  • You can sign up for the USMLE pretty late.

It turns out when you do the application to take the USMLE you don’t actually have to submit the payment until way later. I did not know this. And in some places, you can sign up as much as a month and half before the time you want to take it and still get what you want. Which means if you’re on the fence you don’t need to choose right away. You can wait and see how you feel as you get somewhat closer without blowing large sums of money.

  • You can take the USMLE whenever you want.

We have to take the COMLEX, but for DO students, the USMLE isn’t our test, which means it’s kind of a free-for-all. If you want to take a week from the time you take COMLEX to the time you take the USMLE, that’s fine. If you want to take it at the start of fourth year after finding out you really love a specific MD program, cool. It’s up to you.

  • You must report BOTH scores

In the past, you could take both tests and if you weren’t feeling your USMLE score you had no obligation to report it. Due to the changes occurring in the ACGME and AOA, this is no longer an option. You MUST report both scores and failing to do so can disqualify your applications in 4th year. No one wants that.

Reasons to take both exams:

  • You don’t know what you want to do

A general consensus (of my classmates mostly) says that the less you have an idea of what you want to do, the more sense it makes to have more options available to you. The way to do that is to take both COMLEX and USMLE. In the most ideal situation, this means you have no limitations in applying to any specialty or program.

  • You’ve done well in classes/previous examinations

If you’ve had a good test-taking record, chances are you’ll keep that general trend and the differences in the exams won’t be as strong a factor in what your score may be.

  • You’re confident in your ability to recover

While you can take the USMLE whenever you want, most people take it within a week or two of their COMLEX. These tests are awful to sit through just one time. It really can be torture to have to force yourself to immediately get right back to doing questions and keep preparing for whichever one you take second. If you can get yourself to get back on the horse and ride it out, then go for it.

  • You think you’ll want to apply ACGME

Some ACGME residency programs do accept COMLEX scores. Some. But there’s a big discrepancy in score conversion and the percentile of the scores certain programs want you to have. An example is that an ACGME program may say you need a USMLE score of at least 210 to apply but a COMLEX score of 540. There are not even close to same percentile. So if you think one of these programs is what you want, you’ll be giving them what they want to see by taking the UMSLE.

  • OMM is not your fave

You’ve had two years of manipulation and you find “hey, this isn’t really for me, I don’t particularly like it, I’m not too good at it” then you may have a better time with the USMLE since it obviously won’t incorporate any osteopathic principles AND it will open you to more programs where you won’t have to work with it.

Reasons not to take:

  • You don’t know what you want to do

For many people, it’s hard to set a goal for yourself when you really have no idea what you want to do. It’s even harder with the prospects of two exams looming over you. To really keep your options open to every specialty you may want to consider taking just the COMLEX so you can really focus your efforts on doing your best on one exam.

  • Taking both exams can cause discrepancy

So you took both exams. On one test you score in the 85th percentile. Awesome! But on the other you score in the 55th. Pretty good, but not outstanding. Now there’s a 30 percent discrepancy between your scores. Regardless of what type of program you apply to, that could be viewed as a red flag. And you can’t assume they’ll say the lower score was a fluke, because in reality they’ll probably say the higher score was a fluke. Don’t give them a reason to say anything was up to chance.

  • AOA programs are what you think you’d want

The best part of the ACGME and AOA coming together is that residency programs will be standardized and even-paced. Which means the training will become pretty similar, and there won’t be those ancient differences people like to harp about. Plus, if you find you’re cool with OMM and want to be able to continue using it as a tool, AOA is really the way to go.

  • You suffer from somewhat severe anxiety/depression

I’ll be completely honest here. Taking boards will be the most stressful thing you’ve done in medical school at this point. It’s terrifying. So if you don’t handle the stress in a constructive way and you let it eat you from the inside out, taking both tests in seriously a no-go. You don’t have to put yourself through the extra anxiety if you are already suffering from some. And you shouldn’t. You need have one focus and make sure you’re getting the appropriate help if needed.

  • You take an NBME and it doesn’t go so well

I mean, you’re your taking COMSAEs and those aren’t going well either, that’s a completely different situation. However, if you find you’re doing fine on COMLEX style questions and QBanks, but struggling with the USMLE material and question style, you don’t need to force yourself to take USMLE. DO schools tend to have a slightly different approach in teaching and if they do focus on testing, it would be for the COMLEX. This relates back to score discrepancy as well.

  • If you’re interested in certain specialties

Again, let’s be honest. Would you like to know how many DO students went on to ACGME orthopedic residencies in 2015? One. Just one. Why? There’s a ton of reasons why, but one of the biggest is that as competitive programs, they have many, many qualified MD students applying for the same positions that you may want. With such limited capacity, MD programs are likely to pick their own students because technically we’re still the only ones who get access to both ACGME and AOA residencies.


“I think I’m cool just taking COMLEX.”

Cool, you’re done. You can stop reading and go do other things.

“I want to take both!”

I hope you’re ready for the next questions of “which do I take first?”

Good question. For some reason, people are very passionate about this topic and you’ll hear varying opinions but really you have to do what will work best for you to get you the best scores.

Points to consider:

  • Do you tend to do better the first time you take the test or the second?

You only get one shot at these exams (granted you pass of course), but for some they tend to do better after feeling the real stress. Others come out of the gate running and slay it the first time. If you’re in a good place with practice test scores, then it’s really about what type of program you’re more interested in is whatever test you should take when you know you’ll perform the best. If you’re a little iffy, then you need to take the COMLEX in your stronger position. Remember, you must pass the COMLEX as a DO student. Anything else is bonus.

  • Are you unsure if you’ll be in the right condition to take another big test?

This is something you won’t really know right off the bat. If you tend to be knocked out after you’re regular, run of the mill med school exam, what could happen after 8 hours of non-stop questions? If this is something worrying to you, you may want to consider taking the USMLE second because that’s an exam you can move back without restriction or not take at all without repercussion if you change your mind at the last minute. You can only move the COMLEX to a certain date based on your school’s guidelines.

  • How are you with OMM?

Osteopathic principles are a big part of the COMLEX, sometimes up to 30% of the entire test. A lot of students opt to take the USMLE first and take the next chunk of time until their COMLEX (usually a week) studying OMM from QBanks or books like Saverese. If you find OMM is something you’re pretty proficient at, or you’re planning on doing good incorporation into your study schedule, this week probably isn’t needed. You can take the COMLEX first, then focus on busting out more questions for the USMLE later or whichever way you feel will be more beneficial to you.

These exams are scary. They’re hard. But that doesn’t mean you need to take them on blindly, or do exactly as someone says you should. A big part of medicine is learning from others, but an even bigger part if trusting to do what’s right by your own volition. Taking boards is no different.

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