Most States Don’t Actually Require COMLEX Exams

Update 2/11/2020: The NBOME cancelled indefinitely postponed COMLEX Level 2-PE. Not sure why they needed the extra shame of waiting two weeks to cave to reality. Here’s the refund waiver link for students who already paid.

On the heels of this week’s USMLE Step 2 CS cancellation and the immediate bold non-cancellation of the COMLEX Level 2-PE (Restarting April 2021? Are you joking?), I thought it’d be worth sharing some information about which states actually require the COMLEX for osteopathic licensure. You see, many DO students already take and pass the more common USMLE exam required for allopathic physicians/MDs.

While schools impose their own graduation requirements and traditionally DO residences may have their preferences, most states don’t care if a DO student passes the COMLEX or the USMLE.

The American Osteopathic Association (AOA) released this licensure summary back in May 2020 (currently unavailable for public consumption save through the magic of the Wayback Machine, h/t Mustafa Basree). The summary is this:

• In 44/50 states, DO students can complete the USMLE exams for licensure.
• 5 more states (CA, MI, OK, WV, and PA) are more complicated. These often have requirements that are clearly in need of an update (such as permitting the substitution of the defunct FLEX exam for older doctors but with no mention of USMLE). MI, OK, and WV may give reciprocity (i.e. get licensed in one of the usual 44 and you may be able to transfer). Pennsylvania also requires a dedicated OMT exam if you haven’t passed Level 2-PE. The language here sometimes says “similar” requirements and sometimes says “equal requirements.” I have no idea what constitutes what here, but certainly wanting to work in these states would be a reason to finish the COMLEX series for now.
• Only Florida actually specifically demands a full suite of COMLEX scores.

Given that Step 2 CS is canceled, the world has changed. SOMA, the largest osteopathic student association, has already called for a single licensure exam, but students are–at best–the bottom of the stakeholder food chain. I encourage physicians to lobby their state medical boards to modernize their rules and legislate away redundant requirements. I encourage the entire DO community to put pressure on the AOA to change the COCA accreditation requirements that require students to take the COMLEX in order to graduate.

I’m not saying that the COMLEX shouldn’t count (of course it should); I’m saying it shouldn’t exist.

If the USMLE is enough for MDs, it should be enough for DOs as well. Let the market decide. I don’t think the NBOME, a broadly despised organization, is doing osteopathy any favors here.

Whenever possible, I hope DO organizations, schools, and students walk away from the offerings of the NBOME and put pressure on the organization to reform itself into nonexistence. A system of two separate but otherwise analogous licensing exams is wasteful and expensive (and profitable). Osteopathic principles and manipulative medicine are not sufficient justification for complete redundancy, and there is no future where COMLEX overtakes the USMLE. Just add in a short dedicated OMM exam and call it day. Practically, I don’t think there’s a future where most traditionally allopathic program directors ever accept COMLEX in place of USMLE without bias until at least Step 2 CK becomes pass/fail. The NBOME might be holding on specifically for that future, at which point no one will care who takes what.

For now, students who are able to graduate without taking COMLEX Level 2-PE due to the pandemic and don’t need to practice in the exception states but who have taken USMLE Step 1 and Step 2 CK can finish out the series with Step 3 and call it a day. I hope folks doing this opens the common sense floodgates, but organized medicine doesn’t change easily.

In the 21st century, I’m not convinced physicians are best served by maintaining distinct osteopathic and allopathic pathways at all. A physician is a physician, and the easiest way to get rid of the unfair DO stigma is not to make it a PR issue–but to make it a non-issue. I understand there’s a lot of history here (though much of it not so positive) and plenty of strong feelings. However, even if one buys the argument that the underlying educational philosophy is sufficiently different to warrant different degrees, that’s no justification for perpetuating a separate-but-equal system for licensure given that post-graduate training has already merged and the vast majority of states don’t care.

The eventual outcome is the same. As we all know, it’s the residency training that really makes the doctor.