Both the United States Medical Licensing Examination (USMLE) Step 1 and the Comprehensive Osteopathic Medical Licensing Examination (COMLEX-USA) Level 1 are now scored on a pass/fail basis. While these exams assess similar foundational medical knowledge, they differ in content, requirements, and how students use them when applying to residency programs.
All osteopathic (DO) medical students must take COMLEX Level 1, but some choose to take USMLE Step 1 as well. So, is taking both exams worth the additional time, preparation, and expense?
In this guide, I'll compare USMLE Step 1 and COMLEX Level 1, explain how residency programs evaluate exam results, and help you decide whether taking both makes sense for your residency goals.
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USMLE Step 1 vs. COMLEX Level 1: Key Differences
USMLE Step 1 and COMLEX-USA Level 1 both assess your understanding of foundational medical sciences and your ability to apply that knowledge to clinical scenarios. However, COMLEX Level 1 also emphasizes osteopathic principles and practices, including osteopathic manipulative treatment (OMT).
Both exams are pass/fail, but they differ in eligibility, content, and testing format.
| Feature | USMLE Step 1 | COMLEX Level 1 |
| Administered by | National Board of Medical Examiners (NBME) and Federation of State Medical Boards (FSMB) | National Board of Osteopathic Medical Examiners (NBOME) |
| Who takes it? | MD students and graduates, eligible international medical graduates, and DO students who choose to take it | DO students |
| Required for DO students? | No | Yes |
| Scoring | Pass/fail since January 2022 | Pass/fail since May 2022 |
| Content emphasis | Foundational biomedical sciences and clinical applications | Foundational biomedical sciences, clinical applications, and osteopathic principles and practices |
| Exam format | Up to 280 multiple-choice questions in 14 blocks of 30 minutes | 320 multiple-choice questions in 8 sections |
| Exam duration | 8 hours | 8 hours |
How Do Residency Programs Evaluate USMLE and COMLEX Results?
Residency programs look at both USMLE and COMLEX results when reviewing applications, but how much weight they give each exam depends on the program and specialty.
Since Step 1 and Level 1 are now pass/fail, program directors can no longer compare applicants based on their numerical scores. However, they can still see whether you passed on your first attempt and how you performed on later licensing exams.
USMLE Step 2 CK and COMLEX Level 2-CE still use numerical scores, so these results can play a bigger role in helping programs assess applicants. Some residency programs accept COMLEX scores alone, while others prefer or require DO students to submit USMLE results.
Of course, your board exam results are just one part of your application. Programs also look at your clinical performance, letters of recommendation, experiences in your chosen specialty, and how well you interview.
Should DO Students Take Both USLME Step 1 and COMLEX Level 1?
While all DO students must take COMLEX Level 1, taking USMLE Step 1 is optional. Whether it's worth taking both depends largely on your specialty interests, the residency programs you're considering, and how prepared you feel for the additional exam.
Taking both exams may be a good idea if:
- You're interested in a competitive specialty. Some residency programs, particularly in competitive fields such as surgery, may prefer or require USMLE results from DO applicants.
- You want to keep your residency options open. If you're still exploring specialties or haven't narrowed down your program list, taking USMLE may give you more flexibility when it's time to apply.
- Your preferred programs expect USMLE results. Look into individual program requirements early, especially if you have particular institutions or geographic areas in mind.
On the other hand, you may not need to take USMLE if the programs you're interested in accept COMLEX alone. Taking another exam also means additional registration fees, preparation time, and the possibility of an unsuccessful attempt.
Keep in mind that passing both exams doesn't automatically make you a stronger residency applicant. You still need to demonstrate strong clinical performance, build meaningful experiences, and prepare a well-rounded application.
I recommend talking with your medical school's residency advisors before committing to both exams. They can help you weigh the potential benefits against the additional work involved and make a decision that fits your goals.
FAQs
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Jeanie Gribben, MD
Dr. Gribben is a graduate of the Icahn School of Medicine at Mount Sinai and a Merrill Presidential Scholar from Cornell University. She offers tutoring for Steps 1 and 2 and med school coursework, as well as advising support for medical students. She’s dedicated to personalized teaching strategies for student success.
