Medical Licensing Part 2: How to Give the COMLEX Level 2 PE the Overhaul It Desperately Needs

For a practicing physician, I spend a lot of time thinking about medical licensure. I passed my tests years ago, but, as an educator and residency Program Director, I’m still very connected to the process. I see the hard work my students put into preparing for their exams, and I’ve watched with concern as the cost of medical education and licensure — and student stress levels — have continued to climb. 

Naturally, students and residents have a lot of complaints about the tests and the costs. They always have, but the intensity of their frustration and the number of practicing physicians joining students in calling for change has increased in recent years. Many argue that the current medical licensure system — especially the COMLEX series required for DOs — is outdated and should be eliminated.

You can read my thoughts on that in Part 1 of this series, but I want to use this article to focus on one of the most hotly debated tests in the COMLEX sequence: the COMLEX Level 2 PE. I’ll give a brief overview of the test and the controversy surrounding it, and then do a deep dive on what I feel are the test’s major problems and how the NBOME can fix them.

What is the COMLEX Level 2 PE? 

The COMLEX Level 2 PE is part of the COMLEX-USA exam series required (with few exceptions) for DO students to graduate and become licensed osteopathic physicians. Students typically take the test late in their third year or early in their fourth year of medical school. The test involves a series of mock patient encounters designed to test whether a student can competently examine and interact with a patient. 

The COMLEX Level 2 PE is the only practical test in the COMLEX series. To pass it, students must demonstrate that they have the medical knowledge, physical skills, and communication skills needed to examine and interview a patient, gather the information needed to make a diagnosis, and develop a treatment plan.

Cost & accessibility — The real problems with the COMLEX Level 2 PE

Until very recently, both DOs and MDs were required to complete a practical patient assessment skills exam. Critics have long argued the expensive tests are a waste of time and money since medical schools already assess practical skill competence and require it for graduation. Despite the criticism, both the NBOME and the USMLE maintained their commitment to the exams — until COVID-19 made safely administering the tests temporarily impossible. 

After a lengthy suspension, the USMLE announced their decision to permanently discontinue the USMLE Step 2 Clinical Skills assessment. The NBOME hasn’t followed suit yet, but they have suspended the COMLEX Level 2 PE indefinitely. Many DO students and physicians hope the suspension will become permanent, but I think that would be a major mistake. 

Here’s the thing: the problem has never been with the test itself.  

We need a way to assess minimum competence to practice medicine as a DO and the ability to conduct a successful patient encounter is a critical component of competent medical practice.  

The problem with the COMLEX Level 2 PE is the high cost and lack of accessibility due to how the test is administered.  

Take a look.

Problem #1 — Accessibility 

The NBOME requires students to travel to either Chicago or Philadelphia to take the COMLEX Level 2 PE at one of its official testing centers (a third one is under construction). This means students have to set aside a minimum of three days to travel to and from the testing center and complete the test. Carving out that kind of time from a busy schedule is extremely difficult for students.

Problem #2 — Cost 

It costs $1300 just to take the test. When you factor in the associated travel costs such as plane tickets or gas, a hotel room, and food, the cost to students adds up quickly and easily hits $2500 or more for a single test. It’s no wonder students want the test gone!

Three Ways to Reform the COMLEX Level 2 PE

The problems associated with the COMLEX Level 2 PE are serious. Fortunately, it doesn’t have to be this way. As you may have figured out by now, I feel strongly that the solution isn’t to scrap the test. Abandoning the test because pass rates are high and people don’t like it is a bad idea. It’s short-sighted and leaves a major gap in assessing students’ minimum competence to practice medicine. 

We can do better than that. The best way for the NBOME to maintain the ability to assess students’ practical skills while reducing the burden placed on DO students is to implement major changes in how the test is administered. 

Fortunately, the necessary changes aren’t complicated and would be relatively simple to implement. Here’s what I propose:

1. Decentralize exam administration 

There’s no reason to administer the test at national testing centers when there are 37 osteopathic colleges of medicine spread over 58 locations in 33 states. As part of their COCA accreditation requirements, all these schools already have the equipment and technology to administer the COMLEX Level 2 PE. 

So why not administer the test at the DO schools? This would increase accessibility, decrease travel time, and eliminate the need to maintain costly testing centers (or build new ones.) It’s also easily scalable and continues to work as the number of DO students grows. 

You don’t even have to make changes to how the test is given or scored. As things stand now, the mock patient encounters are recorded and scored later by an examiner. Schools could simply record the test, upload the video, and send it off to be scored. 

Some may be worried about potential conflicts of interest if schools administer tests to their own students, but there’s a simple solution — just send students to take the test at a neighboring school. That’s still a much better idea than forcing students to fly across the country to take the test.

2. Decrease student costs to take the test 

Decentralizing the exam administration already saves students as much as $1000 or more by eliminating the need for expensive long-distance travel, but it should also lead to lower testing fees.

How? 

If the NBOME doesn’t have to maintain multiple centralized testing centers, overhead costs should go down. I propose the savings be passed directly to students by reducing the testing fee.

3. Make exam costs transparent 

If the NBOME expects students to continue to pay high fees to take the COMLEX Level 2 PE, they must embrace cost transparency. They should be crystal clear about how they set exam costs and what the testing fee is used for. That means releasing details about everything from fixed costs and overhead to variable costs like paying standardized patients and paying colleges to administer the exam. 

Wait, it can’t be that easy to fix the Level 2 PE, can it? I really think it is, and I hope the NBOME agrees with me and implements major changes soon.

Like what you read? Have questions? Disagree? Either way, I want to hear from you. Continue the conversation by leaving a comment below or sending me a message.