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NBOME
Enhancing COMLEX-USA
COMLEX-USA Level 3

FAQ for Residency Program Directors

Why is the COMLEX-USA Level 3 examination changing to a two-day format?

The COMLEX-USA Level 3 examination is changing to a two-day format as part of the overall enhancement of the COMLEX-USA examination series, aligning with the new Master Blueprint that will be implemented in September 2018. This is in response to substantive changes in the evolution of osteopathic medical practice, and to ensure COMLEX-USA remains current in meeting the needs of state licensing boards. To read more about the enhanced COMLEX-USA, you can access the COMLEX-USA Master Blueprint.

Eligibility/Attestation

What is the new attestation requirement for the Level 3 examination?
Residency program directors will need to attest to the fact that candidates for the Level 3 examination are in good academic and professional standing and are approved to take the Level 3 examination. It is recommended but not required, that residents take the examination after a minimum of six months in residency. Please see the COMLEX-USA Bulletin of Information for a comprehensive list of Level 3 eligibility requirements.
Why do Level 3 candidates need to have attestation now?
Attestation is an important step to ensure residency program directors agree a candidate is ready to take the final examination in the COMLEX-USA series and prepare for licensure.
Can program directors attest prior to the release of a candidate’s graduation status by their school?
No, the school must release graduation status prior to attestation.
A resident graduated from a college of osteopathic medicine last year, but hasn’t taken the Level 3 examination yet, is an attestation required?
Yes, all registrations effective after March 15, 2018 for Level 3 will be required to have an attestation. We have provided advance notice of the new attestation requirement during 2017, including in the COMLEX-USA Bulletin of Information, and will continue to provide this notice.
If a DO graduate from a college of osteopathic medicine is not in a residency program, how do they obtain attestation?
A residency program director must provide an attestation that a resident is in good standing in their program.
A resident graduated from a residency program, how do they obtain attestation?
If the resident has already graduated from a residency program, the program director can provide an attestation after graduation from the residency program. If the resident is within six months of completing the residency program, the program director can provide the attestation. Once the resident receives an attestation, they will have a total of six attempts to complete Level 3 with a maximum of four attempts in any 12 month period unless the program director rescinds the attestation (no other time limit).
If a resident cannot find their residency program on the list, what should they do?
The resident should contact the NBOME Client Services via email clientservices@nbome.org or call 866-479-6828 for assistance.
When will the resident know if their attestation has been approved?
Candidates will be notified immediately by email from the NBOME when the program director completes the attestation.
A resident sent an attestation request a week ago, but has not heard back, what should they do?
If the program director has not provided an attestation ten days after a request has been submitted, the NBOME will send the resident a reminder indicating they should follow-up with their residency program director to confirm that he/she received the email in response to the request. If the program director did not receive the email, the reminder sent to the resident contains instructions to confirm the email address in the NBOME system.
Will the program director receive a reminder six months after the resident begins their residency if they have not received an attestation?
No, it is the responsibility of the resident to request attestation. Once the resident has submitted a request, the NBOME sends reminder emails to the program director until the attestation is completed.

Attestation Guidelines

Does a resident need to wait for the full six months to be approved to take Level 3?
We recommend program directors wait six months to attest and approve candidates to take the Level 3 examination, but this is not a requirement. The final determination is made by the program director.
A resident is taking a leave of absence from their residency program, is he/she eligible to take Level 3?
A resident is eligible to take Level 3 if they have an attestation from the program director which has not been rescinded. If a resident is enrolled in a residency program or within six months of leaving or graduating from their residency program, the program director can provide an attestation.
A resident is currently transitioning from one residency program to another, how does this affect the attestation process?
If the previous program director provided an attestation for the resident and it has not been rescinded, the candidate is eligible to take the Level 3 examination up to a total of six attempts with a maximum of four attempts in any 12 month period (no other time limits apply). A resident may obtain this attestation from a program director during the residency program or up to six months after leaving or graduating from the previous residency.
If a residency program director rescinds approval after the resident took the Level 3 examination, what is the resident’s status with the examination?
If the resident completed the Level 3 examination prior to the program director rescinding the attestation, and the Level 3 score was not yet reported, the NBOME would not report a score. If a score had been reported, a special review would occur and a score annotation and other actions may be required. If the resident is notified by the residency program director that his/her attestation is being rescinded prior to the administration of the examination, the resident should not take the examination as his/her score could be voided.
Must the attestation come from only the current residency program director? Is there a grace period?
Yes, the attestation should come from the resident’s current program director but the attestation is valid after the resident leaves or graduates from the residency program for up to a total of six attempts to complete Level 3 with a maximum of four attempts in any 12 month period (no other time limit) as long as the program director has not rescinded the attestation. If the resident has left or graduated from a residency program there is a six month period after graduation (extension of eligibility period) to obtain an attestation from their previous RPD.
Is there a transition period when the program director is leaving a program?
Yes, if a program director has provided an attestation for a candidate and has not rescinded the attestation, the candidate would remain eligible for up to a total of six attempts to complete Level 3 with a maximum of four attempts in any 12 month period (no other time limit).
If an intern completes a transitional rotating internship and doesn’t have a PGY2 position, can the program director from the transitional rotating internship provide an attestation? If so, must it be completed before the program ends? If not, within how many days after must the attestation be completed?
The director of the transitional rotating internship program can provide an attestation for the intern. Once this attestation is provided to the intern to take the Level 3 examination it does not expire. The intern would have up to a total of six attempts to complete Level 3 with a maximum of four attempts in any 12 month period (no other time limit) as long as the attestation is not rescinded. If the intern has graduated from the program the intern will have a six month period after graduation (extension of eligibility period) to obtain an attestation from their program director.
If a candidate has failed the one day Level 3 examination, does he/she need attestation to retake the two day exam?
Yes, after Sept 1, 2018 an attestation will be required for all Level 3 examinations.

Registration & Scheduling

When will administration of the two-day COMLEX-USA Level 3 examination begin?
The new two-day exam format begins in September 2018. Candidates may register for the two-day Level 3 exam beginning on March 16, 2018.
What is the last day a candidate can register for the one-day COMLEX-USA Level 3 examination?
The last day to register for the one-day Level 3 exam is March 15, 2018.
Can a candidate register for the one-day Level 3 examination after March 15, 2018?
Please contact Client Services (clientservices@nbome.org or 866-479-6828) with questions.
What is the last day a candidate can take the one-day COMLEX-USA Level 3 examination?
The last day to take the one-day Level 3 exam is April 28, 2018. Administration of the two-day Level 3 exam will begin on September 10, 2018.
Are there any restrictions for scheduling the two-day Level 3 examination?
Yes, candidates are required to successfully complete each of the two days in a 14-day window. Day 1 must be completed before Day 2.
Why is the Level 3 exam not being administered between April and September 2018?
This timing coincides with the conclusion of the Level 3 exam as a one-day examination format, ending in April 2018. From May through August, the NBOME will be preparing for the administration of the new two-day examination format.
What is the cost of the new two-day COMLEX-USA Level 3 examination?
The cost of the new two-day Level 3 exam is $875. This is the same cost as the current one-day Level 3 examination.

Clinical Decision-Making

What is a Clinical Decision-Making (CDM) case?
CDM cases focus on critical decisions and key challenges related to patient care that osteopathic generalist physicians routinely face. A typical CDM case consists of a clinical scenario followed by two to four questions. CDM cases feature two question types: short answer and extended multiple choice (one or more correct). Test questions involve data acquisition (e.g., obtaining history or physical exam findings, ordering tests), data interpretation (e.g., generating a diagnosis), and treatment (e.g., prescribing medication, counseling, or planning follow-up care). For more information on CDM cases, please see the practice examination.
Why does the COMLEX-USA Level 3 examination include CDM cases?
The NBOME's Blue Ribbon Panel on Enhancing COMLEX-USA, a prestigious group of academic subject matter experts, practicing physicians, and psychometric experts recommended the development and implementation of novel item types that evaluate clinical decision-making performance beyond the scope of standard multiple-choice questions. CDM cases offer an opportunity to test critical steps that enable candidates to show their abilities over a wider range of clinical challenges.1, 2 Research indicates that these item types have a greater capacity to discriminate candidates' performance over more traditional multiple-choice questions.3, 4 References
  1. Farmer EA, Hinchy J. Assessing general practice clinical-decision making skills: The key features approach. Aust Fam Physician. 2005; 34: 1059-61.
  2. Page G, Bordage G. Allen T. Developing key-feature problems and examinations to assess clinical-decision-making skills. Acad Med: 1995; 70: 194-201.
  3. Page G, Bordage G. The Medical Council of Canada's Key Feature Project: A more valid written exam of clinical decision-making skills. Acad Med. 1995; 70: 104-110.
  4. Trudel JL, Bordage G, Downing SM. Reliability and validity of key feature cases for the self-assessment of colon and rectal surgeons. Ann Surg. 2008; 248: 252-8.
What are the benefits of CDM cases?
The Medical Council of Canada first developed the CDM exam in 1992, and countries across the world, including Australia and Germany, have adopted it. CDM cases assess the ability to make appropriate patient management decisions as an independently practicing osteopathic generalist physician. The cases are not meant to simply assess factual knowledge but rather to assess the ability to apply knowledge at specific decision points in patient care, a special emphasis for the Level 3 examination.
What content is being assessed in the CDM cases?
CDM cases follow the same content blueprint as COMLEX-USA, which can be accessed on the NBOME website.
How many CDM cases are included in the two-day COMLEX-USA Level 3 examination?
The morning session of the second day of the exam will comprise CDM cases, with a quarter of the total exam time spent on CDM.
How should candidates respond to short-answer questions?
Short-answer responses should be concise and limited to a specific diagnosis, examination step, diagnostic study, or treatment. It is unnecessary to answer short-answer questions with full sentences. Candidates should not include reasoning or justifications in their responses. The short-answer text boxes allow up to 100 characters per box. Each text box should contain only one response. If a candidate enters what is deemed to be two responses in a single text box, the candidate’s responses in that box will be counted as two responses and be applied toward the question’s response limit as such.
Can candidates use abbreviations in their answers?
It is generally advisable to avoid or limit abbreviations due to lack of standardization. Use of abbreviations when completing short-answer questions runs the risk of misinterpretation in scoring and should be done with caution. It is therefore recommended that candidates spell out names and terms rather than abbreviate.
Will candidates be penalized for misspellings?
The examination does not include a spell-check feature; however, misspellings in answers are acceptable when the meaning and interpretation are still clear. There is technically no penalty for misspelling answers unless the meaning is ambiguous or incorrect.
Can candidates use protocols in their answers?
Use of protocols as answers will not be accepted as correct because they are not universal. The necessary steps or components of protocols must be listed individually in separate boxes. For example, the answer “ACLS protocol” would not be accepted as correct when “synchronized cardioversion” is the next step.
How should candidates write an order as an answer?
Candidates should write an order just as they would on a hospital or urgent care order record, in specific terms that a technician, nurse, or other health care professional could understand and carry out. However, medication dosages are not required in answers.
Can candidates answer a question with a laboratory test that is not included on the list of approved lab panels?
Yes, candidates may answer with any specific test. The approved lab panels are the only panels that are acceptable as answers. If a panel is not listed in the approved lab panels list, the specific test(s) the candidate wants to order can be entered. Separate tests should each be entered in a separate text box.
Should a candidate repeat an answer they already provided on a previous question within a case?
Each question will be scored separately. Previous answers will not be taken into account in the scoring of each individual question. For example, if the candidate believes an answer is correct for question 3 of the case even though he/she has already responded with the same answer to question 1, the candidate should respond with that answer for question 3 to receive the point for question 3.
How will a candidate know which medical resources are available for use in each case?
For each case, the candidate may assume all necessary resources are available as an osteopathic generalist physician in the setting described, and answer accordingly.
Can a referral be an appropriate answer to a question?
If the correct plan of action requires a specialty referral and/or consultation, the candidate must specify the appropriate procedure or management steps. However, if the next step in management is one that an osteopathic generalist physician could perform, the candidate may respond with simply the management step.
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