To the Editor: Response to: Limitations and Alternative Approaches to a USMLE COMLEX-USA Concordance

We appreciate the attention our colleagues at the National Board of Medical Examiners (NBME) have paid to our concordance study.¹  We agree that the use of licensure examinations in the resident selection process is “overweighted.”²  We support practices that foster diversity, equity, and inclusion as well as the holistic review of residency applicants.

To that end, our study was not meant to be a panacea but to provide some additional information to the subset of program directors who are unfamiliar with the Comprehensive Osteopathic Medical Licensing Examination of the United States (COMLEX-USA) score scale in that holistic review. As Jurich et al point out, the associations between United States Medical Licensing Examination (USMLE) and COMLEX-USA scores are far from perfect, and concordant scores may in some cases both overestimate and underestimate true ability.²  Given that the concordance analyses were based on a sample of osteopathic students only, that the examinations measure different but overlapping constructs, and that the standard-setting procedures for COMLEX-USA and USMLE vary, this is not surprising. DO students should perform better on examinations that are aligned with osteopathic medical education and practice. We conduct this type of research to better educate residency program directors about COMLEX-USA.

Some believe that a single licensure examination pathway would create efficiencies and level the playing field in residency applications. However, while some osteopathic students may gain some advantage in residency selection for some specialties by performing well on the USMLE, there is no evidence that they are better residents or become better practicing physicians. A single examination series that is aligned with neither the MD nor DO professions could be disadvantageous to both groups and provide less valid measures of the relevant competencies. A more parsimonious solution would be to provide more information on the content, uniqueness, and scoring of each licensure pathway. In addition, the residency application process could be revamped to further foster inclusion and eliminate discriminatory practices.³  With an increased understanding and acceptance of all residency applicants based on holistic review, the single accreditation system for graduate medical education will offer enhanced training opportunities for all and, ultimately, better care for the patients we serve.

Professional self-regulation requires that members of a profession set their own standards for competency. COMLEX-USA is the only examination entrusted for the licensure of osteopathic physicians in all 50 states, territories, and various international jurisdictions. The USMLE program was developed to harmonize state medical licensing examinations for MDs and international medical students/graduates; a separate valid licensure pathway was maintained for DOs—COMLEX-USA.⁴  Osteopathic physicians have a distinctive philosophy and curricular program, as well as their own unique competencies and practice. These are assessed with distinctive integrated examinations. The Commission on Osteopathic College Accreditation has standards that require successful completion of COMLEX-USA Levels 1 and 2 to graduate from an osteopathic medical school. COMLEX-USA is supported by the Federation of State Medical Boards, the American Medical Association, and the Coalition for Physician Accountability.^3,5,6  We will continue to work with our colleagues to promote equity and inclusion and to respect the privilege each profession has for professional self-regulation.