For osteopathic medical students, the second year comes with an extra decision. COMLEX-USA Level 1 is required on the path to osteopathic licensure, but many DO students also consider taking USMLE Step 1. Some want to keep options open with residency programs that are more familiar with USMLE results; others decide one board exam at this stage is enough.
Whichever way you lean, the good news is that the two exams share most of their foundation. With a thoughtful plan, preparing for both is far more like preparing for one exam with an extra layer than preparing for two separate exams.
How the Two Exams Compare
| COMLEX-USA Level 1 | USMLE Step 1 | |
|---|---|---|
| Administered by | NBOME | FSMB and NBME |
| Score reporting | Pass/fail (since May 2022) | Pass/fail (since January 2022) |
| Current format | One day, 352 multiple-choice questions, eight hours of testing time | One day, seven 60-minute blocks, up to 280 questions |
| Organized around | Competency domains and clinical presentations | Disciplines and organ systems |
| Osteopathic content | Osteopathic principles and practice (OPP) and OMT are integrated throughout | Not tested |
A change is on the way for Level 1. NBOME has announced that it plans to reduce the exam from 352 to 320 questions beginning with the spring 2026 test cycle, targeted for May, while keeping the same eight hours of testing time. If you are testing in 2026, check NBOME's website for the details that apply to your date.
The Big Overlap and the Real Differences
What's shared: Biochemistry, physiology, pathology, pharmacology, microbiology, immunology, anatomy, and behavioral science form the core of both exams. Mechanisms, disease presentations, drug effects, and lab interpretation all transfer directly.
What's different:
- Osteopathic principles and practice. OPP and OMT concepts appear across COMLEX, from diagnosing somatic dysfunction to choosing an appropriate treatment and recognizing contraindications. Step 1 does not test them.
- Question feel. Many students find COMLEX questions shorter and more direct, while Step 1 vignettes often require more steps of reasoning. Experiences vary, so try the official sample questions for each exam to see for yourself.
- Blueprint. COMLEX is built around osteopathic competency domains and clinical presentations. Step 1 is organized by discipline and system. The medicine underneath is the same, but the framing differs.
Should You Take Both?
This is a personal decision, and it's worth making deliberately rather than by default. Consider:
- Your specialty interests. Look at what programs in your field of interest say about USMLE and COMLEX results.
- Your timeline and bandwidth. Taking both means more registration, scheduling, and practice test logistics.
- Your school's guidance. Advisors see how recent graduates matched and can tell you what has mattered for students like you.
Since both exams are pass/fail, the focus for both is the same: pass comfortably and build a durable foundation for the scored exams that come next.
Building One Plan for Two Exams
1. Make the shared foundation your main track:
- Organize content review by organ system and study each system once, deeply.
- Pair content review with practice questions from the start. Mixed question practice is what builds the reasoning both exams require.
2. Give OMM its own daily slot:
- OPP rewards consistent review more than cramming. Thirty to forty-five minutes a day adds up fast.
- Prioritize the high-yield framework topics: naming and diagnosing somatic dysfunction, Fryette's principles of spinal motion, muscle energy and counterstrain concepts, HVLA indications and contraindications, rib mechanics, viscerosomatic reflexes, and Chapman's reflexes.
- Revisit your school's OMM lab materials. They often mirror how these concepts appear on the exam.
3. Practice both question styles:
- As test day nears, rotate between shorter, direct questions and longer multi-step vignettes so neither format feels foreign.
4. Use each exam's official self-assessments:
- NBOME offers COMSAE self-assessments for COMLEX, and NBME offers self-assessments for Step 1. Use them to judge readiness for each exam separately.
5. Schedule the exams close together:
- Many students take the two exams within a few weeks of each other so the shared content stays fresh. Leave enough time between them to rest and do focused review for the second exam.
A Sample Daily Structure
| Block | Focus | Time |
|---|---|---|
| Morning | System-based content review (shared) | 2–3 hours |
| Midday | Mixed practice questions and review | 2–3 hours |
| Afternoon | OMM/OPP review and questions | 30–45 minutes |
| Evening | Spaced repetition flashcards | 30–60 minutes |
Adjust the proportions as you go. If your practice results show a system is weak, give it more of the morning; if OMM questions are costing you points, extend the afternoon block.
How MedMatrix Supports DO Students
- Practice on your exam's topics: MedMatrix supports both COMLEX Level 1 and USMLE Step 1. Build practice tests from MedMatrix Standardized Content to cover the shared foundation.
- Turn OMM lab handouts into practice: Upload your OMM slides or handouts (PDF, PPTX, or DOCX) and generate practice questions and flashcards on osteopathic principles, using the same materials your faculty taught from.
- Learn diagrams actively: Create image flashcards from labeled figures in your uploads, so tender points, dermatomes, and anatomical relationships become recall practice instead of passive viewing.
- Get a second explanation: Ask the AI Tutor to walk through a concept you keep missing, like how Fryette's principles determine how you name a segmental dysfunction.
- See where you stand: Smart Performance Reports after each practice test show which areas are holding you back, so you can shift time between systems and OMM as needed.
Preparing for both COMLEX Level 1 and USMLE Step 1 is demanding, but it isn't double the work. Build your plan around the medicine the exams share, give osteopathic content its own steady time, and practice in both styles. You'll walk into each exam ready for what makes it different.