To the Editor: COMLEX-USA and USMLE-More Reasons to Unify.

Abstract

As of June 30, 2020, the Accreditation Council for Graduate Medical Education (ACGME) became the sole accreditor for MD and DO graduates in the United States.1 In a Letter to the Editor in the Journal of Graduate Medical Education, Terry and Lavertue petitioned that residency programs in the United States discriminate against DO graduates.2 They argued that poorly justified differences between the Comprehensive Osteopathic Medical Licensing Examination of the United States (COMLEX-USA) and the United States Medical Licensing Examination (USMLE) function as a smokescreen to discriminate against DO applicants.2 Their justification uses National Resident Matching Program (NRMP) data from 2022, which revealed a disproportionate number of residency programs that either do not consider applications from or choose not to interview DO graduates.2,3NRMP Program Director Survey data from 2022 reports that 9% of residency programs do not consider USMLE Step 1 and 11% do not consider USMLE Step 2 CK.3 Meanwhile, 16% of programs do not consider COMLEX-USA Level 1 and 18% do not consider COMLEX-USA Level 2.3 Perhaps residency program directors sincerely perceive these examinations as incomparable. Although it is not unreasonable to question whether this perception among program directors is justified, DO students score lower than MD students on USMLE examinations. In 2022, the average USMLE Step 1 and Step 2 scores were 236 and 248 for matched MD seniors and 227 and 241 for matched DO seniors, respectively.4,5 As the USMLE series of licensing examinations functions to protect the public, are residency programs actually valuing this discrepancy in scoring inappropriately? Additionally, DO students who take USMLE score higher on COMLEX-USA compared to those who do not take USMLE.6 This suggests that USMLE and COMLEX-USA may not be comparable and that program directors are therefore justified in their preference for USMLE. In other words, if COMLEX-USA and USMLE are comparable, then DO students who take USMLE should not score higher on COMLEX-USA than those who do not take USMLE, and DO students should not score lower than MD students on USMLE.Compared to MD graduates, DO graduates often have fewer research experiences. In 2022, matched MD seniors averaged 4 research experiences and 7.9 combined abstracts, presentations, and publications.4 Conversely, DO seniors averaged 2.2 research experiences and 3.4 combined abstracts, presentations, and publications.5 While most allopathic medical schools in the United States are affiliated with academic hospitals, this is not the case for osteopathic medical schools. Therefore, the differences in research experience may simply reflect access to research opportunities. Assuming that residency program directors appropriately value this experience, DO applicants are at a disadvantage, but they are not necessarily discriminated against.Requiring residency programs to disclose more information about their selection processes might be helpful for all applicants. However, doing so would presumably confirm the aforementioned discrepancies. Proposing that DO applicants are discriminated against is premature, insofar as DO applicants have lower licensing examination scores and fewer research experiences. Designing one common series of licensing examinations would suit the advancement of this debate.