COMLEX Step 1: White Horse of the Apocalypse

Right now, I am preparing for the first out of 4 parts, COMLEX Step 1. I am going to write about each section of the COMLEX as I go through them. This way, you will get more details and more of my thoughts as I prepare for it.

COMLEX Step 1 is supposedly the hardest of the four. First of all, it is the very first medical licensing exam and your first experience with this ordeal. I have heard that it takes 3 months to prepare for step 1, 3 weeks to prepare to step 2, and 3 days to prepare for step 3.

For these medical licensing exams, it is not supposed to be a simple “remember and recall facts” kind of a test. The examiners want to see if you can apply what you know to a clinical scenario. Still, you must memorize a lot if you want to do well on this exam.

COMLEX Step 1 - White Horse of the Apocalypse

White Horse of the Apocalypse (aka COMLEX Step 1)

(Just on a side note, it is really supposed to be COMLEX Level 1, not COMLEX Step 1. But most people refer to it was COMLEX Step 1 anyways. If I write COMLEX Level 1 or even COMLEX 1, know that I am referring to COMLEX Step 1.)

When Will You Take It?

You will be taking the exam at the end of your second year of medical school. I know that my school mandated that students take the COMLEX between June 1 and August 31. So if you are really behind in your boards studying, you can take it during your first rotation.

In my opinion, it would be best to take it before rotations start. First, the medical knowledge should be fresh in your head because school did not end too long ago. Second, you will be on rotations, which requires your presence in the hospital. It would be a bit tough to come home at 5:00 PM, study for boards, and then wake up early to go to rotations. Third, you should be studying for COMLEX Step 2 during rotations.

Right now, in April 2012, my second year of medical school is almost coming to an end. I am wholeheartedly preparing for the boards because I’m taking it in June 4, 2012. I’m hoping to get a nice 2 week vacation before rotations begin.

What Will Be on the Test?

In short, you will be tested on everything you have learned in the first two years of medical school. COMLEX Step 1 is test on the basic science components of medicine. The following subjects are tested:

If you are also preparing for the USMLE, lots of the subjects listed above are also tested on the USMLE. The only subject not tested is Osteopathic Manipulative Medicine.

However, COMLEX is a complex test and you will be required to know a bit more then what you may have learned in school. The breakdown of COMLEX Step 1 is as listed:

  • Scientific Understanding of Disease Mechanism (subjects listed above) – 75% to 85% of total questions
  • History and Physical Exam – 5% to 12% of total questions
  • Management – 3% to 7% of total questions
  • Diagnostic Technology – 1% to 5% of total questions
  • Health Promotion and Disease Prevention – 1% to 5% of total questions

So make sure you know your heart murmurs. Make sure you know how to read CT images. Know which cancer causes the highest mortality in women (which is lung cancer).

How Is the Exam Scored?

COMLEX Step 1 is a multiple-choice exam with one right answer per question. There may be cases where another answer is somewhat correct, but the point is only awarded for the best answer.

The score range from 200 (low) – 800 (high). The mean is a 500. You need a minimum of 400 to pass. The standard deviation is 79. So if you know a bit about confidence internals, you can estimate the percentage of people who fail to be less than 17%.

Anyways, I’ll give you the percentiles for a score of 400 to 700:

  • 400 = 12%
  • 500 = 54%
  • 600 = 89%
  • 700 = 99%

As you can see, about 11% fail the exam. The fail rate of USMLE is 10%.

Surprisingly, COMLEX 1 is not scored based on a curve. If everyone did well, everyone could get a high score. But I’m sure that the score distribution will fall into a bell curve. If a question is too easy, the people in charge of the exam, National Board of Osteopathic Medical Examiners (NBOME), could easily throw the question out. The same thing could happen if if the question was too difficult.

Just be aware that not all questions will count towards your grade. There are some new questions in there (but you won’t know which ones are which) that are added to the exam to see if they are suitable as future test questions. You are not only taking your exam, you are also testing new questions out. Based on the results, the new questions could be real questions in the future for someone else. Too bad you don’t get paid to be a guinea pig, huh?

How Long Is COMLEX Step 1?

The exam has a total of 400 questions. The questions are divided evenly over 8 blocks, which comes out to 50 questions per block.

You get a total of 8 hours to complete the exam (not including a 40-minute lunch break). That comes out to 1 hour per block. Basically, you have 1 hour to complete 50 questions. If you take the eight hours to do questions, the average question should take you at most 72 seconds to complete.

Just be careful because the exam will not exactly give you 1 hour per block. It will give you 4 hours for four blocks. If you take 2 hours to finish one block, then you will only have 2 hours left to finish three blocks. You will have to pace yourself!

You do have the option of taking a 10-minute break after block 2 and another 10-minute break after block 6. Do understand that these optional breaks will come out of your total test time. So if you take the two breaks, you will only have 7 hours and 40 minutes to complete all 400 questions. That means you have less time for each question.

COMLEX Level 1 used to be a 750-questions exam that took two days (16 hours) to complete. Thankfully, the length of the exam has been reduced. It is now a 400-questions exam that takes one day (8 hours) to complete.

Expect to spend 8 hours (for the test) and 40 minutes (for lunch) in the testing center.

How Much Will COMLEX Step 1 Cost?

In 2010, the fee for COMLEX 1 was $505. Thanks to inflation, I get to pay $520 in 2012.

The amount is only for the test alone. I did not include cost of the books and question banks that I used to help me prepare for the exam. Depending on how much materials you are using to prepare for the exam, the total cost could be more than $1,000.

As a last note, if you decide to reschedule the exam, do so before 30 days of the scheduled exam date or else you’ll have to pay money. If you decide to cancel the exam, do so before 5 days of the scheduled exam date or else you’ll have to pay money.

With all the money NBOME is already making, they do not need any more. So just watch out.

Clarification: At the time when I wrote the first draft in April 2012, I was preparing for the exam. But now, I am done with it and I am glad to say that I passed it.

More About COMLEX Step 1

My COMLEX Step 1 Experience – You Call This an Exam?
This section will show you what my first board exam was like. Even after 6 months if intense studying, I was sorely disappointed with it. Read more to find out why and what you can do to be more prepared.

No Textbooks Needed for COMLEX Step 1 – So What Resources Did I Use?
Click on the link above to learn about what resources I highly recommend you use to prepare for your first board exam. I can make you one promise though: no textbooks! I talk about each resource and explain why I recommend what I do. If you want to save money and get only the high-yield and useful resources, this is the article for you.

How to Study for COMLEX Like a Rockstar
You seriously cannot miss this section. I reveal loads of study techniques to rock the COMLEX without rote memorization. This is my personal study technique to effortlessly pass my first 2 licensing exams. (I’ve heard that the Step 2 had one of the highest fail rates, too!) This was so good, I should have charged for it.

New! Learn how to pass COMLEX 2-PE on the first try. See here to find out more.

This article is part of The Complete Guide to COMLEX. Click on the link if you want more tips and hints about the osteopathic medical board exams.


  1. Wish I had found your blog before. I just finished level 1 an hour ago and it was neuro/msk heavy. And micro I have never even heard of! I feel like I could not have passed so I hope, like you, that I did.

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