COMLEX Step 2-PE: Black Horse of the Apocalypse

Chances are, Step 2-PE will be your very last COMLEX exam during medical school. Hooray! You’re almost at the homestretch, but if you’re not careful, this exam could cause you a whole lotta headache.

Step 2-PE is supposed to be the easiest of the 4 exams. But it comes with a catch …

There is only one place you can take the PE: freakin’ Conshohocken, PA.

PE Testing Center

This is the only place in the whole world you can take COMLEX Step 2-PE.

Alright, so what does this mean for you? It means that you will be competing with osteopathic medical students from all over the US for testing slots. If you think competing with the gunners from your class is bad enough, imagine competing with gunners from all schools. It’s not fun.

Once you get the ok from your school to sign up, sign up ASAP! Or else you may not get an early enough testing spot. I waited just one week to sign up, and the earliest spot I got was in October. In the span of one week, all the spots of July, August, and September were taken. Gunners be crazy!

Having only one testing spot (in freakin’ Conshohocken, PA) also means that it sucks to be you … if your rotation is not around the area. Luckily, my rotation was close to Philadelphia. So I only had to drive an hour to get to the testing site. But some people had to fly. Others had to drive for a whole day. Overall, getting there could be a huge, huge hassle.

Therefore, make sure you don’t fail. Because if you gotta do it over again … that just plain out sucks — especially if you were the kid who had to fly from California, had to rent a car, had to drive around an area you’re not familiar with, had to stay overnight in some craptastic hotel, and had to fork over a few thousand dollars to make the wonderful experience possible.

Now that the huge warning and rant is out of the way, let’s get down to business. Let’s talk about sex …

Oh wait. Wrong topic.

Let’s talk about COMLEX Step 2-PE. And I mean the nitty gritty stuff.

COMLEX Step 2-PE: Black Horse of the Apocalypse

Black Horse of the Apocalypse (aka COMLEX Step 2-PE)

When Will You Take It?

Most likely, you will take the exam sometime in your fourth year. As I mentioned earlier, try to take your exam earlier in the fourth year, rather than later. The main reason for doing so is to guarantee that you will graduate on time and to transition smoothly into residency.

Look … there is a very small chance that you will fail the exam. It can happen to anyone. I’ve heard of stories about people who did well throughout medical school, rock both Step 1 and Step 2-CE, but then failed the PE.

So think about this scenario:

You receive the ok from your school to sign up for the test. Instead of following my advice, you drag your butt and dilly-dally around. Sometime around October or November of your fourth year, you realize that you gotta pass the PE to graduate. So you finally make your way over to the NBOME site to sign up. The earliest date you can find is in February, during the osteopathic match. “No problem,” you tell yourself, “I’ll just take my exam then.”

The fateful days come and you totally bomb the PE. You did not prepare for it because you thought it was a “joke” exam. Whatever, most people pass … right?

But then 3 months later, in May, you get a letter in the mail saying that you failed. Shoot! That can’t be right. You have a graduation coming up. You have a residency lined up. And now, just because of a “joke” exam, you can’t pass Go, and you can’t collect your $200. You’re royally screwed.

Had you taken your exam earlier, such as during the first half of the fourth year, and then failed, at least you can schedule to re-test and pass in time.

So when you should take the PE? As early as you can. At the very least, try to take it in the first half of your fourth year.

What Will Be on the Test?

Everything that a competent and empathetic primary care doctor will need to know.

Know how to get a history and how to conduct a physical exam.

Know how to write a SOAP note.

Know your diseases from head to toe.

Know the tests and treatments for those diseases.

Know your OMM.

Know how to show that you care for the patient as a human being.

Some people may tell you that you don’t need to study for it. That it is a piece of cake and is a “joke” exam. Well, I agree that the exam is a joke and is primary for enriching the NBOME, under the guise of making sure that we are competent doctors. (Old-timer doctors didn’t have the PE, and they were able to treat their patients.)

However, you will need to study for the PE. Get it done once and get it done right. It’ll really blow if you had to pay all that money and waste all that time to endure through the bullcrap exam a second time around.

What Resources Did I Use?

There are basically two main resources to help you prepare for the PE:

1. COMLEX Level 2-PE Review Guide

This is the only guide that I know of that specifically deals with the COMLEX Step 2-PE. Therefore, you don’t have much in terms of options.

The good thing about this book is the mnemonics. If you burn the mnemonics into your mind, you can make sure you ask all the really important questions. This will help you get high marks in the biomedical / biomechanical domain.

The book is also good for giving you a preview of what to expect, and how you should approach the encounters.

It also comes with practice cases. However, they are not so good. Answers are provided only for the first 2 cases. That is why you need to pair the JB Review COMLEX Level 2-PE Review Guide with …

2. First Aid for the USMLE Step 2 CS

First Aid for the USMLE Step 2 CS makes up for the deficiencies in the JB Review. In FA, you will have around 40 or so full-length cases — with sample SOAP notes. The SOAP notes really help you get an idea what the right answer would look like.

In addition, it has numerous mini-cases. In my opinion, the mini-cases is where the book really shines.

First, it will give you a generalized complaint (i.e. headache, sore throat, etc.)

Next, it will list the key characteristic of each complaint you should watch out for. If the chief complaint is headache, you should find out its location, if it is associated with nausea, if there is jaw claudication, and more.

Then, it will tell you what physical exam you should do. For a headache, inspect the head, eyes, ears, nose, and throat. Do a neurologic exam. And so on.

Finally, it will list the differentials and will teach differences among them. Again, with a chief complaint of headache, you want to consider migraine, tension headache, cluster headache, pseudotumor cerebri. It will also include a plan to help you pinpoint the diagnosis. So you should get a CT of the head, MRI of the brain, lumbar puncture, and whatnot.

Overall, it is best if get both books to help you prepare for the PE. Over-preparing is better than under-preparing. But if you can only get one book, get the First Aid for the USMLE Step 2 CS.

How Is the Exam Scored?

Basically, the exam is scored in a magical black box. So what do I mean by this? Everything is subjective. It is scored by the graders’ impression.

There are two “domains” that you gotta pass:

  1. Biomedical / Biomechanical Domain

  2. Humanistic Domain

The biomedical / biomechanical domain includes all your skills as a doctor … history taking, physical exams, SOAP writing, OMM treatments, etc. You should be somewhat competent at this by your fourth year. If you’re not, it is ok. Just study and practice.

The humanistic domain includes your communication and interpersonal skills. So at all costs, whenever you are with the patient, treat him or her like royalty. Be extra nice. Bend your back to accommodate the patient in any and every way. Make sure you communicate everything you are thinking, so the patient is on the same page as you. And always let the patient have the final say … do not argue.

If you fail even one of these domains, you fail. So make sure you prepare beforehand.

The patients will grade the history-takings, the physical exams, and anything included in the humanistic domain. So remember … use the butt-kissing you’ve learned in the third year to the absolute fullest.

The doctors or some type of grading specialists will grade the OMM and the SOAP notes. No butt-kissing is needed for this part. (Thank goodness.)

Alright, I hope you’re not too confused by now.

Chances are … you will pass the PE on the first try. The pass rate is 95% – 97%. These rates are better than the written exams. So don’t worry too much. Just worry a little bit.

How Long Is COMLEX Step 2-PE?

The COMLEX Step 2-PE will take 1 day and will be around 8 hours long. There are two sessions in a day:

  • 8:00 AM – 3:30 PM

  • 2:00 PM – 9:30 PM

(You should get there 30 minutes earlier than the starting time.)

In the first hour, you’ll have to take a survey, fill out forms, and get your picture taken.

In the second hour, you’ll go through orientation. You’ll watch a video and get all your questions answered.

And in the last six hours, you’ll take the exam. You’ll have a total of 12 patient encounters. After the first 4 patient encounters, you’ll get a 30-minute lunch. (The testing center will provide drinks and a lunch.) And after the second 4 patient encounters, you’ll get a 15-minute break. So there is enough time throughout the exam  for bathroom breaks and whatnot.

Each patient encounter is 23 minutes long. You will have 14 minutes to gather the history, do the physicals, and talk to the patient. And the remaining 9 minutes are for writing the SOAP note. (Just know that as of July 1, 2014, you will no longer write out the SOAP note. Instead, you will type it. So if you’re an old geezer or a technophobe, start working on your typing.)

Since you’ll be so busy throughout the day, it’ll go by quite quickly.

How Much Will COMLEX Step 2-PE Cost?

A whole lotta money. For my exam in 2013, I paid $1,210. For you, if you’re taking it after 2013, it’ll most likely be higher.

NBOME is making a killing on these exams.

More About COMLEX Step 2-PE

For more details, I highly recommend that you read the Orientation Guide for COMLEX Step 2-PE. In the guide, you’ll see a sample doorway information, a sample SOAP note, and a list of common abbreviations.

In addition, I highly recommend that you watch the orientation video. It is only 30 minutes or so and will help prepare you for the big day.

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. I did all the above and still failed. I have never ever failed anything at DO school. I have an MD from overseas and practice as a physical therapist in USA. I have seen and wrote notes for thousands of patients and continue to do so. It just tells you how subjective this test is. There are so many serious problems with this test and the NBOME is not willing to listen or seek feedback from candidates other than brief survey at the end of day of test when everybody is tired and dying to get out of the test center. They keep testing people end of year and not releasing scores on time for ranking or match. Some times they release result in 5 weeks and sometimes in 10 weeks. There is no accountability and they can mess you up whenever they want and whichever way they want.

    • Hey Ahmed,

      I understand your frustration. There is not much you can do, because they pretty much hold all the power.

      As I wrote, some people can do super well on everything else and bomb the PE. In your case, it sounds like you got unlucky.

      Good luck on your next try! Let me know if you have any questions.

  2. Where did you get the pass/fail rate for the COMLEX PE from? From personal observation only, it seems the pass rate is less than 95%.

    • Hey Justin,

      I got it here:

      “First-time examinees in the 2004-2005 testing cycle had a pass rate of 96.1%, compared with a pass rate of 94.7% for first-time examinees in the 2008-2009 testing cycle. Pass rates were fairly consistent across all testing cycles.”

      If you’re interested, I’m going to come out with a book on how to dominate the PE. But in the meantime, if you have any questions on passing, just ask.

  3. How many PE’s are held every year? I can’t find anywhere online that talks about how often throughout the year the tests are held and how many slots are actually in existence to fight over.

  4. Nicole Ross says:

    Hello, Do you need your PE score in order for a residency program to schedule and interview with you? I just moved my test from a middle of the moth to 12 days from now and am a little worried i wont have time to fully prep. So am now thinking of pushing it back to October BUT am also worried it will have an impact if a program will interview me if I do not have my passing score back yet.


    • Alex Ding says:

      Hi Nicole,

      You do not need your PE score before you start interviewing. But the residencies will assume that you will pass your PE. If you don’t pass, you cannot start residency.

  5. Can someone who thought they did bad on the SOAP note part of the exam and still passed let us know how bad the notes were? I’m flying back home as I’m typing this from taking the PE for the 2nd time and I’m really stressing out. Im a 4th year and am accepted into my residency of choice and now i have to worry for the next 2 months about if i passed or not. I studied my brains out the past 5 weeks and did many practice exams cases and notes. Anyway, the time limit is what gets me because if I had a little more time to think things through and get everything typed how I want it it would have been great and I wouldn’t be worried right now. My subjective and objectives were great but I often didn’t get at least 3 differentials and my plans were often lacking because I would run out of time and even missed an entire plan and assessment section on 1 pt. Anyway, any feedback would be appreciated. I’ve never felt this horrible in my life ever and can’t believe of all things this PE is the thing that gets me. If I fail it a second time I have no idea what my options are with residencies assuming I pass it the 3rd time and my school only gives you 3 shots and your out.

    • Jeremy,

      You should have gotten your scores yesterday (I took mine 2 days after you and got them back.) If you passed, congrats! If not, your notes are starting in the wrong place IMO. you should start with the objective or assessment and move from there. the subjective portion has a TON of material to document that isn’t worth as much as other sections. it is much more important that you document what you did, what you think, and what you’re going to do than document a patient has a fhx of htn. as far as plans, simple is best. don’t overthink things. we are still students, not attendings. we aren’t supposed to know every obscure test to order. stick to the basics.
      hopfully you passed. if not, good luck

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