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Medical Education  |   July 2011
Pass/Fail Patterns of Candidates Who Failed COMLEX-USA Level 2-PE Because of Misrepresentation of Clinical Findings on Postencounter Notes
Author Notes
  • From the National Board of Osteopathic Medical Examiners (NBOME) National Center for Clinical Skills Testing in Conshohocken, Pennsylvania. 
  • Address correspondence to Erik Langenau, DO, Vice President for Clinical Skills Testing, NBOME, 101 W Elm St, Suite 150, Conshohocken, PA 19428-2004. E-mail: elangenau@nbome.org 
Article Information
Medical Education / Professional Issues / COMLEX-USA
Medical Education   |   July 2011
Pass/Fail Patterns of Candidates Who Failed COMLEX-USA Level 2-PE Because of Misrepresentation of Clinical Findings on Postencounter Notes
The Journal of the American Osteopathic Association, July 2011, Vol. 111, 432-436. doi:10.7556/jaoa.2011.111.7.432
The Journal of the American Osteopathic Association, July 2011, Vol. 111, 432-436. doi:10.7556/jaoa.2011.111.7.432
Abstract

Context: In 2007, The National Board of Osteopathic Medical Examiners (NBOME) instituted a policy to address the accuracy and integrity of postencounter written documentation recorded during the Comprehensive Osteopathic Medical Licensing Examination Level 2-Performance Evaluation (COMLEX-USA Level 2-PE). This policy was instituted not only to protect the integrity of the examination, but also to highlight that overdocumentation of clinical findings not obtained during patient encounters may jeopardize patient safety.

Objective: To investigate overall and domain pass/fail patterns of candidates who misrepresented clinical findings with regard to past and subsequent performance on COMLEX-USA Level 2-PE. Specifically, to investigate what percentage of candidates failed because of misrepresentation on first attempts and how they performed on subsequent administrations, as well as the previous performance patterns of candidates who failed because of misrepresentation on examination retakes.

Methods: Historical records from NBOME's COMLEX-USA Level 2-PE database (testing cycles 2007-2008, 2008-2009, and 2009-2010) were used to analyze overall and domain pass/fail patterns of candidates who failed at least once because of misrepresentation of clinical findings.

Results: Of the 24 candidates who failed because of misrepresentation of postencounter (SOAP) notes, 20 candidates (83%) were first-time examinees. Four candidates (17%) were repeating the examination, 2 of whom were making a third attempt to pass. Among these 20 candidates who failed because of misrepresentation of clinical findings on their first attempt, 19 passed on their next attempt. At the time of study analysis, all but 2 candidates eventually passed the examination in subsequent attempts.

Conclusion: Among candidates found to have misrepresented clinical findings on postencounter written documentation on COMLEX-USA Level 2-PE, no pattern existed between their past or subsequent performance with regard to overall or domain pass/fail results. The vast majority of these candidates passed the examination on subsequent administrations, and none failed twice because of misrepresentation. Consequences of misrepresentation of clinical findings on COMLEX-USA Level 2-PE are severe and may serve to both raise awareness and prevent these types of errors in the future.

The 1999 Institute of Medicine report To Err Is Human: Building a Safer Health Care System emphasized the need for healthcare professionals to address patient safety. The report estimated that 44,000 to 98,000 deaths per year in the United States were due to preventable medical errors.1 Negative patient outcomes may result from errors in diagnosis, treatment, monitoring, and communication.1-3 In particular, documentation errors have been identified as contributing to a substantial number of preventable negative patient outcomes.4,5 
Errors in documentation have not only been reported in the patient-care literature but also in medical education.6-10 Errors include underdocumentation (errors of omission), overdocumentation (errors of commission), or inaccurate documentation (errors in fact or recall).6,7 Errors of commission are of particular concern not only in the assessment of practitioner professionalism, but also with respect to patient safety: Documenting information in a patient chart that was not obtained during a clinical encounter may lead to diagnostic or treatment errors. This type of overdocumentation has been considered unprofessional, careless, harmful, and dangerous.6,7,10 
In 2007, the National Board of Osteopathic Medical Examiners (NBOME) implemented a policy to address the accuracy and integrity of information documented in written postencounter notes (SOAP notes) that states the following: 

Misrepresentation of clinical findings of the medical record (written SOAP Notes) in COMLEX-USA Level 2-PE by documenting medical history that was not elicited, or physical examination maneuvers or techniques that were not performed, is considered irregular conduct and will be thoroughly investigated and dealt with as specified in NBOME's Bulletin of Information.6,11,12

 
This policy was instituted not only to protect the integrity of the examination, but also to raise awareness that overdocumentation in clinical practice may jeopardize patient safety. 
Sandella et al6 describe the processes for identifying candidates who may have misrepresented elements of their SOAP notes during the examination. These processes involve the identification of discrepancies in candidates' documentation by trained physician examiners who score SOAP notes, as well as the identification of scoring disparities between data collection and SOAP note scores. When a candidate is identified by one of these screening methods, the contents of the SOAP notes are compared to video recordings of the standardized patient encounters. These videos and SOAP notes are reviewed first by physician staff of the NBOME and again by an external panel of reviewers. Following these reviews, external reviewers decide whether the errors in the written notes represent a consistent pattern of misrepresentation in the candidate's notes. If the external panel of reviewers deem that such a pattern is present, the candidate with discrepant notes will receive a failing score report with an annotation of “Irregular Conduct.” 
The purpose of the present study was to review the pass/fail patterns of candidates affected by the implementation of this policy. Of those who failed because of misrepresentation of clinical findings on the written postencounter notes, we will investigate each candidate's status as a “first-time candidate” or “repeat candidate” in the examination. Secondly, we will examine how these candidates fared on subsequent attempts to pass the COMLEX-USA Level 2-PE. 
Methods
Historical records from NBOME's COMLEX-USA Level 2-PE database were accessed to analyze the pass/fail patterns of candidates who failed the examination because of misrepresentation of clinical findings for the 2007-2008, 2008-2009, and 2009-2010 testing cycles. When candidates take the COMLEX-USA Level 2-PE, they give permission for their deidentified data to be used for research purposes. Because no individual scores or outcomes are reported, institutional review board approval was not required. 
Results
Throughout the 2007-2008, 2008-2009, and 2009-2010 testing cycles, 12,510 candidates (first-time and repeat) took the COMLEX-USA Level 2-PE (Table 1). Of the sample, 24 (0.2%) failed the examination because of misrepresentation of clinical findings on postencounter SOAP notes. 
Table 1.
COMLEX-USA Level 2-PE Failures Due to Misrepresentation of Clinical Findings for Testing Cycles 2007-2008, 2008-2009, and 2009-2010 (N=24)

Testing Cycle

Candidates Tested, No.*

Candidates Failed, No. (%)
2007-200837518 (0.2%)
2008-2009 4698 9 (0.2%)
2009-2010 4061
7 (0.2%)
Total
12510
24 (0.2%)
 *Numbers reflect the total number of candidates (first-time and repeat candidates) who took the Comprehensive Osteopathic Medical Licensing Examination-USA Level 2-Performance Evaluation (COMLEX-USA Level 2-PE) in the given testing cycle.
Table 1.
COMLEX-USA Level 2-PE Failures Due to Misrepresentation of Clinical Findings for Testing Cycles 2007-2008, 2008-2009, and 2009-2010 (N=24)

Testing Cycle

Candidates Tested, No.*

Candidates Failed, No. (%)
2007-200837518 (0.2%)
2008-2009 4698 9 (0.2%)
2009-2010 4061
7 (0.2%)
Total
12510
24 (0.2%)
 *Numbers reflect the total number of candidates (first-time and repeat candidates) who took the Comprehensive Osteopathic Medical Licensing Examination-USA Level 2-Performance Evaluation (COMLEX-USA Level 2-PE) in the given testing cycle.
×
Overall first-time pass rates for the 2007-2008, 2008-2009, and 2009-2010 testing cycles were 93.5%, 94.7%, and 94.8%, respectively (Table 2). Previous and subsequent examination pass/fail results for the 24 candidates who failed because of misrepresentation of clinical findings are presented in Table 3. 
Table 2.
First-Time Candidates Who Passed or Failed the COMLEX-USA Level 2-PE for Testing Cycles 2007-2008, 2008-2009, and 2009-2010 (N=11672)


Testing Cycle, No. (%)
Examination Outcome
2007-2008 (n=3476)
2008-2009 (n=4353)
2009-2010 (n=3843)
Pass3249 (93.5)4124 (94.7)3644 (94.8)
Fail* 227 (6.5) 229 (5.3) 199 (5.2)
□ Humanistic domain121 (3.5)115 (2.6)105 (2.7)
□ Biomedical/biomechanical domain 83 (2.4) 81 (1.9) 76 (2.0)
□ Both domains
23 (0.7)
33 (0.8)
18 (0.5)
 *Domain-specific fail rates add up to the overall fail rate for the Comprehensive Osteopathic Medical Licensing Examination-USA Level 2-Performance Evaluation (COMLEX-USA Level 2-PE).
Table 2.
First-Time Candidates Who Passed or Failed the COMLEX-USA Level 2-PE for Testing Cycles 2007-2008, 2008-2009, and 2009-2010 (N=11672)


Testing Cycle, No. (%)
Examination Outcome
2007-2008 (n=3476)
2008-2009 (n=4353)
2009-2010 (n=3843)
Pass3249 (93.5)4124 (94.7)3644 (94.8)
Fail* 227 (6.5) 229 (5.3) 199 (5.2)
□ Humanistic domain121 (3.5)115 (2.6)105 (2.7)
□ Biomedical/biomechanical domain 83 (2.4) 81 (1.9) 76 (2.0)
□ Both domains
23 (0.7)
33 (0.8)
18 (0.5)
 *Domain-specific fail rates add up to the overall fail rate for the Comprehensive Osteopathic Medical Licensing Examination-USA Level 2-Performance Evaluation (COMLEX-USA Level 2-PE).
×
Table 3.
Pass/Fail Patterns of Candidates Who Failed COMLEX-USA Level 2-PE Because of Misrepresentation of Clinical Findings for Testing Cycles 2007-2008, 2008-2009, and 2009-2010 (N=24)


Attempt
Candidate*
First
Second
Third
Fourth
AFail: BM/BMFail: MisrepresentationPass
B Fail: BM/BM and HUM Fail: BM/BM and HUM Fail: Misrepresentation
CFail: MisrepresentationPass
D Fail: Misrepresentation Pass
EFail: MisrepresentationPass
F Fail: Misrepresentation Fail: HUM Pass
GFail: MisrepresentationPass
H Fail: Misrepresentation Pass
IFail: MisrepresentationPass
J Fail: Misrepresentation Pass
KFail: MisrepresentationPass
L Fail: Misrepresentation Pass
MFail: MisrepresentationPass
N Fail: Misrepresentation Pass
OFail: MisrepresentationPass
P Fail: Misrepresentation Pass
QFail: MisrepresentationPass
R Fail: BM/BM Fail: HUM Fail: Misrepresentation Pass
SFail: MisrepresentationPass
T Fail: Misrepresentation Pass
UFail: MisrepresentationPass
V Fail: Misrepresentation Pass
WFail: MisrepresentationPass
X Fail: HUM Fail: Misrepresentation
 Abbreviations: BM/BM, Biomedical/Biomechanical Domain; COMLEX-USA Level 2-PE, Comprehensive Osteopathic Medical Licensing Examination-USA Level 2-Performance Evaluation; HUM, Humanistic Domain.
 *Data are presented in chronologic order, with candidate A in 2007 through candidate X in 2010. To protect candidate identity, specific dates for examination administrations are not reported.
Table 3.
Pass/Fail Patterns of Candidates Who Failed COMLEX-USA Level 2-PE Because of Misrepresentation of Clinical Findings for Testing Cycles 2007-2008, 2008-2009, and 2009-2010 (N=24)


Attempt
Candidate*
First
Second
Third
Fourth
AFail: BM/BMFail: MisrepresentationPass
B Fail: BM/BM and HUM Fail: BM/BM and HUM Fail: Misrepresentation
CFail: MisrepresentationPass
D Fail: Misrepresentation Pass
EFail: MisrepresentationPass
F Fail: Misrepresentation Fail: HUM Pass
GFail: MisrepresentationPass
H Fail: Misrepresentation Pass
IFail: MisrepresentationPass
J Fail: Misrepresentation Pass
KFail: MisrepresentationPass
L Fail: Misrepresentation Pass
MFail: MisrepresentationPass
N Fail: Misrepresentation Pass
OFail: MisrepresentationPass
P Fail: Misrepresentation Pass
QFail: MisrepresentationPass
R Fail: BM/BM Fail: HUM Fail: Misrepresentation Pass
SFail: MisrepresentationPass
T Fail: Misrepresentation Pass
UFail: MisrepresentationPass
V Fail: Misrepresentation Pass
WFail: MisrepresentationPass
X Fail: HUM Fail: Misrepresentation
 Abbreviations: BM/BM, Biomedical/Biomechanical Domain; COMLEX-USA Level 2-PE, Comprehensive Osteopathic Medical Licensing Examination-USA Level 2-Performance Evaluation; HUM, Humanistic Domain.
 *Data are presented in chronologic order, with candidate A in 2007 through candidate X in 2010. To protect candidate identity, specific dates for examination administrations are not reported.
×
Of the 24 candidates, 20 were first-time examinees, 2 were on their second take (1 failed the Biomedical/Biomechanical Domain and 1 failed the Humanistic Domain on first attempt), and 2 were taking the COMLEX-USA Level 2-PE a third time (1 failed both domains on both first and second attempts, and 1 failed one of each domain on each previous attempt). 
After failing COMLEX-USA Level 2-PE because of misrepresentation of clinical findings during their first examination attempt, 19 of 20 candidates passed on their second attempt. The remaining candidate failed the Humanistic Domain on a second attempt and passed the examination on the third attempt. Of the 4 candidates who failed the examination because of misrepresentation on the second or third attempt, 2 went on to pass in subsequent administrations, and 2 had not scheduled subsequent examinations at the time of data collection (Table 3). 
Of the 24 candidates, 22 ultimately passed the examination at the time data were obtained (August 2010), none failed twice because of misrepresentation, and 2 candidates had not yet scheduled retake examinations. 
Comment
Failing the COMLEX-USA Level 2-PE because of misrepresentation of clinical findings is a rare occurrence: Only 24 of 12,510 candidates failed the examination (0.2% failure rate) for this reason during the 2007-2008, 2008-2009, and 2009-2010 testing cycles. Of these 24 candidates, most failed on their first attempt because of misrepresentation of clinical findings, and only 4 (16.7%) failed because of misrepresentation of clinical findings during subsequent examination attempts. It is therefore unlikely that candidates intentionally misrepresent clinical findings after an unsuccessful previous attempt in order to improve examination scores. 
Of those candidates who had previously failed the examination in 1 of the 2 performance domains prior to failing because of misrepresentation of clinical findings, there was no clear pattern of prior performance. Students failed both the Humanistic Domain and the Biomedical/Biomechanical Domain with equal frequency. Intentionally misrepresenting SOAP notes would theoretically provide an advantage only to those scores within the Biomedical/Biomechanical Domain. Therefore, one might again draw the conclusion that this misrepresentation is not necessarily the result of a previously unsuccessful candidate intentionally “gaming” the examination, particularly for a candidate trying to compensate for previous poor performance in the Humanistic Domain. 
Most candidates in our sample went on to successfully complete COMLEX-USA Level 2-PE on their next subsequent attempt. Of the 20 candidates who failed because of misrepresentation on the first attempt, 19 passed on their next attempt (95% retake pass rate). Therefore, the candidates who failed their first attempt because of misrepresentation demonstrated higher pass rates on second attempt (95%) than all candidates who failed on their first attempt (87.1% pass rate for candidates on their second-attempts overall).11 
Although the number of candidates misrepresenting clinical findings on SOAP notes appears small, overdocumention in postencounter notes is a disturbing act that represents careless and unprofessional behavior. However, is it considered cheating? Cheating is defined as “depriving something valuable by the use of deceit or fraud” or “influencing or leading by deceit, trick, or artifice.”13 Implied in the use of the term “cheating” is intent, and if intent cannot be established, then the behavior cannot be considered cheating with certainty. In a previous study including respondents from 120 medical schools in the United States and Canada, Stimmel et al14 reported 181 formal allegations of cheating with 30 (16.6%) of those representing cheating on the National Board Examinations. Because Stimmel et al predates the incorporation of clinical skills testing for high-stakes licensing examinations,15 the analysis excludes issues of overdocumentation on postencounter notes. 
Under the Health Insurance Portability and Accountability Act of 1996, fraud is defined as knowingly and willfully executing a scheme to defraud; this is contrasted with abuse, which is unintentional practice.16,17 Therefore, as is the case with cheating, intent is used to distinguish fraud from abuse. Sandella et al6 reported that medical students may overdocument, particularly for high-stakes clinical skills examinations, for a variety of reasons: feeling pressure to pass the examination, presuming that standardized patients are unlikely to have positive findings on examination, failing to recognize overdocumentation as inappropriate because the behavior was not identified during previous standardized patient-based exercises at school, and assuming the consequences will not have negative patient outcomes because the testing environment is artificial and the patients are not “real.”6 
Other investigators have speculated that overdocumention may be due to recall bias, misunderstanding of physical examination, misuse of acronyms or abbreviations, inference of findings of a clinical case, and intentional reporting of findings after realizing they neglected to ask questions or perform maneuvers pertinent to the case.9 However, without understanding or knowing the intent of candidates when writing post encounter notes that contain information that was not obtained during the clinical encounter, we cannot consider this behavior as cheating with certainty. The fact of the matter is that the recorded information may not be accurate, the information was not obtained during the patient encounter, and this overdocumentation may lead to serious negative patient outcomes if continued in clinical practice. Identifying candidates who misrepresent clinical findings in their documentation is therefore not necessarily a mechanism to recognize cheating, but rather to identify a practice that may compromise patient safety. 
The consequence for a candidate who has demonstrated a consistent pattern of misrepresentation on his or her postencounter notes is severe: a failure on the COMLEX-USA Level 2-PE. This outcome results in preserving examination scoring validity by not scoring notes that are inaccurately formulated, as well as raising awareness of the importance of documentation accuracy throughout medical education and beyond. Consistent with NBOME's mission to protect the public, identifying overdocumentation practices that may lead to negative patient outcomes is an important step toward reducing medical errors. 
Conclusion
Among candidates found to have misrepresented clinical findings on postencounter written documentation on the COMLEX-USA Level 2-PE, no clear pass/fail pattern was identified in their past or subsequent examination performance, and the majority of these candidates passed on subsequent examination attempts. The NBOME will continue to monitor the accuracy and integrity of contents included in written postencounter documentation to continue to fulfill its mission to protect the public. 
 Financial Disclosures: None reported.
 
Kohn LT, Corrigan JM, Donaldson M, eds. To Err Is Human: Building a Safer Health System. Washington, CD: Institute of Medicine; 1999.
Kopec D, Tamang S, Levy K, Eckhardt R, Shagas G. The state of the art in the reduction of medical errors. Stud Health Technol Inform. 2006;121:126-137.
Weingart SN, Wilson RM, Gibberd RW, Harrison B. Epidemiology of medical error. BMJ. 2000;320(7237):774-777.
Edwards M, Moczygemba J. Reducing medical errors through better documentation. The Health Care Manag. 2004;23(4):329-333.
Shenfield GM, Robb T, Duguid M. Recording previous adverse drug reactions—a gap in the system. Br J Clin Pharmacol. 2001;51(6):623-626.
Sandella JM, Roberts WL, Gallagher LA, et al. Patient note fabrication and consequences of unprofessional behavior in a high-stakes clinical skills licensing examination. Acad Med. 2009;84(10 suppl):S70-S73.
Szauter KM, Ainsworth MA, Holden MD, Mercado AC. Do students do what they write and write what they do? The match between the patient encounter and patient note. Acad Med. 2006;81(10 suppl):S44-S47.
Macmillan MK, Fletcher EA, Champlain AF, Klass DJ. Assessing postencounter note documentation by examinees in a field test of a nationally administered standardized patient test. Acad Med. 2000;75(10 suppl):S112-S114.
Worzala K, Rattner SL, Boulet JR, et al. Evaluation of the congruence between students' postencounter notes and standardized patients' checklists in a clinical skills examination. Teach Learn Med. 2008;20(1):31-36.
Dresselhaus TR, Luck J, Peabody JW. The ethical problem of false positives: a prospective evaluation of physician reporting in the medical record. J Med Ethics. 2002;28(5):291-294.
Langenau E, Dyer C, Roberts WL, Wilson CD, Gimpel JR. Five-year summary of COMLEX-USA Level 2-PE examinee performance and survey data. J Am Osteopath Assoc. 2010;110(3):114-125.
National Board of Osteopathic Medical Examiners. 2011-2012 Orientation Guide COMLEX-USA Level 2-PE. http://www.nbome.org/docs/PEOrientationGuide2011-2012.pdf. Accessed July 5, 2011.
Definition of cheat. Merriam-Webster Dictionary Web site. http://www.merriam-webster.com/dictionary/cheating. Accessed November 9, 2010.
Stimmel B, Yens D. Cheating by medical students on examinations. Am J Med. 1982;73(2):160-164.
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Rudman WJ, Eberhardt JS III, Pierce W, Hart-Hester S. Healthcare fraud and abuse. Perspect Health Inf Manag. 2009;6:1g .
Table 1.
COMLEX-USA Level 2-PE Failures Due to Misrepresentation of Clinical Findings for Testing Cycles 2007-2008, 2008-2009, and 2009-2010 (N=24)

Testing Cycle

Candidates Tested, No.*

Candidates Failed, No. (%)
2007-200837518 (0.2%)
2008-2009 4698 9 (0.2%)
2009-2010 4061
7 (0.2%)
Total
12510
24 (0.2%)
 *Numbers reflect the total number of candidates (first-time and repeat candidates) who took the Comprehensive Osteopathic Medical Licensing Examination-USA Level 2-Performance Evaluation (COMLEX-USA Level 2-PE) in the given testing cycle.
Table 1.
COMLEX-USA Level 2-PE Failures Due to Misrepresentation of Clinical Findings for Testing Cycles 2007-2008, 2008-2009, and 2009-2010 (N=24)

Testing Cycle

Candidates Tested, No.*

Candidates Failed, No. (%)
2007-200837518 (0.2%)
2008-2009 4698 9 (0.2%)
2009-2010 4061
7 (0.2%)
Total
12510
24 (0.2%)
 *Numbers reflect the total number of candidates (first-time and repeat candidates) who took the Comprehensive Osteopathic Medical Licensing Examination-USA Level 2-Performance Evaluation (COMLEX-USA Level 2-PE) in the given testing cycle.
×
Table 2.
First-Time Candidates Who Passed or Failed the COMLEX-USA Level 2-PE for Testing Cycles 2007-2008, 2008-2009, and 2009-2010 (N=11672)


Testing Cycle, No. (%)
Examination Outcome
2007-2008 (n=3476)
2008-2009 (n=4353)
2009-2010 (n=3843)
Pass3249 (93.5)4124 (94.7)3644 (94.8)
Fail* 227 (6.5) 229 (5.3) 199 (5.2)
□ Humanistic domain121 (3.5)115 (2.6)105 (2.7)
□ Biomedical/biomechanical domain 83 (2.4) 81 (1.9) 76 (2.0)
□ Both domains
23 (0.7)
33 (0.8)
18 (0.5)
 *Domain-specific fail rates add up to the overall fail rate for the Comprehensive Osteopathic Medical Licensing Examination-USA Level 2-Performance Evaluation (COMLEX-USA Level 2-PE).
Table 2.
First-Time Candidates Who Passed or Failed the COMLEX-USA Level 2-PE for Testing Cycles 2007-2008, 2008-2009, and 2009-2010 (N=11672)


Testing Cycle, No. (%)
Examination Outcome
2007-2008 (n=3476)
2008-2009 (n=4353)
2009-2010 (n=3843)
Pass3249 (93.5)4124 (94.7)3644 (94.8)
Fail* 227 (6.5) 229 (5.3) 199 (5.2)
□ Humanistic domain121 (3.5)115 (2.6)105 (2.7)
□ Biomedical/biomechanical domain 83 (2.4) 81 (1.9) 76 (2.0)
□ Both domains
23 (0.7)
33 (0.8)
18 (0.5)
 *Domain-specific fail rates add up to the overall fail rate for the Comprehensive Osteopathic Medical Licensing Examination-USA Level 2-Performance Evaluation (COMLEX-USA Level 2-PE).
×
Table 3.
Pass/Fail Patterns of Candidates Who Failed COMLEX-USA Level 2-PE Because of Misrepresentation of Clinical Findings for Testing Cycles 2007-2008, 2008-2009, and 2009-2010 (N=24)


Attempt
Candidate*
First
Second
Third
Fourth
AFail: BM/BMFail: MisrepresentationPass
B Fail: BM/BM and HUM Fail: BM/BM and HUM Fail: Misrepresentation
CFail: MisrepresentationPass
D Fail: Misrepresentation Pass
EFail: MisrepresentationPass
F Fail: Misrepresentation Fail: HUM Pass
GFail: MisrepresentationPass
H Fail: Misrepresentation Pass
IFail: MisrepresentationPass
J Fail: Misrepresentation Pass
KFail: MisrepresentationPass
L Fail: Misrepresentation Pass
MFail: MisrepresentationPass
N Fail: Misrepresentation Pass
OFail: MisrepresentationPass
P Fail: Misrepresentation Pass
QFail: MisrepresentationPass
R Fail: BM/BM Fail: HUM Fail: Misrepresentation Pass
SFail: MisrepresentationPass
T Fail: Misrepresentation Pass
UFail: MisrepresentationPass
V Fail: Misrepresentation Pass
WFail: MisrepresentationPass
X Fail: HUM Fail: Misrepresentation
 Abbreviations: BM/BM, Biomedical/Biomechanical Domain; COMLEX-USA Level 2-PE, Comprehensive Osteopathic Medical Licensing Examination-USA Level 2-Performance Evaluation; HUM, Humanistic Domain.
 *Data are presented in chronologic order, with candidate A in 2007 through candidate X in 2010. To protect candidate identity, specific dates for examination administrations are not reported.
Table 3.
Pass/Fail Patterns of Candidates Who Failed COMLEX-USA Level 2-PE Because of Misrepresentation of Clinical Findings for Testing Cycles 2007-2008, 2008-2009, and 2009-2010 (N=24)


Attempt
Candidate*
First
Second
Third
Fourth
AFail: BM/BMFail: MisrepresentationPass
B Fail: BM/BM and HUM Fail: BM/BM and HUM Fail: Misrepresentation
CFail: MisrepresentationPass
D Fail: Misrepresentation Pass
EFail: MisrepresentationPass
F Fail: Misrepresentation Fail: HUM Pass
GFail: MisrepresentationPass
H Fail: Misrepresentation Pass
IFail: MisrepresentationPass
J Fail: Misrepresentation Pass
KFail: MisrepresentationPass
L Fail: Misrepresentation Pass
MFail: MisrepresentationPass
N Fail: Misrepresentation Pass
OFail: MisrepresentationPass
P Fail: Misrepresentation Pass
QFail: MisrepresentationPass
R Fail: BM/BM Fail: HUM Fail: Misrepresentation Pass
SFail: MisrepresentationPass
T Fail: Misrepresentation Pass
UFail: MisrepresentationPass
V Fail: Misrepresentation Pass
WFail: MisrepresentationPass
X Fail: HUM Fail: Misrepresentation
 Abbreviations: BM/BM, Biomedical/Biomechanical Domain; COMLEX-USA Level 2-PE, Comprehensive Osteopathic Medical Licensing Examination-USA Level 2-Performance Evaluation; HUM, Humanistic Domain.
 *Data are presented in chronologic order, with candidate A in 2007 through candidate X in 2010. To protect candidate identity, specific dates for examination administrations are not reported.
×