Every chiropractic student asks it.

And nobody wants to say it out loud:

“Which board exam is actually the hardest?”

The real answer?

It depends on you — your strengths, your stress patterns, your study strategy.

But across thousands of students, clear patterns emerge.

Based on:

• Student surveys

• Score data trends

• Faculty observations

• What students say after passing…

Here’s the full ranking — hardest to easiest — with the real reasons why.

#1 — NBCE Part III (Clinical Decision Making + DXI)

Why students struggle:

• Must make fast decisions with incomplete info

• “Multiple right answers” — only one is safest

• DXI blindsides students trained in school-style radiology

• Anxiety skyrockets under time pressure

“Part III is the first time I worried: Am I thinking like a doctor yet?”

What improves performance:

• Learning board logic, not memorizing textbooks

• Mixed timed practice

• Pattern recognition for X-ray danger signs

#2 — NBCE Part I (Volume + Overwhelm)

Why students struggle:

• Too much to memorize → burnout

• Integration expected before students feel ready

• Timing fatigue — 255 questions in one sitting

“It felt like learning all of chiropractic school again.”

What improves performance:

• High-yield systems-first strategy

• Retrieval-based study method

• Short + frequent practice sets

#3 — NBCE Part IV (Confidence + Practical Execution)

Why students struggle:

• Hands-on performance under observation

• History + exam + technique must feel automatic

• Stress changes speed, clarity, communication

“You can know it — but can you perform it while someone is judging every move?”

What improves performance:

• Repetition with feedback

• Communication routines

• Refining technique consistency

#4 — NBCE Part II (Clinical Integration + Endurance)

Why students struggle:

• Must connect multiple systems

• Long exam → decision fatigue

• Distractor traps reward hesitation

“The questions weren’t hard… the test was long.”

What improves performance:

• Clinical consequence thinking

• Weekly mixed-subject sets

• Simulated long-session practice

#5 — Physiotherapy Exam (PT)

Why students struggle:

• Often taken when students are mentally exhausted

• Memorization-only study → retention drops fast

“It looked easy — until I misread the small details.”

What improves performance:

• Spaced recall

• Practice questions with rationale

• Studying before burnout sets in

So Which One Is the “Real” Hardest? 

Most students say Part III is the hardest because performance is under the most pressure and timing is tight.

But the hardest exam is the one you are unprepared for.

The Confidence Equation

Success comes from:

• Clarity on what’s tested

• A realistic plan

• Training your test-day brain

The students who pass on the first try don’t study more —they study smarter with strategy.

Frequently Asked Questions (FAQ)

Does everyone struggle with Part III?

Not everyone — but those who don’t typically:

• Start decision-training early

• Practice DXI in NBCE format

• Build confidence intentionally

How many attempts do students usually need?

Most pass within 1–2 attempts per part— but early strategy prevents delays in graduation.

Should I take Part I and II close together?

If your foundations are strong → yes

If not → spacing them reduces overwhelm

What’s the key to passing the hardest board for you?

Figure out your weakest stress response zone:

• Volume?

• Speed?

• Practical skills?

• Confidence?

Then build a plan that strengthens it.

Still stuck on how to study for your chiro board exam?

Check out all of Chiro Aligned Learning’s products, follow us on Instagram for what to expect during your exams or reach out to us with questions via email at [email protected]!