USMLE Step 3

Step 3 is the final exam in the USMLE series of examinations. It is part of the licensing requirements for Doctors of Medicine (M.D.), including international medical graduates aiming to practice medicine in the United States. Generally, it is a pre-requisite of the majority of the state licensing boards.

Most of the USMLE Step 3 exam (75 percent) consists of multiple choice questions, while the remaining 25 percent are clinical case simulations. A full description of the content of the exam can be found on the USMLE website.^[1] USMLE Step 3 exams are delivered online but administered only at Prometric testing centers, which emphasize identity verification and security. Examinees must provide official photo identification and fingerprints as well as pass both metal detector and physical inspection every time they wish to enter the examination room. Materials allowed within the exam room are extremely limited and most require prior approval, including medical equipment. Examinees are on video surveillance during the examination. The test is available throughout the year to the examinees.

Since 2014 USMLE Step 3 can be taken on two non-consecutive days, instead of two consecutive days.^[2]

Examination content

USMLE Step 3 examination tests on general topics that are required to understand and practice concepts of general medicine/ family medicine.

The following components are tested:

Normal conditions and disease categories (normal growth and development, basic concepts, and general principles)

Clinical encounter frame (initial work up, continuing care, urgent intervention)

Physician task (applying scientific concepts, formulating a diagnosis based on history, physical exam, and lab findings, and managing the patient).

Clinical encounter frames are common clinical scenarios physicians may encounter. They range from nonemergency problems, to the continuity of care, to life-threatening emergency situations encountered in emergency departments, clinics, offices, care facilities, inpatient settings, and on the telephone. Each test item, in an encounter frame, represents one of the six physician tasks. For example, initial care encounters emphasize taking a history and performing a physical examination. In contrast, continued care encounters emphasize decisions regarding prognosis and management.

Day 1 (Foundations of Independent Practice [FIP]) will continue to be divided into six 60-minute blocks. Each FIP block will have 38 to 40 multiple-choice questions (MCQs). The total number of MCQs on the FIP portion of the examination will be 233. The total testing day will be approximately 7 hours.

Day 2 (Advanced Clinical Medicine [ACM]) will continue to be divided into six 45-minute blocks of MCQs, and 13 computer-based case simulations (CCS). Each ACM MCQ block will have 30 items. The total number of MCQ items on the ACM portion of the examination will be 180. The second half of day 2 will contain the 13 CCS cases. ^[3]

Eligibility for USMLE Step 3

To be eligible to take the USMLE Step 3 exam, the physician must hold a medical degree, and pass the USMLE Step 1 and Step 2 Clinical Knowledge exams. International medical graduates (IMGs) must obtain certification by the Educational Commission for Foreign Medical Graduates (ECFMG). (Prior to December 2009, one could alternatively complete a "Fifth Pathway" program.) Certification in 2020 required the Occupational English Test instead of the Clinical Skills (CS)^[4] The Step 2 CS may also be required. Canadian M.D. graduates are not considered IMGs.

Starting November 2014, fulfillment of specific requirements from individual medical licensing authorities will not be needed.^[5]

Preparation strategies for USMLE Step 3

Typically, worldwide examinees require two to three months to prepare for this exam, although in the US, examinees who are American medical school graduates commonly prepare for only a few days to a few weeks. Physicians in post-graduate training that plan for fellowships or additional training often are advised to consider more detailed preparation. An examinee is tested on clinical skills, diagnostic acumen, decision making, treatment guidelines and follow up care. Most recently, some changes have been made to USMLE Step 3 multiple choice questions including increased emphasis placed on biostatistics, epidemiology, and population health, literature interpretation, medical ethics, and patient safety.

Since the USMLE Step 3 exam is typically taken after matching into a residency, it does not require a physician to obtain a competitive score and only need to pass to obtain their medical license. However, a competitive score may be needed if they want to apply for a fellowship.

Scoring

Beginning January 1, 2020 the recommended Step 3 minimum passing score was raised from 196 to 198.^[6]

Pass rates

First-time USMLE pass rates for D.O. and M.D. students in 2020 were 91 percent and 98 percent, respectively.^[7] The first-time pass rate for students from schools outside of the United States and Canada was 90 percent.^[7] Trainees in fields which encompass multiple specialties, such as emergency medicine or internal medicine, tend to perform well on Step 3 regardless of when they take the exam; trainees in other fields tend to do better if they take the exam shortly after medical school.^[8]

References