USMLE® Step 3

USMLE Step 3 FAQs: When to take the exam, how to prepare

Brendan Murphy , Senior News Writer

AMA News Wire

USMLE Step 3 FAQs: When to take the exam, how to prepare

Jul 11, 2024

The transition to physician residency brings with it more responsibility and less bandwidth. Even still, resident physicians have one major testing milestone on the docket: Step 3 of the United States Medical Licensing Examination (USMLE).

The final licensure exam in the USMLE series, Step 3 a two-day exam. The first day focuses on the foundations of independent practice and is in a multiple-choice format. The second day covers advanced clinical medicine and is a combination of multiple-choice questions and computer-based case simulations.

How can first-year residents succeed on the exam? An expert in USMLE Step 3 prep offered her insights in response to residents’ frequently asked questions.

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A practicing internist with a focus on preventive and lifestyle medicine, Janani Krishnaswami, MD, MPH, is also an author for UWorld, an online learning platform used to prepare for high-stakes exams. Her expertise includes exam preparation across the entire USMLE series.

When pondering the amount of study time it takes to pass Step 3, she said the intensity and extent of your exam preparation will depend on what you cover in your day to day as a first-year resident. In general, she recommended an exam-preparation window of about 90–120 days. If you are in a highly specialized field or have a history of struggling as a test-taker, you might want to begin preparing as much as six months out.

“If a resident’s specialty is highly subspecialized, and they're not in internal medicine, that field being the bulk of the exam, they may need more time to prep because a lot of the experience with Step 3 studying is really going to come from clinical practice,” Dr. Krishnaswami said. “If your clinical practice spectrum is narrower, if you're practicing in a very specific field, it's going be more difficult to remember some of that general knowledge from the fourth year of medical school.”

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Considering that resident physicians have limited bandwidth, they are unlikely to have extra hours in the day to read textbooks. Instead, Dr. Krishnaswami recommended active learning methods such as using a Qbank, going over weaker areas and thoroughly reviewing the explanations as a form of reference material. If additional reference material is necessary, she recommended the First Aid books, including the Step 1 edition  that covers basic science concepts.

“You're looking for frequent, consistent exposure to questions,” Dr. Krishnaswami said. “It's always good to use a question bank that simulates the real exam and gets your mind in that practice mode of doing the questions that will help performance on the actual test.”

UWorld for Step 3 resources include questions, explanations, and performance tracking, as well as the ability to create flashcards, customize exams and compare your progress with others.

This can be difficult for those in the busy first year of residency. One physician highlighted a method for getting studying done during rotations.

“Rotations definitely make it hard to find free time,” said AMA member Ellia Ciammaichella, DO, a spinal cord injury medicine physiatrist in Nevada who completed residency and fellowship training in Texas and Utah, respectively. “Some people liked to hang out and talk between patients, but I used that time to do practice questions or look things up on the computer. That helped me learn something new every day so I didn’t have to cram it all in right before the test.” 

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While the AMA and others advocate a change to pass-fail scoring on Step 3, along with the Comprehensive Osteopathic Medical Licensing Exam of the United States (COMLEX-USA) Level 3. That switch would follow in the footsteps of the change that took place with Step 1 scoring in 2022—the exam’s current format includes a numerical score. How much does that UMSLE Step 3 score matter?

“Passing Step 3 matters, but the score itself very rarely matters,” Dr. Krishnaswami said. “The only real exception I can think of is if someone is applying to fellowship and they did poorly on Step 1 or Step 2. In that case, it may be a chance to show that they're able to make up for that.

“Obviously it’s important to pass. That matters for a number of reasons, including getting licensed, being able to prescribe controlled substances and moonlighting.”

According to the USMLE program, the total number of attempts allowed to pass any exam in the Step series is four.

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Most residency programs require a passing score on Step 3 during one’s intern year to matriculate to PGY-2. As far as when to take it, that is typically up to the resident.

“I recommend taking it on an elective block,” Dr. Krishnaswami said, noting that tends to be a more flexible portion of intern year. “It's not the kind of thing I would try to put off too long—that material is going to get rustier, especially if you're going into a subspecialty that's farther away from internal medicine. So, I think it's like good to take it a little earlier in the year rather than later, but it's not by any means a set prescription.” 

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Illustration of resident looking at a diagnostic image

In terms of content there is some crossover with the basic science concepts that are covered on Step 1 and the general medicine concepts that are covered on Step 2. The real difference is the exam’s duration and a stronger focus on management nuances.

“The hardest thing about the exam is just the sheer volume,” Dr. Krishnaswami said. “It's two days. Sixteen hours. No resident has never done anything with this level of intensity and attention requirement.”

Doing a practice exam during intern year is very difficult, though Dr. Krishnaswami has seen some residents do it.

“Rather than a full-on practice test, what might be more realistic for residents is doing a block of practice questions,” she said. “Do it on a lighter clinical month. Gauge your performance based on that sample size and repeat that process a few times and see how it goes.”

The second day of the exam includes computer-based clinical simulation questions. Don’t ignore those in your studies, Dr. Krishnaswami said. The other mistake is underestimating the difficulty of the exam.

“Make sure you don’t ignore the test,” Dr. Krishnaswami said. Conversely, “you don't want to go crazy overpreparing for it because you have enough to deal with in the intern year.”

When formulating a study plan, the first question many students want to know is: What’s on the test? That’s the one USMLE-related question that no one can answer. Yet there are methods and subjects in what are considered high-yield areas.

The objective of the exam is to test general medicine concepts in an ambulatory setting. In short, that means internal medicine is the most common topic and should be the heaviest area of focus during study.

“Anything with internal medicine is going to be the bulk of the exam,” Dr. Krishnaswami said. “It just encompasses so many different areas that if you look at the test’s content outline, most of the areas of emphasis are internal medicine.”