The Final “Step” – How to Efficiently Tackle the USMLE

To those that are reading this post, it might sound silly to be overly concerned about Step 3. And that’s fair. At this point, you are an old pro at ...

To those that are reading this post, it might sound silly to be overly concerned about Step 3. And that’s fair. At this point, you are an old pro at taking exams and have completed Steps 1 and 2 in appropriate fashion. You have started your residency and are focusing on becoming the best doctor you can be, as you should. So why bother thinking much about Step 3? The main reason, I would say, is that all of those prior successes on Step examinations came from diligent and thoughtful preparation. Though Step 3 is the least “high-stakes” exam of the 3, it at least deserves a portion of the same preparation and work. The other reason is that, much like Step 2 differs from Step 1 (with both CS and CK), Step 3 has some new components that will be less familiar. So let me take this opportunity to break the exam down and give some basic advice.



WHAT DOES STEP 3 LOOK LIKE?
Step 3, unfortunately, is a 2-day exam. I know—great, right? Here’s how it breaks down:

Day 1 is much like Step 1 and Step 2 CK. It consists of all multiple-choice questions in the same style as prior Steps. There will be 233 multiple-choice questions divided into 6 blocks of 38-40 questions each. Each block is 60 minutes long. With the allotted break time of 50 minutes, this day amounts to about 7 hours of testing time. Day 1 is a bit shorter than the second day—I suppose they ease you into it. On this day expect nothing different from prior Step examinations in the question style and pace.

Day 2 is where the new component comes in. It is a 9 hour testing day, broken into 2 distinct test taking formats. First are 180 multiple-choice questions. This is divided into 6 blocks of 30 questions with 45 minutes to complete each. Next is a section of case simulations completed on the computer in a standardized format. I will explain this format and the process of these simulations in more detail below. There will be 13 case simulations, each of which is allotted a maximum of 10 or 20 minutes. Day 2 has 45 minutes of break time, as well as tutorial time which can be used as a break.

After the grueling 2-day affair, 16 hours in total, you will be done with the USMLE! You will be relieved of all Step exams and free to throw yourself into the clinical and research work of residency! And to just enjoy life. Most importantly.



WHEN SHOULD I TAKE STEP 3?
One important thing to note about Step 3 is that the 2 days do not have to be completed back-to-back. You are free to schedule them as you please. Many people want to knock the test out in 2 consecutive days and be done with it. I was one of them. Others scheduled the test on 2 spaced out days during the same week, or even 1 week apart. There is no right answer. Go about this how you please and however is feasible in terms of scheduling with your residency program.

The next thing to consider is what point during the year to take the exam. In general, Step 3 is taken during intern year of residency, so that license applications can be completed at the end of intern year and received during second year. Different programs may have more specific requirements, but sometime during intern year is the general rule. There is no right answer as to when to take the exam. The most influential factor will be your residency schedule. I would recommend finding a time during the year when you might have a few weeks or even a month of consecutive outpatient or consult time (if possible—I know this is less feasible in certain specialties). It is easiest to schedule Step 3 for an outpatient block when you will not miss the clinical duties of inpatient and require coverage. Maybe more importantly, if you schedule at the end of one month of outpatient, you will have those first 3 weeks to prepare. I think everyone approaches the exam differently in terms of how long and how intensely they prepare (see below). But I would plan to give yourself at least 3-4 weeks of dedicated studying after work and on weekends in order to get through enough practice questions and simulations to feel comfortable on test day.



HOW MUCH DOES MY SCORE ACTUALLY MATTER?
Another consideration is what your goal is for this exam. In general, I think we should always strive for our best score on any exam, our best result on any endeavor we undertake. With that said, life has realistic limitations that we have to operate within the confines of. Residency provides plenty of those limitations. One question people often ask is: how much does my Step 3 score actually matter? Unfortunately, this is not an easy question to answer. I searched far and wide for the answer to this question and at best was able to unearth several opinions. But never a clear answer. Let me first say that unless you are in a specialty in which you will apply for a fellowship, your actual score on the exam likely does not matter much, if at all. As long as you pass you should be fine, as there is no need to use the exam score as a metric of your quality on a future application.

For those who will be applying to a fellowship beyond residency, myself included, here is the general consensus: the exam does not matter nearly as much as Step 1, which is still weighed the most heavily for fellowship applications, believe it or not. Many residents who were applying for fellowship in medicine and even some attendings said the score does not matter at all. Some said it likely matters a bit, but is far less important than letters of recommendation and research. One exception was a Cardiology fellowship program director who told me he does look at the Step 3 score. And though it is less important than Step 1 and 2 in his eyes, he does like to see relative consistency in the score range among the 3 exams. So again, there is no clear answer but the takeaway is this: if you are applying for a fellowship, the score may matter for you in the future, though it will matter less than your other Step scores. Either way though, why not strive for your best (within reason)?



HOW SHOULD I PREPARE?
For this portion, I will give you my general thoughts and what my approach was. Each individual will of course have to create their own plan, based on their study habits, goals, and level of comfort with the exam. And remember: when setting your goal, think about your career plans and how this score may or may not be relevant to your future applications!

As I mentioned before, I think at least 3-4 weeks of dedicated studying for the exam would be an intelligent approach, on average. And because this will be during intern year, this means studying in addition to work. If during an outpatient or easier rotation, this will be less burdensome. If during an inpatient rotation, this time period may need to be elongated a bit. In addition to this, others choose to study at a more leisurely pace for a longer period prior to the exam. Perhaps this would be more palatable to, say, a medicine resident applying for GI fellowship (for whom the exam score may matter in the future).

Once you’ve decided on the timeline, get to the practice questions. No different from Steps 1 and 2, UWorld is the way to go. I didn’t use any resources beyond this and I think that would be my approach again. So Uworld has a set of 1500 multiple choice questions. There is a time-tiered pricing scheme, as you can buy 30, 60, 90, 180 or 360 day subscriptions for incrementally increasing prices. I would definitely buy this for whatever time period you plan to study.

Here’s an important piece of information: you must pay extra to get the UWorld Clinical Case Simulation (CCS). Do this! The CCS and a practice exam are only an additional $50 or so over the Qbank. Do not forget to buy the CCS as well. Here’s why. The clinical cases on the exam are in a somewhat non-intuitive format that takes some getting used to. I would explain it here, but honestly it won’t do it any justice. What you need to do is buy the UWorld CCS, which looks just like the cases on the actual exam, and go through several of them to get a feel for it. To give you a brief idea, you are given a patient with a presenting complaint. You then need to ask for additional pieces of information, lab studies, imaging, etc. Meanwhile, you advance the time forward to see the results, to simulate an actual encounter. You may have to escalate the level of care, or you may be able to send the patient home. Ultimately the case will end and you will provide a final diagnosis. It is stepwise approach that takes some getting used to. I guess I did explain it briefly after all, but check out the UWorld CCS and you will better understand what I mean! Once you’ve gotten the hang of it, you can simply read through the explanations for the remainder of the cases to save time if you prefer.

Last piece of advice about UWorld. I would recommend buying the Biostatistics Subject Review as well. This is $25 for a 90-day subscription. It is a very brief but relevant overview of biostats topics that will appear on the exam. It can be completed in a few hours. I found that the exam had a significant number of biostats questions, more than prior steps. I was prepared for them because I completed this UWorld module. It’s pretty high yield.

Completing these 3 UWorld components (or as much of them as you can) would be my recommendation for Step 3 studying. In my opinion, this is sufficient, or should be for most. Augment this as needed with other materials based on your comfort or expected performance. But this is where I would start.



GO GET ‘EM
Once you’ve put in the work, go ahead and show what you know! I think you’ll be very comfortable on exam day if you prepare this way. I will note that the 2-day process is a bit grueling if done back-to-back, so be mentally prepared for that. But you will all do great. Hope this review has been helpful. Good luck to all my fellow residents on Step 3!

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