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Michael Stephens and Dr. Mike Ren contributed to this post. 

“Two months for Step 1, two weeks for Step 2 CK, and a number 2 pencil for Step 3, right?” Not exactly.

You cannot bring your own pencils into the testing facility nor would you need them. And more importantly, Step 3, though not the most crucial of the three USMLE examinations, is not an exam to disregard. It is an expensive and grueling exam that you would only wish to have to take once and is increasingly being used in the fellowship match. This outline will breakdown how to plan for the Step 3 exam and what to expect as you prepare and take the test.

How to plan for Step 3 exam prep: 

1. Realize that USMLE Step 3 is not like the others.

Step 3 is different from the other components of the USMLE in many ways. As a result, preparing for it requires a tailored approach that may not be the same as what you utilized for Step 1 or Step 2 CK.

First of all, the exam is divided into two separate days that can be, but do not have to be, contiguous. The first day consists of your standard multiple choice questions in a timed setting, while the second day is similar but with the addition of clinical cases. The cases cover a variety of clinical scenarios from emergency, to acute care, to chronic care, and you’ll need to familiarize yourself with triage as well as treatment. Overall, Step 3 heavily emphasizes triage and the delivery of care. And of course, don’t forget to study ethics and biostatistics.


2. Establish a timeline and a test date.

The first step in any study plan is to develop a timeline to establish boundaries regarding when you plan to take the exam and how much time you will have to prepare.

We must reiterate that leaving an open-ended Step 3 test date is strongly discouraged, as the associated perception that you have an unlimited amount of time to study may lead to inefficiency and procrastination.

Moreover, when you later attempt to book your test date, you may find that the dates previously available are no longer options and you have to defer your exam to later or travel to a distant testing center.

Which dates to select for the exam should be based on consideration of your schedule and when would be reasonable for you to both prepare for the test and have two days off to take it.

Specifically, you should be realistic about when you will have time to study. If you have a series of challenging rotations on which you will be putting in long hours, it’s probably not wise to schedule your exam at the end of said block. What would be preferable is to identify a period of time when you may be off or have a lighter workload, during which you may have nights and/or weekends available for studying.

Finally, one last aspect is how you want to schedule the two days relative to each other. Many people elect to take both parts back to back and finish the exam in two days, while others might prefer to have a break in between the days. The decision is personal, though I’d recommend taking a few days in between to recuperate and prepare a bit more for the clinical cases as they are lengthy, have a difficult user interface, and are something you have not yet encountered in your career. 


3. Don't neglect practice questions and practice tests.

The single most important component of any study plan is incorporating practice questions. Among qbanks, the best and go-to option is UWorld which, much like it did for Step 1 and Step 2 CK, incorporates the highest-yield concepts into questions with well-written and researched explanations. In fact, this is the best place to start your studying, and you should make it a priority to get through a first pass with reasonable efficiency to afford time to return to these questions and do as much of a second pass as possible. One great advantage to the UWorld qbank is that it accounts for, and will test you on, the higher-level ethics and biostatistics questions that you will encounter in the first test day.

If you finish UWorld once, or even twice, and have time remaining in your study period, you may be looking for more questions. AMBOSS is a newer qbank that also offers Step 3-specific questions through which you can work. The AMBOSS questions tend to be slightly more challenging, in that they require you to pick up on minute details in longer vignettes in order to arrive at the right answer.

Regarding practice tests, your choices are the same as they were for the previous board exams and specifically are the NBMEs and UWorld Self-Assessments. It is worthwhile to at least do the latter and then consider also purchasing the former as time permits. While these tests will result in a three-digit conversion of your raw score, you should note that they are not full-length and only cover concepts tested in the multiple choice components on the exam days; they do not incorporate the CCS component which you will have to practice separately as described below.


4. Buy a textbook to assist your Step 3 studying.

Regarding textbooks for Step 3, much like Step 2 CK, a single stand-alone textbook does not exist as the go-to resource in the way that First Aid is for Step 1.

To that end, there is no single option that you should feel compelled to use. One textbook that is worth looking into is First Aid for the USMLE Step 3. While it’s not realistic or practical to read this or another similar resource from cover to cover, one way that it may be incorporated is by using it as a secondary resource to take a deeper dive into certain topics you self-diagnose as areas of opportunity.

For example, if you feel like you are consistently getting questions about the indications for different classes of antiarrhythmics wrong and, despite the question explanations, still do not have a clear framework for how to think about these medications, it may be worthwhile to review this section in the textbook you choose. What is not necessary or advisable is spending excess time reviewing the entire cardiology chapter to relearn concepts with which you already felt comfortable.


5. Use computer-based case simulations.

A unique aspect of Step 3 is the Primum® Computer-based Case Simulations (CCS) component of the exam. While the multiple choice components of Step 3 may be very similar to what you had experienced on Step 1 and Step 2 CK, this part will be very different. The single most important recommendation for approaching these cases is to become familiar with the software and how you will be timed and scored.

Specifically, on the day of the exam, you will be presented with thirteen cases which start with a brief patient vignette including whether the context is an emergency department or an outpatient clinic and routine vitals signs. It is then your responsibility to perform a physical examination and begin to order diagnostic tests and begin to develop a therapeutic plan.

As you work through these cases, there are two simultaneous clocks running. One clock counts down how much real-world time you have remaining in the simulation which generally starts at ten or twenty minutes. The other clock moves forward in simulated time to correspond to the evolution of the condition of a patient.

If this seems confusing, you should rest assured that it is not intuitive for most people. However, for that reason, it is all the more important to do the practice cases within the UWorld interface to develop dexterity with placing orders in this simulated context and hone your clinical reasoning. If you finish these with time to spare, there are so-called printable cases that walk through additional examples so that you can continue to familiarize yourself with the rubrics with which you will be scored.


The Bottom Line

In short, Step 3 is not the same as Step 1 or Step 2 CK and therefore requires a specialized approach. While practice questions and supplementary textbooks remain the backbone of tackling the multiple choice questions, handling the CCS cases and the logistics of having the test span two days create added levels of complexity to the testing experience.

Success with Step 3 requires confidence, dedication, and time. Create a timeline and gather your resources and then get started. Check out our other blog posts for a detailed study timeline, resources, and contact us if you have any questions. We’re always here to help!


Looking for more Step 3 study resources? We have you covered:

VIDEO: How to Balance Being a Busy Resident & Preparing for USMLE Step 3

Mastering Step 3: Which Resources Should I Use?

Cracking the CCS Cases: Preparing for USMLE Step 3

Studying for Step 3: 6 Tips to Help You Ace Exam Day

How I Scored 258 on Step 3 While Figuring Out How to Be an Intern

Image by congerdesign from Pixabay 

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