About the Step 3 Exam

The USMLE Step 3 is the last in a series of 3 USMLE examinations that all physicians applying for a license to practice medicine in the United States are required to pass. After successfully completing the 3 steps of the USMLE, a physician is eligible to practice medicine in an independent, unsupervised setting (some period of U.S. postgraduate training is also required).
This test is not merely a more advanced and detailed version of the Step 2 CK or CS exams. Understanding this concept is key to this challenging exam. Step 3 tests whether a physician not only can assimilate data and diagnose clinical conditions but also has acquired the ability to make clinical decisions about patient management in a way that ensures appropriate management in an unsupervised setting. In addition, Step 3 will test your understanding of basic science correlations.
How can the Step 3 test all first-year interns if they are working in such varied subspecialty settings? The same concepts that medicine house-officers learn about managing a diabetic with heart failure can be equally applied to the postsurgical patient with heart failure.

How Is Step 3 Different?

Unlike the Step 2 exams, which emphasize diagnosis of medical conditions, Step 3 evaluates your ability to evaluate the severity of a patient’s condition and discern the most appropriate clinical management based on the presenting scenario. This assessment of your clinical judgment distinguishes Step 3 from Step 2. In Step 3, you are required to think beyond the diagnosis (which is often implicit in the question itself) and make decisions in management. The cases presented will include options that may all appear appropriate; however, for the presented situation, there is only ever one correct answer. Your interpretation of laboratory data, imaging, and elements of the presenting history and physical examination will assist you in selecting the correct management.

Step 3 Examination Structure

The USMLE Step 3 is a 2-day computerized examination. The first day and a half tests your knowledge with a total of 413 traditional multiple-choice questions, which are arranged in blocks organized by one of the 3 clinical settings. Within a block, you may answer the items in any order, review responses, and change answers. However, after exiting a block, you can no longer review questions or change answers within that block. A link to view standard lab values, as well as access a calculator, is available at any time within the block of questions.

Day 1 includes 233 multiple-choice items divided into six 60-minute blocks of 38–40 items. A total of 60 minutes is allowed for completing each block of questions, for a maximum of 7 hours of testing. A minimum of 45 minutes of break time and an optional 5-minute tutorial complete the 8-hour day. Extra break time can be gained by completing question blocks or the tutorial before the allocated time.

Day 2 includes 180 items divided into 6 blocks of 30 questions. You will have 45 minutes to complete each of these blocks. The time allotted for these blocks is 3 hours. The second day also includes 13 clinical case simulations (CCS), preceded by a 5-minute tutorial. CCS cases vary from 10 to 20 minutes in duration. As with the first day, a minimum of 45 minutes of break time is allocated for the day. Traditional multiple-choice questions may either be single-item questions, multiple-item sets, or cases. The examination will also be given on 2 test days; however, examinees will be able to schedule the 2 test days on nonconsecutive days.

Day 1: Step 3 Foundations of Independent Practice (FIP). Day 1 will focus on assessment of knowledge of foundational medicine and science essential for effective health care. This test day will be entirely devoted to multiple-choice questions and will 29 include some newer item formats, such as those based on scientific abstracts, pharmaceutical advertisements, and basic science correlates.

Day 2: Step 3 Advanced Clinical Medicine (ACM). Day 2 will focus on assessment of applying comprehensive knowledge of health and disease in the context of patient
management. This test day will include multiple-choice questions and computer-based case simulations (CCS).