Mastering Step 3: My Journey and Tips for Success

Exams are a fundamental part of education and the medical field. As all non-US International Medical Graduates (IMGs) know, good USMLE scores are vital for acceptance into residency programs and obtaining a medical license after graduation (Step 3). Over the past few years, there have been changes to the USMLE exams, beginning during the COVID-19 period. The Step 2 Clinical Skills exam was discontinued and replaced with a medical English exam (OET). Additionally, Step 1 transitioned to a pass/fail grading system rather than providing a numerical score. These changes have influenced how program directors interpret exam results.

In contrast, Step 3 has remained unchanged in recent years and continues to be an important milestone in the USMLE journey (though the American Medical Association recently announced its support for Step 3 to transition to a pass/fail format). Some non-US IMGs choose to take Step 3 before applying to residency to improve their chances of acceptance, while others take it during residency. Certain residency programs require Step 3 to be completed by the first or second year or mandate it before allowing residents to participate in moonlighting. Regardless, it is a critical exam for residency continuation, and fellowship applications.

As a resident who recently completed USMLE Step 3 exam, I want to share my experience because this exam is different from other USMLE exams and can be tricky for the first time. To make this more helpful for your study planning, I will also include some data along with my personal insights.

USMLE Step 3 is a two-day examination with different content on each day. Day one is a 7-hour exam, including a 45-minute break, and consists of 232 multiple-choice questions divided into six sessions (each with 37–40 questions, sixty-minute blocks). It covers a mix of biostatistics, ethics, communication, and medication ad-style questions, in addition to clinical topics. Clinical questions may test your knowledge of medication mechanism of actions or the pathophysiology of diseases, pushing you to recall Step 1 knowledge. Day two has a different format. It’s a 9-hour exam, including a 45-minute break, with 180 multiple-choice questions divided into six sessions (each with 30 questions, 45-minute blocks) and 13 interactive cases, each lasting 10–20 minutes. Unlike day one, day two does not include biostatistics or medication ad-style questions but focuses on diagnostics, treatment, medical decision-making, and interpersonal skills. It’s more similar to Step 2 (you can check my recommendations for USMLE Step 2 exam), with some questions requiring you to choose the “most correct” answer among vague options. Given vagueness, I do think day two is harder than day one.

The interactive cases simulate electronic medical records and test your knowledge of patient care in various settings, including outpatient clinics, emergency rooms, inpatient wards, and ICUs. These cases challenge you to assess patients based on acuity, order the appropriate labs for differential diagnoses, and administer the correct treatment in a timely manner.

Residents on specialties that provide broad acute or subacute medical care (e.g., emergency medicine, internal medicine) typically perform better at baseline on Step 3 compared to other specialties (e.g., psychiatry, pathology) (Feinberg et al., 2011), because they are already familiar with interactive cases as part of their daily work (Table 1). Feinberg et al. reported a statistically significant difference between broadly focused vs narrowly focused residencies in both overall and CCS scores (p<0.001). Interestingly, the same study found that participants who were native English speakers outperformed those who were not (215 vs 208). In my opinion, this could be due to encountering some less commonly used phrases or words, especially in the social sciences questions, which may explain some of the difference. However, the same study also suggested that native language only explained 2% of the variance in Step 3 overall scores, indicating a very small effect. It should be also noted that there are no significant difference between groups on Step 2 scores. I should also note that this study was from 2011, and if applied to the current year, the scores would likely be higher overall. Also, some specialties may require more competitive Step 3 scores for fellowship applications (e.g., internal medicine, pathology), which could motivate individuals to dedicate more effort to studying. For non-US IMGs, achieving a high Step 3 score can serve as a strong asset for residency applications.

That said, most residents focus on simply passing Step 3 rather than achieving a high score. It is also important to note that Step 3 scores are not equivalent to Step 2 scores. For comparison, the mean score for Step 2 is 249 (±15), while the mean score for Step 3 is 227 (±15). Despite these differences, the passing rate for Step 3 is notably high, around 97%.

I started studying for the Step 3 exam during my second year in residency and spent about 2.5 months preparing. What makes USMLE exams particularly effective is their standardization, which provides clear pathways to success. Over the years, thousands of students have agreed on proven methods for preparing, and the same holds true for Step 3.

The UWorld Step 3 question bank is essential for success on this exam. The QBank includes approximately 2,400 questions, and I managed to complete 63% of it with a 67% correct rate. I recommend completing the entire QBank for better preparation, as UWorld questions closely mirror those on the actual exam. However, if time is limited, I suggest completing at least 50% of the QBank. I usually recommend completing UWorld on mixed questions as real testing mode, as it depicts real exam better than going system-based questions. I think from the beginning, it is important to study the whole exam rather than focusing on its parts (e.g., only biostatistics, only CCS, or only clinical questions). However, if you’re running short on time and only have a few days left before day 1, prioritize biostatistics and social sciences. Afterward, focus on clinical questions and interactive cases to prepare for day 2. Some candidates prefer to take day 2 immediately after day 1, while others, like me, schedule the two days apart to focus more on interactive cases. I scheduled six days between my two exam days, which gave me the opportunity to focus more on biostatistics before Day 1, and after it was done, I didn’t care about biostatistics anymore and focused more on CCS cases.

Another critical resource is CCS Cases, which is a question bank for interactive cases. It contains around 170 cases that can be categorized from high yield to low yield. While UWorld also includes interactive cases, the CCS platform is much better for both learning the software and practicing clinical cases. I completed around 60 High Yield CCS cases with a 40-90% success rate. Then, I revisited the lower-rated cases a second time before Day 2. I found that the real cases I encountered during the exam were quite similar to the CCS cases. I recommend completing at least first 30 high yield CCS cases, but I believe that completing 50-60 cases is necessary to achieve a good score. If you have the time, completing all 170 cases will definitely be helpful during the real exam. One key thing to note is to start working on CCS cases early in your study period, because there will be a learning curve with both the software and the logic behind the interactive cases. You’ll need to get familiar with the software, timing, and encounter types, and not just focus on the differential diagnosis and what labs to order. You should also consider a more holistic approach (e.g., activity orders, scheduling lab repeats, reassuring patients, smoking cessation, diet orders, notifying state health departments, USPSTF recommendations, vaccinations).

Some videos might be helpful to orient you to the interactive cases:

• https://www.youtube.com/watch?v=qmxWuV4psFs
• https://www.youtube.com/watch?v=M9ROL3qiyDk

Additionally, it’s crucial to learn not only what to order but also what not to order in order to avoid harming the patient or using unnecessary resources (e.g., ordering a CT head with contrast for a stroke, or failing to order an emergent needle thoracostomy and instead ordering a glucose tolerance test). I also highly recommend making a list of orders you want to consider for every emergency or non-emergent case. Do not forget that you can do Ctrl+C and Ctrl+V during exam, rather than typing everything for every case. This will help you manage your time more effectively and cover a broader differential.

Common orders I used during exam:

• Pulse oximetry
• Oxygen
• IV Line
• EKG
• ECHO, if necessary
• Chest x-ray
• CBC
• CMP
• Phosphorus
• Magnesium
• TSH
• Lipid panel
• Urinalysis
• Urine pregnancy
• Lactate
• LDH
• CRP
• ESR
• Creatine Kinase
• INR/aPTT, if necessary
• Blood type & cross match, if necessary
• Medication compliance
• Reassure patient, if appropriate
• Pain management, if necessary
• Nausea management, if necessary
• Advance directives > 60-year-old
• Activity orders
• Diet
• LMWH/Enoxaparin

It’s important to understand that some interactive cases will require you to quickly identify and treat the problem (e.g., STEMI), while others will require you to develop a broad differential and assess whether you’re considering every possible underlying cause (e.g., sarcoidosis in outpatient settings). During the real exam, there will be times when you need to give the treatment more time to show improvement, so remain calm and don’t panic if you’re confident in your management. For example, starting an antibiotic may require waiting 24-48 hours before the software indicates that the patient is improving. In other situations, if there’s a negative update (e.g., the patient is feeling worse), you should pause and reconsider the situation before moving on. Some people believe interactive cases don’t significantly affect scoring, but each case can impact your total grade by 2-2.5%, contributing to 26-32% of your Step 3 score. So, do not underestimate interactive cases before taking Step 3 exam.

The third resource is the First Aid Step 1 book. Many people recommend skimming through the microbiology and medications sections of all chapters before Day 1, and I agree. I skimmed through First Aid Step 1 the day before my exam, and it helped me a lot. However, how useful this is can depend on how long it’s been since you took Step 1 or Step 2. I took Step 1 about 3 years ago and Step 2 about 2 years ago.

Other important things to consider include reviewing the vaccination calendar, USPSTF recommendations for screening, watching Rendy Neil’s biostatistics videos, and reading the important Divine Intervention podcast series. If you feel up to read Divine Intervention, I recommend checking on Episode 37, 97, 184 (risk factors), Episode 137 (next best step in management), Episode 250 (vaccines), and Episode 325 (screening guidelines) by clicking here. If you’re scoring low or feeling uncomfortable with drug-ad questions or biostatistics, it might be helpful to review Amboss questions on these topics a couple of days before the exam. Lastly, don’t forget that self-assessment are crucial for measuring your level of preparation, so make sure to take UWSA or NBME exams before your real exam days.

Recommended resources

• UWorld Step 3 Question Bank (high importance)
• CCS Cases (high importance)
• Free 137 (high importance, cases are quite similar to real exam)
• First Aid Step 1 Book (middle importance, microbiology and pharmacology of all systems)
• Rendy Neil Biostatics (middle importance)
• USPSTF recommendations (middle importance)
• Memorizing vaccination calendar (middle importance)
• Mehlman High Yield Risk Factors PDF (middle importance for day 2)
• UWorld Self-Assessment-2 (middle importance)
• UWorld Self-Assessment-1 (middle to low importance, skippable, do not forget it predicts lower than your level)
• NBME exams (middle to low importance)
• Amboss Question Bank (low importance, could be middle to low importance for biostatistics)
• Divine Intervention Podcasts (low importance)
• Anki (low importance, also depends on your studying style)

For completion and future reference, I received 24X on Step 1 and 26X on Step 2. For my Step 3 preparation, my self-assessment scores were: UWSA 1 – 199 (3 weeks ago), UWSA 2 – 215 (2 weeks ago), and Free 137 – 73% (one week ago). During the real exam, I felt like I was guessing on most of the answers, which is a common reaction for Step 3 due to the vagueness of many questions. Most of my CCS cases ended early, and I was unable to figure out the diagnosis for one case out of the 13. I received 23X on Step 3. I wish success to everyone! Feel free to share your experiences or thoughts in the comments section below.

Author: Bekir Nihat Dogrul, M.D.

STAP has no affiliation with USMLE, UWorld, CCS Cases or any aforementioned brands. This post is for only educational purposes for healthcare professionals.