USMLE Step 3 Exam: Optimize Your Performance on Test Day

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The USMLE Step 3 exam is the final assessment first-year residents take before they can practice medicine independently. The exam assesses a physician’s knowledge of advanced clinical medicine and is different from the other two USMLE examinations taken in medical school. The experience of sitting for Step 3 of the USMLE will be distinct from that of Steps 1 and 2. The most striking difference is that the exam is administered over the course of two separate days. Each day has its own unique structure and set of expectations.

Given that the USMLE is graded on a normally distributed bell curve: as you perform better, the curve steepens. This means that every single question counts towards distinguishing you from the pack. Being flustered and unfamiliar with the cadence of the exam can put you at a disadvantage. To avoid this, you should ask yourself: what strategies can I use on exam day to secure those extra 1-2 questions per block?

One of the best ways to prepare is to have a clear mental representation of how the test is structured (on each day) and how you will choose to budget your allotted break time. There is a bit of strategy involved in this, which is highlighted below.

USMLE Step 3 Exam Strategy: Scheduling Your Test Date

You may schedule your exam dates on either consecutive or non-consecutive days. If possible, the latter is preferable as the first exam day can be quite taxing.

Since the vast majority of individuals taking Step 3 are busy, overworked interns, it will be important to coordinate exam dates with your chief residents and/or program director. Check with your hospital’s GME office (or your program coordinator) to find out the last possible test date your institution will allow you to sit for the exam.

Reflect on your intern year rotations and be proactive about securing dates that will be optimal for you. Ideally, schedule the USLME final assessment at the end of a lighter (perhaps outpatient) rotation, leaving you plenty of time to study and prepare.

Morning of the Exam

At this stage of your career, you already know what works for you (and what doesn’t) on test day. Don’t deviate from what works for you as an individual. However, there are a few strategies that are specific to Step 3 and may help optimize your test performance.

Breakfast

Consider restricting fluid intake the morning of your exam. Prometric test centers will require you to present your ID, sign your full name, examine your fingerprints, and inspect your clothing EACH TIME you exit and re-enter the exam room. This can shave precious minutes off your total allotted break time, particularly if there is a line of other test takers ahead of you (and only a single proctor). Of course, do not allow yourself to be dehydrated to the point of dysfunction, but be mindful of the liability of a full bladder.

Clothing

The test center proctor will do the following EACH time you enter/ re-enter the exam room:

• Ask you to turn out any and all pockets
• Examine your collar, waistband, sleeves, and socks/shoes
• Inspect your wedding ring, eyeglasses, and any hair accessories (including headbands)

For Step 1, I made the mistake of wearing 5 pocket jeans, a hoodie (with multiple pockets), and sneakers to the exam. This slowed down each re-entry into the exam room to an excruciating degree. For Steps 2 and 3, I was much wiser and wore a comfortable, sleeveless, pocketless sundress and simple sandals. It may not seem like a big deal, but streamlining the check-in process will salvage precious break time and mental bandwidth.

In the Exam Room

Once in the USMLE Step 3 exam room, you will be given a laminated note board and a dry-erase marker. Given that Step 3 heavily emphasizes biostatistics and epidemiology, it is essential that you commit the formulas for sensitivity, specificity, positive and negative predictive value, odds ratio, etc., to memory.

As soon as you are able, immediately jot down your 2×2 tables and biostats formulas on your laminated notepad. This will serve as an extremely useful reference tool as you navigate the exam (particularly the dreaded abstract / drug advertisement questions)! Remember, you will encounter ~7-10 biostats questions for EACH question block.

Structuring Break Time

The most significant factors within your control on exam day are: when you choose to take your breaks, how many minutes you budget for each break, and WHERE you choose to take each break (at your desk vs. exiting the exam room). Planning your break schedule ahead of time (and allowing yourself flexibility as needed) is crucial for optimizing your exam conditions.

Day 1 consists of 6 blocks of 38-39 multiple choice questions lasting one hour each. If you skip the tutorial (recommended), you will have 50 minutes of total break time. I recommend taking ~5-7 minute breaks between block 1-2, 2-3, 4-5, and 5-6 to allow yourself a full 20-25 minute break between block 3 and 4.

Remaining inside the exam room during short breaks will allow you to skip the cumbersome re-entry process, which can take up to 2 minutes each time. Closing your eyes and taking several mindful, deep breaths can give you needed mental clarity before proceeding to the next block.

Day 2 will also consist of 6 question blocks, albeit with only 30 questions per block (lasting 45 minutes each). This will feel like a breeze in comparison to the hour-long blocks of Day 1. However, following the 6 question blocks, you will face 13 Clinical Case Scenarios (CCS).

The good news is that each case has a 1-minute start screen that can be skipped, adding to your total allotted break time on each test day. Each case is scheduled for 10-20 minutes but usually ends early, with the remaining time added to your total break time. This is normal and typically does not mean you mismanaged the patient’s case. Because of this, on Day 2, you should feel free to budget your 50 minutes of allotted break time during the first 6 question blocks.

Key Takeaways for Step 3 Exam Day

• Bee sure you are properly prepared for the USMLE exam day by utilizing our Step 3 QBank
• Schedule USMLE Step 3 at the end of a less time-intensive rotation during intern year.
• USMLE Step 3 is a two-day exam: you may schedule both days back-to-back or non-consecutively (so long as both days are within the eligibility period).
• Familiarize yourself with the test structure and plan your breaks ahead of time.
• Exiting and re-entering the exam room can consume precious minutes of break time. Consider taking several short breaks at your desk.

USMLE Step 3: Frequently Asked Questions

What is the USMLE Step 3 exam?

According to USMLE.org, the Step 3 exam assesses medical decision-making and whether residents can apply basic medical knowledge and understanding of biomedical and clinical science essential for the independent practice of medicine. There is a specific emphasis on patient management and delivering general medical care. Passing USMLE Step 3 is required in order for physicians to practice medicine without supervision.

How many hours is the USMLE Step 3 exam?

USMLE Step 3 consists of about 7 hours on Day 1 and 9 hours on Day 2, for a total of 16 hours of test time. That includes 45 minutes of break time each day.

How many times can you fail USMLE Step 3?

You have 4 attempts at passing Step 3. Your fourth attempt must be a year or more after you took your first USMLE Step 3 exam.