Tips to Prepare for and Ace the USMLE Step 3

Two months, two weeks, two pencils. Image from Unsplash

Dr. Suzanne M. Miller February 17, 2016

The last exam on the way to becoming a licensed physician, the USMLE Step 3 tests knowledge essential to practicing medicine without supervision. Here are expert tips and strategies for passing this two-day trial.

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This is it — the final examination in the three-step series separating med school grads from licensed doctors who can practice medicine without supervision.

If you’d like an overview of eligibility, registration, scheduling, structure, content, and scoring, see my overview of the U.S. Medical Licensing Exam (USMLE) Step 3. As I mention there, this exam tests whether the examinee can apply medical knowledge deemed essential to the unsupervised practice of medicine. It is administered over two days, is entirely computer-based, and features a mixture of multiple-choice questions and clinical simulations.

As the Step 3 overview explains, you’re only eligible to take this part of the exam after passing Step 1, Step 2 CS, Step 2 CK, and graduating from medical school. You’ll probably end up taking the test at a point in your residency during which you’ve got some study time (often during research or vacation).

Though there’s a common tongue-in-cheek saying in the medical community — “two months, two weeks, two pencils" — to refer to the prep time required for Steps 1, 2, and 3, respectively, Step 3’s recent expansion to a more rigorous two-day format requires at least a few weeks of study time for most examinees. Plus, competitive fellowships do care about scores on Step 3. So if you want to get into that subspecialty fellowship you’ve got your eye on, you’ll need to do more than just pass.

Here’s how to prepare so you can ace this ultimate exam.

Preparation Resources

Step 3 study resources fall into three main categories:

1. USMLE Free Practice Questions

Each year, USMLE.org offers free practice test items for Step 3, including a tutorial, an overview, and question blocks. The blocks can be timed to simulate the high-pressure exam experience. Use this resource as your starting point for studying so you can quickly learn how to navigate the computer system and get comfortable with the style of questions.

2. Courses

Live courses offer structured classroom lectures and preparation materials. Most are run by private companies, similar to other USMLE and MCAT prep courses. The traditional test prep companies, Kaplan and Princeton Review, offer USMLE Step 3 courses in addition to question banks and books. There are many other options for live courses, too, some of which test-takers find more effective, including Dr. Red’s Step III Reviews and CCS Workshop and Premier Review.

Please note that you do not need to take a live course to excel on the USMLE Step 3. Courses are best for students who perform well given structure, a defined program, and a set schedule. When choosing a course, take note of the timeline, study materials, teachers’ backgrounds, class sizes, and success rates.

3. Question Banks (and Books)

Question banks are essential for USMLE Step 3 preparation. Most Step 3 examinees even believe they’re more important than books. They provide hundreds of questions and lots of flexibility: Test-takers can — with or without an active timer — simulate full tests, practice blocks within the exam, isolate questions by category, and get explanations for every answer. Many examinees are tripped up by the CCS questions, as these differ in format significantly from typical multiple-choice questions. Gaining familiarity with the Primum software and understanding how to complete the CCS are keys to success in the USMLE Step 3.

Though question banks trump book preparation for most Step 3 examinees, there may still be a place for reviewing Step 3 boards in print. Here are the most popular options:

Preparation Strategies

Gearing up for the test, you should think as much as you can about balancing efficiency and thoroughness. This is important throughout the test, but nowhere is it as crucial as on the computer-based care simulations. As I noted in my overview of Step 3, test-takers are allotted either 10 or 20 minutes of time for each simulation, but the cases themselves can cover weeks or months of simulated time as you manipulate the clock, moving with patients from the emergency department to the inpatient ward to their homes. You are responsible for ordering everything for each patient — lab tests, radiology, medications, IV fluids, and procedures — in addition to providing patient education and prevention counseling.

Though the USMLE has kept quiet about exactly how Step 3 CCS cases are graded, it is clear that shrewd management is key. Failure to order specific tests or treatments, a lack of efficiency in patient care, and the decision to order inappropriate or dangerous tests or treatments can all result in a lower grade. Timing and sequence of care matter. You’ll need to find the sweet spot between working quickly and working carefully on this whole exam.

Once you’ve absorbed this large-scale advice (and decided whether or not to take a course and which materials you’ll use to study), you should employ the following preparation strategies:

Determine the best time to take the test (bear in mind your busy residency schedule).
Make a schedule for the weeks leading up to the exam — including breaks, times to eat, and days for taking a full-length test. If at any point your schedule is not working, then change it.
Take a practice test early to see where you stand. You need to get used to the pace of the exam’s question blocks and get your body ready for the long and grueling two-day testing process.
Go through as many questions and question banks as you can. Then go through them again.
Focus your CCS preparation on gaining familiarity with the software and on balancing efficiency with thoroughness in the virtual care of patients. Work on completing the diagnosis and management aspects quickly; perform only a focused physical exam in an emergency; and avoid ordering tests that delay urgent treatment. Master the most common types of orders in real medical care — putting in an IV, getting patient consent for surgery, and providing counseling. Finally, remember to order follow-up labs and procedures, such as clopidogrel for patients who have received a stent, or liver function tests for patients you’ve started on statins.
Identify areas in which your knowledge is weakest — and review, review, review.
Study what you don’t know. It’s easy to fall into the trap of reviewing what you already know to boost your confidence. If you have mastered a subject, then spend time studying areas in which you are struggling.
On a related note, if you are taking the test for the second or third time, focus your preparation on the areas in which you did not excel. Fortunately, the score report from your previous test(s) will have provided graphical performance profiles for each testing category so you can see where you need the most work.
Take breaks, especially on days when you’re deep in question blocks and books. Go outside. Exercise.

Test-Taking Strategies

As the test day arrives, here are some tips to help you ace USMLE Step 3:

Learn how to get to the test site, and do a practice run. There are few things worse than feeling rushed on the morning of the test.
Arrive at the test site at least 30 minutes early, and be sure to have a valid picture ID with your signature and a printed copy of your scheduling permit.
Bring a lunch, a snack, and earplugs.
Answer every question. Wrong answers do not count against you, so guess away when you’re not sure.
Be sure you have checked all the questions in a block before you move on to the next one. Once a block has ended, you cannot re-enter it to review questions.
Gain extra break time by skipping the optional tutorial. You should be so familiar with the format of the test that you don’t need it anyway.
Decide what you’re going to do during breaks ahead of time. Consider using this time to review your overall strategy.
Get a great night’s sleep the night before the night before the test. Studies have shown this night of sleep is important for enhancing test performance.

Though you’ll have to wait up to eight weeks for score reports to come in, you’ll probably find out in fewer than four. And as I mentioned in my last article, the pass rate in 2015 for graduates of U.S. and Canadian medical schools was 96 percent, so be confident in your abilities.