The USMLE Step 3 exam tests the ability to apply the knowledge of biomedical and
clinical sciences in “unsupervised” clinical setting, with an emphasis on
patient management. It is a test of the student’s holistic understanding of medicine
and his or her ability to apply it in patient care.
While it is part of the USMLE Step series, it is
different from Step 1 and 2 in its eligibility requirements. From the
perspective of an International Medical Graduate (IMG) it is not required for
ECFMG certification, and in fact can only be taken after that certification has
been obtained. It is administered by the Federation of State Medical Boards
(FSMB) and requires certain State-specific application criteria to be met
before an applicant can take the exam.
The Step 3 examination is also a computer-based exam with a
standard single response MCQ format. It is administered over a two day period
with the last session being a newly added Computer-based Case Simulation (CCS)
module. Better known as the Primum CCS, this section has nine that are
presented to the candidate for investigation, diagnosis, and treatment through
an interactive computer-based simulation. It is a comprehensive test of the
student’s knowledge and patient management skills.
Given the nature of the test, the curriculum is less focused
around specific basic science and clinical subjects and more around their
clinical application and the ability to pull from all these subjects to
effectively treat and manage a patient. Nonetheless, there are certain textual
and online resources that can help you prepare for the Step 3 exam.
To learn more about the Step 3, choose the appropriate section:
- Computer-based Case Simulation (CCS)
All medical students must complete
the USMLE Step 1, Step 2, and Step 3 exams within a seven year period from the
time of taking the first one. Even though all students have to take the Step3
exam, whether it needs to be taken before the residency program or during/after
the residency varies based upon the status and needs of the student. Most
students who take the exam before residency are international medical graduates
who need the Step 3 results to be eligible for an H-1b visa. American citizens
or green card holders need not take the Step 3 exam and can safely postpone
taking it without affecting their chances of getting a residency.
For IMGs who do wish to
take the exam, they should apply as soon as they have cleared the Step 1 and 2
exams. From the time you apply for the Step 3 exam to when you revive the
results is on average a 3-4 month period and so applying as soon as you can is
advisable. It is important to point out however that clearing the Step 3 exam
does not guarantee an H-1b visa. Having a Step 3 score is needed more by the
Immigration and Naturalization Service (INS) as a prerequisite for getting the
H-1b rather then by the residency program. Most hospitals and programs have
their own policy on sponsoring H-1b visas which is primary factor in
determining whether they sponsor you for that visa status. Almost all programs,
however, that accept IMG applications will sponsor them for a J-1 visa.
Step 3 scores do not
affect your chances of getting interview calls or admission into a residency
program. Most hospitals will not look at your Step 3 scores in determining your
admission. On the other hand if a residency program as a policy does not
sponsor for an H-1b visa, then your Step 3 scores might be a disadvantage, as
some program directors might be lead to believe that you would be more
interested in a program that does offer H-1 visas. While this does not happen
often, it is important that you weigh your options very carefully before
appearing for the Step 3 exam.
The USMLE Step 3 exam is a computer-based test that is offered throughout the year at Prometric Test Centers in the US. Unlike Step 1 and 2, it is not available outside the United States. Also, the eligibility requirements for the Step 3 vary from State to State.
The Federation of State Medical Boards administers the USMLE Step 3 for International Medical Graduates (IMG) as well as for American graduates. The application materials for the exam can be requested from the FSMB at the following address,
Federation of State Medical Boards
Department of Examination Services
400 Fuller Wiser Rd.
Suite 300
Euless, TX 76039-3855
Tel - (817) 571-2949.
Beginning with the 2001 test cycle,
application materials will be provided to examinees in a new format. In
mid-September of 2000, the USMLE Step 3 application for 2001 will be posted on
the FSMB web site. Applicants will be able to view and print the Step 3
application materials for their use directly from the web site at any time.
Those materials that previously appeared in hard copy format, such as the
Bulletin of Information and Step 3 Content Description, will be incorporated
into the USMLE compact disc that all applicants will receive. The 2001 USMLE CD
will also contain the software for sample test materials, including the
computer-based Clinical Case Simulation (CCS) portion of the Step 3 exam.
In order to take the Step3 examination, a candidate has to meet certain eligibility criteria. These include:
· Obtain passing scores in both USMLE Step 1 and Step 2
· For IMGs, obtaining an ECFMG certification which means clearing the TOEFL and CSA in addition to the USMLE Steps
· Satisfy the eligibility requirement of the respective State Medical Board you are applying for
The last eligibility criterion depends on your reason and
timing for taking the Step 3 examination. Most IMGs sit for the Step 3 exam
because it makes them eligible for an H-1b visa and so often take the exam
before applying for residency programs. The majority of the US States require
that a candidate have undergone one to three years of a residency program in
the United States to be eligible for the Step 3 exam. Some states, however, do
not have this requirement and candidates can take the Step 3 for these states
without even enrolling in a residency program. IMGs who wish to take the exam
for H-1b visa purposes have to take the exam in one of these states. Today the
states that allow this are Arkansas, California, Connecticut, Florida,
Louisiana, South Dakota, New York, North Carolina, Utah, West Virginia, and
Wyoming.
The choice of most International Medical Graduates is Connecticut, because it has the lowest application fee for the Step 3 exam among all the states. Application fees for Connecticut are $475. This, however, does not restrict which residency program you can attend or where you actually take the exam. The Step 3 can be taken in any state for any state and it is valid for residency programs nationwide. So for example, you can take the Step 3 exam for Connecticut State in New York and then enroll in a residency program in California.
You will receive a scheduling
permit once your application for the Step 3 has been accepted and processed,
typically a few weeks after sending in the application. The permit will have
your identification number on it and with it you are then ready to schedule
your test date and center. You can do this by calling Prometric at the numbers
given on the permit and should do so as soon as the scheduling permit is
received.
It is important to note that your scheduling permit will specify a period within which you are required to call Prometric and select your test center and test date. You can always change your test dates, and this is done free of cost up to 5 days prior to your selected test date. Thereafter you have to pay a rescheduling fee for the same service. Your rescheduled date however must fall within a testing period mentioned on your scheduling permit which is typically 90 days plus two weeks for postage from the time your permit is processed.
The
busiest testing times for USMLE testing at Prometric testing centers are May
and June. Examinees who plan to take Step 3 during this time need to be
flexible in scheduling the date and site of the exam or need to schedule fairly
in advance.
Computer-based Case Simulations, or CCS, is an interactive test format that allows you to care for a simulated patient. It has been developed for the Step 3 exam as a new section designed to test you patient management skills. The CCS section is computer-based and is administered on the second day, afternoon of the Step 3 exam. It consists of nine simulated cases that last for 25 minutes each.
Each CCS is set in one
of four locations - physician office, emergency room, inpatient ward, or
satellite health center, and requires the student to devise a management and
treatment plan that is not only appropriate for each setting but also cost
effective.
The case begins with
the patient location (one of the four) and a brief patient history. From here
you control the way the case progresses based on the tests, investigations, and
medications ordered. You may
request information from the patient’s history and physical examination, order
lab studies, procedures and consultations, and start medications and other
therapies. When there is nothing further you wish to do, you decide when to
re-evaluate the patient by clicking on the clock to advance time. With the
passage of time, the patient’s condition changes based upon the underlying
problem and your interventions. You cannot go back in time, but you can change
orders to reflect an updated patient management plan. You can review vital
signs, progress notes, nurses’ notes, test results, and reports from your
orders. You may see and move the patient among the office, home, emergency
room, intensive care, and inpatient unit settings as well as receive feedback
from the patients and relatives.
While the results of
your actions or interventions are shown immediately to you on the screen, they
do take up a certain amount of simulated time in the case. For example, the
software is so designed that it takes two minutes of simulated time to examine
each system whereas the real time elapsed may be only a few seconds. This
introduces an element of time criticality and makes the simulation more real
life. So while the whole case takes only 25 minutes in real time, you may see
the patient in simulated time of days to weeks.
At the end of each case you enter a
final diagnosis and treatment protocol. After you complete the care of a group
of patients, your management strategy is then compared with those of experts to
determine a score. The closer your handling of the patient matches those of the
experts, the higher the score.
While method of testing is quite rigorous and often difficult, it is important to note that because the CCS presents a new testing format, the weight of the CCS portion is initially less than the proportion of testing time allocated to it. Currently, the weight applied to the CCS portion of the exam is no greater than 25 percent of the total score.
I would recommend following texts for step 3 preparation.
|
1. |
Appleton
& Lange’s Review for the USMLE Step 3 |
|
2. |
The
Instant Exam Review for the USMLE Step 3 |
|
3. |
Mosby’s
USMLE Step 3 Reviews: Specialty Clinical Sciences (Windows) |
|
4. |
Usmle
- United States Medical Licensing Examina- Tion: Step 3 |
|
5 6. |
USMLE
Step 3 Review: 225 Questions & Answers |
|
Family
Practice Review: A Problem Oriented Approach |
Study material is basically an extension of what you have already done for step 2. You may visit various CME sites on the web for sharpening your knowledge.
The Step 3 exam is in many ways harder for international medical graduates (IMGs) because it tests the ability to practice unsupervised medicine and patient management in typically US ambulatory settings. In addition, it is a form of testing and clinical problem solving that most IMGs are not familiar with from their medical undergraduate education. Given its holistic nature, it is harder to identify specific areas of clinical sciences that students can just focus on, or conversely not have to do in as much detail. However, there are certain general tips that students can follow both before and during the exam to help that we have tried to list here.
· Get familiar with the computer-based testing format by going through the sample tests on the USMLE CD-ROM.
· For the Step 3, ensure that you get familiar with the CSS type of questions before you take the exam (refer to Online Resources for Step 3)
· Relax the night prior to your examination. Get up fresh in the morning, and reach your exam center at least half an hour in advance
· Do not forget the necessary identification documents, such as your passport, your Scheduling Permit and a pen/pencil
· Carry a lunch packet and a bottle of water with you
· You can ask for a locker at the time registering to keep your belongings. Don’t hesitate to do so if you have any valuable with you
· Only start a block of questions when you are ready to do so. You cannot take breaks unless you finish a block or you will loose time if you do so. Each block lasts 30-60 minutes and so plan accordingly
· You can take a break between two blocks, but space out the breaks between blocks. The total permitted break time is 45 minutes so make sure you have some time for rest between each block
· Once you start taking an exam you cannot cancel or schedule it unless there is a technical error in the running of the software –Attempt your blocks with utmost attentiveness. Be sure to keep in mind the negative phrases, such as EXCEPT, DOES NOT, NONE etc. in the questions
· It is better to follow the order of the questions rather than leaving too many questions un attempted in the hope of returning to them at the end
·
Most importantly, stay calm and don’t get upset or
disheartened during the exam