When to Take Step 3? A Timeline for Residents in Primary Care

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The old adage of “Two months for Step 1, two weeks for Step 2, and two #2 pencils for Step 3” doesn’t make sense anymore. Things have definitely changed—Step 3 is a serious exam, and you don’t want to take it lightly.

Now, the adage that’s perhaps more relevant when it comes to Step 3 is timing is everything. In other words, you’ll want to schedule the exam in a way that works to your benefit. So in this post our focus won’t be on how many pencils to bring to the exam (you won’t need one anyways), but rather, on when to take Step 3.

What is Step 3?

The USMLE Step 3 is administered over two days and consists of MCQs (single best answer multiple–choice questions) and case simulations. Below is a bit of detail, but visit the USMLE website for the most updated information.

Day 1: Multiple-Choice Items Only

The testing session is seven hours long.

There are six, 60-minute question blocks with approximately 38-39 items per block and 232 items in total.

Day 2: Advanced Clinical Medicine (ACM)

There are multiple-choice questions and computer-based case simulations.

The testing session is nine hours long.

There are six 45-minute blocks of multiple-choice items, with 30 items per block and 180 items in total.

There are also 13 computer-based case simulations (lasting 10-20 minutes each) that have free-response questions.

When am I eligible to take Step 3?

To be eligible to take USMLE Step 3, you must have passed the Step 1, Step 2 CK, and Step 2 CS exams and have either:

Graduated from an accredited medical school in the US or Canada, or
Graduated from a medical school listed in the World Directory of Medical Schools as meeting the eligibility requirements of the Educational Commission for Foreign Medical Graduates (ECFMG) and have ECFMG Certification.

Medical graduates typically sit for the USMLE Step 3 during postgraduate residency training. Many take the exam during their intern year of residency, although your timing may differ based on the duration and type of residency program you’re completing.

That said, let’s take a look at some considerations for when to take your final Step exam.

When should you take Step 3?

There’s a few things to consider when planning your Step 3 test date. These include how soon you want a medical license (which you need to moonlight), how confident of a test taker you are, and what your rotation schedule is like each year of residency.

Let’s dive into the pros and cons of taking it during each year of residency.

Intern Year

Benefits

Taking Step 3 in intern year has its benefits. You’re fresh out of school and accustomed to multiple-choice exams in a timed setting. Step 3 covers a wide breadth of topics in medicine and as a recent graduate, you’re versed in all of it. Trust me, you forget some of what you learned in medical school during residency. So if you’re wondering when to take Step 3, there’s some benefit to taking it during intern year.

Additionally, residents just starting out will practice with their resident’s license. However, taking Step 3 early allows you to apply for your actual medical license, which in turn allows you to moonlight and make some decent money while gaining valuable experience.

Finally, taking Step 3 intern year is liberating. Imagine walking out of the testing center and never having to take another Step exam!

Drawbacks

If you’re wondering when to take Step 3, you should know testing early has its downsides, too. Intern year is stressful. Interns have medical knowledge, but spend the majority of their time acquiring clinical understanding, learning how to function as part of a treatment team, and writing notes…ugh, so many notes.

Most residencies in primary care heavily front-load inpatient rotations in PGY-1 year. You have six-day work weeks with hectic hours, leaving little time for test prep. Unless you’re a specialist not in primary care, a very confident test taker, or know that you need to moonlight early, I’d recommend holding off on taking Step 3 if possible.

Why PGY-2 Is a Good Time to Take the Exam

Frankly speaking, PGY-2 may be the ideal year to take the exam if your program allows. Your schedule should be much more relaxed and flexible. Fewer inpatient rotations translates to more golden weekends, more predictable 8-to-5 work days, and more time to study.

You’ve gained the clinical experience from PGY-1 and still retain the majority of your medical knowledge from school. Completing the exam this year gives you ample time to apply for your license, which means you have at least a full year to moonlight. Furthermore, you’ll have the entirety of your next year to focus on the board exam.

Most of my colleagues in primary care took Step 3 in their second year. It’s the balanced approach that I’d recommend. So if you’re wondering when to take Step 3, I’d say PGY-2 is the best time to do it if that option is available.

Why PGY-3 Isn’t Optimal

Taking Step 3 the same year as your boards can be tricky. Though there’s some overlap in material, the stress of having two major exams the same year can be too much.

You’re a PGY-3, a leader on the team! This is your time to manage interns, mentor students, and focus on applying for jobs—not studying for Step 3.

Some residency programs require you to complete Step 3 prior to starting your third year, and for good reason. If you fail, you can retake it before you graduate. Waiting until your last year for Step 3 makes that harder.

Step 3 in third year isn’t recommended unless there was an unforeseen circumstance that prevented you from taking it earlier or you absolutely need more time to study. Selecting the right study materials will have you well on your way to a successful Step 3 study period.

Can I take Step 3 before residency?

You can. Step 3 is a different beast, but it has many similarities to Steps 1 and 2. There are a fair amount of Step 1 basic science MCQs as well as Step 2 style clinical reasoning questions. The majority of the exam is IM (internal medicine) based but it also includes pediatrics, women’s health, outpatient, surgery and emergency care content. These are likely all questions and scenarios you’ve encountered during your core clinical rotations and shelf exams.

For some applicants, it’s not possible to take Step 3 before residency because their medical school graduation hasn’t been verified yet and thus they’re unable to schedule the exam. If you’re able to sit for the exam and feel prepared, however, it could be a good idea to cross Step 3 off of your to-do list prior to starting residency.

The Bottom Line

Step 3 can be taken any time after you graduate, but be sure to check and see what your residency program requires. And of course, you must have passed Steps 1 and 2 in order to apply for Step 3.

Application to take Step 3 is often made in conjunction with application for licensure by a particular state (though Step 3 is a requirement for licensure). Check specific state requirements here.

Some states such as Texas have imposed a three strikes rule for USMLE exams, meaning that to become a licensed physician in the state of Texas, you must pass each Step (1, 2 CK or 3) in three attempts or less. Failure to pass any of the Steps within three attempts will disqualify you from Texas licensure.

Final Thoughts on When to Take Step 3

According to the American Medical Association, the majority of trainees will complete USMLE Step 3 by the end of their intern year. PGY-2 is our preferred time to take Step 3, but this depends on individual circumstances and program requirements.

Some programs require all PGY-1s to pass the exam prior to starting PGY-2 year, while others simply require it before graduation or sitting for the board exam. Please check with the specific residency as requirements vary and can change.

Looking for more (free!) content to help you through residency? Check out these other posts on the Rosh Review blog:

By Mike Ren, MD

Mike is a driven tutor and supportive advisor. He received his MD from Baylor College of Medicine and then stayed for residency. He has recently taken a faculty position at Baylor because of his love for teaching. Mike’s philosophy is to elevate his students to their full potential with excellent exam scores and successful interviews at top-tier programs. He holds the belief that you learn best from those close to you in training. Dr. Ren is passionate about his role as a mentor and has taught for much of his life–as an SAT tutor in high school, then as an MCAT instructor for the Princeton Review. At Baylor, he has held review courses for the FM shelf and board exams as Chief Resident. For years, Dr. Ren has worked closely with the Office of Student Affairs and has experience as an admissions advisor. He has mentored numerous students entering medical and residency and keeps in touch with many of them today as they embark on their road to aspiring physicians. His supportiveness and approachability put his students at ease and provide a safe learning environment where questions and conversation flow. For exam prep, Mike will help you develop critical reasoning skills, and as an advisor, he will hone your interview skills with insider knowledge to commonly asked admissions questions.