USMLE Step 3 assesses whether you can apply medical knowledge and understanding of biomedical and clinical science essential for the unsupervised practice of medicine, with emphasis on patient management in ambulatory settings.
It is the final examination in the USMLE sequence leading to a license to practice medicine without supervision.
The examination material is prepared by examination committees broadly representing the medical profession.
The committees comprise recognized experts in their fields, including both academic and non-academic practitioners, as well as members of state medical licensing boards. Step 3 content reflects a data-based model of generalist medical practice in the United States.
The test items and cases reflect the clinical situations that a general, as-yet undifferentiated, physician might encounter within the context of a specific setting.
Step 3 provides a final assessment of physicians assuming independent responsibility for delivering general medical care.
The Step 3 examination devotes attention to the importance of assessing the knowledge and skills of physicians who are assuming independent responsibility for providing general medical care to patients.
The first day of the Step 3 examination is referred to as Foundations of Independent Practice (FIP), and the second day is referred to as Advanced Clinical Medicine (ACM).
Day 1: USMLE Step 3 Foundations of Independent Practice (FIP)
This test day focuses on assessment of knowledge of basic medical and scientific principles essential for effective health care. Content areas covered include application of foundational sciences.
understanding of biostatistics and epidemiology/population health, and interpretation of the medical literature; and application of social sciences, including communication and interpersonal skills, medical ethics, systems-based practice, and patient safety.
The test day also includes content assessing knowledge of diagnosis and management, particularly focused on knowledge of history and physical examination, diagnosis, and use of diagnostic studies.
This test day consists solely of multiple-choice questions and includes some of the newer item formats, such as those based on scientific abstracts and pharmaceutical advertisements.
Day 2: USMLE Step 3 Advanced Clinical Medicine (ACM)
This test day focuses on assessment of the ability to apply comprehensive knowledge of health and disease in the context of patient management and the evolving manifestation of disease over time.
Content areas covered include assessment of knowledge of diagnosis and management, particularly focused on prognosis and outcome, health maintenance and screening, therapeutics, and medical decision making. Knowledge of history and physical examination, diagnosis, and use of diagnostic studies also is assessed.
This test day includes multiple-choice questions and computer-based case simulations.
USMLE Step 3 Exam Format
Step 3 is a two-day examination.
The first day of testing includes 232 multiple-choice items divided into 6 blocks of 38-39 items.
60 minutes are allotted for completion of each block of test items.
There are approximately 7 hours in the test session on the first day, including 45 minutes of break time and a 5-minute optional tutorial.
Note that the amount of time available for breaks may be increased by finishing a block of test items or the optional tutorial before the allotted time expires.
There are approximately 9 hours in the test session on the second day.
This day of testing includes a 5-minute optional tutorial followed by 180 multiple-choice items, divided into 6 blocks of 30 items.
45 minutes are allotted for completion of each block of test items. The second day also includes a 7-minute CCS tutorial.
This is followed by 13 case simulations, each of which is allotted a maximum of 10 or 20 minutes of real time.
A minimum of 45 minutes is available for break time.
There is an optional survey at the end of the second day, which can be completed if time allows.
The content description that follows is not intended as a curriculum development or study guide, but rather models the range of challenges that will be met in the actual practice of medicine.
It provides a flexible structure for test construction that can readily accommodate new topics, emerging content domains, and shifts in emphasis.
The categorizations and content coverage are subject to change. Successful completion of at least one year of postgraduate training in a program accredited by the Accreditation Council for Graduate Medical Education or the American Osteopathic Association should be helpful preparation for Step 3.
All USMLE examinations are constructed from an integratedcontent outline, which organizes content according to general principles and individual organ systems.
Test questions are classified in one of 18 major areas, depending on whether they focus on concepts and principles that are important across organ systems or within individual organ systems.
Sections focusing on individual organ systems are subdivided according to normal and abnormal processes, including principles of therapy.
USMLE Step 3 MCQ Test Content Specifications
General Principles of Foundational Science
Immune System, Blood & Lymphoreticular System, and Multisystem Processes/Disorders
Nervous System & Special Senses
Skin & Subcutaneous Tissue
Renal/Urinary & Male Reproductive Systems
Pregnancy/Childbirth & Female Reproductive System & Breast
Biostatistics & Epidemiology/Population Health & Interpretation of the Medical Literature
Social Sciences: Communication Skills/Ethics/Patient Safety
Percentages are subject to change at any time.
The general principles category for the Step 3 MCQ examination includes test items concerning normal processes not limited to specific organ systems. These test items are typically related to normal development. Categories for individual organ systems include test items concerning those normal and abnormal processes that are system-specific.
USMLE Step 3 CCS Test Content Specifications
Categories in bold are covered in CCS cases
categories not in bold are not covered.
General Principles of Foundational Science
Blood & Lymphoreticular System
Nervous System & Special Senses
Skin & Subcutaneous Tissue
Renal & Urinary System
Pregnancy, Childbirth, & the Puerperium
Female Reproductive & Breast
Multisystem Processes & Disorders
Biostatistics & Epidemiology/Population Health, & Interpretation of the Medical Literature
An additional organizing construct for Step 3 design is physician tasks and competencies. More information about the physician task and competencies outline is available. Items are constructed to focus on assessing one of the following competencies:
Medical knowledge/scientific concepts: Applying foundational science concepts
Patient care: Diagnosis
Patient care: Management
Communication and interpersonal skills
Professionalism, including legal and ethical issues
Systems-based practice, including patient safety
Practice-based learning, including biostatistics and epidemiology
Systems-based Practice/Patient Safety and Practice-based Learning
The expected outcome of the USMLE process is a general unrestricted license to practice medicine without supervision.
Step 3 is the final examination in the USMLE sequence. The test items and cases reflect the clinical situations that a general, as-yet undifferentiated physician might encounter within the context of a specific setting.
Step 3 patients reflect the diversity of health care populations with respect to age, gender, cultural group, and occupation. The patient population mix is intended to be representative of data collected from various national health care databases in the United States.
Site of Care
The physician-patient encounters described in Step 3 multiple-choice items are usually associated with a setting in which the encounter first occurs. There are three sites of care, which are described below.
Ambulatory: Ambulatory includes office/health center, home care, outpatient hospice, and ambulatory surgical center. You primarily see patients in two locations: an office suite, which is adjacent to a hospital, and at a community-based health center.
Inpatient Facilities Inpatient Facilities includes hospital, ICU/CCU, inpatient hospice, acute rehabilitation facility, and subacute rehabilitation facility, including skilled nursing care facility.
Emergency Department: Emergency Department includes emergency department and urgent treatment center.
Clinical Encounter Frames
Step 3 clinical encounter frames encompass several elements that are critical to the definition of a patient-physician encounter. These elements include whether the problem or concern is new or ongoing, the urgency of the need for intervention relative to the underlying problem, the chronology of events, and the degree of familiarity with the patient or the patient’s history.
INITIAL WORKUP: Patient encounters characterized by initial assessment and management of clinical problems among patients seen principally in ambulatory settings for the first time. These encounters may also include new problems arising in patients for whom a history is available.
Clinical problems include ill-defined signs and symptoms; behavioral-emotional; acute limited; initial manifestation and presentation of chronic illness.
Physician tasks emphasized include data gathering and initial clinical intervention. Assessment of patients may lead to urgent intervention.
CONTINUING CARE: Patient encounters characterized by continuing management of previously diagnosed clinical problems among patients known to the physician and seen principally in ambulatory settings. Encounters focused on health maintenance are located in this frame. Also included are patient encounters characterized by acute exacerbations or complications, principally of chronic, progressive conditions among patients known to the physician. These encounters may occur in inpatient settings.
Clinical problems include frequently-occurring chronic diseases and behavioral-emotional problems. Periodic health evaluations of established patients are included here.
Physician tasks emphasized include recognition of new problems in an existing condition, assessment of severity, establishing prognosis, monitoring therapy, and long-term management.
URGENT INTERVENTION Patient encounters characterized by prompt assessment and management of life-threatening and organ-threatening emergencies, usually occurring in emergency department settings. Occasionally, these encounters may occur in the context of a hospitalized patient.
Clinical problems include severe life-threatening and organ-threatening conditions and exacerbations of chronic illness.
Physician tasks emphasized include rapid assessment of complex presentations, assessment of patients’ deteriorating condition, and prompt decision making.
Read each question carefully.
It is important to understand what is being asked.
Try to generate an answer and then look for it in the option list.
Alternatively, read each option carefully, eliminating those that are clearly incorrect. Of the remaining options, select the one that is most correct.
If unsure about an answer, it is better to guess since unanswered questions are automatically counted as wrong answers.
Patient Scenario Formats of USMLE Step 3 questions
Patient scenarios for any Single Item or Sequential Item Set may be provided in either Vignette (paragraph) format, or in Chart/Tabular format.
Test items using the chart/tabular format are designed to resemble patient charts but are not intended to be an exact representation of a patient chart.
Questions written in chart/tabular format will contain relevant patient information in list form, organized in clearly marked sections for ease of review. Familiar medical abbreviations may be used within chart/tabular format questions.
Single-Item Questions: A single patient-centered vignette is associated with one question followed by four or more response options. The response options are lettered (\A, B, C, D, E). A portion of the questions involves interpretation of graphic or pictorial materials. You are required to select the best answer to the question. Other options may be partially correct, but there is only ONE BEST answer. This is the traditional, most frequently used multiple-choice question format on the examination.
Multiple Item Sets: A single patient-centered vignette may be associated with two or three consecutive questions about the information presented. Each question within these sets is associated with the patient vignette and is independent of the other question(s) in the set. The items within this type of format are designed to be answered in any order. You are required to select the ONE BEST answer to each question.
Sequential Item Sets: A single patient-centered vignette may be associated with two or three consecutive questions about the information presented. Each question is associated with the initial patient vignette but is testing a different point. You are required to select the ONE BEST answer to each question. Questions are designed to be answered in sequential order. You must click “Proceed to Next Item” to view the next item in the set; once you click on this button, you will not be able to add or change an answer to the displayed (previous) item.
Pharmaceutical Advertisement (Drug Ad) Format: The drug ad item format includes a rich stimulus presented in a manner commonly encountered by a physician, eg, as a printed advertisement in a medical journal. Examinees must interpret the presented material in order to answer questions on various topics, including (See Example Drug Ad Item).
Decisions about care of an individual patient
Development and approval of drugs and dietary supplements
Abstract Format: The abstract item format includes a summary of an experiment or clinical investigation presented in a manner commonly encountered by a physician, eg, as an abstract that accompanies a research report in a medical journal. Examinees must interpret the abstract in order to answer questions on various topics, including (See Example Abstract Item).
Decisions about care of an individual patient
Use of diagnostic studies
USMLE Step 3 Practice Materials
Primum Computer-based Case Simulations (CCS): You will manage one case at a time. Free-text entry of patient orders is the primary means for interacting with the format. Buttons and check boxes are used for ordering a physical examination, advancing the clock, changing the patient’s location, reviewing previously displayed information, and obtaining updates on the patient. At the beginning of each case, you will see the clinical setting, simulated case time, and introductory patient information. Photographs and sounds will not be provided. Normal or reference laboratory values will be provided with each report; some tests will be accompanied by a clinical interpretation. To manage patients using the Primum CCS software, it is essential that you complete the Primum tutorial and sample cases provided.