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Next Steps: Reevaluating the Value of Step 3

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For most medical students, including myself, studying for board exams can be the most stressful time in medical school. Typically, medical students dedicate three to eight weeks to study for each of the following exams: Step 1, which emphasizes clinical knowledge, and Step 2, which focuses on clinical application. During this study period, I spent my days memorizing facts, building frameworks, and gaining a foundation for clinical gestalt. These skills were incredibly helpful when I started an infectious disease elective: I saw patients and applied my studying to more than just multiple choice questions. Now, I am wrapping up medical school having finished interviews and finalized a rank list. Starting intern year, beyond caring for patients, I will also have to take Step 3, a two-day test consisting of multiple choice questions and computer-based case simulations, the last exam between me and a medical license. While I understand the importance of the other two exams, I do not believe Step 3 is necessary — and in fact, I believe the harms outweigh the gains. 

Per the USMLE, Step 3 “reflects a data-based model of generalist medical practice in the United States … [for a] general, as-yet undifferentiated, physician” that aims to be a “final assessment of physicians assuming independent responsibility for delivering general medicine care.” Yet, first-year residents are neither “general” nor “undifferentiated,” given that trainees are entering fields as specific as radiology or surgery. Moreover, the NBME itself has noted this point and further stated that “there were mixed opinions on whether all physicians should be required to demonstrate mastery of a common set of knowledge and skills.” Studies demonstrate that Step 3 score is correlated to the broadness of a specialty. While having a broad general knowledge is important, it must be noted that this was already tested in Step 1 and Step 2, exams required by residency programs prior to candidacy consideration. The truth of the matter is that nuances of care are often forgotten if you are not observing particular types of cases every day; this idea is reflected in the fact that most residency programs encourage their trainees to take Step 3 as early as possible. Given the stage residents are in their training, the knowledge scope of Step 3 is not applicable. 

Additionally, Step 3 contributes to resident burnout from both a time perspective and a financial one. Medical burnout is of serious concern, and was a large factor for why Step 1 recently shifted from a three-digit numeric score to pass/fail. Though it’s true that Step 3 is also pass/fail, it must be noted that unlike previous Step exams, Step 3 takes place when trainees no longer have dedicated time to study. Thus, interns not only face the challenge of integrating into a new system and dealing with an increase in workload and hours, they also face the challenge of finding time to prepare for Step 3.

Additionally, Step 3 is financially costly for interns: As of 2023, the exam itself costs $915, which does not include study materials that can run to at least $100. While many residency programs provide educational funds to cover some of these costs, it’s undeniable that these funds could be put to better use — such as allowing trainees to attend medical conferences or to pay their medical society dues. 

For Step 3, the financial loss from the trainee’s perspective is just as important to consider as the financial gain of the NBME, a 501c3 nonprofit that serves as a gatekeeper to the medical profession. Since the early 1990s, the NBME has operated with the Federation of State Medical Boards to cosponsor the USMLE. Most physicians and medical students are familiar with the NBME since they are the main source of nearly all the NBME’s revenue: Per publicly available tax data, the NBME had revenues of $153.9 million (M) and net assets of $177.6M in 2017; earnings (revenue-less expenses) of $39.7M in 2013-2017; and a highly compensated management team. As a medical student, I recall spending hundreds of dollars to take practice tests for both Step exams and several shelf exams that spanned from surgery to pediatrics. Meanwhile, when students fail Step exams, they need to pay for a second test fee. Without a doubt, the NBME plays a role in the debt of graduating medical students, which averages to around $200,000. Through the years, the NBME has grown to be a powerful monopoly resembling a for-profit corporation — which begs the question of who is truly benefiting from the Step exams. 

Ultimately, exams are a valuable way to assess medical trainees’ foundational knowledge of clinical care and ensure that they can provide safe, high-quality care for patients. Yet, the exam structures are viable to change, as seen by: 1) Step 1 becoming pass/fail; 2) the introduction (in 2004) and later suspension (in 2021) of the Step 2 Clinical Skills exam, which consisted of a series of patient encounters with standardized patients; and 3) Step 3 having computer-simulated cases with multiple-choice questions rather than the latter alone. Why can’t we take these changes one step further and eliminate Step 3 altogether?

After all, though it’s true that the pass rate of Step 3 is quite high (98% in 2022), and the exam has been around for over 30 years, it’s also true that Step 3 comes with numerous problems: The exam focuses on materials not consistent with trainees’ clinical knowledge, often contributes to resident burnout, and is not in the best financial interest of residents. At a time when health care labor trends toward increasing burnout and union activity, it is more important than ever to reconsider the utility of a Step 3 exam. 

Do you think Step 3 should be eliminated? Share in the comments!

Ellen Zhang is a Harvard Medical Student who is passionate about using writing as a lens to unravel the complexity of medicine, enhance empathy, and provide humanistic care. She enjoys hiking, baking, and exploring local cafes. Ellen is a 2022–2023 Doximity Op-Med Fellow.

Illustration by Diana Connolly

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