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Sunday, August 29, 2010

Step 3, All You Need to Know

  (The article is taken from "Another Road to Residency" compiled by class of 2003 and 2004 of Agha Khan University, Karachi Pakistan.)
By   Shehzad Sami
Updated by Class of 2003

A few comments of update:

The fee for Step 3 is now $625, not $570 as mentioned below.
At the time of application, you will be asked which state board you would like to sit for. Do not be confused. Simply click on “Connecticut” and move on. Different states have different requirements for when one would be eligible to sit for Step 3. Some places require completion of postgraduate training. Others require an application for state licensure. The Connecticut board has no special requirements except ECFMG certification. Hence, the reason for applying for it. Furthermore, the state board which you sit for has no impact on anything. You can apply for the Connecticut Board of Step 3 and sit for the exam in any city in the USA (not just in the State of Connecticut). Furthermore, you don’t even have to match in Connecticut. There will be no need to convert anything to anything just because you have matched at a different state. So, click on Connecticut and move on!
I’d like to differ (partially) with the mentioned timeline. I applied for my Step 3 on January 29th (the day I receive my Step 2 CS result) and I gave my Step 3 on 1st March. [I was officially ECFMG certified in early Feb.] I could have given it earlier, but I opted not to. Since I sat for my exam in the earlier half of the week, my result was  dispatched in three weeks, that is, March 23rd. Admittedly, I received the score after the match, however, it did not interfere with the processing of my state license, and hence H1B visa. This is because it takes the program at least a few days to send out your information packet (containing state license documents). Thus, you can easily manage if you give Step 2 CS in November. However, as Shehzad mentions, the earlier the better. After all, the more exams you’ve passed, the more interview calls you’ll get. Another point of notice is that certain programs have been known to wait for up to six weeks after match day for Step 3 scores. So, one can actually get away with a highly delayed Step 3. However, visa delays in recent years have forced programs to be sterner regarding these timelines. Ask program directors regarding their current policies.
The application form requires you to submit the date of issue of your ECFMG certificate. Hence, the natural assumption is that you cannot apply until your ECFMG certificate is issued. Fortunately, this is not the case. The time lag between the dispatch of the Step 2 CS result (if this was the last certifying exam you gave) and the issuance of the ECFMG certificate is quite short. About a week, perhaps. For some odd reason, if one just enters the date of dispatch of the last certifying exam that one gave (that is, usually, Step 2 CS) instead of the date of certificate issuance, the Step 3 application gets accepted. Why? I assume it is because there is also a time lag between your sending your application and FSMB’s receipt. That covers for the earlier mentioned time lag. So, FSMB checks as to whether your certificate has actually been issued. When they see that is has, FSMB forgives you for your stupidity in making such a simplistic error, and processes your form anyway. The benefit of doing this will only be realized when you are counting days at the end of interview season because your three month visit visa is about to expire. However, don’t be so over efficient that your form gets to them before your certificate is issued!
TOEFL is no longer required for ECFMG certification.
I cannot personally comment on the books mentioned as I used none of them, however, I have been told that “Crush the Boards for Step 3” is indeed the single best resource for Step 3 preparation. I opted to read both the Kaplan Step 3 books and tried to solve as many Q Bank questions as I could. If, however, you have not given Step 2 CK recently, they will be insufficient as these books are not exhaustive. Perhaps, Step 2 books can be used then. In case your wondering how I fared in my Step 3, my score was a few points lower than Shehzad’s. So, have a look and see what suits you. Also, don’t forget to go over the CD sent by USMLE.
As Shehzad mentions, the Step 3 is a two day exam. The first day is exactly like Step 2, format wise. However, it is more difficult (naturally). Each block is an hour long. The second day is quite different. The first half consists of four blocks, each forty five minutes long. The second half are clinical cases which are based on a completely different computer program. This is the true challenge as you will be managing a patient in an undirected environment. All you are given is a brief history. Now, you decide what to do. You can choose to take further history. If so, further history is revealed. You can choose to examine certain systems. You can choose to start certain medications. Whatever you do, the simulated time keeps ticking. Take too long to manage a critical patient, and the patient dies. What you do affects what will happen next. It is like role playing a “Choose your own adventure book.” If you do unnecessary investigations, you lose points. If you manage efficiently, you gain points. It is loads of fun when you get the hang of it, even during the exam, as you always have more time than you need. So, the second day seems to go better than the first.

Why should you read this article? 99/98/94…..need I say more!!!!

Why give Step 3 before starting residency: If you want an H1B visa, it is essential that you give Step 3 before starting the residency.

The other reason which many people thought in my class was valid enough to take Step 3 before residency was that you won’t have to study other subjects ever again once you get on with your residency. So in a way, it never hurts to give Step 3 before the start of your residency, even if you don’t want an H1B visa, especially when you are in the US for the interviews and all.

Requirements: You need to be ECFMG certified before you can apply for Step 3.

How to Apply: Go to and and from there please print the Step 3 application. You need to send a copy of ECFMG certificate and AKU degree.

Be sure to take all the original documents along with you to the US because you will need them for various reasons, including Step 3 application. Not to forget the money, $570. So if you plan to give Step 3, please include the fee in your total expenditure calculations which you need to take from here.

The Strategy (The most important part of the whole discussion): Why does not everyone give Step 3 before the start of their residency?  As mentioned earlier, you have to be ECFMG certified before you can apply for Step 3. This means, you have to take your CSA in time for you to be ECFMG certified, preferably well in advance of the end of interview season, which is by the end of February. That means you have to follow a fairly tight schedule from the beginning, right from starting your studies for Step 1 after graduation. Here is a rough calculation of the time periods and how to negotiate them:

It is advisable to take Step 3 latest by mid March, preferably mid Feb to end of Feb.
It takes 4 weeks for the Step 3 permit to reach you. So you have to be ECFMG certified by the end of Dec to mid January. It usually takes 6 weeks for the CSA result and approx 1-2 weeks for the ECFMG certificate to reach you. So you have to take CSA preferably in October. This will mean that you have to take Step 2 before October, which is always the advisable thing to do. Therefore, I will just summarize the timeline which needs to be followed if one is considering giving Step 3 in order to obtain an H1 visa.

Step 1: Start of March-Mid April. Although in a perfect world, everyone would be done with their step 1 by the start of March.

Step2: September. No later than 30th of September. This will make sure that you will be able to leave for the US in October.

CSA: Apply soon after you receive your Step 1 score card. Give TOEFL soon after step 1. Schedule CSA in October, perhaps by 15th October.

Step 3: In February.

The whole timeline should be shifted to earlier dates if anyone thinks he/she can. Because the earlier, the better.

The reason to give Step 3 as soon as possible is that most places like the candidates to have Step 3 result by the match date. Some even want you to have the Step 3 result in your hand at the time of the interview. You cannot do anything about that, but you can still go ahead and tell them about your plans and try to convince them that you are a winning horse and won’t falter in Step 3 and will pass it without any trouble. All they are afraid of is lest you may fail after they have agreed to sponsor you for an H1B. Even then, it is not their headache that you have failed Step 3. They will just give you a J1. But they just don’t want to get into the hassle of dealing with failures. You have to convince them that you will pass Step 3 without any problem in light of your Step 1 and Step 2 score.

Study Material: “Crush the Boards for Step 3” is the single best source for the preparation of Step 3. It is one book that every one should do before taking Step 3. Swanson is good too. Do it. But I don’t think that it helps a great deal. But due to dearth of good material for Step 3 preparation, it is well worth the effort to go through this book. Better than Swanson are the Step 2 Medicine notes. I personally think that doing medicine notes should take precedence over Swanson. These 3 sources should prepare you enough to take on Step 3 in a very strong way. Also try to get your hands on the Kaplan Step 3 CD. It is available in the US through students and friends, though I am not sure whether it is available here in Pakistan or not. (Editor’s note: It is available in Urdu Bazaar)

Format of the Exam: It is immaterial right now for me to tell you about the format of the entire exam. When you get around to taking the exam, I assure you, you will get to know about all the details. In short, it is a 2 day exam. First day is just like Step 2. But you just have to pass it instead of acing it. That helps boost the morale. Next day, half of the exam is like Step 2, other half is cases. When you get down to studying for the exam, send me an e-mail at and I will try to help you in this regard. But only if I like you.

How long to study: 4 weeks is good enough. I studied for a little over 3 weeks. I got 94. For those of you who know me, I am no genius. Smart and intelligent hard work is the key. Without this, even 3 months is not enough.

Summary: Step 3 is more of a hassle than a difficult exam. Nonetheless passing it requires a considerable amount of planning and hard work, which is very much doable and less stressful than many of the other things in life. Everyone should try and plan to give Step 3 while they are in the US for their interviews. 

Thanks: Special thanks to Zainab Samad for her noble efforts to compile this guide. May God bless her with lots of love and happiness in her future life. I hope that it proves to be helpful for many to come.

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