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Changes to Step 3 examination in 2013

Posted: November 28, 2012

As previously announced, changes to the USMLE Step 3 examination are scheduled to take place no earlier than 2014. The redesigned examination will include assessment of "a comprehensive knowledge of both foundational science and clinical medicine," as well as "a demonstration of evidence-based medicine and quantitative reasoning skills important to patient care and to life-long learning."

Over the next few years, Step 3 examinees will see a gradual increase in test items that assess knowledge of foundational science.  To give examinees a sense for what such an item might look like, an example of a 2-item set is provided below. The second item in the set is an example of how foundational science might be assessed in Step 3.
Example Step 3 item set:

A 74-year-old man comes to the ED with a 2-week history of nosebleeds with associated nausea. He says the blood drips down his throat. He denies recent trauma. Medical history includes hypertension and a stroke 2 years ago. Medications: enteric-coated 81-mg aspirin, simvastatin, and losartan. BMI is 21 kg/m2. The patient is pale. Vital signs: T=36.9°C (98.4°F), P=110/min, R=18/min, and BP=115/85 mm Hg. Pulse ox =93% O2 sat.  PE: dried blood around the right nostril; left nostril is clear. Muscle strength is 4/5 in the left upper extremity. Stool occult blood is positive.

Serum      Blood
  Urea nitrogen 49 mg/dL        Hematocrit 18%
  Creatinine 1.49 mg/dL        Hemoglobin 6.1 g/dL
       WBC 13,100/mm3
       Platelet count 212,000/mm3
       INR 1.3

Which of the following is the priority in management?
(A) Infusion of 0.9% saline
(B) Nasal packing
(C) Referral for colonoscopy
(D) Transfusion of packed red blood cells*

The patient is admitted to the hospital and undergoes transfusion of packed red blood cells. Four hours later, the patient's bleeding recurs. Following cautery and nasal packing, the bleeding ceases. Twelve hours later, the patient develops headache, vomiting, and muscle weakness. He is disoriented and delirious. He appears flushed and uncomfortable. Vital signs: T=38.3°C (100.9°F), P=110/min, R=26/min, and BP=92/60 mm Hg. Physical examination discloses nonpurulent conjunctivitis and a diffuse, erythematous maculopapular rash over the trunk and both lower extremities.

Which of the following is the most likely pathophysiologic mechanism of this patient's current condition? 
(A) Exotoxin-mediated T-cell activation*
(B) Interleukin-mediated inhibition of CD 4+ T-lymphocytes
(C) Lipopolysaccharide-induced cytokine production
(D) Sphingosine kinase activation in inflammatory cells

*Correct answers shown in bold.

In 2012, new item formats that assess an examinee's ability to appropriately interpret information presented both in the form of a research abstract and a pharmaceutical advertisement were introduced into the Step 3 examination. More information about these item formats is provided in the Comprehensive Review of USMLE updates.

In 2013, Step 3 examinees will see an increase in the number of research abstract and pharmaceutical advertisement questions.


Computer-Based Case Simulations (CCS) Field Trial

Posted: August 17, 2015
Updated: September 19, 2015

The National Board of Medical Examiners® (NBME®) has developed new software to deliver the Primum® Computer-based Case Simulations (CCS) component of Step 3 of the United States Medical Licensing Examination® (USMLE®), which is jointly owned by the NBME and the Federation of State Medical Boards. The new software incorporates user-adjustable display features, specifically text magnification and reverse color (color inversion).

NBME is planning a field trial of the software from November 16, 2015 through February 29, 2016 at select Prometric test centers in the United States. NBME is seeking medical students and graduates with varying levels of visual ability (with or without visual impairments) to participate in the field trial.

Individuals who anticipate taking USMLE Step 3 at a future date may find participation useful. The field trial will include some cases not currently available as Step 3 CCS practice cases on the USMLE website.


  • Each participant who completes all sections of the field trial, including the end-of-exam survey, will receive a $50 honorarium approximately two weeks after the field trial ends; this timeline is subject to change.
  • There are no fees associated with participation in the field trial.
  • Performance on the field trial will be strictly confidential. Score reports will NOT be provided to participants nor reported to any third party.
  • Results of the Primum CCS field trial cannot be substituted for USMLE Step scores for the purpose of medical licensure in the United States nor for meeting the requirements for a United States H-1B visa.


November 16, 2015 to February 29, 2016


The Primum CCS field trial is a half-day (3-hour, 36-minute) exam. The testing day will be divided into the following components:

  • 15-minute tutorial1
  • Five 21-minute blocks, each containing one 20-minute case
  • Six 11-minute blocks, each containing one 10-minute case
  • One 20-minute block with CCS feedback2
  • 10 minutes total break time (to be taken between blocks)

1 It is highly recommended that participants practice with the Primum CCS software before the field trial, becoming familiar with both the software interface and background information. Click here to review the orientation material and practice with sample cases. The software in the field trial will be a new version with enhanced usability features, and therefore, different from the current software interface available on the USMLE website. Nonetheless, it will be beneficial to practice with the existing software interface in advance of the field trial.

2 This block includes feedback on diagnostic and management steps for the sample Step 3 CCS cases. The CCS database contains thousands of possible tests and treatments. Therefore, it is not feasible to list every action that might affect an examinee's score. The descriptions are meant to serve as examples of actions that would add to, subtract from, or have no effect on an examinee's score for each case.


Click here to see a list of all field trial test center locations. 

* Test center locations are subject to change


  • No additional applications are being accepted.
  • The deadline for submitting applications was September 18, 2015 at 11:59 pm Eastern Time in the United States.


After the application deadline, the NBME will use stratified random sampling to select participants from the pool of applicants. Only one application per person will be considered in the selection pool; duplicates will be excluded.

Those selected to participate will receive e-mail notifications and electronic scheduling permits (e-permits), which will provide instructions for scheduling appointments. Applicants who have not been selected will also be notified by e-mail. The NBME plans to send notification e-mails on or around October 5, 2015.

Please note that e-permits and other communications will be sent to the e-mail address you enter into the online application. Therefore, it is very important that you check your information for accuracy prior to submitting the application.

Those applying to participate in this field trial acknowledge that they have read, understood, and agreed to be bound by the provisions contained in this announcement. Those who do not wish to be bound by these provisions should not apply.

  • Due to the limited duration of the field trial, rescheduling may not be possible if a participant’s plans change.
  • A participant who fails to appear for a scheduled appointment cannot request another appointment.
  • A major purpose of the field trial is to test the enhanced functionality of the Primum CCS Software. There is no guarantee that a participant will be able to start, or complete, any or all sections of the field trial. Rescheduling will not be possible if technical difficulties occur that prevent the start or completion of the trial at a test center. However, if a participant is unable to complete the field trial due to technical difficulties, the full $50 honorarium will be provided.
  • Participation in the field trial is free. However, any associated costs (e.g., travel, meals) are the responsibility of the individual participant.
  • Under no circumstances shall the NBME be liable for any damages or costs that may result in any way from participation in the field trial or from a participant’s use of the information derived from participation in the field trial.

New Features

Two new user-adjustable display features will be piloted:

  • Reverse color (color inversion)
  • Text magnification

The new display features are NOT currently available on live USMLE administrations or in practice materials available on the USMLE website.

Examinees are encouraged but not required to use the new features; they will not interfere with an examinee’s practice experience. Examinees will be asked to complete a brief post-session survey about their experience, which will help USMLE determine whether examinees like the new features.

If the features become available in the future for use in USMLE Step examinations or the online practice materials, examinees will be notified well in advance.

Reverse color
Inverts the color of the text and background from black-on-white to white-on-black. The ability to reverse color (also known as color inversion) improves readability for some users.

Screen capture: reverse color

Text magnification

Two levels of text magnification will be available.

Screen capture: text magnification, before
Screen capture: text magnification, after


    The NBME is providing the materials presented in this field trial for personal use only. The materials are owned and copyrighted by the NBME or jointly by the FSMB and the NBME. The materials may not be transferred or reproduced in any way. Any unauthorized reproduction of these materials, by any means, including but not limited to, copying or printing of electronic files, reconstruction through memorization and/or dictation, and/or dissemination of these materials or any part of them is strictly prohibited.


    Questions about this field trial may be directed to fieldtrial@nbme.org

Review of USMLE Step 3 minimum passing performance

Posted: September 09, 2015

The USMLE program recommends a minimum passing level for each Step examination. The USMLE Management Committee is responsible for establishing and monitoring these standards, and is asked to complete an in-depth review of standards for each examination every three to four years.

For the 2015 Step 3 review, information from multiple sources will be considered, including:

  • Results of content-based standard setting exercises conducted with three independent groups of physicians in 2015;
  • Results of surveys of various groups (e.g., state licensing representatives, medical school faculty, samples of examinees) concerning the appropriateness of current pass/fail standards for Step examinations;
  • Trends in examinee performance;
  • Score precision and its effect on the pass/fail outcome.

The USMLE Management Committee is scheduled to review the minimum passing score for the USMLE Step 3 examination at its meeting on December 9-10, 2015.

If the Committee determines that a change to the minimum passing score is appropriate, the new recommended minimum passing score will become effective for all examinees who take a Step 3 examination on or after January 1, 2016. The decision of the Committee will be posted at the USMLE website.

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