USMLE Step 3 is the final test marathon of the USMLE series. This exam is conducted only on weekdays and only within the territory of the United States. USMLE Step 3 is a two-day test, consisting of 7 hours of test and a break of 45 min on both Days 1 and 2. Day 1 and 2 have to be scheduled separately, with Day 2 needing to be scheduled within a 14-day time frame of day 1. This makes it a stay in the USA for at least 3 to 15 days. This makes USMLE Step 3 a very costly affair for international medical graduates. This humongous toll in the wallet is the main reason for candidates postponing or not taking an exam before applying for a residency or entering a residency program.

The costs involved are significantly higher than those for a candidate residing in the USA because the hotels are very expensive and short-term stays are not readily available. We cannot rent or lease a room for the short term at the same rate as long-term leases. Short-term stay options are not always safe and there is no way to verify the credibility of both the owner and the tenant. Travelers on a Visitor Visa do not have a Social Security or Paycheck to provide proof of payment security to their owners. Third-party websites have no way of verifying the criminal records of both the owner and the tenants.

Transportation to and from the Exam Centers may be very expensive considering Uber / Lyft ($100 avg per day). Travel planning is very difficult due to the long-term planning required to obtain permission, a visa, and substantial bank account financing, as required by the Immigration Department. And there is no logical reason to hold the exam in the USA alone.

The Assistant Director of the FSMB told me over the phone that this issue had been raised many times, but they did not take any steps towards it because they were concerned about security measures in exam centers outside the USA. Unfortunately, they were unaware of the USMLE Step 1, and Step 2CK is being conducted in centers inside and outside the USA and is being run by the same Prometric testing agency. She said FSMB is not ECFMG, indeed they are not the same, but the agency they have contracts for conducting the exam is the same and they use same FRED software for the all the usmle exams. FSMB does not have to create new centers. They can just use the already existing USMLE testing centers.

Some people may argue that Step 3 is a licensing requirement for physicians practicing medicine, not outside the US, so there is no need to do so in foreign countries. I beg to disagree because it is not just a licensing requirement, but a need for residency selection by many programs. Although the residency programs do not advertise the need for a Step 3 exam on their program website, they do consider the outcome of Step 3 when selecting candidates.

The Prometric Centers follow standardized safety and testing protocols. USMLE clearly states that there is no difference between the test centers because they are all standardized. The FSMB is conducting Step 3 test and they also claim that there is no difference in safety and security measures between the Prometric Test Centers. USMLE Step 3 is a fully online test, unlike the USMLE Step 2 CS, where interactions and subjective assessments are conducted by American citizens participating as standardized patients.

Residency programs welcome candidates to complete the Step 3 exam before starting a residency, as interns are more focused on patient care than thinking about clearing one more exam on the busy schedule of the internship year. Almost all states require that the completion of Step 3 before the end of the internship year be eligible for state licensing, which is mandatory for continued practice in the second year of residency.

All in all, this is a win-win situation for everyone, because the interns are stress-free, the programs are assured that the interns will be promoted to junior residents next year and the guaranteed availability of the workforce, and for the FSMB, more candidates will take the exam which will increase their revenue.

The only group that will be affected by this decision are hotel owners who may lose some of their clients. However, given that the majority of candidates are from Asia and Europe, the hotspots for COVID-19, FSMB can also avoid this public health risk of having more people entering the USA for exam purposes.

Taking into account all the benefits and no practical risks involved, the FSMB should conduct Step 3 examinations in Prometric centers outside the United States from this year onwards.

Mukesh Kumar Sathya Narayanan