So I know the last time I wrote, it came off a little bit angry and a little bit sad. I said things like “none of this matters,” and “bloated, terminally diseased healthcare system,” and mentioned Wharton’s Jelly again.

I am happy to report… that I took Step 3, the final step in the general medical board exams. And it was stupid.

In case you had forgotten, becoming a Real Doctor in the USA requires taking and passing five exams. Four exams are administered by the USMLE, the Imperial Empire of medical testing services, while the fifth is “boards certification” and is specialty specific.

Step 1 was the worst test ever. Step 2 CK was the longest test ever. Step 2 CS is such a tremendous waste of money that in 2016 there was nearly a full-blown rebellion over it; the uprising was extinguished only because the original authors of the petition to cancel it graduated medical school, and no longer had time to fan the flames of revolt while working 100-hour weeks as interns.

Here is how it (doesn’t) work: You take the USMLE Step 1 in the middle of med school. Step 2 CK, a multiple choice test lasting 7 hours, and Step 2 CK, a “skills test” costing $1600 and a full lost day you will never get back, happen toward the end of med school.

Then, you graduate medical school… and yet, there is still another USMLE test, called Step 3. Remember, your now-doctor has already GRADUATED MEDICAL SCHOOL. The university where they went to medical school has already seen fit to grant them their highest degree in recognition of their achievements. A residency program has already decided that they are willing to pay your now-doctor a hilariously small pittance in exchange for multiple years of indentured servitude and, ostensibly, training.

And yet. Despite completing the long, hard road to reaching residency, there is yet another USMLE test to check off.

Step 3 is supposed to be taken during intern year. When exactly to schedule is it kind of a mystery, but it ends up being whenever you can get two days off in reasonable proximity, which happens only once or twice during intern year anyway.

But wait, you might be wondering. What, exactly, is Step 3 for?

That is an excellent question.

The USMLE themselves say the following:

“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.”

Wait a minute. I feel like I’ve read that before. Hmm.

“Step 2 assesses whether you can apply medical knowledge, skills, and understanding of clinical science essential for the provision of patient care under supervision and includes emphasis on health promotion and disease prevention.”

“Okay,” you might be thinking. “Step 2 is for practicing under supervision, and Step 3 is practicing independently.”

You would be wrong, because you have not had to take any of these tests. As usual, the only thing these tests assess is your ability to take the test. Most of us passed Step 2 without much advance studying; despite graduating medical school and jumping through all the USMLE hoops, personally I was in no way qualified to provide patient care despite the closest supervision possible. It is only out of the sheer miracle of evolution and dumb luck that no one died my first week as an intern.

For comparison, I studied not at all for Step 3. I would be shocked if I had issues passing. Part of my confidence is because the pass rate is 92% overall, and 98% for MDs trained in American medical schools. (By itself, that should make you question what the exam is testing for.)

This poses a dilemma. Follow me along this logic journey:

IF Step 3 is supposed to assess for readiness to practice without supervision; AND

IF a resident takes Step 3 prior to finishing residency, with additional training still ahead; AND

IF the pass rate is 98%; AND

People who fail the first time simply take it again and almost invariably pass…

THEREFORE… What the hell is the point of the test? What, exactly, is it assessing?

(If you understand the above reference, you are much too nerdy. Go outside.)

I suspect the true answer is that it is a holdover from an era when there were few specialty board exams (because there were far fewer specialties at all) and when residency was split between Year 1 internship and residency. Also it makes money for the USMLE.

Neither of these reasons justify its continued existence. Step 3 is a dreadfully expensive dinosaur, an archaic test that is around only through the immense inertia of the conservative medicine world and the voracious greed of a predatory testing agency from whom there is no escape.

Not to be dramatic or anything, but the USMLE Step 3 is exactly that.

I took it last week, like the good little obedient slave I am, and it was a profound waste of time and two days I will never get back.

Like I said at the beginning, it was stupid.