USMLE Step 3

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USMLE Step 3 & CCS

  • USMLE Step 3 exam is designed to test your medical knowledge, its application to patient care and clinical decision-making. In other words, USMLE wants to make sure that you will do fine, practicing medicine independently and without supervision.
  • Residents usually take Step 3 after their first year of medical residency (PGY 1).

You must pass the Step 3 exam for the following reasons...

  • To complete your residency program. You will not get a letter of completion from your residency program if you do not pass Step 3 successfully.
  • To be eligible to sit for the boards (ABIM)
  • To be eligible to get a permanent medical license from any state medical board, you should have successfully completed USMLE Step 3 exam. Visit FSMB website for USMLE Step 3 eligibility info of different state medical boards.

USMLE Step 3 exam information

  • You must be ECFMG certified to be eligible to apply for USMLE Step 3 exam.
  • USMLE Step 3 exam is given on two consecutive days (8 hours each) at a Prometric test center and has two components.
  • On the first day, the test consists of 336 multiple-choice questions (MCQs) given in several blocks of 25 to 50 MCQs each. Each block may last from 45 to 60 minutes.
  • On the second day, 144 MCQs will be given in the first 3 hours. Over the next 4 hours you will be given nine Computer-based Case Simulations (CCS).
  • Total Multiple choice questions (both days included) = 480
  • As the questions reflect common diseases seen in residency, think of the USMLE Step 3 test as a two-day vacation - away from your busy overworked residency program.
  • There is one-hour of break time, which can be split up and used in-between blocks as you like. The test also includes nine Computer-based case simulations (CCS) given over four hours, on the second day. USMLE Step 3 & CCS sample questions.
  • USMLE Step 3 exam can be taken at Prometric centers in the U.S. only. Step 3 is not available outside the United States. Click here to view USMLE Step 3 Prometric test center locations.
  • The test is given continuously, through out the year.
  • If you don't require a H 1 visa to join a medical residency program in the U.S., then don't be in a hurry to take the USMLE Step 3 exam.
  • Generally, residents take the Step 3 exam at the end of their first year of internship or residency (PGY 1).
  • Step 3 is not just an assessment of your medical knowledge. It is mainly an assessment of your clinical decision-making ability and medical management skills.
  • You will be proficient at this, by the end of your first year of residency and that is the best time to take USMLE Step 3 exam. Click here for USMLE Step 3 & CCS tips .
  • The majority of questions for USMLE Step 3 will be in an Outpatient/ ambulatory setting.
  • Emergency Room (ER) and Inpatient/hospital setting will also be part of the Step 3 exam.
  • The test content will closely reflect the common diseases seen in your medical residency training.
  • Internal Medicine will consist of approximately, 60% of questions.
  • If you are not an Internal Medicine or Family practice Resident, please devote the majority (90 %) of your preparation time on Internal Medicine.
  • OBGYN, Pediatrics and Surgery will account for approximately 10 % each. Psychiatry, Medical Ethics and other content will account for the rest.

Preparing for USMLE Step 3

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Give special attention to the following...

  • Screening tests- Fecal occult blood, Rectal exam, Colonoscopy / Sigmoidoscopy, Mammogram, Breast exam, Pelvic exam, Pap smear, PSA, and Prostate exam.
  • Clinical guidelines and age at which to initiate the above measures, Pneumococcal and influenza vaccination, meningococcal vaccine (e.g. military recruits). These are the same guidelines that you follow in your residency program.
  • Side effects of common medications are a favorite topic for USMLE Step 3 questions (e.g. statins-muscle pain/ Rhabdomyolysis).
  • Depression, anxiety, bipolar, hyponatremia, Marfan’s, child abuse, vaginal bleeding, STD, Vaginal infections, PID, eclampsia, Hypertension, Diabetes, MI, CHF, chest pain work up- exercise treadmill, cardiolyte / Thallium scan, Stress echo etc.

Minimum USMLE Step 3 pass scores

  • The minimum score to pass the USMLE exams is 75 on the two-digit scale. To achieve a minimum score of 75, you must answer about 60 to 70 % of the questions correctly.
  • The two digit minimum pass score of 75 does not change. The two digit score is calculated so that a score of 75 will always correspond to the minimum passing score (even if the three digit score changes).
  • The two digit score is provided to fulfill the score reporting requirements of various state medical licensing boards.
  • The three digit minimum passing score may change from time to time. You are advised to check the USMLE website periodically. The current three digit minimum pass score for USMLE Step 3 is 187.
  • The three digit score scale: Most scores on this scale fall between 140 and 260. First time exam takers (from US Medical schools), usually have a mean score of 200 to 220.
  • It is in your interest to get a good USMLE score. This increases your chances of getting into a good residency program and especially into highly competitive specialties like Radiology, Orthopedics and Dermatology.

Tips for USMLE CCS examination

  • Pay close attention to the setting (location) of the patient encounter. The setting helps you decide on the aggressiveness of your treatment orders and whether to send the patient home. It also gives a clue to the medical diagnosis.
  • If the setting is ER and you are not sure of the medical diagnosis, admit the patient and work him up. You can always discharge him from the hospital, the next day. USMLE Step 3 CCS is testing you to see if you practice safe medicine. One year of medical residency should help you in your decision making.
  • Write down the age, sex, chief complaint, and allergies of the patient on the writing sheet provided at the exam. This will help you save time when considering medical differential diagnosis.
  • Counseling is a major part of outpatient office visits. Pay particular attention to counseling in normal/ routine patient visits. This is similar to real counseling provided by you in your medical residency.
  • Important counseling topics include smoking, alcohol, drugs, safe sex practices, exercise, weight reduction, diet, and self-breast exam. You can score points for these orders in the USMLE Step 3 CCS test.
  • If the patient presents with breathing difficulty, remember to order Oxygen, albuterol PRN and hook him up with a pulse oximetry.
  • Patients presenting to the ER in an unresponsive state should have a finger stick glucose done with a glucometer stat, naloxone given if opiates are suspected (Pupils), and thiamine added to IV fluids if alcoholic.
  • Patients with Hypertension and diabetes should have appropriate diets ordered (2 gm salt restricted or 1800 ADA diet)
  • For abnormal LFTs order a hepatitis profile/panel if appropriate. USMLE CCS exam assesses the appropriateness of medical orders.
  • Order tests to diagnose H. pylori if patient has GERD. The H. pylori antibody should be ordered if the patient has never been diagnosed before and the Urease breath test if checking for elimination/ recurrence.
  • Overdose/poisoning patients should be admitted to the ICU for closer monitoring and suicide precautions. Don’t forget to get a Psychiatry consult.
  • Inpatient hospital admissions need a physical exam everyday and appropriate lab and medical orders. Remember what you do daily in your residency, and you will be fine.
  • When writing orders, you can save time by holding down control and selecting multiple orders with your mouse.
  • Acute abdomen and most surgical emergencies need frequent and multiple interval H&P.
  • Don’t forget to advance the clock during the USMLE Step 3 CCS exam. Remember, you will not get results and nothing will happen until you advance the clock.
  • Get appropriate consults. You will get credit for this. However, once you ask for a consult, the computer may ask you to manage it yourself temporarily, as the consultant is busy. Don’t worry. Do the routine pre-op stuff and stabilize the patient.
  • Use keywords to get order lists- Stop, Avoid, Diet, Vaccine, Advice etc
  • Have a routine scheme / checklist to follow for USMLE CCS exam. This avoids overlooking common orders. You can even write down this checklist on the writing sheet provided at the USMLE testing center. You can then rapidly refer to the checklist(see below) and make sure that you have not forgotten anything.
  • In the ER setting, first do a brief physical exam (2 min). Then write orders and labs. Once the patient is stabilized and lab results reviewed, do a full physical exam. Then shift the patient to the ICU or ward.
  • Remember First stabilize, then full physical, and then admit. This is also what you would do, in your residency training and real life.
  • When ordering labs in the ER, avoid asking for panels (e.g. CMP or BMP), the results will be delayed. Instead order the individual components of the panel. You can order panels in other settings.

USMLE Step 3 CCS Checklist

Labs: CBC, CMP, Urine routine, TSH, Lipid Profile, Cardiac enzymes, ABG
Glucometer check, Drug levels, Toxicology screen-Urine and serum, ANA, ESR.
Bleeding & pre-op patients: Type Blood and cross match, PT/INR, PTT.
Infections: cultures of Blood, Urine, Sputum or CSF, as appropriate.
Acute abdomen: order amylase, lipase, b HCG & acute abdominal X ray series.
Imaging & EKG: EKG, EEG, Echo, Ultrasound, Carotid Doppler
CXR, X ray Joints, acute abdominal series
CT, MRI, Exercise treadmill, Cardiolyte / Thallium scan for angina.  
Nursing orders: NPO, Diet, IV Fluids, Vitals, Input/output, Physical therapy
Tubes- NG, Foley, Pulse oximetry & Oxygen, cardiac monitor 
Medication orders 
Counseling: Weight loss, exercise, diet, smoking & alcohol cessation.
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