USMLE Step 3

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Step 3 is the final exam of the United States Medical Licensing Examination™ (USMLE™) series of examinations. It is part of the licensing requirements for M.D.s, D.O.s, and FMGs to practice medicine in the United States. It is considered the final step in the series of medical licensure examinations. It generally is a pre-requisite of the majority of the state licensing boards, and it is usually taken during intern year in residency training. It is a two-day examination that includes multiple choice questions and clinical case scenarios (CCS) that assess medical knowledge in the clinical setting. Step 3 provides a final assessment of physicians assuming independent responsibility for delivering general medical care. Template:Physician education and training in the United States

Exam Content

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.

Topics include:

  • Internal Medicine
  • Biostatistics
  • Surgery
  • Obstetrics
  • Gynecology
  • Pediatrics

Exam Structure

Step 3 consists of multiple choice questions (MCQs) and computer-based case simulations, in a two-day examination. Assess the knowledge and skills of physicians who are assuming independent responsibility for providing general medical care to patients, with emphasis on patient management in ambulatory settings.

Step 3 Format & Length:  

Day 1: 6 x 60-minute blocks | 7-hour testing session | Up to 232 items

Day 2: 6 x 45-minute blocks | 9-hour testing session | Up to 180 items and 13 to 14 case simulations

Day 1: Step 3 Foundations of Independent Practice (FIP)

The first day of testing, includes 232 multiple-choice items divided into 6 blocks of 38-39 items with 60 minutes provided to complete each block. There are approximately 7 hours in the test session on the first day, including 45 minutes of break time and a 5-minute optional tutorial. This test day includes multiple-choice questions and newer item formats include scientific abstracts and pharmaceutical advertisements.

This test day focuses on assessment of knowledge of basic medical and scientific principles essential for effective health care. Content areas include: application of foundational sciences; understanding of biostatistics and epidemiology/population health, and interpretation of the medical literature; and application of social sciences, including communication and interpersonal skills, medical ethics, systems-based practice, and patient safety.

The test day also includes content assessing knowledge of diagnosis and management, particularly focused on knowledge of history and physical examination, diagnosis, and use of diagnostic studies.

Day 2: Step 3 Advanced Clinical Medicine (ACM)

On the second day, there are approximately 9 hours in the test session. It includes a 5-minute optional tutorial followed by 180 multiple-choice items, divided into 6 blocks of 30 items; 45 minutes are allotted for completion of each block of test items. The second day also includes a 7-minute CCS tutorial, followed by 13 to 14 case simulations, each of which is allotted a maximum of 10 or 20 minutes of real time. A minimum of 45 minutes is available for break time. There is an optional survey at the end of the second day, which can be completed if time allows.

This test day focuses on assessment of the ability to apply comprehensive knowledge of health and disease in the context of patient management and the evolving manifestation of disease over time. Content areas include assessment of knowledge of diagnosis and management, particularly focused on prognosis and outcome, health maintenance and screening, therapeutics, and medical decision making. Knowledge of history and physical examination, diagnosis, and use of diagnostic studies also is assessed. This test day includes multiple-choice questions and computer-based case simulations (CCS).

Computer Based Case Simulations (CCS)

Computer-based case simulations are interactive patient simulations presented on a software, designed to evaluate your approach to clinical management. They test diagnosis, treatment, and monitoring. Each case is presented in a consistent format.

Sample Questions

Exam Study Prep


Biostatistics Review

DIAGNOSTIC TESTS

Disease Nondisease Total
Test Positive TP FP PPV = TP / (TP + FP)
Test Negative FN TN NPV = TN / (TN+ FN)
Total Sens =

TP / (TP + FN

Spec = TN

/ (TN + FP)

All subjects (population)

TP: true positive; FP: false negative; TN: true negative; FN: false negative


FORMULAS

  • Sensitivity (true positive rate) = TP/ (TP + FN) = 1 - FN rate “people with disease”
  • Specificity (true negative rate) = T N / (TN + FP) = 1 - FP rate “people without disease”
  • Positive Predictive Vale (PPV) = TP / (TP + FP)
  • Negative Predictive Value (NPV) = TN / (TN + FN)
  • ACCURACY = TP + TN / (TP + TN + FP + FN)
  • Prevalence = TP + FN / TP + FN + TN + FP
  • Positive Likelihood Ratio = Sensitivity / (1- specificity) “pro
  • Negative LR = (1-sensitivity)/ specificity
  • False negative rate = 1- sensitivity
  • False positive rate = 1- specificity
  • High Yield Info:
  • A highly sensitive test (to rule out) increases the negative predictive value by decreasing few false negative results
  • NPV increases as sensitivity increases (fewer FNs)
  • PPV and NPV change with disease prevalence. Specificity, sensitivity and LR don’t change

STUDIES

Risk Factor Diseased Non-diseased Total
Exposure a b a / (a +b) = incidence

of exposed

Non-exposure c d c / (c + d) =

incidence of unexposed

Total a + c = diseased b + d = healthy All subjects

(population)

Exposure could be a Risk factor or an intervention


  • Relative Risk (RR) = Incidence exposed/ Incidence unexposed = a / (a+ b) // c / (c + d)
  • Relative Risk reduction (RRR) = 1 – RR
  • Odds Ratio (OR) = (AXD)/ (BxC) = a/c / b/d (FOR CASE-CONTROL STUDIES)
  • Attributable Risk (AR) = Incidence exposed – Incidence unexposed (or controls) = a/ (a+b) - c/ (c + d) = EXPOSED - CONTROL
  • Number Needed to Harm = 1/ Absolute Risk (AR)
  • Attributable Risk Reduction (ARR) = c/c+d - a / (a+ b) = probability of having the disease in exposed - probability of having the disease in non-exposed = CONTROL - EXPOSED
  • Attributable Risk Reduction (ARR) = Incidence unexposed (c for controls) – Incidence exposed
  • Number Needed to Treat = 1/ Absolute risk reduction or ARR = 1/ ARR

Computer Based Case Simulations (CCS) General Approach

Find a general summary on how to approach CCS cases on Step 3 on a step-wise approach:


1. GENERAL INFO:   write age, gender, chief complaint on your erasable board

  • Symptoms (pain, fever, vomit) to address them later on 🡪  (morphine, acetaminophen, phenergan)
  • Write social history (smoking, sex) to address towards the end of the case

2. EMERGENT ORDERS (if patient unstable, in acute distress)

  • Pulse ox +/- oxygen therapy
  • Cardiac monitor (telemetry)
  • IV access +/- Normal saline
  • Finger stick glucose
  • ECG, naloxone

3. PHYSICAL EXAM

  • IF STABLE 🡪  COMPLETE PHYSICAL (check all the boxes).  (e.g., trauma pt 🡪  full physical)
  • IF UNSTABLE 🡪  FOCUSED PHYSICAL (heart, CV/lungs) + system of interest

4. LABS/STUDIES

  • BLOOD:  CBC, CMP, TSH, Blood culture (if fever), Lipid profile, ESR/CRP, Phos, Mg, ABG (acid base), Amylase, lipase
  • PT/INR, PTT, blood type and cross match, blood alcohol (drugs levels).
  • URINE:  UA, UCx, urine tox screen, Urine ketones, Urine B-Hcg (qualitative)
  • IMAGES:  CXR (portable if emergent, or PA/LAT), US, XRAY, CT (head), echo, MRI, cardiac stress test, VQ Scan, ERCP, EMG conduction studies
  • OTHER:  ECG, PEFR (peak flow), Biopsy, Arthrocentesis, LP, colonoscopy/EGD
  • MICRO:  Gram, culture and sensitivity, glucose, cels, protein, LDH
  • STOOL:  FOBT (before warfarin/heparin), ova, parasites, white cells, bacterial culture, 72-hour fat stain, C. difficile toxin, Hpylori toxin (urea breath test)
  • PREGNANCY:  urine Bhcg, delivery, oxytocin, C-section, pelvic/transvaginal ultrasound, (IF HTN:  hydralazine, alpha methyldopa, IV Mg), if bleeding aboid Digital vaginal exam
  • 🡪  STDS:  Urethral/cervical gram, culture and sensitivity, NAAT, wet mount (vaginal), HIV/VDRL, Hep B/C (if high risk), treat partner, safe sex
  • 🡪  ABS:  ANA, RF/anti-citruclinated, dsDNA/Smith.
  • Overall:  avoid invasive, discomfort tests/procedures

5.  LOCATION

🡪  Send HOME, or transfer to ER (do minimal stabilizing orders before).  If pt is on new med and is sent home, monitor with CMP/CBC.

🡪  ADMIT to Ward/ICU:

  • IV access
  • Fluids: normal saline (0.9%)
  • Diet:  (NP), diabetic, low salt/fat, calorie restricted
  • Activity Level: bed rest, head of bed elevated, ambulate at will
  • Tubes:  NG tube, Foley
  • Urine output (ins and out):
  • Vitals:  Q 4h, Q8h
  • DVT Prophylaxis:  LMW (Lovenox), Compression device stockings
  • Daily weights (CHF)  

6. SYMPTOM CONTROL

  • Pain:  morphine (avoid if hypotensive), ketoprofen, Ketorolac
  • Nausea/Vomit:  Phenergan (promethazine)
  • Antispasmodics:  L-hyoscymine sulfate (Buscapine)
  • Antidiarrheals:  Loperamide
  • PPI Prophylaxis:   IV Pantoprazol
  • Anti-inflammatory:  Ketoprofen
  • Push oral fludis:  peds

7.  TREATMENT (advance time results 2-4-6 hours to see results)

  • Antibiotics:  Zosyn (GI), cefazolin
  • Steroids:  (IV Methylprednisolone, IV hydrocortisone, oral prednisone)
  • Consults:  up to 3 (eg, colon CA:  surgery, GI, oncology; fall: neuro, cardio, ortho).
  • Surgery:  (after imaging, labs results),  Order the surgery (e.g., appendectomy, oophorectomy)
  • PreOp orders:  PT/INR, PTT, blood type and cross match, IV preop Cefazolin, NPO

8.  REASSESS 🡪  Interval follow up +  focused (or complete if not have done it already)

9.  SCREENING AND COUNSELING “ideally after patient improves before final orders”

  • CA SCREENING:  colonoscopy (>50 Q 10 years), mammography (>50 Q 2 years), PAP smear (start at 21 Q 3 years)
  • VACCINES:  influenza IM (yearly), varicella zoster (>60), DPT (Q 10 y), Hep A, B, MMR, Hib, Meningococcal, HPV (11-26y)
  • COUNSELING:  

10. FINAL ORDERS (last 2 minutes): “PRIORITIZE MOST IMPORTANT ORDERS”

  • Final counseling
  • Labs to monitor condition:  New med:  CBC (if infection), CMP (if renal failure), condition:  CBC, ESR/CRP.  UTI test of cure (UA, UCx)
  • Cancel unnecessary orders
  • Transition IV Meds to PO
  • Diet advance after GI surgery (clear liquid, full liquid, bland diet, full regular diet)
  • F/U consult in 1-2 weeks

High Yield Review

WikiDoc Resources

USMLE Updated Resources

External Resources


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