USMLE Step 3: The Ultimate Study Guide

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What is the USMLE Step 3

The USMLE Step 3 is the final examination you must pass to become a licensed, unsupervised practicing physician in the United States. To be an eligible candidate for USMLE Step 3, you must first pass USMLE Steps 1 and 2, both CK and CS, have a DO, MD, or international medical degree, and be ECFMG certified if you are an international medical graduate. Additionally, you must have not failed Step 2 CS six or more times. You will also have a total of 6 USMLE Step 3 attempts, but only 3 attempts can be made within a 12-month period. You are to apply for Step 3 using the USMLE links in the Federation of State Medical Boards (FSMB) physician portal. Your registration will only be completed after the FSMB receives your online application, the fee of $895, and the certification of identity form (CID). To complete your registration, the FSMB must also verify that you meet all the eligibility requirements. When you apply, you must indicate the eligibility period of your preference when you would like to take the test. After you submit your application, you will have a chance to change the eligibility period, but you will need to pay extra fees. Just a reminder, USMLE Step 3 is written in Prometric centers all over the United States. Be aware that the two busiest eligibility periods for Prometric centers are May through July and November through December. Since the test dates are provided on a first-come, first-served basis, I would strongly advise you to plan ahead, but no more than 6 months in advance. Tip: once you receive your schedule permit, you should schedule your USMLE Ste 3 exam early in the eligibility period to provide flexibility in case you need to reschedule it – this way you can avoid additional stress and fees that come with rescheduling your date. Remember, this is a two-day exam. You can schedule your test dates back-to-back or you can choose to break them apart but by no more than 14 days. Step 3 Foundations of Independent Practice (FIP) portion of the exam must be written first followed by the Advanced Clinical Medicine (ACM) part of the exam. Even if you decide to have a break between the two portions, you must schedule both test sections with Prometric of your choice at the same time and the same center.

USMLE Step 3 Format

As I already mentioned, the USMLE Step 3 tests your knowledge and skills as you prepare to take on the role of an independent physician. You must convince the USMLE committee that you are ready for the responsibility of providing general medical care to patients. Due to the large volume of material that needs to be tested, the exam is divided between two days. The first day of the examination is titled Foundations of Independent Practice (FIP), while the second day is referred to as Advanced Clinical Medicine (ACM).

Day 1 of the exam is dedicated to the evaluation of your knowledge of the basic medical and scientific principles that are essential for delivering effective healthcare. The content areas that will be covered in this portion of the exam include the application of foundational sciences, understanding of biostatistics and epidemiology/population health, interpretation of the medical literature, and application of social sciences, including communication and interpersonal skills, medical ethics, system-based practice, and patient safety. The first day of the exam also includes the assessment of your knowledge of diagnosis and management. You will have to demonstrate your ability to take patient history and perform medical examinations, draw a diagnosis, and your ability to use diagnostic studies. The assessment will be done using multiple-choice questions and will include some of the new item formats, such as items based on scientific abstracts and pharmaceutical advertisements. On the first day of testing, you will be faced with 232 multiple-choice items divided into 6 sections of 38-39 items. You will have 60 minutes to complete each section of the exam. The first test day will run for approximately 7 hours, which includes a 45-minute break and a five-minute optional tutorial. Keep in mind that if you finish an exam section earlier than the allotted time, your time available for breaks will increase.

The second test day will evaluate your ability to apply comprehensive knowledge of health and disease in the context of patient management and the evolving manifestation of disease over time. The content areas that will be covered in this examination portion include the evaluation of your knowledge of diagnosis and management, particularly focused on prognosis and outcome, health maintenance and screening, therapeutics, and medical decision making. Not unlike the examination on the first day, this section of the exam will also assess your knowledge of history-taking and physical examination, diagnosis, and use of diagnostic studies. Your knowledge will be tested using multiple-choice questions and computer-based case simulations. The second exam day will last approximately 9 hours. On the day, you will have the option to run a 5-minute tutorial. The actual test-portion is composed of 180 multiple-choice questions divided into 6 sections of 30 items each. You will have 45 minutes to complete each section of the test. You will also have a 7-minute CCS tutorial to prepare you for the case simulations of which there will be 13. For each case simulation, you will have a maximum of 10 or 20 minutes of real-time. You will also have 45 minutes for a break during this exam day.

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USMLE Step 3 Settings

Typically, students take the USMLE Step 3 examination during the first year of their residency training. There is no standard time period when you must take the exam. Largely, it will depend on your residency schedule. Most importantly, on whatever date you decide to schedule your exam, keep in mind that you will need a few weeks or months to prepare for the test. Another important thing to keep in mind about this test: while you may have already started to train in your choice of specialty, for USMLE Step 3 you are to assume the role of a general and as-yet undifferentiated physician. During the exam, you are a member of an independent group practice affiliated with a number of managed care organizations. You have regular office hours. You can admit patients to a 400-bed regional hospital, which provides care for both the urban and the outlying rural communities. The hospital provides standard diagnostic, radiologic, and therapeutic options, including ICUs and cardiothoracic surgery. There are a labor and delivery suite. A fully equipped emergency department adjoins the hospital, and medical evacuation helicopter service is available for emergency transfer to a regional trauma center. You do not have specialty-oriented hospital privileges, but you may request any specialty consultation.

The multiple-choice questions you will encounter in USMLE Step 3 will be based in physician-patient encounters associated with a setting in which the encounter first occurs. The following are the sites of care where your patient scenarios will take place:

USMLE Step 3 Content

To see a full content outline of USMLE Step 3, please visit this page. It gives a detailed account of the content, topics, and domains that will be represented in this exam – read these outlines carefully, as they also represent the challenges that you will be faced within the actual practice of medicine. It's very important to remember that Step 3 test items will be based on patient encounters, so it is crucial to get familiar with a variety of patient encounter types you may be faced with during the test. These encounters will involve problems or concerns that are new, ongoing, or urgent. Here’s a short breakdown of the clinical encounter frames you should be familiar with:

USMLE Step 3 Question Types

Let’s go over the USMLE Step 3 question formats. Having a thorough knowledge of the types of questions you can expect will greatly aid your preparation strategies.

To start with, you should know that USMLE Step 3 questions will be based on patient scenarios. These scenarios will be presented in either a vignette/paragraph format or in a chart/tabular format. If your item is presented in a chart/tabular format, it will resemble a patient chart, but don't expect it to be an exact replica of it. Chart/tabular formats will contain the relevant patient information in the list form organized in clearly marked sections for easier review. Familiar medical abbreviations may be used within the chart/tabular format questions.

Single Item Questions

Most of you will be familiar with this most common multiple-choice format. You will be presented with a single patient scenario in the vignette format, which will be followed by a question with four or more response options. You will be required to interpret a graphic or pictorial material that will be part of the scenario. You must select one best response, even if other options may be partially correct.

Sample

A 30-year-old man comes to the emergency department because of an acute episode of renal colic. Medical history is remarkable for episodes of painful urination and passing of what he calls "gravel in my urine." Urinalysis demonstrates microscopic hematuria with some crystalluria and no casts. The supine x-ray of the abdomen shows no abnormalities. A 4-mm renal calculus is detected in the distal right ureter on ultrasonography. There is no evidence of the dilation of the collecting system. The patient's pain is responsive to narcotic medication. In addition to administering intravenous fluids, which of the following is the most appropriate next step?

a. Acidification of urine by drinking cranberry juice

b. Cystoscopic removal of the calculus

c. Cystoscopic ureteral lavage

d. Shock wave lithotripsy

e. Straining of the urine

(Answer: E)

Multiple Item Sets

In this format, a single patient scenario may be followed with two or three questions, each with its own response options. Each question within these sets is related to the patient scenario presented, while the questions sets are not related to each other. You can answer the items in this question format in any order you like. Remember to choose only one best answer even if several options are feasible.

Sample

A 52-year-old man returns to the office for a reevaluation of an ulcer on his right great toe. The patient has a 15-year history of diabetes mellitus and takes glipizide and rosiglitazone. He first noticed the ulcer 2 months ago. One month ago, a 14-day course of oral amoxicillin-clavulanate therapy was prescribed. He has smoked one pack of cigarettes daily for the past 37 years. He is 178 cm (5 ft 10 in) tall and weighs 102 kg (225 lb); BMI is 32 kg/m2. Today, vital signs are temperature 38.8°C (101.8°F), pulse 96/min, respirations 12/min, and blood pressure 130/85 mm Hg. Physical examination of the right great toe discloses a 1.5-cm non-tender ulcer with a depth of 0.5 cm, a moist base, yellow exudate, and surrounding erythema to the level of the malleoli. Vibration sense and sensation to monofilament examination are absent. Pulses are diminished in both feet. Capillary refill time is 2 seconds in the right great toe. Urinalysis discloses 3+ protein.

1. Which of the following historical factors or physical examination findings is most strongly associated with the development of this patient's foot ulcer?

a.    Diminished pedal pulses

b.    Neurologic findings

c.     The patient's weight

d.    Proteinuria

e.    Tobacco use

(Answer: B)

2. Which of the following is the most appropriate action at this time?

a.    Begin aggressive debridement in the office

b.    Begin intravenous antibiotic therapy

c.     Refer the patient for transmetatarsal amputation

d.    Schedule the patient for a third-degree skin graft

e.    Switch the amoxicillin-clavulanate to oral ciprofloxacin

(Answer: B)

Sequential Item Sets

You will be faced with one patient scenario followed by two or three consecutive questions in relation to the patient problem. Each question will be related to the patient scenario but will be testing different points of the problem. Important to note: the questions are designed to be answered in sequential order. That is, you must answer questions one-by-one in the order they are presented. You will be presented with the first question and response items; once you answer it, you must click “proceed to next item” to view the next question and responses. Once you click to move onto the next question, you will not be able to change your answer to the previous item. Once again, please choose only the best response option available.

Pharmaceutical Advertisement (Drug Ad) Format

This question format will present you with a drug ad item. You will recognize this drug as format as it is commonly encountered by physicians in instances such as printed ass in a medical journal. You must interpret the presented material to answer questions on various topics, including:

• Decisions about care of an individual patient
• Biostatistics/epidemiology
• Pharmacology/therapeutics
• Development and approval of drugs and dietary supplements
• Medical ethics

Please follow this link to see an example of a drug ad item.

Abstract Format

The abstract format items include a summary of an experiment or clinical investigation presented in a manner commonly encountered by a physician, such as an abstract that accompanies a research report in a medical journal. You must interpret the abstract to answer the question concerning:

• Decisions about care of an individual patient
• Biostatistics/epidemiology
• Pharmacology/therapeutics
• Use of diagnostic studies

Please follow this link to see a sample abstract format item.

Primum Computer-based Case Simulations (CCS)

You will encounter and manage one case at a time. The primary means for interacting with this question format is the free-text entry of patient orders. You will use buttons and checkboxes to order a physician examination, advancing the clock, changing the patient's location, reviewing previously displayed information, and obtaining updates on the patient. At the beginning of each case, you will see the clinical setting, simulated case time, and introductory patient information. There will be no photographs or sounds provided. Normal or reference laboratory values will be provided with each report. Some tests will include clinical interpretation. Make sure to complete the Primum tutorial and sample cases using the Primum CCS software before you begin the simulations.

How to Study for USMLE Step 3

Know the Exam Format and Question Types

As I already mentioned, USMLE Step 3 is the final step in your journey to becoming a licensed, independent practicing physician in the United States. Since it is the last step, it is also the most comprehensive and broad. You have already spent several years studying for the USMLE Steps 1, 2 CK, and CS, so USMLE study strategies should be familiar to you. Remember, USMLE Step 3 is a long affair, so you must be thoroughly prepared for the exam format. It is also essential to know what kind of question formats you will encounter. Once you know the exam format and question types, practice building stamina, and patience for when you take the real exam. Having all possible information about the exam is a good first step to preparing for USMLE Step 3.

Research Your Schedule and Set the Exam Dates

Residency training is a busy time. Remember, the USMLE Step 3 exam is a two-day affair, but you do not need to complete the two days back-to-back. Whether you schedule the test days one after another or take a short break is up to you. However, it might be advisable to take care of the entire exam in one go, if possible. Firstly, you will not prolong the stress and anxiety associated with exam taking. Secondly, you will need not prolong the study period – once you set two dates back to back, you will have a study deadline and will not be able to procrastinate. However, it is completely up to you how you organize your exam dates and study schedule, as only you know your strengths and weaknesses and can design your plan accordingly.

Practice with Realistic Mock Multiple-Choice Questions and Case Simulations

You have already gone through the rigors of studying for USMLE Step 1 and 2 CK and CS, so you probably know what it’s like to prepare for multiple-choice exams using UWorld. However, Step 3 has a unique component that you will need to prepare for separately, the Primum Computer-based Case Simulations. The best way to prepare for this portion of the exam is to familiarize yourself with the software and how you will be timed and scored. Use the UWorld software to see how this portion of the exam works and practice with it as much as possible. Tip: in addition to practicing the case simulations in UWorld, you should also run through as many Step 3 multiple-choice questions as possible. The questions you will encounter in the UWorld practice exams will be more challenging than the real Step 3 exam. Some students can get discouraged when they see their practice score, but do not be dismayed. Such practice only makes you a stronger candidate. Go through the questions a few times and you will eventually see improvement in your knowledge and test-taking skills. Do as many questions as possible and do all the case simulations that the UWorld has to offer.

Focus on Patient Encounters

Preparing for the USMLE Step 3 multiple-choice portion of the exam may be taxing, but also familiar. I want to stress that Step 3 items, whether they are questions or case simulations, will be founded in patient encounters – therefore, it is crucial that you hone your skills related to patient encounters and dealing with patient problems. Case simulations require you to consider the subtleties of patient care and patient interaction. It is absolutely necessary to run through as many cases as possible when you are preparing for this exam portion.

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To your success,

Your friends at BeMo

BeMo Academic Consulting

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