USMLE Step 3-The Final Frontier

Faraz Khan Luni

Isra’a Khan

(Dow Medical College-Class of 2008)

USMLE Step 3 is the last of the series of USMLEs and the one in which it is the hardest to score. You do not need your step 3 scores for the match unless you want an H1 visa. The best thing is that passing is good enough and scores do not matter as much as it does in Step 1 and 2 but it obviously gives you an edge to get better scores. That is the case nowadays, but the way the competition is mounting and given how tough things are getting day by day, they may also be looking at Step 3 scores. Saying this, I am all for giving your Step 3 “as soon as” you give your Step 2. The syllabus is almost the same as Step 2 so it is better if you appear for it while everything is fresh in your mind.

USMLE Step 3 is a two day exam. The first day has only MCQs with 1 tutorial block and 7 blocks of MCQs, each block containing 48 MCQs. The next day has 4 blocks of MCQs with 36 MCQs in each block and 45 minutes for each block. After that you have 9 CCS cases and you have 25 minutes for each case.

TIME MANAGEMENT

Time management for the MCQs is the biggest problem that everyone faces in Step 3 so step on the accelerator from the first second. On the other hand you have more than enough time for the CCS cases. The best way to keep track of time is that on the first day each block has 48 MCQs so divide an hour into quarters and in the first 15 minutes, you should have done 12 MCQs, in 30 minutes 24 MCQs and so on. This will give you an idea of how much you are lagging. Do not leave any questions unanswered as the last questions which you leave out may be the easiest ones so whatever you do, DO NOT LEAVE ANY UNATTEMPTED QUESTIONS. On the second day there are 36 MCQs in 45 minutes so apply the same rule here with 12 questions per 15 minutes.

CCS stands for Clinical Case Simulation. I loved that part of the USMLE as it is like playing a video game (and there was a time I loved Mortal Combat ) The case starts with a short history and you have to manage the patient. More on this later.

There is no book which one can confidently refer for Step 3 as there are so many options. I personally went over Kaplan Step 3 once and appeared for the exam. In Kaplan Step 3, the Step 2 books have been condensed by cutting out the pathophysiology, making it shorter and naming it as foundation. They are followed by the CCS cases which teach you how to tackle them. The drawback is that it is too detailed and takes long to study

If you have recently given Step 2 than you may just go through your Step 2 Books as you will be more oriented to it and it will take lesser time to go through. If you don’t have time then maybe you should just go for Master the Board by Conrad Fischer. Crush the boards doesn’t seem to be the in thing. I personally don’t know anyone who has read it. Perhaps you can see from what I have written that I do not have a clear idea as to what book to recommend as Step 3 is one of those exams which is customized.

What I can recommend confidently is that Usmle World is yet again, the most comprehensive and important learning tool for Step 3.  There are 29 MCQ blocks, 52 online practice CCS cases and 41 printable CCS cases. Do them well and do the CCS cases twice so you get an idea of how to handle the software. Also download the sample exam and the CCS software from www.USMLE.org and play around with that too.

Clinical Case Simulation (CCS)

The CCS part of the exam is the part of the exam which everyone can and should improve a lot on as it is not very hard. With practice and proper approach one can drastically improve his CCS skills so revise your CCS cases at least twice from Uworld.

Before you read further, I suggest that you do at least one case from the sample exam from www.USMLE.org to get an idea what I am talking about.

There are four buttons at the top of the screen, which you will use to manage your case. You can access any of them till the last 5 minutes of the case. They are History/physical, write orders/review chart, clock and change location. I shall explain them as I go ahead.

The CCS cases evaluate on how you handle common cases. The cases are usually common and the most important thing is how you go about managing them. The diagnoses DOES NOT carry any weightage at least till the time I am writing this article. The reason they ask for diagnosis is not to grade you but to review what you had in mind if you handled a case in a very different manner.

So if you see a case and recognize the diagnosis then don’t jump off your seats and go straight for the treatment. The SEQUENCING and TIMING of tests and treatment carries a lot of weightage than just ordering them anytime. If a patient presents with hemiparalysis and you are sure the patient has had a stroke, don’t immediately order tPA. First confirm with a non-contrast head CT and when the result rules out hemorrhage, only then should you start tPA.

Another thing to keep in mind is that while ordering tests, don’t worry if the test coming back negative. It does not matter if they do come negative, what matters is the diagnosis you had in mind while ordering the tests.

So CCS starts off with a presenting complaint and then it gives you a detailed history. First thing you should look for is whether it is an emergency or not.

If the patient is VITALLY STABLE then you can order physical examination and relevant tests. You can choose to either run a complete examination on the patient or selective systemic examination. And then choose your tests accordingly.

However, if patient is VITALLY UNSTABLE then TIME is the key. First go for the ABC (Airway, breathing, circulation). If BP is low pass IV lines, start normal saline, put patient on BP monitoring and send blood for cross match. If his respiratory rate is fast, hook him to pulse oximetry and start oxygen (you may also consider doing ABGs depending on his suspected diagnosis). If he has any cardiac complaint, order a 12-lead EKG and cardiac monitoring if necessary. Then you can go ahead with a focused physical examination but as I mentioned earlier that time is of the essence. If a patient comes with breathlessness and you suspect he has pneumothorax, it is clearly an emergency situation so DO NOT WASTE TIME ordering unnecessary tests. Ordering a blood count or electrolytes will cause you to lose marks. Go straight for the relevant that is chest and CVS examination and when you see the words hyper resonance then pass a chest tube. I will mention that again. TIME IS KEY HERE.

Two other important things to look out for are the LOCATION and CLOCK.

LOCATION

If a patient who may have a serious illness presents to your office, send him to the emergency room preferably or to the ward. If you are not sure if he is that serious to justify being admitted, it is still safe to admit him.  If a person with breathlessness is sent home and it turns out to be pneumothorax then you have clearly messed up your case but on the other hand it is ok to admit an asthmatic patient to the ward for observation. Just do not send a patient with minor urinary tract infection to the ICU. It’s ok to be safe but don’t be over aggressive.

CLOCK

The clock button allows you to manipulate the case time clock (virtual time). This is completely different from your real time clock which is found at the bottom of the screen throughout the case. You have 25 minutes of real test time to manage your case from the beginning to the end. But to get test results or schedule a patient appointment, you will need to move the case time clock ahead.

For example, in an emergency case, move time forward by 5 min or when the result comes back (whichever one is faster). You may increase this to 15 min and more when the patient stabilizes. In office settings you may even increase time by a week or more. You will get the hang of moving the clock ahead and the key here is practice. After having moved the clock ahead, you can also order interval history which describes how the patient is doing after a certain time period elapses or medication is given or therapeutic intervention is tried.

I had my own technique of attempting CCS cases. On the marker and sheet that Prometric provides, I wrote 3 headings of diagnosis, tests and counseling before starting the CCS cases. This helped me minimize errors because as the case progressed I sometimes forgot to order simple tests and once you enter the tests and move clock forward there is no going back just the way it happens in real life.

So for example, if the case described a patient with burning urination and who used alcohol I would write this on the sheet

DIAGNOSES>> UTI, vulvitis, vaginitis, cervicitis, PID, (every relevant Differential that came to my mind)

TESTS >>> CBC, BMP, vaginal swab, vaginal pH, wet mount, microscopic exam after potassium hydroxide, Ultrasound abdomen, B Hcg (consider this in every fertile woman, whether or not she presents with a gynecological complaint), CT pelvis

COUNSELLING>>> alcohol cessation

So I wrote everything down and as the case progressed, I added more to the Differential Diagnosis, Tests and Counseling list. That did not mean I ordered all of the tests at once. I just looked at this list to order tests to make sure I did not miss anything (which happens a lot). As I got more clues from examination, test results and patient progress, I added more differentials and tests to the list.

In the last 5 minutes, a screen pops up which tells you that the case will end in 5 minutes of “real” time. During that time, you can delete orders you want cancelled, add orders to be done now or in the future (counseling) and finally enter a diagnosis.

Some noteworthy points:

You do not need to know doses for CCS cases but route of administration is important because when you order a certain drug (generic names are used), you also have to order the route with which is to be given, whether PO, IM, IV or SC. Also you need to write the name of the drug so instead of writing cephalosporins you will have to mention the name ceftriaxone.

You have an option to order a specific consult but you are supposed to state the reason in 10 words or less. The consultant will not tell you anything, nonetheless you are supposed to continue managing the patient according to the differentials you had in mind.

Like in Step 2 CS, counseling is an important part of clinical practice in the US. Each case may have some specific things you need to counsel the patient about. But make sure you remember the basics. Stop alcohol, smoking, and counsel regarding safe sex, wearing a seat belt.

We hope this information is enough to guide you for Step 3. Wish you best of luck and a USMLE free future!

Faraz KhanLuni

Dow Medical College

Class of 2008

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