USMLE Step 3 Content: What’s on the Exam?

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The USMLE Step 3 exam is the final examination first-year residents need to pass to practice medicine independently. USMLE Step 3 content assesses a practitioner’s knowledge of advanced clinical medicine and is vastly different from the other two USMLE examinations, so interns should know what to expect and how to prepare to face examination committees.

How Is USMLE Step 3 Content Different?

The biggest difference between the USMLE Step 3 content and the other two USMLE exams taken in medical school is that it is held over two days. On the first test day, you will be tested on 232 multiple-choice questions divided into 6 blocks. You will typically be given 38–39 questions per block and 60 minutes to complete each set of test items. With 45 minutes of breaks and a 5-minute tutorial, this exam is scheduled to last 7 hours.

On day two, the test is divided into 180 multiple-choice questions and 13 computer-based case simulations (CCS). The multiple-choice questions are divided into 6 blocks of 30 questions, with 45 minutes to complete each block. Each CCS varies in complexity and provides between 10-20 minutes to complete the clinical scenario. The day is scheduled for a total of 9 hours with 45 minutes of breaks, a 5-minute multiple choice tutorial, and a 7-minute CCS tutorial.

The exam format for the CCS is different from the previous USMLE Step examinations. The most important step in your preparation is to become familiar with the testing interface. Having familiarity with the software will not only save you time but will reduce your stress and allow you to think more clearly during the exam. The USMLE practice test is an excellent resource and provides feedback after the completion of each practice CCS.

What is covered on Day One of the USMLE Step 3 Exam?

According to the USMLE website, the content of the Step 3 exam “reflects a data-based model of generalist medical practice in the United States.” Or the exam content addresses clinical situations that a general medical care practitioner may encounter.

Day one of testing covers materials that are considered the Foundations of Independent Practice (FIP). As opposed to the basic medical questions assessed in the previous exams, the questions on Step 3 consist of clinical vignettes followed by questions accessing your knowledge of physical exam findings, diagnoses, and use of diagnostic testing. Additionally, there will be questions testing topics such as biostatistics, medical ethics, advanced clinical medicine, and patient safety.

When reading these vignettes, it is important to pay attention to the age and gender of the patient. Additionally, if ethnicity is mentioned it is likely to be useful in answering the question. For example, a question may state that a 52-year-old female of Asian descent presents with eye pain, conjunctival injection, nausea, and fixed, moderately dilated pupils to get you to consider the diagnosis of closed-angle glaucoma.

Be able to identify key facts that can help you identify a diagnosis, and do not expect eponyms to be included in the question. For example, if they are looking for a diagnosis of Histiocytosis X, they may describe the presence of “tennis-racket” cytoplasmic organelles rather than tell you Birbeck’s granules are present. In addition, knowing these to be a key finding in Langerhans’ cell histiocytosis can lead you to the correct answer.

Overall, make sure to dedicate an ample amount of time to answer questions during the Foundations of Independent Practice section of the test. Also, make sure you understand why the answer is correct, or in other words, what in the vignette leads you to that answer. Finally, understand why the other choices are incorrect and possibly what would have made them the correct choice. Working through test questions in this way during your test preparation will ultimately improve your diagnostic skills, which can not only improve your exam scores but also how you practice medicine.

What to expect on Day Two of the Step 3 Exam

Day two of the USMLE Step 3 focuses on testing your comprehensive medical knowledge and disease management. The questions are also primarily focused on prognosis and outcome, health maintenance and screening, therapeutics, medical decision-making, and patient management.

These questions will require you to determine the next step or most appropriate treatment for a particular condition. In addition, they will not provide you with the diagnosis but rather have you develop that on your own from the information provided in the clinical vignette. For example,

A 51-year-old chronic smoker presents with chest pain and difficulty breathing. Chest x-ray shows the collapse of the left lung with a mediastinal shift. A needle decompression significantly improves symptoms, and a chest tube is placed. What is the next step in managing this patient?

In this example, they want you to identify the patient had a tension pneumothorax that was correctly treated with needle decompression and chest tube placement. But the main point being tested is whether or not you know that a chest x-ray is needed as part of the physical examination in order to verify the correct placement of the chest tube.

USMLE Step 3: Computer-Based Case Simulations of Advanced Clinical Medicine

These computer-based case simulations (CCS) assess your ability to perform a physical exam, order diagnostic tests, make a diagnosis, and determine the appropriate next steps in treatment through clinical situations like managing a patient in the emergency room, hospital, and office.

The key to success on the CCS portion of the USMLE Step 3 exam is to take the same stepwise approach to each case. Here are some quick tips that can improve your scores.

• Read the complaint and identify the body system affected. Order an appropriate/relevant physical exam (e.g., chest pain — perform heart and lung examination).
• Order relevant tests and labs (e.g., advanced imaging such as MRI is unlikely to be the first test ordered).
• Perform emergent procedures and stabilizing the patient is the first priority (e.g., perform needle decompression of tension pneumothorax).
• Order confirmation imaging (e.g., get a chest x-ray to verify chest tube placement).
• Determine appropriate follow-up or consult appropriate service to definitively manage the patient (e.g., general surgery consult for acute appendicitis).
• Do not forget to provide patient education (e.g., smoking cessation), health maintenance, and counseling.

In addition, it is important to understand that a patient may deteriorate despite adequate treatment and may get better with inadequate treatment. Therefore, if the case is not going well, pause and reassess your thought process during the exam. However, be careful not to second-guess yourself if you are confident in your diagnosis.

USMLE Step 3 Exam: Your Final Assessment

The USMLE Step 3 examination is a long two-day exam and provides a final assessment of physicians assuming independent responsibility for delivering general medical care. Plan ahead of time to use your breaks and maintain good sleep habits prior to the exam. Make sure to do plenty of practice questions and get familiar with the CCS format before the test date to ensure that you are successful when taking the actual exam.

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