USMLE Step 3 - My two cents by Dr. B

USMLE step 3 - My two cents!

My name is Dr. B and I have recently finished my Step 3 - results aren’t out yet, but I hope I can stay as just the author of this article and not have to read it once more. Fingers crossed!!

I had some trouble wrapping my head around what exactly this exam involves and how to prepare for it - had to talk to a number of extremely helpful folks to get an idea. I wanted to distill that into something that could be helpful for future test takers.

The Step 3 is regarded as a sort of optional exam on an IMGs path to getting a residency position. It is also regarded as the least important of the steps which I would agree with in large part, unless you happen to fail it, in which case it suddenly becomes your Achilles heel.

The reason I emphasize this point is that a lot of people rush into this exam in the hope of getting results before match day for a number of reasons (H1B visa). Ideally you would want to finish the exam by December 31st to be absolutely certain, but I do believe that upto early February you still have a chance of getting your results in time (visa wise).

The Step 3 is also very different for a number of reasons:

1. No real dedicated study time for a majority of students - Many of you are gonna be giving this exam in the middle of interview season. This means a lot of travelling, studying in airports and greyhounds and no real fixed continuous time at your disposal which you’re
used to from previous steps.

2. Mentally you tend to underestimate this exam - Since its widely known to be the least important, and the fact that most people just want to clear and don’t really care too much about the score.

3. Additionally, this is a lot more clinical and ideally targeted towards someone who has started their residency.

4. The materials are a lot less comprehensive and the tests are a lot less predictive of certain parts like the CCS.

5. The CCS is a beast of its own.

Pros of taking the exam:
A. Get it out of the way, focus on learning and having fun in your residency.
B. The visa - H1B!!!! H1B!!!! H1B!!!!
C. Some older grads as well as applicants with red flags / weak profile try to compensate with a Step 3 score.
D. Gives you something useful to do with the ton of free time you have during interview season.

Cons of taking the exam:
A. THE COST
B. As mentioned earlier, if you do fail this exam - It becomes the most negative part of your application.

All  this  being  said,  the  Step  3  is  a very  very  doable  exam.  The  amount  of  time  needed  is  highly variable  based  on  how  much  you  hope  to  score  (a  number  of  competitive  fellowships  are starting  to  look  into  the  step  3  scores  during  their  selection  process  I  have  heard)  as  well  as  how strong  you  are  in  your  other  steps  and  how  long  ago  you  gave  them. In  general  I’d  say  as  long  as  you  have  got  over  240s  in  your  steps,  you  should  be  able  to  finish the  Step  3  in  about  2  to  2  and  a  half  months. I  gave  the  exam  with  just  about  1  month  of  preparation,  but  DISCLAIMER:  I  am  an  old  grad, have  given  my  CK  just  a  few  months  back, scored  pretty  well  there  and  was  focused  on  JUST PASSING  the  exam  -  not  so  much  on  the  score. Finally, getting  down  to  the  matter  of  studying  for  the  exam  itself,  let  me  briefly  outline  what  I  did and  my  thoughts  on  what  I  think  I  should  have  done  differently.  The  2  days  consist  of  MCQs  on both  days  -  content  varies  from  one  person's  exam  day  to  another,  so  generalizations  like Biostat  only  on  Day  1  /  Day  2  is  easier  etc.  do  not  hold  true  in  my  opinion.

For  the MCQs I would suggest:
1. UWOrld  (duh!!!)
2. UWs Biostat  book  from  Step  1  prep  -  100  cases  in  a  small  pdf
3. ‎Go through  the  2010  Kaplan  Behav  science  -  Biostat  videos  if  you  are  really  struggling with  Biostat
4. This  is  a  really  nice,  brief  overview  of  Biostat  that  many  of  you  are  probably    familiar  with. For  those  who  aren’t  -  YOU’RE  WELCOME!!! https://www.youtube.com/watch?v=75pQPB1RF50
5. ‎Any  notes  from  CK  that  you  have  taken
6. ‎FA  Step  1  -  For  surprise,  surprise  -  BIOSTAT!!
7. ‎I  would  also  suggest  going  through  the  Psychiatry  part  and  bits  and  pieces  of  Neurology  etc. Many of my friends  have  struggled  with  neurological  localization  -  I  suggest  you  spend extra  time  on  neuroanatomy,  lateral  medullary  syndrome  etc.  if  its  a  weak  area,  as  quite a  few  questions  arise  from  that. As the aforementioned  list  suggests,  for  better  or  for  worse  -  Biostat  is  a  huge  part  of  this exam  (right  behind  CCS).  Please  do  not  underestimate  it  and  please  don’t  go  in  without going  through    #2  in  the  list!!  (There’s  a  lot  of  focus  on  things  like  population  attributable risk,  risk  reduction  percentage  etc.  which  are  well  covered  here.)  You  will  get  a  number of  cases,    abstracts,  drug  ads  etc.  in  EVERY  BLOCK.
8. ‎Regarding  the  UWSA  and  NBME  -  I  don’t  know.  Didn’t  have  time  to  take  any  mock  tests, so  can’t  comment.  But  from  what  I  know  they  do  not  factor  in  the  CCS  -  hence  are inherently  inaccurate,  since  the  CCS  accounts  for  a  significant  part  of  your  score.
9. ‎Regardless of everything you do, just a heads up - keep in mind that for step 3 the UW is nowhere near as all-comprehensive as with the other steps. 

CCS - This is probably the most important part of the exam. It is also the part most people are least well equipped to deal with. One, because most IMG applicants don’t have a significant amount of clinical experience. And two, even for those who know how to manage a real life patient, this software is terribly non-intuitive and I for one found it hard to think about the patient in this fashion.
Anyway, with regards to study sources:
1. Uworld CCS - Do all the combined 90 odd cases - Practice AND Interactive cases 2
2. ‎Usmle.org - practice material - 6 practice cases.
3. ‎Archer videos - I didn’t have time for this, but have heard that doing a couple of videos can be pretty helpful.
4. CCScases.org - Paid - Didn’t have the time and didn’t feel like shelling out more cash at this point. Personally - feel it’s a bit of an overkill.

At first, the whole process seems terribly overwhelming and daunting, but just keep at it and somehow get through all the Practice cases first. You can get through them quite quickly. TAKE NOTES of points you had missed or not thought of - this will be invaluable on the morning of the exam. Once you’re done with th practice cases, you have a brief idea of what the process involves. Next move on to the Interactive cases - I would suggest start with a case you are very confident with - eg. Cardiology - Chest pain. This is so that you can focus on learning the work-flow or process rather than breaking your head about the medical aspects of the case. Move your way through the interactive cases, taking notes as you proceed once more.  Overall, you can finish CCS within around 4-5 days easily. BUT I would suggest that if you have the time, do a quick second round/ revision of the topics.

Finally, do the 6 practice cases on the USMLE website - The software is slightly different from UW and there is a bit more of a time lag between entering orders and them getting activated. However, get used to it as this is exactly how it works on exam day.

Between all 90 + 6 cases - MAJORITY of your exam day cases WILL be covered -                                                             Dont worry!!

Another point to note is that a lot of people will talk about how they finished their exam early on CCS day - Lots of time etc. PLEASE  note  that  they  are  referring  to  a  lot  of  break  time  that  appears  between  cases  during CCS,  but  since  you  tend  to  do  5-8  cases  at  a  stretch,  this  break  time  accumulates  and  hence you  finish  early.  This  does  not  refer  to  the  time  for  the  case  itself  -  which  is  just  about  enough  if you  know  what  you’re  doing  and  by  no  means  excess.  If  you’re  unsure  of  how  to  proceed  or spend  a  lot  of  time  thinking  -  you  will  struggle  for  time.

So it’s  very  important  to  have  your  own  set  common  approach  to  every  case.  I  would suggest  that  you  write  down  the  things  you  tend  to  forget  and  a  basic  flowchart  / algorithm  of  how  to  deal  with  the  cases  on  your  laminated  paper  before  starting  the  CCS -  perhaps  during  your  7  minute  CCS  tutorial. Some  random  thoughts,  in  no  specific  order  -  I  WROTE  MOST  OF  THESE  DOWN  IN  MY ROUGH PAPER - some of  these  are  things  I  tend  to  forget  -  so  would  glance  at  the  paper towards  the  end  of  my  case  to  see  if  I  missed  anything.
1. Stabilize  -ABC  etc
2. Get  history
3. Basic  orders  -  CBC ,BMP, UA  for  ALL  patients  (Sometimes  -  eg.MI  you  jump  into management  and  forget  to  get  these  basic  tests  done)  -  STICK  to  a  system.
4. ‎Think  of  a  DD  -  However  certain  you  are  of  a  diagnosis  -  Do  some  tests  to  rule  out  the DDs.  -  THis  is  an  area  many  people  neglect   eg.  -  Lady  with  chest  pain  and  s1q3t3  after  a  flight  and  maybe  even  on  OCPs  for  good  measure -  STILL  get  Trops  etc.
5. ‎Any  female  -  get  a  pregnancy  test
6. ‎ Vaccinations  -  Pneumovac,  hepatitis  etc. PAP  smear  etc.
7. ‎Remember  to  change  the  location  if  you  need  to  -  This  again  is  something  a  lot  of  people overlook  or  forget  about
8. ‎Get  Consults  towards  the  end  -  The  subspecialists  in  the  software  are  notoriously useless,  but  the  order  must  be  documented.
9. ‎Remember  DVT  prophylaxis  -  Starting  heparin  -  get  aPTt,Pt/  INR When  needed  pneumatic  compression  stockings.
10. ‎NPO!!!!  Never  forget  this  -  Sometimes  you  take  these  things  for  granted  and  end  up forgetting.
11. ‎Try  to  mention  diet  and  exercise  when  applicable  -  eg.  patient  with  a  SAH  -  Complete Bed  rest.
12. ‎Remember  to  address  their  symptoms  right  off  the  bat!!  You  will  lose  points  if  you  leave them  in  pain  /  vomiting  etc. Stick  to  a  few  common  drugs  you’re  comfortable  with  and  keep  using  them,  to  name  a  few, (MAKE  A  NOTE OF ANTIBIOTICS  USED  FOR  ALL  THE CASES YOU GO THROUGH)
Ketorolac  /  Naproxen Pantoprazole  -  I  prefer  this  over  omez,  as  it  can  be  used IV
Fentanyl
Morphine
Loperamide
Senna  /  Docusate
Azithro, Xone, Vanco, Metronidazole, etc
TMP-SMX  prophylaxis
13.  REMEMBER  pre  surgical  antibiotics  -  IV  cefazolin
14. ‎Counselling.
15. ‎Remember  follow  up  investigations  -  eg.  Temporal  arteritis  -  ESR  on  f/up Or  if  you’re  starting  steroids  -  check  sugars  etc  on  follow  up

A last  tip  -  write  down  important  points  that  strike  you,  in  your  rough  paper  as  you  read the  history  and  physical.  This  is  important,  because  there  is  a  lot  of  data  that  you’re skimming  through  in  a  short  time  and  might  make  a  mental  note  of  something  that  you’ll end  up  forgetting  as  the  case  is  coming  to  and  end. Eg.  patient  is  a  smoker  -  need  to  counsel  accordingly  or  he  has  dyslipidemia  which  might  be unrelated  to  his  present  issue  -  but  remember  to  get  a  lipid  profile  at  some  point.

Will  update  this  article  with  anything  else  I  can  think  of. BEST  OF LUCK everybody!!!