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!!
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.
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.
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.
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.
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.
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
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!!!
You're awesome, thanks!
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