Step 3 Announcements

Bulletin of Information

The USMLE Bulletin of Information is a compilation of all the facts and details about the USMLE. Before you apply for any of the three steps of the USMLE, you must become familiar with the bulletin.

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Overview


Step 3 assesses whether you can apply medical knowledge and understanding of biomedical and clinical science essential for the unsupervised practice of medicine, with emphasis on patient management in ambulatory settings.  It is the final examination in the USMLE sequence leading to a license to practice medicine without supervision.  The examination material is prepared by examination committees broadly representing the medical profession. The committees comprise recognized experts in their fields, including both academic and non-academic practitioners, as well as members of state medical licensing boards. Step 3 content reflects a data-based model of generalist medical practice in the United States. The test items and cases reflect the clinical situations that a general, as-yet undifferentiated, physician might encounter within the context of a specific setting. Step 3 provides a final assessment of physicians assuming independent responsibility for delivering general medical care.

The Step 3 examination ensures that attention is devoted to the importance of assessing the knowledge and skills of physicians who are assuming independent responsibility for providing general medical care to patients. The first day of the Step 3 examination is referred to as Foundations of Independent Practice (FIP), and the second day is referred to as Advanced Clinical Medicine (ACM).

Day 1
Step 3 Foundations of Independent Practice (FIP)
This test day focuses on assessment of knowledge of basic medical and scientific principles essential for effective health care. Content areas covered include application of foundational sciences; understanding of biostatistics and epidemiology/population health, and interpretation of the medical literature; and application of social sciences, including communication and interpersonal skills, medical ethics, systems-based practice, and patient safety.

The test day also includes content assessing knowledge of diagnosis and management, particularly focused on knowledge of history and physical examination, diagnosis, and use of diagnostic studies. This test day consists solely of multiple-choice questions and includes some of the newer item formats, such as those based on scientific abstracts and pharmaceutical advertisements.

Day 2
Step 3 Advanced Clinical Medicine (ACM)

This test day focuses on assessment of the ability to apply comprehensive knowledge of health and disease in the context of patient management and the evolving manifestation of disease over time. Content areas covered include assessment of knowledge of diagnosis and management, particularly focused on prognosis and outcome, health maintenance and screening, therapeutics, and medical decision making. Knowledge of history and physical examination, diagnosis, and use of diagnostic studies also is assessed. This test day includes multiple-choice questions and computer-based case simulations.

Exam Format

Step 3 is a two-day examination. The first day of testing includes 256 multiple-choice items divided into 6 blocks of 42 to 43 items; 60 minutes are allotted for completion of each block of test items. Items with an associated pharmaceutical advertisement or scientific abstract are included in each of these multiple-choice blocks. There are approximately 7 hours in the test session on the first day, including 45 minutes of break time and a 5-minute optional tutorial. Note that the amount of time available for breaks may be increased by finishing a block of test items or the optional tutorial before the allotted time expires.

There are approximately 9 hours in the test session on the second day. This day of testing includes a 5-minute optional tutorial followed by 198 multiple-choice items, divided into 6 blocks of 33 items; 45 minutes are allotted for completion of each block of test items. The second day also includes a 7-minute CCS tutorial. This is followed by 13 case simulations, each of which is allotted 10 or 20 minutes of maximum real time. A minimum of 45 minutes is available for break time. There is an optional survey at the end of the second day, which can be completed if time allows.

The expected outcome of the USMLE process is a general unrestricted license to practice medicine without supervision. Step 3 is the final examination in the USMLE sequence. The test items and cases reflect the clinical situations that a general, as-yet undifferentiated physician might encounter within the context of a specific setting.

Although you already may have begun specialist training, for this examination you are expected to assume the role of a general, as-yet undifferentiated physician. You are a member of an independent group practice affiliated with a number of managed care organizations. Your office has regularly scheduled 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 is 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. Laboratory values provided in the USMLE Step 3 Sample Test Questions booklet are the normal ranges for this hospital.

Step 3 patients reflect the diversity of health care populations with respect to age, gender, cultural group, and occupation. The patient population mix is intended to be representative of data collected from various national health care databases in the United States.

Clinical Settings


The physician-patient encounters described in Step 3 multiple-choice items are usually associated with a setting in which the encounter first occurs. There are two settings, which are described below.

Setting I: Office/Health Center

You see patients in two locations: an office suite, which is adjacent to a hospital, and a community-based health center. Patients are seen for routine and urgent care. The laboratory and radiology departments have a full range of services available. Your office practice is in a primary care generalist group. Occasionally you will see a patient cared for by one of your associates and reference may be made to the patient's medical records. Known patients may be managed by telephone. You may have to respond to questions about information appearing in the public media, which will require interpretation of the medical literature.

Setting II: Emergency Department and Inpatient Facilities

You encounter patients in the emergency department and inpatient facilities, including the hospital, the adjacent nursing home/extended-care facility, and detoxification unit. Most patients in the emergency department are new to you and are seeking urgent care, but occasionally you arrange to meet there with a known patient who has telephoned you.

You have general admitting privileges to the hospital, including to the children's and women's services. On occasion you see patients in the critical care unit. Postoperative patients are usually seen in their rooms unless the recovery room is specified.

You may also be called to see patients in the psychiatric unit. There is a short-stay unit where you may see patients undergoing same-day operations or being held for observation. Also available to you is a full range of social services, including rape crisis intervention, family support, and security assistance backed up by local police.

Clinical Encounter Frames


Step 3 clinical encounter frames encompass several elements that are critical to the definition of a patient-physician encounter. These elements include whether the problem or concern is new or ongoing, the urgency of the need for intervention relative to the underlying problem, the chronology of events, and the degree of familiarity with the patient or the patient's history.

Three stages of clinical encounters
INITIAL WORKUP CONTINUING CARE URGENT INTERVENTION
Patient encounters characterized by initial assessment and management of clinical problems among patients seen principally in ambulatory settings for the first time. These encounters may also include new problems arising in patients for whom a history is available. Patient encounters characterized by continuing management of previously diagnosed clinical problems among patients known to the physician and seen principally in ambulatory settings. Encounters focused on health maintenance are located in this frame.
Also included are patient encounters characterized by acute exacerbations or complications, principally of chronic, progressive conditions among patients known to the physician. These encounters may occur in inpatient settings.
Patient encounters characterized by prompt assessment and management of life-threatening and organ-threatening emergencies, usually occurring in emergency department settings.
Occasionally, these encounters may occur in the context of a hospitalized patient.
Clinical problems include ill-defined signs and symptoms; behavioral-emotional; acute limited; initial manifestation and presentation of chronic illness. Clinical problems include frequently-occurring chronic diseases and behavioral-emotional problems. Periodic health evaluations of established patients are included here. Clinical problems include severe life-threatening and organ-threatening conditions and exacerbations of chronic illness.
Physician tasks emphasized include data gathering and initial clinical intervention. Assessment of patients may lead to urgent intervention. Physician tasks emphasized include recognition of new problems in an existing condition, assessment of severity, establishing prognosis, monitoring therapy, and long-term management. Physician tasks emphasized include rapid assessment of complex presentations, assessment of patients' deteriorating condition, and prompt decision making.

Content Outline and Specifications


Content Description
The content description that follows is not intended as a curriculum development or study guide, but rather models the range of challenges that will be met in the actual practice of medicine. It provides a flexible structure for test construction that can readily accommodate new topics, emerging content domains, and shifts in emphasis. The categorizations and content coverage are subject to change. Successful completion of at least one year of postgraduate training in a program accredited by the Accreditation Council for Graduate Medical Education or the American Osteopathic Association should be helpful preparation for Step 3.

Content Outline
All USMLE examinations are constructed from an integrated content outline, which organizes content according to general principles and individual organ systems. Test questions are classified in one of 18 major areas, depending on whether they focus on concepts and principles that are important across organ systems or within individual organ systems. Sections focusing on individual organ systems are subdivided according to normal and abnormal processes, including principles of therapy.

Table 1: Step 3 MCQ Test Content Specifications

System
Range
General Principles of Foundational Science**
1% – 3%
Immune System
Blood & Lymphoreticular System
Behavioral Health
Nervous System & Special Senses
Skin & Subcutaneous Tissue
Musculoskeletal System
Cardiovascular System
Respiratory System
Gastrointestinal System
Renal & Urinary System
Pregnancy, Childbirth, & the Puerperium
Female Reproductive System & Breast
Male Reproductive System
Endocrine System
Multisystem Processes & Disorders
80% – 85%
Biostatistics & Epidemiology/Population Health, & Interpretation of the Medical Literature
Social Science
14% – 18%

* Percentages are subject to change at any time. See the USMLE Web site for the most up-to-date information.

** The general principles category for the Step 3 MCQ examination includes test items concerning normal processes not limited to specific organ systems. These test items are typically related to normal development. Categories for individual organ systems include test items concerning those normal and abnormal processes that are system-specific.

Table 2: Step 3 CCS Test Content Specifications
Categories in bold are covered in CCS cases; categories not in bold are not covered.

System
General Principles of Foundational Science
Immune System
Blood & Lymphoreticular System
Behavioral Health
Nervous System & Special Senses
Skin & Subcutaneous Tissue
Musculoskeletal System
Cardiovascular System
Respiratory System
Gastrointestinal System
Renal & Urinary System
Pregnancy, Childbirth, & the Puerperium
Female Reproductive & Breast
Male Reproductive
Endocrine System
Multisystem Processes & Disorders
Biostatistics & Epidemiology/Population Health, & Interpretation of the Medical Literature
Social Sciences

Physician Tasks/Competencies

An additional organizing construct for Step 3 design is physician tasks and competencies. More information about the physician task and competencies outline is available. Items are constructed to focus on assessing one of the following competencies:

  • Medical knowledge/scientific concepts: Applying foundational science concepts
  • Patient care: Diagnosis
  • Patient care: Management
  • Communication and interpersonal skills
  • Professionalism, including legal and ethical issues
  • Systems-based practice, including patient safety
  • Practice-based learning, including biostatistics and epidemiology

Table 3: Step 3 MCQ Physician Tasks/Competencies Specifications

Competency
Step 3 Foundations of Independent Practice
Step 3 Advanced Clinical Medicine
Medical Knowledge/Scientific Concepts
18% - 22%
Patient Care: Diagnosis
  • History/Physical Examination
  • Laboratory/Diagnostic Studies
  • Diagnosis
40% – 45%
  • Prognosis/Outcome
20% - 25%
Patient Care: Management
  • Health Maintenance/Disease Prevention
  • Pharmacotherapy
  • Clinical Interventions
  • Mixed Management
  • Surveillance for Disease Recurrence
75% - 80%
Communication and Professionalism
8% - 12%
Systems-based Practice/Patient Safety and Practice-based Learning
22% - 27%

Table 4: Step 3 CCS Physician Tasks/Competencies Specifications
Categories in bold are covered in CCS cases; categories not in bold are not covered.

Competency
Medical Knowledge/Scientific Concepts
Patient Care: Diagnosis
  • History/Physical Exam
  • Laboratory/Diagnostic Studies
  • Diagnosis
  • Prognosis/Outcome
Patient Care: Management
  • Health Maintenance/Disease Prevention
  • Pharmacotherapy
  • Clinical Interventions
  • Mixed Management
  • Surveillance for Disease Recurrence
Communication and Professionalism
Systems-based Practice/Patient Safety and Practice-based Learning

Strategies


  • Read each question carefully. It is important to understand what is being asked.
  • Try to generate an answer and then look for it in the option list.
  • Alternatively, read each option carefully, eliminating those that are clearly incorrect. Of the remaining options, select the one that is most correct.
  • If unsure about an answer, it is better to guess since unanswered questions are automatically counted as wrong answers.


Single-Item Questions


A single patient-centered vignette is associated with one question followed by four or more response options. The response options are lettered (ie, A, B, C, D, E). A portion of the questions involves interpretation of graphic or pictorial materials. You are required to select the best answer to the question. Other options may be partially correct, but there is only ONE BEST answer. This is the traditional, most frequently used multiple-choice question format on the examination.

Example Question 1

1. 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. 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 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?

  1. Acidification of urine by drinking cranberry juice
  2. Cystoscopic removal of the calculus
  3. Cystoscopic ureteral lavage
  4. Shock wave lithotripsy
  5. Straining of the urine

(Answer: E)

Multiple Item Sets

A single patient-centered vignette may be associated with two or three consecutive questions about the information presented. Each question within these sets is associated with the patient vignette and is independent of the other question(s) in the set. The items within this type of format are designed to be answered in any order. You are required to select the ONE BEST answer to each question.

Example Questions 2 to 3

A 52-year-old man returns to the office for 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 nontender 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.

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

  1. Diminished pedal pulses
  2. Neurologic findings
  3. The patient's weight
  4. Proteinuria
  5. Tobacco use

(Answer: B)

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

  1. Begin aggressive debridement in the office
  2. Begin intravenous antibiotic therapy
  3. Refer the patient for transmetatarsal amputation
  4. Schedule the patient for a third-degree skin graft
  5. Switch the amoxicillin-clavulanate to oral ciprofloxacin

(Answer: B)

Sequential Item Sets

A single patient-centered vignette may be associated with two or three consecutive questions about the information presented. Each question is associated with the initial patient vignette but is testing a different point. You are required to select the ONE BEST answer to each question. Questions are designed to be answered in sequential order. You must click "Proceed to Next Item" to view the next item in the set; once you click on this button, you will not be able to add or change an answer to the displayed (previous) item.

Example Questions 4 to 5

A 2-year-old girl is brought to the office by her mother for evaluation of fever. You have been the girl's physician since birth. While in the office, the girl stiffens and then has bilateral, symmetrical shaking of her upper and lower extremities; she becomes mildly cyanotic. The episode lasts for approximately 45 seconds, after which she becomes relaxed and appears to fall asleep. Vital signs at this time are temperature 40.0°C (104.0°F), pulse 120/min, and respirations 40/min. On physical examination she has a generally pink complexion and flushed cheeks. She is limp and somnolent and responds with a cry to noxious stimulus. Tympanic membranes are inflamed bilaterally, nose has a scant, clear discharge, and throat is mildly erythematous. Lungs are clear to auscultation except for transmitted upper airway sounds. Heart has rapid rate with a grade 1/6 systolic murmur at the left sternal border. Complete blood count, blood culture, lumbar puncture, and catheterized urine specimen are obtained and sent for stat analysis. Acetaminophen is administered by rectal suppository. Thirty minutes later the patient awakens and is smiling. She is afebrile. Additional history discloses that she was born at term, she had an uneventful neonatal course, she has normal growth and development, and vaccinations are up-to-date. She has never had an episode similar to this. Initial laboratory results are shown:

Blood
10,400/mm3
WBC
25%
Neutrophils, segmented
5%
Neutrophils, bands
65%
Lymphocytes
5%
Monocytes
0 RBC/mm3
Cerebrospinal fluid
Normal
Urinalysis

Other laboratory studies are pending.

4. In addition to ampicillin for otitis media and acetaminophen, this child also should receive which of the following?

  1. Oral ethosuximide
  2. Oral phenobarbital
  3. Oral phenytoin
  4. Rectal diazepam
  5. No additional medications

(Answer: E)

5. Two weeks later the patient is brought to the office for a follow-up visit. Her mother says that she is doing well and she has had no recurrence of her symptoms. Examination of the ears shows resolution of the otitis media. Which of the following is the most important diagnostic step at this time?

  1. Audiology testing
  2. Cognitive testing
  3. CT scan of the head
  4. EEG
  5. No additional testing

(Answer: E)

Pharmaceutical Advertisement (Drug Ad) Format

The drug ad item format includes a rich stimulus presented in a manner commonly encountered by a physician, eg, as a printed advertisement in a medical journal. Examinees must interpret the presented material in order 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

Abstract Format

The abstract item format includes a summary of an experiment or clinical investigation presented in a manner commonly encountered by a physician, eg, as an abstract that accompanies a research report in a medical journal. Examinees must interpret the abstract in order to answer questions on various topics, including

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

Primum Computer-based Case Simulations (CCS)


You will manage one case at a time. Free-text entry of patient orders is the primary means for interacting with the format. Buttons and check boxes are used for ordering a physical 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. Photographs and sounds will not be provided. Normal or reference laboratory values will be provided with each report; some tests will be accompanied by a clinical interpretation. To manage patients using the Primum CCS software, it is essential that you complete the Primum tutorial and sample cases provided. A brief description of the interface is provided in the Primum Tutorial.