Step 3 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.

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.

Site of Care

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 three sites of care, which are described below.


Ambulatory includes office/health center, home care, outpatient hospice, and ambulatory surgical center. You primarily see patients in two locations: an office suite, which is adjacent to a hospital, and at 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.

Inpatient Facilities

Inpatient Facilities includes hospital, ICU/CCU, inpatient hospice, acute rehabilitation facility, and subacute rehabilitation facility, including skilled nursing care facility. 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, you may visit patients in the adjacent nursing care facility/extended-care facility and detoxification unit.

Emergency Department

Emergency Department includes emergency department and urgent treatment center. 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. 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.

Clinical Encounter Frames

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

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, and Multisystem Processes/Disorders 6–8
Behavioral Health 4–6
Nervous System & Special Senses 8–10
Skin & Subcutaneous Tissue 4–6
Musculoskeletal System 5–7
Cardiovascular System 9–11
Respiratory System 8–10
Gastrointestinal System 6–8
Renal/Urinary & Male Reproductive Systems 4–6
Pregnancy/Childbirth & Female Reproductive System & Breast 7–9
Endocrine System 5–7
Biostatistics & Epidemiology/Population Health & Interpretation of the Medical Literature 11–13
Social Sciences: Communication Skills/Ethics/Patient Safety 7–9

* Percentages are subject to change at any time.
** 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

Category Covered
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

Step 3 Foundations of Independent Practice (Day 1)
Competency Range, % Covered
Medical Knowledge: Applying Foundational Science Concepts 11-12
Patient Care: Diagnosis 33-36
 History/Physical Exam 5-9
 Laboratory/Diagnostic Studies 9-12
 Diagnosis 6-10
 Prognosis/Outcome 8-11
Patient Care: Management 32-35
 Health Maintenance/Disease Prevention 6-11
 Pharmacotherapy 9-13
 Clinical Interventions 5-9
 Mixed Management 6-11
Practice-based Learning & Improvement 11-13
Communication / Professionalism / Systems-based Practice & Patient Safety 7-9
Step 3 Advanced Clinical Medicine (Day 2)
Competency Range, % Covered
Medical Knowledge: Applying Foundational Science Concepts 11-12
Patient Care: Diagnosis 33-36
 History/Physical Exam 5-9
 Laboratory/Diagnostic Studies 9-12
 Diagnosis 6-10
 Prognosis/Outcome 8-11
Patient Care: Management 32-35
 Health Maintenance/Disease Prevention 6-11
 Pharmacotherapy 9-13
 Clinical Interventions 5-9
 Mixed Management 6-11
Practice-based Learning & Improvement 11-13
Communication and Professionalism 7-9

Table 4: Step 3 CCS Physician Tasks/Competencies Specifications

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