Step 3

Overview

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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.

Purpose of the Step 3 Exam

The purpose of Step 3 is to determine if a physician possesses and can apply the medical knowledge and understanding of clinical science considered essential for the unsupervised practice of medicine, with emphasis on patient management in ambulatory care settings. The inclusion of Step 3 in the USMLE sequence of licensing examinations 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.

• Step 3 emphasizes selected physician tasks, namely, evaluating severity of patient problems and managing therapy. Assessment of clinical judgment will be prominent.
• Clinical problems involve mainstream, high-impact diseases. Provision is made for less common but important clinical problems as well.
• Test items and cases are patient centered, starting with a description of a clinical encounter (vignette). Both the multiple-choice items and case simulations pose action-related challenges that require clinical decisions or judgment.
• Emphasis is on ambulatory patient encounters; however, inpatient encounters of significant complexity and reflecting contemporary trends also are represented.
• Provision is made for incorporating applied basic and clinical science concepts, especially as they relate to justification for prognosis or management. It is assumed that basic science and clinical fundamentals have been assessed adequately in the prerequisite Step 1 and Step 2 examinations.

Exam Layout

Step 3 is a two-day examination. You must complete each day of testing within 8 hours. The first day of testing includes 336 multiple-choice items divided into 7 blocks of 48 items each. There will be 60 minutes of time allowed for completion of each block of test items. There is a maximum of 7 hours of testing on the first day. There is also a minimum of 45 minutes of break time and a 15-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.

Items with an associated pharmaceutical ad or abstract are included in some of these multiple choice blocks. Those blocks that include these item types will contain 46–47 items per block. The timing will remain the same for all blocks.

The second day of testing includes 144 multiple-choice items, divided into 4 blocks of 36 items. These blocks will take 45 minutes. The total time allotted for these blocks is 3 hours. The second day also includes a Primum® Tutorial and instructions for which approximately 15 minutes are allowed. This is followed by 12 case simulations, for which 4 hours are allotted. 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 timing and structure of the Step 3 testing days may change without notice.

The Exam

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The bulk of Step 3 is intended to challenge you to consider the severity of illness and to manage ambulatory patients who have previously diagnosed, frequently occurring chronic illnesses and behavioral/emotional problems. The expected outcome of the USMLE process is a general unrestricted license to practice medicine without supervision.

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

For more information on Step 3...

• Bulletin: Examination Content - Step 3

Clinical Settings

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Assessing the patient's situation in the context of his or her environment or family is an important element of many Step 3 questions. The exam questions are usually arranged by the setting in which the patient encounter first occurs; there are two clinical settings on this exam. To help orient you, each setting is described at the beginning of the corresponding test block. As is done for the actual examination, the sample test items are arranged in blocks that are organized by one of the two clinical settings.

Setting I: Office/Health Center

You see patients in two locations: an office suite, which is adjacent to a hospital, or 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 Frame

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The content description that follows is not intended as a study guide, but rather is a model of the range of challenges that will be met in the actual practice of medicine. 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.

Three stages of clinical encounters

	Initial Workup	Continuing Care	Urgent Intervention
Patient Encounters Description	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.	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 in-patient settings.	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.	Include frequently occurring chronic diseases and behavioral-emotional problems. Periodic health evaluations of established patients are included here.	Include severe life-threatening and organ-threatening conditions and exacerbations of chronic illness.
Emphasized Physician Tasks	Include data gathering and initial clinical intervention. Assessment of patients may lead to urgent intervention.	Include recognition of new problems in an existing condition, assessment of severity, establishing prognosis, monitoring therapy, and long-term management.	Include rapid assessment of complex presentations, assessment of patients' deteriorating condition, and prompt decision making.

Physician Tasks

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• Applying Scientific Concepts

  Objectives focus on identifying the underlying processes or pathways responsible for a given condition, recognizing associated disease conditions and complications, and recognizing and evaluating clinical findings or diagnostic studies to identify the underlying factors (eg, anatomic structure).

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• Formulating a Diagnosis

  History and Physical Examination objectives focus on interpreting the patient's history, knowing pertinent factors in the patient's history, interpreting the history in terms of risk factors for the patient, recognizing and interpreting pertinent physical findings, and knowing required techniques in the physical examination.

  Laboratory and Diagnostic Studies objectives focus on selecting the appropriate routine, initial, invasive, special, or follow-up studies; interpreting the results of laboratory or diagnostic tests; knowing the value of and indications for screening tests; and predicting the most likely test result.

  Diagnosis objectives focus on selecting the most likely diagnosis in light of history, physical, or diagnostic test findings. Includes interpreting pictorial material and establishing a diagnosis.

  Prognosis objectives focus on interpreting the vignette, evaluating the severity of the patient's condition, and making judgment on the current status or prognosis of the patient as to the need for further action.

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• Managing the Patient

  Health Maintenance objectives focus on identifying risk factors, knowing incidence within patient groups at risk, knowing preliminary steps to ensure effectiveness of intended therapy, and selecting appropriate preventive therapeutic agents or techniques.

  Clinical Intervention objectives focus on knowing priorities in emergency management, knowing present and long-term management of selected conditions, and knowing appropriate surgical treatment, including pre- and post-surgical events. They also include knowing pre- and post-procedural management and the appropriate follow-up schedule or monitoring approach.

  Clinical Therapeutics objectives focus on selecting the appropriate pharmacotherapy, recognizing actions of drugs as applied to patient management, and knowing the importance of educating patients about effects of drugs and drug-drug interactions.

  Legal/ethical and health care systems objectives focus on issues such as patient autonomy, physician/patient relationships, use of unorthodox or experimental therapies, end-of-life considerations, treatment of minors, and physician error versus negligence.

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Evaluative Objectives

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• Applying Scientific Concepts

  • Identifies the cause/causal agent or predisposing factor(s); or, given an effect, what is the cause.
  • Identifies the underlying processes/pathways that account for, or contribute to, the expression or resolution of a given condition.
  • Recognizes or evaluates given clinical or physical findings to identify the underlying anatomic structure or physical location.
  • Interprets results of clinical studies

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• Obtaining History and Perfoming a Physical Examination

  • Knows signs/symptoms of selected disorders.
  • Knows individual's risk factors for development of condition leading to encounter. Given current symptoms in presented history, identifies pertinent factor(s) in history.
  • Predicts the most likely additional physical finding; selects either the finding itself, or the appropriate examination technique that would result in the finding.
  • Given a specific problem, knows what to ask in obtaining pertinent additional history.

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• Using Laboratory and Diagnostic Studies

  • Selects appropriate routine or initial laboratory or diagnostic studies, or study needed to ensure effectiveness of intended therapy, or study most likely to establish/confirm the diagnosis.
  • Interprets the clinical impact of laboratory or diagnostic test findings.
  • Predicts the most likely laboratory or diagnostic test result.

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• Formulating the Most Likely Diagnosis

  • Selects the most likely diagnosis or knows the most likely presumptive or preliminary diagnosis.

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• Evaluating the Severity of Patient Problems (Prognosis)

  • Evaluates severity of patient condition and identifies indications for consultation or diagnostic assessment.
  • Assesses severity of patient condition and makes judgment as to current status, prognosis, or need for further action.
  • Recognizes factors in the history, or physical or laboratory study findings (given symptoms), that affect patient prognosis or outcome, or determine therapy.
  • Interprets laboratory or diagnostic study results and identifies current status of patient.
  • Recognizes associated disease conditions, including complications, or indicators for potential disease complications, of a given disease.
  • Recognizes characteristics of disease relating to natural history or course of disease, including progression, severity, duration, and transmission of disease.
  • Knows appropriate counseling of patient or family regarding current and future problems, including risk factors related to present encounter.

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• Management of Health Maintenance and Disease Prevention

  • Knows risk factors for conditions amenable to prevention or detection in an asymptomatic patient, or knows the potential condition itself.
  • Knows pertinent incidence statistics and identifies patient groups at risk; knows incidence of symptomless/dangerous disorders among various groups.
  • Knows common screening tests for conditions amenable to prevention or detection in an asymptomatic patient or population.
  • Selects appropriate preventive, therapeutic agent/technique. Knows timing of vaccinations.

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• Clinical Interventions

  • Evaluates severity of patient condition in terms of need for referral for surgical treatments/procedures versus other nonsurgical options.
  • Knows immediate management or priority in management, specifically in emergency or acute cases.
  • Knows most appropriate management of selected conditions.
  • Knows appropriate long-term treatment or management goals.
  • Knows appropriate surgical management among surgical options.
  • Knows pre/post surgical or procedural management.
  • Knows indications for admission to the hospital or to another appropriate setting.
  • Knows most appropriate follow-up monitoring approach regarding the management plan.
  • Knows most appropriate discharge planning.
  • Knows components of rehabilitation program.
  • Educates patient or family regarding self-care.
  • Knows relevant roles of allied health personnel.
  • Knows appropriate use and procedures regarding hospice care.

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• Clinical Therapeutics

  • Selects most appropriate pharmacotherapy.
  • Assesses patient adherence with treatment regimen, recognizes techniques to increase adherence or understanding of the disease state, and knows how adherence may be affected by providing instructions with therapy.
  • Recognizes factors that alter drug requirements for a patient.
  • Knows adverse effects of various drugs, or recognizes signs and symptoms of drug (and drug-drug) interactions resulting from polypharmacy in the therapeutic regimen and knows steps to prevent polypharmacy.
  • Knows contraindications of various medications.
  • Modifies therapeutic regimen within the context of continuing care.

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• Communication

  • Recognizes physician's best choice of words in eliciting history or further description of the patient's problem; knows statements that facilitate communication with the patient.

Content Outlines

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1. General Principles

   Normal Development

   • Infancy/Childhood (eg, normal growth and development)
   • Adolescence (eg, sexuality, physical changes of puberty)
   • Adult (eg, normal physical findings and lifestyle issues)
   • Senescence (eg, normal physical and mental changes of aging)

   Medical Ethics and Jurisprudence

   • Consent and Informed Consent to Treatment (eg, full disclosure, advance directives/health care proxy, permission to treat, competency, autonomy)
   • Physician/Patient Relationship (eg, truth-telling, confidentiality, privacy, adult maltreatment [including elder abuse], child maltreatment [child abuse])
   • Death and Dying (eg, diagnosing death, organ donation, euthanasia/physician-assisted suicide, palliative care)

   Applied Biostatistics and Clinical Epidemiology

   • Understanding Statistical Concepts (eg, understanding statistical concepts, calculations of one thing/multiple things, mixed calculations/interpretations)
   • Interpretation of the Medical Literature (eg, interpretation of a study statement, reading a table or graph, evaluation of the validity of the author's conclusion, identification of the study flaw, design of a study)

   Systems-Based Care and Patient Safety

   • Systems-Based Practice and Quality Improvement (eg, microsystems and teams including hand-offs, standardization of processes, reducing deviance)
   • Patient Safety, Medical Errors and Near Misses (eg, sentinel events, problem identification, root cause analysis)

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2. Disorders of the Nervous System and Special Senses

   Degenerative/Developmental Disorders (eg, Alzheimer disease, Parkinson disease, multiple sclerosis, cerebral palsy)

   Neuromuscular/Degenerative Disorders (eg, paraplegia, myasthenia gravis, spinal stenosis, neuritis)

   Cerebrovascular Diseases (eg, intracranial hemorrhage, transient cerebral ischemias, stroke, vascular dementia [multi-infarct dementia])

   Peripheral Nerve Diseases (eg, carpal tunnel syndrome, nerve compression, neuropathy)

   Headache and Movement Disorders (eg, seizure disorder, trigeminal neuralgia, Bell palsy, torticollis)

   Sleep Disorders (eg, night terrors and sleepwalking, cataplexy and narcolepsy)

   Neoplasms (eg, meningioma, metastatic lesions)

   Infectious Diseases (eg, tetanus, Creutzfeldt-Jakob disease, meningitis, encephalitis)

   Trauma and Toxic Effects (eg, intracranial injury, brain death, coma, concussion)

   Disorders of the Eye (eg, glaucoma, retinal detachment, cataract, corneal abrasion)

   Disorders of the Ear (eg, perforation of tympanic membrane, acoustic neuroma, hearing loss, vertigo)

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3. Disorders of the Respiratory System

   Obstructive Airways Disease (eg, cystic fibrosis, chronic bronchitis, emphysema, asthma)

   Pneumoconiosis/Fibrosing or Restrictive Pulmonary Disorders (eg, sarcoidosis, asbestosis, pneumoconiosis, pulmonary fibrosis)

   Respiratory Failure & Pulmonary Vascular Disease (eg, pulmonary hypertension, respiratory distress syndrome, atelectasis, pulmonary embolism)

   Upper Respiratory Conditions (eg, sinusitis, peritonsillar abscess, otitis, streptococcal throat infection)

   Neoplasms (eg, mesothelioma, paraneoplastic syndrome)

   Lung Infections (eg, pulmonary tuberculosis, pneumonia, influenza, respiratory syncytial virus)

   Trauma and Toxic Effects (eg, pleurisy, pleural effusion, pneumothorax, drowning and nonfatal submersion)

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4. Cardiovascular Disorders

   Hypotension (eg, orthostatic hypotension, hypotensive emergency)

   Ischemic Heart Disease and Atherosclerosis (eg, myocardial infarction, ischemic heart disease, angina pectoris, hyperlipidemia, arteriosclerosis)

   Congestive Heart Failure (eg, congestive heart failure, left heart failure)

   Dysrhythmias (eg, atrioventricular block, paroxysmal supraventricular tachycardia, fibrillation and flutter, cardiac arrest)

   Disorders of the Great Vessels (eg, atherosclerosis of aorta, dissecting aneurysm, aortic aneurysm)

   Valvular Heart Disease (eg, rheumatic heart disease, endocarditis, valve disorders, functional murmurs)

   Peripheral Arterial Vascular Diseases (eg, Raynaud syndrome, intermittent claudication, arterial embolism/thrombosis)

   Diseases of Veins (eg, phlebitis/thrombophlebitis, deep venous thrombosis, varicose veins, venous insufficiency)

   Congenital Disease (eg, ventricular/atrial septal defect, patent ductus arteriosus, coarctation of aorta, tetralogy of Fallot)

   Diseases of Myocardium (eg, hypertensive cardiomegaly, hypertrophic cardiomyopathy, myocarditis)

   Diseases of Pericardium (eg, pericarditis, pericardial tamponade)

   Trauma and Toxic Effects (eg, cardiovascular injury, fat embolism)

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5. Nutritional and Digestive System Disorders

   Mouth, Salivary Glands, and Esophagus (eg, malignant neoplasm of mouth/salivary glands/esophagus, esophageal varices, esophagitis/esophageal reflux, diaphragmatic hernia)

   Stomach (eg, neoplasm of stomach, gastric ulcer problems, peptic ulcer problems, gastritis and duodenitis)

   Small Intestine/Colon and Rectum (eg, inflammatory bowel disease, diverticula, anal fissure or fistula, celiac disease)

   Gallbladder and Bile Duct (eg, calculus of gallbladder, cholangitis, obstruction of common bile duct and biliary atresia)

   Liver (eg, acute hepatic failure, cirrhosis, ascites, fatty liver disease)

   Pancreas (eg, neoplasm of pancreas or Islets of Langerhans, pancreatitis, cyst and pseudocyst of pancreas)

   Nutritional Disorders (eg, obesity, malnutrition and malabsorption)

   Infections (eg, gastroenteritis, coxsackievirus, candidiasis of mouth [thrush], hepatitis A/B/C, Helicobacter pylori)

   Trauma and Toxic Effects (eg, food poisoning, hernia of abdominal cavity, ventral hernia)

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6. Behavioral/Emotional Disorders

   Psychotic Disorders (eg, schizophrenia, paranoid state, psychotic disorder)

   Anxiety Disorders (eg, panic disorder [panic attacks], phobic disorders, obsessive-compulsive disorders, posttraumatic stress disorder)

   Mood Disorders (eg, dysthymic disorder, depressive disorders, bipolar disorders, postpartum depression)

   Somatoform Disorders (eg, somatization disorder, malingering, conversion disorder, hypochondriasis [including body dysmorphic disorder])

   Eating Disorders and Other Impulse Control Disorders (eg, bulimia, disorders of impulse control [gambling, shoplifting], binge eating disorder)

   Disorders Originating in Infancy/Childhood/Adolescence (eg, oppositional defiant disorder, attention-deficit/hyperactivity disorder, developmental speech or language disorder, autistic disorder)

   Personality Disorders (eg, antisocial personality disorder, dependent personality disorder, paranoid personality disorder, schizoid personality disorder)

   Psychosocial Problems (eg, psychosexual dysfunction, bereavement)

   Substance Use Disorders (eg, alcohol abuse and dependence, alcohol withdrawal syndrome, cocaine/opiates/sedatives/hypnotics abuse and dependence)

   Toxic Effects (eg, poisoning by psychotropic agents, including antidepressants)

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7. Disorders of the Musculoskeletal System

   Degenerative/Metabolic Disorders (eg, gout, osteoarthritis, avascular necrosis of bone, disc displacement)

   Inflammatory/Immunologic Disorders (eg, ankylosis/spondylopathy, rheumatoid arthritis, synovitis/tenosynovitis, myalgia and myositis)

   Hereditary Developmental Disorders (eg, genu valgum or varum, congenital dislocation of hip, scoliosis, varus/valgus deformities of feet)

   Neoplasms (eg, secondary malignant neoplasm of bone and bone marrow, osteosarcoma)

   Infections (eg, infective arthritis, infective myositis, Lyme disease, osteomyelitis)

   Traumatic Injuries (eg, tears, fractures, dislocations, contusions)

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8. Disorders of the Skin/Subcutaneous Tissue

   Skin Eruptions (eg, contact dermatitis, erythema multiforme, psoriasis, decubitus ulcer)

   Disorders of Nails/Hair/Sweat Glands (eg, ingrowing nail, seborrhea capitis/folliculitis/sycosis, hirsutism, hyperhidrosis)

   Lumps/Tumors of the Skin (eg, malignant melanoma of skin/lip, keratoderma, sebaceous cyst, neurofibromatosis)

   Infections (eg, tinea infections, cellulitis and abscess, erythema infectiosum, molluscum contagiosum)

   Trauma and Toxic Effects (eg, wounds or burns affecting the skin or subcutaneous tissue, keloid scar, Stevens-Johnson syndrome, frostbite)

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9. Disorders of the Endocrine System

   Thyroid Disorders (eg, malignant neoplasm of thyroid gland, thyrotoxicosis, hypothyroidism, thyroiditis)

   Diabetes Mellitus (eg, ketoacidosis, renal manifestations, neurologic manifestations, hypoglycemic shock)

   Adrenal Disorders (eg, neuroblastoma, hyperaldosteronism, congenital adrenal hyperplasia, corticoadrenal insufficiency [Addison disease])

   Parathyroid/Pituitary Disorders (eg, hyperparathyroidism, hypoparathyroidism, prolactinoma, pheochromocytoma)

   Trauma and Toxic Effects (eg, heat syncope, heat stroke and sun stroke, heat exhaustion)

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10. Renal and Urinary Disorders

    Lower Urinary Tract (eg, neurogenic bladder, enuresis/incontinence of urine, urinary obstruction, cystitis)

    Upper Urinary Tract (eg, glomerulonephritis, renal failure/insufficiency, polycystic kidney disease, calculus of kidney/ureter/urinary tract)

    Fluid, Electrolyte, and Acid-Base Disorders (eg, dehydration, hypovolemia, electrolyte imbalances, metabolic disorders)

    Infections (eg, pyelonephritis, urethritis, urinary tract infection)

    Trauma and Toxic Effects (eg, extravasation of urine)

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11. Diseases/Disorders of the Female Reproductive System

    Breast (eg, fibrocystic/solitary cyst of breast, hypertrophy of breast, disorders of lactation, mastitis)

    Uterus (eg, leiomyoma of uterus, postcoital bleeding, endometriosis of uterus, uterine prolapse)

    Ovary, Fallopian Tube, & Broad Ligament (eg, ovarian or fallopian tube torsion, ovarian cyst, ovarian failure, benign neoplasm of ovary)

    Cervix (eg, cervix uteri, cervicitis and endocervicitis, dysplasia of cervix [uteri], abnormal Pap smear of cervix)

    Vagina/Vulva (eg, vaginitis and vulvovaginitis, prolapse of vaginal walls, imperforate hymen, vaginismus)

    Menstrual Disorders (eg, dysmenorrhea, premenstrual tension syndrome, irregular menstrual cycle, ovulation bleeding)

    Menopause (eg, postmenopausal hormone replacement therapy, premenopausal menorrhagia, postmenopausal bleeding, postmenopausal atrophic vaginitis)

    Pelvic Relaxation and Urinary Disorders (eg, stress incontinence, uterine prolapse, prolapse of vaginal walls, cystocele/rectocele)

    Female Fertility/Infertility (eg, contraception, pre-pregnancy counseling, dyspareunia, female infertility)

    Neoplasms (eg, malignant neoplasm of breast, uterus, ovary, vagina/vulva; cervical cancer)

    Infections (eg, human papillomavirus, sexually transmitted diseases, pelvic inflammatory disease, salpingitis and oophoritis)

    Trauma and Toxic Effects (eg, injuries, wounds, toxic effects, or burns affecting the female reproductive system)

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12. Pregnancy/Labor and Delivery/Fetus and Newborn

    Pregnancy: Complicated (eg, gestational diabetes, ectopic/tubal pregnancy, preeclampsia or eclampsia, cervical incompetence)

    Pregnancy: Uncomplicated (eg, supervision of normal pregnancy, examination of liveborn before admission to hospital)

    Labor, Delivery, & Postpartum (including placenta abnormalities) (eg, premature rupture of membranes, infections complicating childbirth, cesarean delivery, immediate postpartum hemorrhage)

    Fetus & Newborn (eg, congenital anomalies, Down syndrome, neonatal hypoglycemia, feeding problems in newborn [breast-feeding])

    Perinatal Infections (eg, congenital cytomegalovirus infection, neonatal conjunctivitis and dacryocystitis, neonatal sepsis, herpes simplex virus)

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13. Disorders of Blood

    Splenic Disorders (eg, traumatic and nontraumatic diseases of spleen)

    Anemias and Cytopenias (eg, iron deficiency anemia, hereditary spherocytosis, hemoglobinopathies, thrombocytopenic purpura and ITP)

    Bleeding Disorders (eg, coagulation defects, congenital factor VIII disorder/hemophilia, von Willebrand disease, disseminated intravascular coagulation)

    Reactions to Blood Components (eg, transfusion reaction, ABO incompatibility reaction, Rh incompatibility reaction)

    Malignant Neoplasias (eg, Hodgkin disease, lymphomas, multiple myeloma, leukemia)

    Infections (eg, infectious mononucleosis, cat-scratch disease, septicemia, lymphadenitis)

    Toxic Effects (eg, heparin-induced thrombocytopenia)

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14. Disorders of the Male Reproductive System

    Male Reproductive System (eg, neoplasm of male breast/prostate/testes, prostatitis, torsion of testes, orchitis/epididymitis)

    Infections (eg, human papillomavirus, sexually transmitted diseases)

    Trauma and Toxic Effects (eg, injuries, wounds, toxic effects, or burns affecting the male reproductive system)

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15. Disorders of the Immune System

    Immune Deficiency Disorders (eg, hypogammaglobulinemia, IgA deficiency)

    HIV (eg, AIDS, AIDS-related complex, pneumocystosis, Kaposi sarcoma)

    Vascular/Arterial Disorders (eg, Wegener granulomatosis, arteritis)

    MSK/Connective Tissue Disorders (eg, dermatomyositis, polymyositis, polymyalgia rheumatica, systemic lupus erythematosus)

    Vaccinations/Chemotherapy (eg, routine and nonroutine, including travel vaccinations, prophylactic and maintenance chemotherapy)

    Anaphylaxis/Immunologic Reactions (eg, anaphylaxis, reactions to venomous bites, desensitization to allergens)

    Infections (eg, scarlet fever, toxic shock syndrome, Rocky Mountain spotted fever, retrovirus)

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Test Question Formats

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Step 3 consists of multiple-choice questions with only one best answer and computer-based case simulations, distributed according to the content blueprint.

Multiple Choice Questions

Multiple choice items present detailed clinical situations, usually from the patient's perspective. The presentation may be supplemented by one or more pictorials, or audio or video. The response options for all questions are lettered (eg, A, B, C, D, E). Some response options will be partially correct, but only one option will be the best and correct answer.

Strategies for Answering the Multiple-choice Questions

• Read each patient vignette and 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.

Multiple Choice - Single Item Questions

A single patient-centered vignette is associated with one question about the information presented and followed by four or more response options. This is the traditional, most frequently used multiple-choice question format on the exam.

Multiple Choice - 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.

Multiple Choice - 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. Questions are designed to be answered in sequential order. You are required to select the one best answer to each question. 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.

Pharmaceutical Advertisement (Drug Ad) Format

The pharmaceutical advertisement item format includes an advertisement presented in a manner commonly encountered by a physician (eg, 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, 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 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.

Primum® Beta Test

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The National Board of Medical Examiners® (NBME®) is developing updated software for delivery of the Primum® Computer-based Case Simulations (CCS). The updated software is scheduled to be incorporated into USMLE Step 3 examinations beginning in late winter 2011.

NBME is conducting a beta test of the new Primum software. Individuals who are interested in participating in the beta test may download and run the sample Step 3 CCS cases using the new software. Participants in the beta test will then have the opportunity to provide feedback via a brief survey. In order to analyze the functionality of the new software and identify any technical problems, NBME will collect information in two ways:

1. As in the USMLE Step 3 examination, the Primum software creates a record of all of the transactions you order while running each case (e.g., diagnostic tests or therapies). This transaction log will be transmitted to the NBME. If you experience any errors while running the software, an error log will also be created and transmitted to NBME.
2. In order to assist with identifying any problems experienced while running the software, NBME will collect certain basic information about the kind of computer you are using (e.g., computer type, memory, processor speed).

There is no charge for downloading the beta version or providing feedback to NBME.

No results will be reported to beta test participants. In addition, results from this beta test cannot be substituted for USMLE Step scores for the purpose of Educational Commission for Foreign Medical Graduates (ECFMG®) Certification or medical licensure in the United States.

Any information obtained from running the beta version will be strictly confidential; results will not be reported to any third party.

These materials are intended to expose a broad range of individuals to the beta version of the new Primum driver software and collect feedback from users.

If you have any questions, feel free to contact us.

Learn more about the Primum Beta Test »