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.
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 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...
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
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.
|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.|
- 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.
Test Question Formats
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.
A 45-year-old African-American man comes to the office for the first time because he says, "I had blood in my urine when I went to the bathroom this morning." He reports no other symptoms. On physical examination his kidneys are palpable bilaterally and he has mild hypertension. Specific additional history should be obtained regarding which of the following?
- Chronic use of analgesics
- Cigarette smoking
- A family history of renal disease
- Occupational exposure to carbon tetrachloride
- Recent sore throats
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.
Example Questions (set of 2)
A 38-year-old white woman, who is a part-time teacher and the mother of three children, comes to the office for evaluation of hypertension. You have been her physician since the birth of her first child 8 years ago. One week ago, an elevated blood pressure was detected during a regularly scheduled examination for entrance into graduate school. Vital signs on examination today are temperature 37.0C (98.6F), pulse 100/min, respirations 22/min, and blood pressure 164/100 mm Hg (right arm, supine).
1. The physical examination is most likely to show which of the following?
- An abdominal bruit
- Cardiac enlargement
- Decreased femoral pulses
- Thyroid enlargement
- Normal retinas
2. To assess this patient's risk factors for atherogenesis, the most appropriate test is determination of which of the following?
- Plasma renin activity
- Serum cholesterol concentration
- Serum triglycerides concentration
- Urinary aldosterone excretion
- Urinary metanephrine excretion
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.
Example Questions (set of 3)
A 24-year-old man comes to the office because of intermittent chest pain that began a few weeks ago. You have been his physician for the past 2 years and he has been in otherwise good health. He says he is not having pain currently. A review of his medical record shows that his serum cholesterol concentration was normal at a pre-employment physical examination 1 year ago. You have not seen him since that visit and he says he has had no other complaints or problems in the interim. He reminds you that he smokes 1 pack of cigarettes per day. When you question him further, he says that he does not use any alcohol or illicit drugs. Although the details are vague, he describes the chest pain as a substernal tightness that is definitely not related to exertion.
1. Which of the following findings on physical examination would be most consistent with costochondritis as the cause of his chest pain?
- Crepitation over the second and third ribs anteriorly
- Deep tenderness to hand pressure on the sternum
- Localized point tenderness in the parasternal area
- Pain on deep inspiration
- Normal physical examination
2. In light of the patient's original denial of drug use, which of the following is the most appropriate next step to confirm a diagnosis of cocaine use?
- Ask the laboratory if serum is available for toxicologic screening on a previous blood sample
- Call his family to obtain corroborative history
- Obtain a plasma catecholamine concentration
- Obtain a urine sample for routine analysis but also request toxicologic screening
- Present your findings to the patient and confront him with the suspected diagnosis
3. Cocaine use is confirmed. The patient admits a possible temporal relationship between his cocaine use and his chest pain and expresses concern about long-term health risks. The patient should be counseled regarding which of the following?
- Cocaine-induced myocardial ischemia can be treated with blocking agents
- Death can occur from cocaine-induced myocardial infarction or arrhythmia
- The presence of neuropsychiatric sequelae from drug use indicates those at risk for sudden death associated with cocaine use
- Q wave myocardial infarction occurs only with smoked "crack" or intravenous cocaine use
- Underlying coronary artery disease is the principal risk for sudden death associated with cocaine use
End of Case
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
- Development and approval of drugs and dietary supplements
- Medical ethics
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
- 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
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:
- 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.
- 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.