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

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.