What is USMLE STEP 3 ?

STEP 3

Step 3 is organized along two principal dimensions: clinical encounter frame and physician task (see Table 4). Step 3 content reflects a data-based model of generalist medical practice in the United States.

Encounter frames capture the essential features of circumstances surrounding physicians' clinical activity with patients. They range from encounters with patients seen for the first time for nonemergency problems, to encounters with regular patients seen in the context of continued care, to patient encounters in (life-threatening) emergency situations. Encounters occur in clinics, offices, skilled nursing care facilities, hospitals, emergency departments, and on the telephone. Each test item in an encounter frame also represents one of the six physician tasks. For example, initial care encounters emphasize taking a history and performing a physical examination. In contrast, continued care encounters emphasize decisions regarding prognosis and management.

USMLE Step 3 Specifications*

Clinical Encounter Frame

20%-30% Initial care
50%-60% Continued care
15%-25% Emergency care

Physician Task

8%-12% Obtaining history and performing physical examination
8%-12% Using laboratory and diagnostic studies
8%-12% Formulating most likely diagnosis
8%-12% Evaluating severity of patient's problems
8%-12% Applying scientific concepts and mechanisms of disease
45%-55% Managing the patient

• health maintenance
• clinical intervention
• clinical therapeutics
• legal and ethical issues

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

Primum® Computer-Based Case Simulations (CCS)

Step 3 examinees test using two formats: multiplechoice questions and Primum computer-based case simulations (CCS), a testing format that allows you to provide care for a simulated patient. You decide which diagnostic information to obtain and how to treat and monitor the patient's progress. The computer records each step you take in caring for the patient and scores your overall performance. This format permits assessment of clinical decision-making skills in a more realistic and integrated manner than other available formats.

In Primum CCS, you may request information from the history and physical examination; order laboratory studies, procedures, and consultants; and start medications and other therapies. Any of the thousands of possible entries that you type on the "order sheet" are processed and verified by the "clerk." When you have confirmed that there is nothing further you wish to do, you decide when to reevaluate the patient by advancing simulated time. As time passes, the patient's condition changes based on the underlying problem and your interventions; results of tests are reported, and results of interventions must be monitored. You suspend the movement of simulated time as you consider next steps. While you cannot go back in time, you can change your orders to reflect your updated management plan.

The patient's chart contains, in addition to the order sheet, the reports resulting from your orders. By selecting the appropriate chart tabs, you can review vital signs, progress notes, patient updates, and test results. You may care for and move the patient among the office, home, emergency department, intensive care unit, and hospital ward.

The cases used in the CCS portion of the Step 3 examination are based upon a CCS examination blueprint. The blueprint defines the requirements for CCS examination forms. The CCS blueprint is used to construct CCS examination forms focusing primarily on presenting symptoms and presenting locations. Presenting symptoms relate to the Step 3 Problem/Disease List and are associated with the central nervous system, eye/ear/nose/mouth/throat, respiratory system, circulatory system, digestive system, behavioral/emotional disorders, musculoskeletal system, skin/subcutaneous tissue, endocrine/nutrition/ metabolic disorders, kidneys/urinary tract, reproductive system, pregnancy/childbirth, neonate/childhood illnesses, blood and blood-forming organs, infectious/parasitic diseases, injuries/wound/toxic effects/burns, and health maintenance issues. Presenting locations include the outpatient office, emergency department, inpatient unit, intensive care unit, and the patient's home.

You will see cases related to some, but not all, of these problem/disease and location categories. The intent is to ensure that all examinees encounter a broad range of cases reflecting common and important symptoms and diagnoses. The selection of cases is also guided by specifications relating to age and gender. Each CCS examination form is structured to reflect a balance of cases that is fair and equitable for all examinees.

Details at www.usmle.org