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Recently took my Step 3 so I thought I'd do a quick, low-profile write up for those perusing the boards. I can't say if this strategy worked as scores are delayed during the first quarter of the year generally to do quality improvement so I have no idea how things went.

1. When should I take USMLE Step 3?
It really depends on where you match. Lots of primary care community programs or subspecialties will urge you to take it ASAP to get ancillary material not related to your field out of the way. If your program gives you a firm recommendation, I would take their advice because they probably have their reasons.

For those in IM/FM or who have the equivalent of a medicine year, I suggest taking it after year 1 as you gain some good clinical reasoning as an intern. More on that later. Some students may feel differently if they excel on board exams in general, but as an average US MD this is how I felt. IMGs likely have the stuff they need for this given they've done an intern year and they generally study for the USMLE Steps in close proximity and can afford to take it earlier.

2. What is the difference between Step 2CK and Step 3?

#1: The most apparent difference is CCS which is a case-based simulation you take at the end of day 2. Just like CS, you assume you're practicing independently and you're given random cases and you need to read hx, choose exam maneuvers, and search/place appropriately and the computer simulation responds based on what you do to the patient. Based on my practice, you're scored the highest for 1) timely, complete & accurate treatment 2) work up.

#2: Multiple choice questions are a bit harder. Obviously there are exceptions and overlaps, but this is how it is in general.

Step 1: Here is classic presentation, give us a diagnosis or identify the pathophysiology at play.
Step 2: Here is a less obvious presentation, give us diagnosis or initial step.
Step 3: Here is a less obvious presentation, you need to presume the diagnosis and give us the next step based on the situation.

Ex. 1) Pyloric stenosis with the only clues being the demographics/electrolytes hidden in an otherwise long stem. The answer choices will be A) ultrasound, B) fluids, C) ex-lap, D) abdominal XR which you'd only get if you first got the dx and correctly knew that resuscitation>diagnosis. True this is basically fair game for CK now, but I chose this example because medical students will understand it and most got it wrong the first time unless they were lectured about it or heard what OnlineMedEd had to say about Pyloric Stenosis.

Ex. 2) Cryptococcal Meningitis. The presentation won't be the most difficult thing. When you get to the choices, you're going to see A). Amphotericin B) Amphotericin+Flucytosine C.) Mechanical Intubation D.) Lumbar Puncture E.) VP Shunt. These are all pretty reasonable things to do at some point of the diagnosis but you have to read the prompt which may for example say patient is unresponsive in which case the answer is C, intubate the patient.

Ex. 3) PCOS with only clues being amenorrhea and LH/FSH. No comments about overt hirsitism or follicles on the ultrasound. The choices are A) Combined Oral Contraceptives B) Metformin C) Clomiphene D.) Spironolactone. This threw me for a loop because I didn't even immediately recognize this as PCOS but when I read the answer choices I reverse deduced it was probably what was being referenced, but then blindly picked Metformin as I'd memorized that as a first line. I missed the line in there saying she was interested in having kids.

As you can see, it tests more on more nuanced situations and I think a medicine intern year helps as most the test is general medicine. If you're FM/EM, even better! You've probably retained more Peds/OB-GYN.

#3: The test is 2 days with each day being different. The questions are all over the place on Day 1 and focus on basic science. There are actually quite a bit of basic science questions that may seem like it they could have made its way onto Step 1 in all fairness. It would not hurt to review USMLE First Aid for Step 1 briefly before the exam (the week before, don't focus too much on it during the meat of your prep). Secondly, drug ads and biostats principles are hammered hard so make sure you're comfortable with them. Practice them daily. Day 2 is more of the questions you prepared for on UWorld and then CCS at the end.

3. How Should I Study:
This question is really a function of how much time you have. Residency's busy so no one has a lot of time or $$$. I recommend keeping it simple. Give yourself 2 months. Do UWorld in a random order with 40Q/day. I did timed tutor, but it's up to you. Then find a vacation block (2 weeks) and do UWorld again by system with 120Q/day (systems go way faster as the same concepts repeats themself). Take a practice test before your first pass and after your first pass. Don't worry about the scores so long as you're passing. Two major things you need to tackle early are biostats and CCS. Try to hit a biostats concept every day and get in the habit of practicing biostats questions. I recommend getting a large piece of paper or a white board and drawing the 2x2 table and writing formulas on there and referencing it often. The same thing goes for CCS in terms of practice so do a few cases daily so you know how to play the game. After you feel like you're going to gouge your eye out if you do more questions, switch to a comprehensive lecture series a few days before the test. OnlineMedEd was for Step 2CK and you'll think it's basic but it works for Step 3 too.

My vote for resource goes to CCScases.com. For one, it's 100 interactive cases which is better than UWorld (even if you don't have time for 100, do every 4th case and try to cover equal amounts of Peds, IM, etc.). Second, it actually grades how you played the simulation. UWorld is not as interactive because the simulation responds but then you're left to read their one page summary without any input on what you did. Chances are you're not learning as much. The downside is it's $60ish. I would start cases on day 1 of prep and do 4/day if you have time and 10-15 a day if you're cramming. Then I would schedule exam day 2 a few days apart from day 1 and drill cases a second time in the gap. Now in terms of the actual strategy, I think everyone's biggest fear is to get a case where they don't know the diagnosis and just stare at the screen. That hardly happens. Where I think people lose the most points is 1.) Accurate management 2.) Work Up.

Ex 1) AF case, they give you an elderly vasculopath, palpitations recently, recent EtOH use, history of hyperthyroid. irregularly irregular rhythm @ 124 but stable... slam dunk Afib and you're like I got this...let me get the BB, let's A/C her on DC, let's get an ECHO, consult cardiology to see if she's a CV candidate. That's going to score you points for management, but if you don't order a TSH/Magnesium to rule out basic stuff, you're going to lose lots of points. Also, if the patient was syncopal, getting stuff to rule out syncopal etiologies is important. Also, notice the 4 components to treatment. If you miss 1 of the 4, that's still a decent # of points.

For an IM resident, knowing how to manage a 3rd trimester bleed was uncomfortable and for a OB/GYN resident knowing how to manage Cryptococcal Meningitis (comprehensively with serial LPs, specific antifungals, etc) probably feels the same way so its important to practice lots of diverse cases which CCScases gives you. Doses and durations of meds are not tested, just their routes (ex. make sure you're doing oral vanc for c. diff in adults). There are also lots of small ways to lose points (they expect you to do full screening before leaving the case which includes colonoscopy, mammogram, etc.) but it's best you leave that for the end because they give you two minutes after the case ends to input follow-up/screening stuff so you're not missing a critical treatment during the case. The health maintenance stuff is a much smaller part of the grade unless it's the focus of the case. Overall you don't have to be perfect and there's probably a forgiving curve, but you need to do the big things rights so practice.

4.) What does the score matter for?
I wrote this long ass post. Doesn't Step 3 not matter? Yes it doesn't...so long as you pass it probably hardly matters. Don't judge me based on how I decide to spend my time. I wrote this because I craved more direction before I started studying and there's not a lot of good information out there. Anyways, the good news is that when you pass Step 3, you can apply for a full medical License (as you've completed USMLE 1,2,and 3). Provided you complete your intern year, many programs will allow you to moonlight. Most IM programs and IM fellowships (which everyone always asks about) will not really care for your score as long as long you didn't bomb it. Even with a mediocre/below average score you should be OK provided your other steps were good. Maybe with Step 1 being P/F it may gain some more importance, but who really knows. Point is, it shouldn't keep you up at night.

5.) Other Resources:
- If you're really weak in Step 2 CK stuff (I was) I actually purchased a short UW2 subscription and did OB/Peds because I was super weak in these areas. I also reviewed OME for these areas while doing questions just because I sucked at OB/GYN so much because I wasn't even getting the diagnosis for these multi-step Step 3 questions so I had to go back to the basics and refresh basic differentials for neonatal jaundice, third trimester bleeding, etc.

-NBME Comprehensive exams are another practice exam source. Use it less for predicting your score and more to learn.

-USMLE First Aid for Step 1. I kept it in PDF alongside me and occasionally searched terms. I found it more helpful than USMLE First Aid for Step 3 which reads more like a textbook.

That's really it! Good luck.
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