How to Study for the USMLE Step 3

The old adage has been two months for Step 1, two weeks for Step 2, #2 pencil for Step 3. In reality, it’s probably more like two months for Step 1, 1 month for Step 2, and two weeks for Step 3. But if you are worried about getting that competitive cardiology fellowship, it’s hard to nurse the popular opinion that Step 3 is $815 pass/fail two-day pain-fest that you can simply walk in and take. That said, if you comfortably passed Step 1 and Step 2 and it hasn’t been years and years, you will pass Step 3 with nominal preparation outside of familiarizing yourself with the CCS software and the official sample cases. Step 3 is a normalized test, and because all residents put less effort into studying, you simply need to do less work to achieve the same score. I’d recommend taking it during your intern year, because the relatively fresh Step skills and knowledge from Step 2 CK are more important than the clinical acumen you will gain during residency.

Last updated: 12/31/2015

Your resources

A busy intern doesn’t have much time (or desire) to comb through any review book. If you only plan to dedicate 2-4 weeks part-time studying (which is typical), then all you really have time for is USMLEWorld. The question bank itself is around 1567 questions with 51 CCS cases. Forgo the books. Do the UW qbank and definitely do the CCS cases, and you might have time to go through the questions you’ve marked/gotten wrong a second time. Besides, UW now has an iOS app so you can do questions while your attending prattles on rounds. The questions are still hard and the test itself still feels awful, but because everyone studies less for Step 3, you’re likely to perform similarly to Step 1/2CK with only a fraction of the work. (The caveat is that if you struggled to pass Step 1/2CK, then you need to take this test seriously [of course].) If you still need or want more questions, BoardVitals is a common choice, and you can get 10% off if you’re interested by using code BW10.

Don’t forget to download the official USMLE Step 3 practice materials here, which contain the official software, some sample questions, and six CCS cases (which are a must do). If you don’t bother going through lots of example cases, at least do the six free cases to become intimate with the software.

If you have the time and desire to do a slow-burn and read actual books, you can (but probably shouldn’t/won’t). However, know that none of the entries from the classic series are really as good as their previous Step counterparts.

Crush Step 3 is the fastest, but it’s skeletal and fulls of holes as always. It’s definitely the only book that’s fast enough to blaze through. First Aid was recently updated and likely less out of date; it’s still that densely-packed outline format, which is less high yield and more difficult to get through than it used to be. Master the Boards USMLE Step 3 is probably the best “complete” book on a time and mental energy budget, but there’s still no way most interns will bother getting through it. USMLE Step 3 Triage is more targeted/high yield than First Aid, very readable and well-organized, with a nice conversational tone and a nice free companion website with practice questions [link dead] that anyone can use; unfortunately, it was last updated in 2008. You can also find some free questions on the Archer USMLE site.

As always, questions are most important, and UW is indispensable. Never use a book in place of questions. If you’ve spent a few days on a medicine service, an ER, done any general surgery, played with kids, or avoided poisoning a developing fetus, then your clinical experience will serve you well. But you don’t really need it—as always, this is a test. It tests your ability to take a test, not to be a physician.

A few words about the CCS (Computer-based Case Simulations)

Typically getting the diagnosis and the primary treatment are pretty straightforward. The finesse comes from two skills:

1. Get the diagnosis and management done quickly and efficiently. Do only the focused physical in an emergency.  Don’t order and wait for tests that delay proper management. The amount of virtual time that passes prior to certain diagnostic tests or interventions does matter. Don’t just be thorough when “time” doesn’t allow for it.
2. Know the related but fundamental orders. Using CCS is awkward. You have to order “patient counseling” and other things that you would simply do in real life. You also need to remember to follow up labs and the like. If you start methotrexate, you need to order a follow-up CBC and hepatic function panel.  If you diagnose someone with lupus, they need a renal biopsy. If you give someone a stent, they need clopidogrel. If someone is going to surgery, they should be consented. Statins and LFTs. Pregnancy test before giving teratogens to women. Etc. Keep these sorts of things in mind, and you’ll feel much better as you go through the cases.
3. That said, the little things matter much less than the key management (i.e. appendicitis requires surgery). Like Step 2 CS, you can forget to do a lot of things.

Before you start, it might help you to write out on the test-center sheet the common orders that you would otherwise forget to do so that you can be methodical in your approach (the kinds of things that just happen in the hospital), like starting an IV.

When ordering consults or inputting the primary diagnosis on the final screen, you may ask yourself, “I wonder how this is graded?” Do they have human beings read through more than 25,000 tests to determine if the words deserve credit? Is there an algorithm that checks the text for the presence of the correct words? The answer is neither. This text is not saved as part of the examination, is lost forever in the sands of time, and is in no way used for scoring. Interesting isn’t it? So it makes more sense to use the last two minutes on the final screen of each case to make sure your final orders are as complete as possible rather than making sure you have time to type up the diagnosis.

Recent changes in 2014-15

1. Being able to take the test on two nonconsecutive days is a good thing, both for scheduling flexibility and for test fatigue.
2. I see no reason to be overly concerned about the much-maligned “return of basic sciences.” Content changes for the Step exams have remained minimal for quite some time. It’s not as though the addition of “drug ad” style questions has meaningfully changed the prior Step exams or required a significant shift in study patterns. The basic sciences that will be invoked on this test are unlikely to be of sufficient quantity to matter to most takers and are also likely to be the most relevant or highest-yield bits from the old days—the stuff you are most likely to remember anyway. I personally wouldn’t worry too much.