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[MEHMET EREN YUKSEL]

USMLE Step 3   http://www.usmleweb.com/usmle_step3.html
 
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. Step 3 provides a final assessment of physicians assuming independent responsibility for delivering general medical care. 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 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.
It is a two-day computerized test in clinical medicine consisting of mulitiple-choice questions and computer-based case simulations (CCS). You must complete each day of testing within 8 hours. The first day of testing includes approximately 350 multiple-choice questions divided into blocks of 25 to 50 questions that have to be completed within 30 to 60 minutes. There is a maximum of 7 hours of testing on the first day, plus 45 minutes of break time and a 15-minute optional tutorial. The second day of testing includes approximately 150 multiple-choice questions and computer-based case simulations (CCS). The questions are divided into sets of 25 to 50 questions; each set takes from 30 to 60 minutes and must be completed within 3 hours. After answering the multiple choice questions there is a CCS tutorial for which a maximum of 30 minutes is allowed. The CCS tutorial is followed by approximately 9 case simulations using new, proprietary simulation software called PRIMUM. The case simulations are presented in 1 or more cases per block and 3 hours, 45 minutes are allotted for them. The allotted break time for the second day is also 45 minutes. Taking Step 3 before residency is critical if the IMG is seeking H1B visa and is a bonus that can be added to the application for residency. Step 3 is also required for a full medical license in the US and can be taken during residency for this purpose.
Step 3 Specifications:
 
Physician Task:
1) 8 ?12 % Obtaining History and Performing Physical Examination
2) 8 ?12 % Formulating Most Likely Diagnosis
3) 8 ?12 % Evaluating Severity of Patient?s Problems
4) 8 ?12 % Applying Scientific Concepts and Mechanisms of Disease
5) 45-55 % Managing the Patient
i) Health Maintenance
ii) Clinical Intervention
iii) Clinical Therapeutics
iv) Legal and Ethical Issues
6) Clinical Encounter
7) 20 -30% Initial Work-ups
55-65% Continued Care
9) 10 ? 20% Emergency Care
Eligibility: Most states require that applicants have completed one, two, or three years of post-graduate training (residency) prior to applying for Step 3 and permanent state licensure. The exceptions are the 11 states: Arkansas, California, Connecticut, Florida, Louisiana, Maryland, Nebraska, New York, South Dakota, Texas, Utah, Washington & West Virginia, which allow IMGs to take Step 3 at the beginning of or even before residency. So if you don?t fulfill the prerequisites to take Step 3 in your state of choice, simply use the name of one of the 11 states in your Step 3 application. You can take the exam in any state you choose regardless of the state that you mentioned on your application. Once you pass Step 3, it will be recognized by all states. Basic eligibility requirements for the USMLE Step 3 are as follows:
? Obtaining an MD or DO degree (or its equivalent) by the application deadline
? Obtaining an ECFMG certificate if you are graduate of a foreign medical school or successfully completing ?fifth pathway? program (at a date no later than the application deadline)
? Meeting the requirements imposed by the individual state licensing authority to which you are applying to take Step 3.
Application materials: Step 3 applications can be found online at www.fsmb.org and must be submitted to FSMB. Step 3 is administered only in the US.
Eligibility Period: A three month period of your choice.
Fees: The fee for the 2005 Step 3 is $625 for all state medical boards with the exception of those boards listed below.
Iowa $675
Mississippi $725
South Dakota $775
Vermont $660
Retaking: In the event you failed the test, you can reapply and select an eligibility period that begins at least 60 days after the last attempt. You cannot take the same Step more than three times in any 12-month period.
Test Delivery: The NBME software, known as FREDTM, will replace the Prometric software in USMLE Step 3 in the fall of 2004. Installation of FRED for USMLE Step 3 will be phased in over several weeks in October 2004. If you schedule to take the Step 3, with a test date during the month of October, you should familiarize yourself with both the Prometric test delivery software and FRED.
The FRED software allows you to highlight and strike out item text as well as create annotations to items. Please note that the annotation feature allows you to record brief notes to yourself about individual items; it is not intended as a way to communicate to USMLE staff members. There is no additional time granted for use of the additional features provided by FRED, so you should closely monitor examination time when using these features.
The change to the FRED software will be accounted for in scoring the examination results, so that scores will be comparable to the Prometric software. Because of this change, along with other changes in the Step 3 test item pool, it will be necessary to delay the reporting of scores of some examinees for an additional 3-4 weeks beyond the normal turnaround period. The normal turnaround period for Step 3 examinees is 4 to 6 weeks. All efforts will be made to minimize these delays.
Score Reporting: The score report consists of two scores- a two digit and a three digit score. Both scores reflect your overall performance on the examination. The number of test items you answered correctly is converted to two equivalent scores, one on a 3-digit score scale and one on a 2-digit score scale. Both scales are used for score reporting purposes. The new minimum passing score for Step 3 is 184 implemented in April, 2004.
Statistics: For 2000 and 2001, the pass rates for first-time takers from LCME-accredited US and Canadian medical schools were 95% and 94%, respectively, whereas for non-US graduates/students, the pass rate is 61%. For 2002 and 2003, the pass rates for first-time takers who were graduates of MD-granting US and Canadian medical schools were 95% for both years, whereas, for non-US graduates/students, the pass rate is 68%.
Books Recommended:
a) Crush Step3: The Ultimate USMLE Step3 Review
b) NMSReview for the USMLE Step 3 (Book + CD-ROM)
c) Appleton & Lange's Review for USMLE Step 3
d) Medical Boards Step 3 Made Ridiculously Simple
e) Kaplan Medical USMLE Step 3 Q book
f) Blueprints Computer-based Case Simulation Review: USMLE Step 3
g) Mosby's USMLE Step 3: Comprehensive Review
h) Swanson?s Family Practice Review
i) Washington Manual of Medical Therapeutics
Step 3 Courses available:
a) Center-Prep USMLE Step 3 - Kaplan
b) Live Prep for USMLE Step 3 - Kaplan
c) Med Pass USMLE Step 3 - Kaplan
d) Deluxe Prep USMLE Step 3 - Kaplan
e) UMKC Institute for Professional Preparation
MCQs and CCS for Step 3:
a) USMLE-World
b) Q bank USMLE Step 3 - Kaplan
c) Kaplan Medical USMLE Step 3 Q book
d) Exam Master On-Line - USMLE Step 3
e) American Family Physician Clinical Quiz

http://www.usmleweb.com/usmle_step3.html

[MEHMET EREN YUKSEL]

Step 3 experience:


-If you are travelling across timezones, arrive at your exam city two days prior to adjust. It is a long and tough exam, requiring max concentration.

Day 1 is tougher, I feel. There are seven one hour blocks of MCQs. On either day, you have 1min 15 secs per question, and you'll need it because the questions are long.

-Because of the above, ALWAYS READ THE ANSWERS FIRST!
This will focus what you are looking for when scanning the question. For example, the actual choices may be about what ethical decision to make, but the body of the question will contain lots of technical waffle.

-Focus your studies on satellite/office settings. This is the bulk of the exam. In fact, those of you with family practice experience will love Step 3.

Day 2 includes ~3 shorter blocks of questions, followed by CCS.
Now on to CCS which is what this posting is mainly about:

-The CCS is really good fun to do actually! Very enjoyable.
The cases (nine in all) are usually quite easy to diagnose. The issue is how to manage them appropriately.

-Before doing the actual exam, you MUST play around with the five sample scenarios that you are given by USMLE. You should also do practice scenarios and think yourself through the case.

-When you start, you are given a one sentence introduction, like: "a 45 year old white man attends complaining of severe chest pain."

Next, you will be shown the History of the Presenting Complaint, plus PMH, DH, Allergies, FH, ROS, etc.
Up to this point, you have no options, you just have to read through and note the key points.

Before you leave this page, you should do the following:
-Decide on a NARROW differential diagnosis (yes, even before any physical exam has been done).
-Make note of allergies, so you don't accidentally administer the wrong Rx.
-Make note of risk factors like smoking, obesity, hyptn, etc., and at the end of the case, you will win points by COUNSELLING your patient about these. [in the Order page, you can type 'counsel' and click, which will show you all the choices of things to counsel on]
If pertinent, you can also end your case by ordering sensible screening tests, like mammography, pap smear, etc

Okay, now that you have read the full history and decided on a narrow differential, you must next answer this very important question:

Is the patient stable?
ie. will I need to do anything right now?

If yes, do not waste time proceeding to the physical exam, this is inappropriate. Imagine yourself physically there. If you had a man with severe chest pain before you, would you do a thorough exam first? No. You'd immediately bang on some oxygen, pulsox, iv access (for pain relief, among other things), EKG and portable CXR. Don't forget ABCs, ever.
And if indicated, do not forget obvious tests like: ABG, PEFR, serum glucose, urinalysis!
They are so routine that you might forget about them.

And another important point, what if this happened in an 'office'? You could get away with applying oxygen and perhaps an iv line/analgesia (if the simulator lets you), but you must very soon 'move location' to ER, where you can carry out further management.

If your patient is quite unwell, you will be justified to do lots of emergent things before the actual physical exam. Once you have done those, move on to the PE and click which systems you want examined. A cardio/resp/abdo exam should always be in there, I think, .. plus any other relevant ones.

Once you have read the PE findings, you will be able to narrow your differential even more. And, for example, once the CXR & EKG & blood results come back, you will have a primary diagnosis.

This will be the time to start specific management.

If you have ordered a number of tests and are waiting, you can move the clock forward to get those test results.

If your management is working, you will get feedback like 'the
patient appears less breathless' or 'more comfortable'.

If you've gotten the diagnosis & therefore the management wrong, you may see feedback like 'the patient is getting more breathless', etc.

Remember the location! If your patient is quite unstable, eg. acute heart failure, MI, DKA, pneumothorax, MOVE THEM TO THE ICU. (In the USA, generally DKAs and pneumothoraces are cared for in ICU). If necessary, give them a central line, or PA catheter, or arterial line. If immobile, remember heparin.

If you see a well patient in an office, with a minor complaint, there is no need to rush. You have time to examine them. Then order any tests if necessary. If you need those test results to get your diagnosis, don't leave the patient hanging around in your office all day and all night!

Every test you order will show you what time/day it will be back. In an office, most blood tests take about a day. So, send the patient home (with analgesia or whatever else needed) and give them an appointment to come back when the test results are ready.

Particularly in an office setting, you may need to see your patient two or more times over a few weeks, to make sure they are getting better. So, for example, if you see someone with Fe deficiency anemia, don't just give them some ferrous sulphate and counselling, and not see them again!
And always remember to counsel them as required, eg. drug compliance, smoking cessation.

Altering patient location also applies in the reverse. If your patient on ICU is much better.. send them to a normal ward.

Remember that you will not benefit from overtreating. If you
do an invasive or expensive procedure when not warranted, you risk losing points.

You are expected to be the primary physician to the patient.
But in general, you will not be able to carry out specialised things like evacuating a subdural hematoma. So, if you need to order a specialised procedure, you will need to involve the relevant specialist.

By typing 'consult' in the orders page and clicking, you will get a choice of specialists.

BEFORE you refer to a specialist, you must have enough evidence of your reason for referral, otherwise they won't come. I'll clarify, if you see a patient with a cough, the pulmonary meds will most likely decline your referral. But if you perform imaging on the chest that shows a discrete lesion,
not only will you interest the pulmonologist, but perhaps also the oncologist. So my point is, you must have solid evidence for a referral, eg. by imaging.

Once you refer, you may find that they go ahead and operate on the problem.

[MEHMET EREN YUKSEL]

http://www.imgi.org/

http://www.imgi.org/

[MEHMET EREN YUKSEL]

                                         USMLE STEP-3
http://www.geocities.com/Baja/Canyon/2166/step3.html

Step-3 is a computer based 2 day test comprising of 7-8 blocks of MCQs type questions on day-1 and 3-4 blocks on day two morning session. Afternoon session is Computer cases simulation (8-9 cases on computer, where you manage patient in different settings like in real life). Every block has like 30-55 questions depending the time limit which could be from 30 min to one hour. One key concept of the step-3 exam is that you should know that they are gonna ask something from Clinical SCIENCES, like steps of management, diagnosis protocols, level of treatment, a lot of points in ethics and medical communication, a lot of recent research stuff or recent happenings like GULF WAR syndrome. Weird questions which the patient ask during your own clinical practice. They assume that you know the diagnosis and sometime the intial basic level of management when they ask more advanced level of treatment. PLS. scroll down to look for helpful books for step-3 test...

 It is a more clinical exam but I would say it is easier than USMLE step-2. There are a couple of reasons for that:

 1. In this exam you have an idea that which environment you are working in, because at the start of every section
there is a "heading" which tells you in which environment you are working.

 2. The other thing about the exam is that it is totally clinical and relatively few questions are on the basic sciences.
So you know pretty much that the answer for a certain question has to be clinical not basic and you don't have to
study biochemistry and other basic details.

 3. This exam is basically testing your clinical knowledge at different settings like emergency room, rural health
clinic, primary health clinic and other specific areas, so you have an idea about the answer.

 For instance if there is question about a certain patient and you are sitting in a rural health clinic then obviously
you are not supposed to tick the answer choices which are like high-tech diagnostic tests (CT, MRI etc..), because
in that clinical setting you don't have these equipment......... 

 Anyway, step-3 exam is easier and if you are taking it after 01 year of residency then I think you do not need much to study.

 Without a residency you should prepare the medical ethics and psychiatry topics very well.

 The toll free no. for USMLE step-3 is 1800-USMLEXM (1800-876-5396) or visit the internet at (www.usmle.org), so contact them for your application forms and ask them if you have any specific question.

Step-3 scores are applicable in all state boards and it does not matter whether you pass it in New York or
elsewhere.......... 

COMPUTER BASED STEP-3, CBT

Dear friends, CBT step-3 is not much different, the exam still has 75% MCQs and 25% computer simulated cases (CCS-primum). Total two days, 1st day all MCQs blocks, 2nd day 1st half is MCQs blocks and rest are CCS clinical cases. MCQs are similar as they were in paper-pencil exam. The simulated cases are not too much different only difference is that it is interactve. Some of the good advices from the residents are:

1. Do these cases exactly the way you are trained in your residency programs, follow the standardized protocols you learn during residency.

2. Apply common sense and general medical knowledge as much as you can if you dont know the right answers.

3. In office settings and if specially the patient is coming for first visit, do the complete physical exam. In ER do the limited focused physical exam.

4. The frequently encountered problem is to forget about the clock forwarding settings, so keep in mind to forward the clock.

Some unusual cases, which need attention for management point of view are Turner's syndrome, Alzheimer's, Mental retardation, Congenital syndromes (Down etc..), These were the unusual cases my friends recently got in step-3 and I think they need extra attention.

Please follow the lik below for clinical cases..

Clinical cases on the internet helpful for step-3

 

Important notes from some of recent Step-3 exam

Exam notes from October 2000-2002, CBT:

quite a number on Gulf war syndrome questions and also brest implants, genetics chart and questions about that remember the old Autosomal dominant and recessive basic stuff. Tons of derma pics, some x-rays, and some ECGs. some questions on drugs like under trial or recently FDA approved like a patient would come in with news about the drug (like raloxifene) and how would you advise the pstient on that drug, things like that sort or the drugs FDA has recently disapproved. a lot of ethics questions and situational communication skills, like what would be the best response to the patient.

for clinical cases a lot of people have said HTN, DM, and most common in OB/Gyn are vaginitis cases on step-3. also follow link on my page for USMLE forums, its helpful. people have discussed their step-3 experiences on that forum.

some other notes about previous exams:

A couple of my friends took the exam, but they were mostly taking it without residency experience. One common thing, which all told me is the over all exam idea about management and treatment stragtegies. Since I have not tken it so I would try to put in my friend's words.

Step-3 is basically more of management, ethics and problems which a resident deals in his routine clinical life. It could be an abused woman neglected child or could be step wise treatment of cancer pain. this kind of question is not very common in step-2 but in step-3, quite common.

Generally most questions with HTN, Diabetes, Afro-American people, and quite a no. with thyroid and BPH (prostate Hypertrophy).

Aspirin/acetaminophen toxicity, 10-15 questions. General preventive exams at different aged/sex people. Cancer pain management step-wise. geriatric pts. mostly with stroke and parkinson and some with multiple sclerosis.

male CA: lung (stages and treatment), prostate, testes

female: breast, cervix, endometrium

all skin cancers : basal cell, squamous cell, melanoma, skin slides, derma pictures, common diseases.

derma pictures of lyme disease, rocky mountain spotted fever.

ophthalmoscopic slides of HTN, DM.

some questions on glaucoma, and all types of conjunctivitis.

ENT questions mostly ear infections.

pulmonary embolism with DVT, specific tests/treatment.

endocarditis-prophylaxis, HTN in detail, with drugs and interactiona dn HTN with DM (which drug), HTN with asthma, these were very common questions.

pediatrics infections, croup, epiglotitis, bronchiolitis.

headaches types, myesthenia gravis, Carpel tunnel (usually with acromegaly and hypothyroid).

psychiatric patients and thyroid in reference to lithium, PTU drug and side effects. a lot of pharmacology, drung interactions.

DM , treatment, dose maintenance, lipid profiles in disorders and specific drug of choice.

cardiogenic shock, hemothorax, trauma,

blood anemia, neutropenia and infections, thrombocytopenia, HS purpura, sickle cell pain, anemia pictures.

GERD, raised liver enzymes, two spleen cases both traumatic.

lump breast diagnosis and treatment age wise.

SLE, temporal arteritis

dehydration, electrolyte balance, potassium (very important),

kidney, mostly GN, all types and specific points., UTi post coital drugs, long term repeated infections. incontinence in old ladies.

epilepsy, loading dose, drugs and pharmacology.

biostatistics, and very less questions on AIDS (this is unusual).

ENT question with follow up upto one year, like ear fluid and ear ache, RX immediate adn when pt. comes back with same problem after 3 wk, 6 wk, and 12 wks.

myringotomy pts. ..what to advise the parents.

pt, minor age dying from trauma, ethical question on transfusions..

pt. advance directive signed and the person responsible dies before the patient. what to do if pt nees treatment.

removal methods for tatoos.

this was the review from the friends who took the exam, do send comments and notes if you took the exam too...

The books to study for this exam are:

Dear friends, I recently took KAPLAN course for step-3 (MAY 2000). It was a good motivational course. All they told us is to concentrate on exam based study not medical knowledge. So it is an exam of pretty much current knowledge but not like FDA approves something yesterday and its gonna be on exam. So you have to be careful. The books for this exam are not very much defined but the best you can do is practice all MCQs available for step-3 and the books I have mentioned below.

The books like Mosby's Ace the boards and Washington Manual and Fred Ferri are recommended. You should also consult NIH web site for latest development (HTTP://www.nih.gov). The other thing you can do is just review your basic concepts of Medicine (70-75% exam is gonna be Internal med). Rest the exam would be a lot of ethics, medical communication questions, so be ready for those subjective types of MCQs.

New edition 2000 of Family Practice review by Swanson has arrived . i dont know how good it is but you might wanna check out...It was a good book 3 yrs ago when the author was alive but since then it has not been updated and 33% of information in this book is out dated. So it's not now the no.1 choice for MCQs practice any more. So it's upto you if you want to buy this book or not...
4. USMLE step-3 review, Ace the boards, review by Mosby's for step-3...
ONly MCQs for step-3, good for practice....highly recommended ..
the above two books would be good enough if you have finished one year residency training in USA. I think without residency you should read some more books like mentioned below..

Medical/Clinical Ethics books for STEP-3

1. Clinical ethics : a practical approach to ethical decisions in clinical medicine by Albert R. Jonsen, Mark Siegler, William J. Winslade..... ...... Order clinical ethics, Today!

2. Practical ethics for students, interns and residents: a short reference manual by Charles Junkerman, MD and David Schiedermayer, MD. ...... Order practical ethics, Today!

Boards and wards for step 2 and step-3....
 

A lot of other practice question books and review books are now available all at AMAZON.COM for reasonable prices... following is a list of all books with prices...

1. Crush Step 3 by Adam Brochert

2. Swanson's Family Practice Review by Alfred F. Tallia (Editor), et al (same as i mention ealier)

3. Appleton & Lange's Outline Review USMLE Step 3 by Joel S. Goldberg (Editor)

4. Review Questions for the USMLE, Step 3 Examination by Arshad Majid (Editor)....

5. Appleton & Lange's Review for the USMLE Step 3 by Samuel L., Md. Jacobs

6. Blueprints Q&A Step 3 by Michael S. Clement, Gregory A. Maynard (Editor)........
7. NMS Review for the USMLE Step 3 (Book with CD-ROM) by Mitchell H. Rosner, Andrew E. Lazar



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3. Southland tutorials MCQs for usmle step-3. These are recommended also for practice MCQs, South land series is good but too difficcult.
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. Books for step-3 and to read during residency....

Internal Medicine and Pedi

For antimicrobial therapy, this book is highly recommended.

Sandord Guide To Antimicrobial Therapy, 2000 (pocket edition) by Jay P Sanford .

2. Washington manual of medicine.

Washington Manual ..... ......

3. Fred Ferri Medical series

Practical Guide to the Care of the Medical Patient by Fred Ferri, MD.... .....
For pedi House staff (residents, the book to follow ), is Harriet Lane manual.

Harriet lane manual of pedi.... ....

For surgery House staff (pocket manual of ScHWARTZ)

Highly recommended Mont Reid surgical handbook......

Schwartz surgery manual pocket.... ......

For OB/Gyn House staff (pocket manual of Ob/gyn)

Ob/Gyn and inferility, hand book for clinicians, resident survival guide by GORDON.... .....


Also good series for step-3 and Int med board exams.

Others:

1. Med-study series booklets or MKSAP (it is very good and should be studied for quick review)

Medstudy booklets.

Reasons to do Step-3:There is an

Extra benefit for IMGs/ FMGs, if they pass USMLE step-3 before residency, they would be eligible for
H-1 visa which is much better than the usual J-1 visa for residency.

Most of the states in US requires that you should pass your steps 1, 2 and 3 with in 7 yrs. as a requirement for state medical boards but its my impression that if you dont pass the 3 steps in 7 yrs and they change the system like they did earlier from FMGEMS exams to USMLE then your step-1 and 2 would be disqualified if they bring in some new exams series. and you will have to do the new exam series. So it is better to pass the exams in 7 yrs.

visit for all info on state medical licensure requirementsFederal state medical board