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USMLE Prep STEP3

The purpose of Step 3 is to determine if a physician possesses and can apply the medical knowledge and understanding of clinical science considered essential for the unsupervised practice of medicine, with emphasis on patient management in ambulatory care settings. The inclusion of Step 3 in the USMLE sequence of licensing examinations ensures that attention is devoted to the importance of assessing the knowledge and skills of physicians who are assuming independent responsibility for providing general medical care to patients.

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, in-patient 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.

Clinical Context of Step 3

Step 3 is the final examination in the USMLE sequence leading to a license to practice medicine without supervision. 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. In addition, the items in each test are usually arranged by the setting in which the encounter first occurs. There are four settings described here. To help orient you, each setting is described at the beginning of the corresponding test block.

The expected outcome of the USMLE process is a general unrestricted license to practice medicine without supervision. Although you may already 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. The laboratory values, included as an on-screen reference in the sample test materials, are the normal ranges for this hospital.

Step 3 patients are intended to reflect the diversity of health care populations with respect to age, sex, cultural group, and occupation. The patient population mix is intended to be representative of data collected from various national databases that study health care in the United States.

Step 3 Clinical Settings

The multiple-choice items are organized into blocks that correspond to the clinical settings in which you will encounter patients. Each setting is described at the beginning of its block; these descriptions are shown here as they would appear during your examination.

Setting I: Community-based Health Center

This is a community-based health facility where patients seeking both routine and urgent care are encountered. Hospice and home care are included here. Students from a nearby small university use this setting as a student health service. Several industrial parks and local small businesses send employees with on-the-job injuries and illnesses and for employee health screening. Usually the patients are being seen by you for the first time. There is capability for x-ray films, but CT, MRI, and tests such as echocardiography must be arranged at the medical center.

Setting II: Office

Your office is in a primary care generalist group practice located in a physician office suite adjoining the hospital. Patients are usually seen by appointment. Most of the patients you see are from your own practice and are appearing for regularly scheduled return visits. Occasionally you will encounter a patient whose primary care is managed by one of your associates; reference may be made to the patient's medical records. Known patients may be managed by telephone, and you may have to respond to questions about information appearing in the public media, which will require interpretation of the medical literature. The laboratory and radiology departments have a full range of services available.

Setting III: In-patient Facilities

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 home/extended-care facility and the detoxification unit.

Setting IV: Emergency Department

Most patients in this setting are new to you, but occasionally you arrange to meet there with a known patient who has telephoned you. Generally, patients encountered here are seeking urgent care. 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.

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