Step 3 preparation by Puneet Baweja

Hi all the following post is by Puneet in regards to preparation for Step 3.

Preparation Materials: Master The Boards Step 3, Step 2 CK UWorld notes, Uworld qbank and CCS. 

Preparation: Go through MTB properly once before starting qbank. I added in ccs portion about halfway through the qbank. I had about nine days between the two parts, therefore, the week before each exam I concentrated only on the relevant material. 

Day 1 - Foundations of Independent Practice (FIP): This is basically CK along with basic science correlations. Concentrate on your uworld CK notes and all the basic science in MTB. As for Biostats, go over all the cases in uworld once a couple of days before and create your cheat sheet for the equations. In the real exam, Biostats use up a lot of time therefore if it seems like it could take a while just click something and move on… come back to it if you get time at the end of the block. 

Day 2 - Advanced Clinical Medicine (ACM): This is all about managing comorbidities, risk and prognostic factors. Go over your step 3 uworld notes for this. So make sure you know which risk factor matters more in each patient and know where to pick treatment over investigations. Don’t even bother looking at biostats or basics anymore. Your notes for CCS will help here as well since it’s all management, therefore, don’t wait too long to start CCS. 

CCS: This again requires work if you’re not a resident. Familiarize yourself with the software, it’s all about practice. Approach this like CS- Have a plan of what to do and which differential diagnosis to suspect depending on patient history. Know how to order each investigation in the most convenient way, as in type in oxy to select oxygen therapy as well as pulse ox at the same time. Also, the week before day 2, as I went through MTB, go over all the diseases a general physician should be able to treat in CCS manner. This way you won’t forget the specific investigation and treatment in the real exam. Also, don’t forget to go over the ccs software on USMLE's website since it’s a bit different than uworld.

Best of luck!

Puneet
drpbaweja@gmail.com

Step 3

This post is more on the exam than on a study plan for sure since I feel that is more confusing than the study preparation itself. Basic format of the NEW exam is as follows

DAY 1

• Total exam duration - 7 hours
• Has 6 blocks – 42-43 questions with 60 minutes for each block.

DAY 2

• Total exam duration 9 hours in total. Has 2 parts
• Part 1 –

o   6 blocks with 33 questions and 45 minutes for each block.

• Part 2 – (CCS)

o   13 case simulations with each being either 10 or 20 minutes in length.

The MAIN change according to me is in the scheduling of the exam. I mean in the new pattern you can schedule day 2 of your exam at a different date but at the SAME test centre and within 14 days.

Materials I used:

1. OLD MTB 3
2. USMLE world - Qbank, CCS, UWSA
3. Archer introductory videos

The general question on everyone’s mind at the moment I think is should I read my basic science book like 1^st aid for Step 1 and go through biochemistry and learn the enzymes and also to buy the new MTB 3 (I have not read it so not sure about MTB 3 new addition) My advice would be a firm NO, as I feel step 3 is basically the same as CK but they are more focused on the management aspect of the patient and how you can apply your BASIC science concepts. At least for me it wasn't like step 1 where I had to mug up a couple of enzyme names and know the deficiency of which causes what and so on and so forth. My advice would be prepare the same as you would for the old step 3 examination. In addition to the Uworld qbank do the Uworld self-assessment test and USMLE.org practice materials.

Coming to the CCS part of the exam I felt this part was my Achilles heel. I would highly recommend doing the Uworld CCS cases as many times as possible and read the explanation. Also Uworld also gives you a PDF handout for 40 to 50 cases which I think is good enough. Furthermore to help in CCS there is a person called Archer who has a course.  I recommend watching his CCS Strategies video which is 2.45 hours long which gives you a quick over view of CCS. Also do the CCS cases that USMLE has on their web site.

The difficulty of the questions were essentially according to me like Step 2 CK, but as I do not have my result I would not like to say anything for sure. Also I felt day 2 was tougher than day 1 but some guys I spoke to felt both days were easy. Any how my study time was around a month and a half technically with studies being in between interviews and Christmas festivities. At the moment as my result is unknown I cannot exactly say whether it was sufficient or not but hoping for the best.

Good luck to all who are giving it soon!

(Update 25th March 2015- Pass)

Step 3 application process

1. Go to http://www.fsmb.org/
2. Top right hand side click on Sign in -> USMLE Step 3
3. Create Account and then fill in the details as it is explained
4. Once the account is created, login and register for the examination. There is only 2 month eligibility period. Please Note that you have to be ECFMG certified in order to apply for the exam – in other words pass Step 1, Step 2 CK and CS ALONG with graduating from your medical school.
5. Once done you will be asked to print a Certification of Identity form. Fill this form and get it notarized either in your home town or in the States should you happen to be there. Mail this form to the address mentioned in the form. Wait for them to confirm and that is it.

Just FYI I did my notarization in India prior to coming to the States. Hence just in case people are confused whether it is valid the answer is yes. You can get the Certification of Identity Form in the following link along with the requirements prior to completing the application.  http://www.fsmb.org/licensure/usmle-step-3/requirements. You can use the US postal service to mail the notarized form should you happen to be in the States.

P.S.-  There is no individual State requirement to be filled out now post the new format just in case people are confused about it as I was initially.

U.S. Preventive Services Task Force Recommendations

Summarized version of the latest USPS Task force recommendation. This is used in the USMLE Step 2 CK as well as Step 3.

Link to the post as well as PDF copy at the end of the post :)

Population	Recommendation
Abdominal Artery Aneurysm
Men Ages 65 to 75 Years who Have Ever Smoked	The USPSTF recommends one-time screening for abdominal aortic aneurysm (AAA) with ultrasonography in men ages 65 to 75 years who have ever smoked.
Breast Cancer
Women, Age 50-74 Years	The USPSTF recommends yearly screening mammography for women 50-74 years.
Women, Before the Age of 50 Years	The decision to start regular, yearly screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient's values regarding specific benefits and harms.
Women, 75 Years and Older	The USPSTF concludes that the current evidence is insufficient to assess the benefits and harms of screening mammography in women 75 years and older.
Women who have Family Members with Breast, Ovarian, Tubal, or Peritoneal Cancer	The USPSTF recommends that primary care providers screen women who have family members with breast, ovarian, tubal, or peritoneal cancer with 1 of several screening tools designed to identify a family history that may be associated with an increased risk for potentially harmful mutations in breast cancer susceptibility genes (BRCA1 or BRCA2). Women with positive screening results should receive genetic counseling and, if indicated after counseling, BRCA testing.
Women, Increased Risk for Breast Cancer	The USPSTF recommends that clinicians engage in shared, informed decision making with women who are at increased risk for breast cancer about medications to reduce their risk. For women who are at increased risk for breast cancer and at low risk for adverse medication effects, clinicians should offer to prescribe risk-reducing medications, such as tamoxifen or raloxifene.
Cervical Cancer
Women 21 to 65 (Pap Smear) or 30-65 (in combo with HPV testing)	The USPSTF recommends screening for cervical cancer in women age 21 to 65 years with cytology (Pap smear) every 3 years or, for women age 30 to 65 years who want to lengthen the screening interval, screening with a combination of cytology and human papillomavirus (HPV) testing every 5 years.
Chlamydia and Gonorrhea
Sexually Active Women	The USPSTF recommends screening for chlamydia in sexually active women age 24 years and younger and in older women who are at increased risk for infection.
Sexually Active Women	The USPSTF recommends screening for gonorrhea in sexually active women age 24 years and younger and in older women who are at increased risk for infection.
Colon Cancer
Adults, beginning at age 50 years and continuing until age 75 years	The USPSTF recommends screening for colorectal cancer using fecal occult blood testing, sigmoidoscopy, or colonoscopy in adults, beginning at age 50 years and continuing until age 75 years. The risks and benefits of these screening methods vary.
Prostate Cancer
Men, Screening with PSA	The U.S. Preventive Services Task Force (USPSTF) recommends against prostate-specific antigen (PSA)-based screening for prostate cancer.
Lipid disorder screening for Men
Men 35 and Older	The USPSTF strongly recommends screening men aged 35 and older for lipid disorders.
Men 20-35 at Increased Risk for CHD	The USPSTF recommends screening men aged 20-35 for lipid disorders if they are at increased risk for coronary heart disease.
Lipid screening Women at Increased Risk
Women 45 and Older at Increased Risk for CHD	The USPSTF strongly recommends screening women aged 45 and older for lipid disorders if they are at increased risk for coronary heart disease.
Women 20-45 at Increased Risk for CHD	The USPSTF recommends screening women aged 20-45 for lipid disorders if they are at increased risk for coronary heart disease.
Lung Cancer
Adults Aged 55-80, with a History of Smoking	The USPSTF recommends annual screening for lung cancer with low-dose computed tomography (LDCT) in adults aged 55 to 80 years who have a 30 pack-year smoking history and currently smoke or have quit within the past 15 years. Screening should be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery.
Osteoporosis
Women, 65 and Older	The USPSTF recommends screening for osteoporosis in women aged 65 years and older and in younger women whose fracture risk is equal to or greater than that of a 65-year old white women who has no additional risk factors.
RH Testing
Pregnant Women, During First Pregnancy-Related Care Visit	The USPSTF strongly recommends Rh (D) blood typing and antibody testing for all pregnant women during their first visit for pregnancy-related care.
Antibody Testing Unsensitized Rh (D)-Negative Pregnant Women	The USPSTF recommends repeated Rh (D) antibody testing for all unsensitized Rh (D)-negative women at 24-28 weeks gestation, unless the biological father is known to be Rh (D)-negative.

Information collected from http://www.uspreventiveservicestaskforce.org/BrowseRec/Index

PDF format file:

USPS Recommendations

100 Rules for Step 3

1. If a patient has a fever, give acetaminophen (unless it is contraindicated)
2. If a patient is on a statin or you order a statin, get baseline LFTs and check frequently
3. If a patient is found to have abnormal LFTs, get a TSH
4. If a patient is going to surgery (including cardiac catheterization), make them NPO
5. All NPO patients must also have their urine output measured (type "urine output")
6. If a woman is between 12 and 52 years old and there is no mention of a very recent menses (that is, < 2 weeks ago), order a beta-hCG
7. Don't forget to discontinue anything that is no longer required (especially if you are sending the patient home)
8. When a patient is stable, decide whether or not you should change locations (if you anticipate that the patient could crash in the very near future, send the patient to the ICU; if the patient just needs overnight monitoring, send to the ward; if the patient is back to baseline, send home with follow-up)
9. In any diabetic (new or long-standing), order an HbA1c as well as continuous Accuchecks.
10. If this is a long-standing diabetic, also order an ophthalmology consult (to evaluate for diabetic retinopathy)
11. In any patient with respiratory distress (especially with low oxygen saturations), order an ABG
12. In any overdose, do a gastric lavage and activated charcoal (no harm in doing so, unless the patient is unconscious or has risk for aspiration)
13. In any suicidal patient, admit to ward and get "suicide contract" and "suicide precautions"
14. Patients who cannot tolerate Aspirin get Clopidogrel or Ticlopidine
15. Post-PTCA patients get Abciximab
16. In any bleeding patient, order PT, PTT, and Blood Type and Crossmatch (just in case they have to go to the O.R.)
17. In any pregnant patient, get "Blood Type and Rh" as well as "Atypical Antibody Screen"
18. In any patient with excess bleeding (especially GI bleeding), type "no aspirin" upon D/C of patient
19. If the patient is having any upper GI distress or is at risk for aspiration, order "head elevation" and "aspiration precautions"
20. In any asthmatic, order bedside FEV1 and PEFR (and use this to follow treatment progress)
21. Before you D/C a patient, change all IV meds to PO and all nebulizers to MDI
22. In any patient who has GI distress, make them NPO
23. All diabetic in-patients get Accuchecks, D/C oral hypoglycemic agents, start insulin, HbA1c, advise strict glycemic control, recommend diabetic foot care
24. All patients with altered mental status of unknown etiology get a "fingerstick glucose" check (for hypoglycemia), IV thiamine, IV dextrose, IV naloxone, urine toxicology, blood alcohol level, NPO
25. If hemolysis is in the differential, order a reticulocyte count
26. If you administer heparin, check platelets on Day 3 and Day 5 (for heparin-induced thrombocytopenia), as well as frequent H&H
27. If you administer coumadin, check daily PT/INR until it is within therapeutic range for two consecutive days
28. Before giving a woman coumadin, isotretinoin, doxycycline, OCPs or other teratogens, get a beta-hCG
29. If you give furosemide (Lasix), also give KCl (it depletes K+)
30. All children who are given gentamycin, should have a hearing test (audiometry) and check BUN/Cr before and after treatment
31. Don't forget about patient comfort! Treat pain with IV morphine, nausea with IV phenergan, constipation with PO docusate, diarrhea with PO loperamide, insomnia with PO temazepam
32. ALL ICU patients get stress ulcer prophylaxis with IV omeprazole or ranitidine
33. If you put a patient on complete bedrest (such as those who are pre-op), get "pneumatic compression stockings"
34. If fluid status is vital to a patient's prognosis (such as those with dehydration, hypovolemia, or fluid overload), place a Foley catheter and order "urine output"
35. If a CXR shows an effusion, get a decubitus CXR next
36. If you intubate a patient you ALSO have to order "mechanical ventilation" (otherwise the patient will just sit there with a tube in his mouth!)
37. With any major procedure (including surgery, biopsy, centesis), you MUST type "consent for procedure" (typing consent will not reveal any results)
38. With any fluid aspiration (such as paracentesis or pericardiocentesis), get fluid analysis separately (it is not automatic). If you don't order anything on the fluid, it will just be discarded.
39. With high-dose steroids (such as in temporal arteritis), give IV ranitidine, calcium, vitamin D, alendronate, and get a baseline DEXA scan.
40. In all suspected DKA or HHNC, check osmolality and ketone levels in the serum.
41. In ALCOHOLIC ketoacidosis, just give dextrose (no need for insulin), in addition to IV normal saline and thiamine
42. All patients over 50 with no history of FOBT or colonoscopy should get a rectal exam, a FOBT, and have a sigmoidoscopy or colonoscopy scheduled.
43. All women > 40 years old should get a yearly clinical breast exam and mammogram (if risk factors are present, start at 35)
44. All men > 50 years old should get a prostate exam and a PSA (if risk factors are present, start at 45)
45. If a patient has a terminal disease, advise "advanced directives"
46. In any patient with a chronic disease that can cause future altered mental status, type "medical alert bracelet" upon D/C
47. Any patient with diarrhea should have their stool checked for "ova and parasites", "white cells", "culture", and C.diff antigen (if warranted)
48. Any patient on lithium or theophylline should have their levels checked
49. All patients with suspected MI should be given a statin (and check baseline LFTs)
50. All suspected hemolysis patients should get a direct Coombs test
51. Schedule all women older than 18 for a Pap smear (unless she has had a normal Pap within one year)
52. Pre-op patients should have the following done: “NPO”, “IV access”, “IV normal saline”, “blood type and crossmatch”, “analgesia”, “PT”, “PTT”, “pneumatic compression stockings”, “Foley”, “urine output”, “CBC”, and any appropriate antibiotics
53. If a patient requires epinephrine (such as in anaphylaxis), and he/she is on a beta-blocker, give glucagon first
54. If lipid profile is abnormal, order a TSH
55. All dementia and alcoholic patients should be advised “no driving”
56. To diagnose Alzheimer’s, first rule out other causes. Order a CT head, vitamin B12 levels, folate levels, TSH, and routine labs like CBC, BMP, LFT, UA. Also, if the history suggests it, order a VDRL and HIV ELISA as well
57. Also rule out depression in suspected dementia patients
58. For all women who are sexually active and of reproductive age, give folate. In fact, you should give ALL your patients a multivitamin upon D/C home
59. All pancreatitis patients should be made NPO and have NG suction so that no food can stimulate the pancreas
60. Send patients home on a disease-specific diet: diabetics get a “diabetic diet”, hypertensives get a “low salt diet”, irritable bowel patients get a “high fiber diet”, hepatic failure patients get “low protein diet”, etc
61. Do not give a thrombolytic (tPA or streptokinase) in a patient with unstable angina patient
62. Patients who are having a large amount of secretions, order “pulmonary toilet” to reduce the risk of aspiration
63. Every patient should be advised to wear a “seatbelt”, to “exercise”, and advised about “compliance”
64. In any patient who presents with an unprotected airway (as in overdoses, comatosis), get a CXR to rule out aspiration
65. In any patient with one sexually transmitted disease (such as Trichomonas), check for other STDs as well (Gonorrhea, Chlamydia, HIV, syphilis, etc.) and do a Pap smear in all women with an STD
66. Remember to treat children with croup with a “mist tent” and racemic epinephrine
67. Any acute abdomen patient with a suspected or proven perforation, give a TRIPLE antibiotic: Gentamycin, Ampicillin, Metronidazole
68. Get iron studies in patients with microcytic anemia if the cause is unknown. Order “iron”, “ferritin”, “TIBC”
69. Women with vaginal discharge should get a KOH prep, saline (wet) prep, vaginal pH, cervical gonococcal, chlamydia culture
70. If a woman is found to have vaginal candida, check her fasting glucose
71. When the 5 minute warning screen is displayed, go through the following mnemonic (RATED SEX). I know it probably is not the best mnemonic, but it is difficult to forget!:

• Recreational drugs / Reassurance
• Alcohol
• Tobacco
• Exercise
• Diet (eg. high protein, no lactose, low fat, etc.)
• Seat belt / Safety plan / Suicide precautions
• Education (“patient education”)
• X (stands for safe seX)

72. All suspected child abuse patients should be admitted and you should order THREE consults: consult “child protection services”, consult “ophthalmology” (to look for retinal hemorrhages), consult “psychiatrist” (to examine the family dynamics)
73. When a woman reaches menopause, she should have a “fasting lipid profile” checked (because without estrogen, the LDL will rise and the HDL will drop), a DEXA scan (for baseline bone density), and of course, FOBT and colonoscopy (if she is over 50)
74. If colon cancer is suspected, order a CEA; if pancreatic cancer, order CA 19-9; if ovarian cancer, order CA 125.
75. Remember to give “phototherapy” to a newborn with pathologic unconjugated bilirubinemia (it is not helpful if it is predominantly conjugated). Also, with phototherapy, keep the neonate on IV fluids (the heat can dehydrate them), and give erythromycin ointment in their eyes
76. Before giving a child prednisone, get a PPD
77. If a patient is found to have high triglycerides, check “amylase” and “lipase” (high triglycerides can cause pancreatitis)
78. Remember that any newborn under 3 weeks of age who develops a fever is SEPSIS until proven otherwise. Admit to the ward and culture EVERYTHING: “blood culture”, “urine culture”, “sputum culture”, and even “CSF culture”. And give antibiotics to cover EVERYTHING.
79. If you get a high lead level in a child, you have to check a “venous blood lead level” to confirm. If the value is > 70, admit immediately and begin IV “dimercaprol” and “EDTA”. Order “lead abatement agency” and “lead pain assay” upon discharge.
80. If you perform arthrocentesis, send the synovial fluid for “gram stain” and the 3 Cs: “crystals”, “culture”, and “cell count”
81. If a patient has exophthalmos with hyperthyroidism, it is not enough to just treat the hyperthyroidism (as the eye findings may worsen). You should give prednisone.
82. If any patient has cancer, get an “oncology consult”.
83. In a patient with rapid atrial fibrillation, decrease the heart rate first (then worry about converting to sinus rhythm). Use a CCB (diltiazem) or a beta-blocker (metoprolol) for rate control.
84. In any patient with new-onset atrial fibrillation, make sure you check a TSH
85. In any patient with suspected fluid volume depletion, order “postural vitals” to detect orthostasis
86. Before a colonoscopy or a sigmoidoscopy, you should prepare the bowel: make the patient NPO, give IV fluids (if necessary) and order “polyethylene glycol”.
87. Any patient with Mobitz II or complete heart block gets an immediate “transcutaneous pacemaker”. Then order a cardiology consult to implant a “transvenous pacemaker”
88. If calcium level is abnormal, order a “serum magnesium”, “serum phosphorus”, and “PTH”
89. Treat both malignant hyperthermia and neuroleptic malignant syndrome with “dantrolene”
90. All splenectomy patients get a “pneumovax”, an “influenza” vaccine, and a “hemophilus” vaccine if not previously given.
91. If you give INH (for Tb), also give “pyridoxine” (this is vitamin B6)
92. If you give pyrazinamide, get baseline “serum uric acid” levels
93. If you give ethambutol, order an ophthalmology consult (to follow possible optic neuritis)
94. If you perform a thoracocentesis (lung aspirate), send the EFFUSION as well as a peripheral blood sample for: LDH and protein (to help differentiate a transudate versus an exudates) and pH of the effusion
95. Give sickle cell disease children prophylactic penicillin continuously until they turn 5 years old
96. Any patient with a recent anaphylactic reaction (for any reason), should get “skin test” for allergens (to help prevent future disasters) and consult an allergist
97. Do not give cephalosporins to any patient with anaphylactic penicillin allergies (there is a 5% cross-reactivity)
98. Order Holter monitor on patients who have had symptomatic palpitations.
99. Any patient with a first-time panic attack gets a “urine toxicology” screen, a TSH, and “finger stick glucose”
100. All renal failure patients get: “nephrology consult”, “calcium acetate” (to decrease the phosphorus levels), “calcium” supplement, and erythropoietin.

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