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When it comes to Step 3, it turns out that, in between the 80 hour work weeks and general adjustments to life as an intern, you’re expected to find the time to study for not one, but two days of the USMLE.

And while this is finally the light at the end of the tunnel, for most test takers, it is a significant source of anxiety added to their intern year.

What’s more is that while you are a seasoned veteran when it comes to the standard USMLE questions, the CCS component of Step 3 is a whole new ballgame. However, there is some good news: With a little bit of practice, you can easily turn this unknown entity in to an opportunity to excel and boost your exam score.

In addition to another six blocks of 33 multiple choice questions each, the second day of Step 3 will feature 13 computer based case simulations (CCS), each with a maximum allotted time of somewhere between 10-20 minutes. These cases are designed to assess your abilities to diagnose and treat conditions across all specialties; so just hoping that your own residency experience will carry you through is a bad idea. However, you do not need to be an expert clinician in each discipline to achieve a great score—you just need to practice.

If I could only do one thing to prepare for CCS, it would be completing every one of the UWorld practice cases. Doing well on CCS is mainly about having put in the time practicing in order to master the software and to understand the fine points of the scoring system. Let me demonstrate this with an abbreviated example below:

A 23-year old female presents with right lower quadrant pain that started 3 hours ago. The pain initially began at her umbilicus and later migrated to her right lower quadrant. It is also associated with nausea, vomiting, and chills. She has no significant medical history aside from endorsing smoking ½ pack per day.

It doesn’t take much to recognize that this is likely appendicitis and, fortunately, many of the cases are this straightforward. The trick however, is learning how to efficiently use the software and how to obtain every possible point. Obviously, you are going to remember to order a physical exam. Moreover, most people would know to order the standard labs: CBC, BMP, a urinalysis, and a beta HCG. But would you remember to make the patient NPO? Would you remember to order IV access, pain medications, antibiotics, and the standard perioperative labs? Would you know to counsel the patient on smoking cessation? Did you remember to transfer the patient from the emergency department to the inpatient unit?

The point that I am trying to make is that the CCS cases feature many subtleties and practicing through UWorld is the best way to ensure that you will get every available point. At the end of the day, the better you do on the easier cases and the more points you obtain, the more insurance you have for the one or two difficult ones that may be included.

Another part of completing the CCS practice cases is that it teaches you a very crucial lesion regarding Step 3 in that it is a test over how the USMLE thinks you should manage a condition, not how you might actually do it in your hospital. Personally, I think that this is the biggest difficulty test takers have on this exam. It can become very frustrating missing questions because of this and that frustration often leads to difficulties learning the material. I encourage my students to look past this and accept that, for a short time, they will need to understand how the USMLE wants them to address each condition. Utilizing these CCS cases is the best way to ensure that you learn this strategy and are prepared for the exam.

So we’ve established that you should absolutely complete each of the UWorld practice cases—the question is, when do you do it? Just like anything USMLE related, there is no one size fits all approach. That being said, here are my most commonly used strategies that I would recommend:

1. Do a case per day.

To me, this is the easiest way to ensure that you work through each CCS practice module and allows you to gradually build up the efficiency you need.

2. Line up cases with your studies.

For instance, if you are studying for the cardiology portion of the written exam, you could also work in the cardiology CCS cases as a way of further reinforcing the material.

3. Wait until the end.

For students who are too busy to multi-task, you could consider giving yourself an extra 7-10 days after the first day of Step 3 and study during that time. While this may prolong the misery of the experience, it is an option if you are worried about finding adequate time to study.

At the end of the day, just find a way to practice! If you complete each of the USMLE World modules and really learn how to grab each possible point, then you will do an amazing job on the CCS portion of Step 3.

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Dr. Christopher Carrubba

Dr. Christopher Carrubba

USMLE Tutor & Senior Contributing Editor
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