There is no question that the best strategy for USMLE* success is to know the content tested. Without content knowledge, your chances of passing, let alone doing well on, the Step 3 exam, are slim to none. However, knowing the medicine doesn't guarantee a high score. You also need to be able to APPLY that knowledge to USMLE-style questions. And you need to make sure you can answer the questions in the allotted time! There is nothing more frustrating than running out of time on a standardized test. In addition, the Step 3 exam has the added challenge of the Clinical Case Simulations (CCS)—an idiosyncratic testing format unique to the Step 3 exam. It is imperative that you understand how the CCS cases work BEFORE test day.

Clinical Case Simulations
There are five clinical case simulations (CCS) included as part of the USMLE CD-ROM that you receive when you register for the Step 3. You can also download the software at usmle.org. It is imperative that you repeatedly practice with these five cases! Your first attempt at these cases should be aimed at diagnosing and managing the patient as efficiently and appropriately as possible, as you would do on the real exam. You should then repeat each case, entering multiple different instructions and orders to obtain a sense of the "mechanics and logic" of the software.

Case Management Strategies

		Typically, your first step after reading the case information will be to order a physical examination. You'll need to decide whether to order a complete examination or a more limited examination. Remember that there is a "cost" to performing a complete examination, especially in the acute patient, since a complete exam takes time and it may be very inappropriate to proceed with certain irrelevant segments of the physical while your patient is unstable (e.g., performing a breast exam in a patient who is acutely unstable from a cardiopulmonary standpoint). Choose the elements of the physical that would cover every possibility on your differential diagnosis list.
		NOTE: The acute-unstable patient may require therapy even before the physical exam is obtained. For instance, if the patient is hemodynamically unstable, intravenous access should be obtained even before you proceed with the physical.
		At this point you should again consider your differential list and decide whether you have sufficient information to make a diagnosis and start managing the patient's disorder. Even if you are completely confident of your patient's diagnosis, it may still be very appropriate to order safe confirmatory tests. On the other hand, if you can make a diagnosis in the acute-unstable patient, then you may proceed directly to ordering appropriate therapy even before obtaining confirmatory evidence (e.g., if a patient has no breath sounds on one side and a deviated trachea, you should order a chest tube without confirming the pneumothorax with a CXR)
		After completing the physical examination, it is usually time write orders. Remember that the first order of business is to ensure that the patient is stable and that you have ordered any emergent procedures first. The orders should include both diagnostic tests and any therapy that you think is appropriate at the present time.
		Once you have submitted your orders (including diagnostic tests or treatments), it will usually be time to move the clock to get the orders executed and the results back. However, before advancing the clock you should also ask yourself whether the patient needs to be moved to another location, e.g., the patient who presents to your office hemodynamically unstable will need to be moved to the emergency department before you move the clock. Note: The patient doesn't go anywhere unless you move him/her there! The patient will sit in your office with massive hematemesis and bright red rectal bleeding all over your white office carpet until you decide that the patient should be transferred to the emergency department. Now its time to move the clock. Remember that once you move the clock forward, it cannot go back. The order sheet will inform you how long it will take to get each test back. While you can click the clock option of "move clock to first result," just remember that your patient is still around and it may not be appropriate to move the clock that far ahead before you do something else that can be done immediately (e.g., give the patient pain medication). If the clock is advanced and your patient was unstable before you advanced the clock, the patient will remain untreated during that entire time interval. Therefore, before advancing the clock ask yourself whether anything needs to be done in terms of the patient's management.
		Remember, when you are ordering tests they should address the (hopefully very few) choices in your differential diagnosis and allow you to choose one as the correct diagnosis. Order the simple, noninvasive, low-cost tests first and get the results back before you order second-line tests of greater sophistication, cost, and invasiveness.
		The Primum ® instructions indicate that consultants should be called when appropriate. However, the program indicates that "typically, consultants are not helpful since the exam is designed to assess your patient management skills." However, do not hesitate to order the appropriate consultation when you believe that consultant's input is essential.
		After obtaining any test results, ask yourself whether your differential diagnosis has changed and whether you have sufficient information to make a firm single diagnosis. If you have enough information to be confident in your diagnosis, then you should begin treating the patient appropriately. If you are already confident of the correct diagnosis, do not order unnecessary tests just to convince yourself. This only adds expense, potential risk, and loss of time, all of which may lead to a deduction of points from your score.
		Once you have made your firm diagnosis and ordered treatment for the patient, it is time to examine the outcome of your treatment decisions. This will involve moving the clock forward an appropriate interval. At that point you will be told of the patient's clinical status, which may be improved, worse, or unchanged. If the patient's condition has improved but he/she is not entirely well, then you may need to order additional therapies. If the patient has improved entirely, then the next step would be choosing an appropriate interval for follow-up and moving the clock forward to that time. If the patient's clinical condition worsens after your therapy, then you must consider whether you may have the wrong diagnosis or the wrong treatment for the right diagnosis, or whether you are treating the right diagnosis with the right medication in a patient whose clinical condition is worsening nonetheless.
		Once you are confident that you have chosen the right diagnosis, have treated the patient appropriately, and are told that the patient's clinical condition has improved entirely, decide whether the patient requires any further follow-up and advance the clock to that time.
		At some point, at or before the maximum 20-25 minutes of real time you have to manage the case, a screen will appear that informs you that you 5 minutes left. Do not assume that an early appearance of the "End of Case" notification indicates that you have managed the patient correctly or incorrectly. On the one hand, you may have managed the patient so efficiently and effectively that the case ends well before the maximum 20-25 minutes of "real-time." On the other hand, you may have managed the patient so poorly and dangerously that the program feels that the patient (and you) is beyond salvage at this point. When the "End of Case" screen appears, if there is "real-time" available, you will have a few minutes to consider and finalize your orders. At this point, you can add new orders, as well as cancel orders that have not already been carried out. However, if an order has already been performed, it is impossible to cancel or reverse that order; once something is done, as in real life, you cannot undo it.
		Remember that your attention to "health maintenance issues" is included in the scoring algorithms. This includes appropriate counseling for your patient as well as monitoring the patient to determine the effects of treatment and to determine whether modifying your treatment regimen is appropriate.