r/Step3

If you have any questions, ask them in the comments below -- I'll be happy to answer them.

After I posted my Step 3 score/experience, my inbox got flooded.

I’m guessing mainly because people could tell from my original post that I was not one of those “finished all of UWorld twice + every NBME + 100 CCS cases” people. I’ll be honest..I did not prep much. Residency, life, kids, exhaustion, excuses, whatever you want to call it. This was not some beautiful dedicated study arc. My goal was basically pass and never think about this exam again.

Anyways, instead of replying to everyone one by one, I made this post. Here’s my breakdown:

US-IMG

Step 1: Pass

Step 2: 246

Step 3: 224

Day 1: Weird. Just weird.

Lots of biostats, ethics, drug MOAs, random associations you haven’t thought about in forever, and“why are they asking about THIS?”

Didn’t feel amazing. Didn’t feel terrible. Just mentally cooked.

Day 2: Felt more clinically intuitive. But CCS is what everyone keeps asking about, so here’s the truth. CCSCases.com is honestly a very good mimic. The interface, order system, flow, close enough that if you practiced there, you won’t be lost.

That matters way more than people think.

The 10-minute cases are way more difficult than the 20-minute ones. No breathing room.

CCS advice that will save you 1-2 minutes on the 10m cases (this saved me)

Before Day 2 cases start, during tutorial create a list of all the orders you will need in your cases. There are many posts with generic/template order lists. Learn them and jot them down on the scratchpad first during tutorial (or during a break) to prevent the off-chance that you may blank out on orders during the actual cases.

Then during the first CCS case, quickly type the giant generic order set (even the orders you won't need for that case). Type keywords (as if you're googling) so that multiple orders appear in the same menu (for example: try to type "culture" instead of "urine" so you can click urine and blood culture if needed, or vaccine instead of Tdap or varicella, etc) Practice doing this on CCS cases and then curate your list in the way you will rememeber it.

Then CTRL+C the entire list. Yes, copy/paste works.

For every future case: CTRL+V that "masterlist" of orders and then delete what you don’t need and add case-specific orders. This trick saved me about 2 minutes on the 10m cases, which makes a huge difference.

Obviously, never leave an invasive order on this list by accident.

Broad harmless labs? Fine.

But don’t put intubation, biopsy, surgery, invasive procedures on this masterlist.

Some other random tips are:

1. Get every PE for every patient. Advance your orders one day at a time. Quickly. Any pertinent negative/positives? Stop and assess if patient location needs to change!

2. This deserves another line: Again do not forget to decide on a location as soon as your first location-determining order result comes back.

3. You will probably accumulate break time after each 20 minute case (I think you'll have 5-8 minutes left which rollover into break). So feel free to use up your actual break time during the MCQ blocks, if needed.

4. You will be a little disoriented for the first few cases. Just know that everyone will have this same adjustment period which probably affects everyone's scores in a way. Don't let the first few case mistakes or confusion about the software get to you. By the end of the exam, I was basically just "pasting" my orders from what I had "copied", changing 2-3 things, and the case would end relatively quick with a diagnosed and workup all complete.

5. I believe that more intense studying would have increased my score, but not by a large chunk. Most of my answers were coming from knowledge accumulated over time and more nuance clinical thinking. This means a good night's sleep may affect your score much more than an extra week or two of studying.

6. Lastly, do not be AFRAID of being stressed. I walked into the exam too calm and then realized I was working WAY too slow. I adjusted and timing became manageable, thanks to the "stress." So if you're feeling a bit jittery or nervous the day of, PERFECT, you'll need that for the initial boost.

Good luck!!

P.S. The new block format is much better than prior. For example, instead of realizing you need to pee 10 questions into a block, but needing to hold it in for 30 more questions, you can basically take a break after finishing just 10 more questions!

gonna be honest i barely studied for step 3. got a 260+ on step 2 and was completely burnt out after that, had zero motivation left. told myself id do a proper uworld pass but like 2 weeks in i knew that wasnt happening lol. ended up only giving it about a month total, ditched uworld, and just focused on NBMEs + Free 137s + CCS practice. got 230s. not a flex score but i passed comfortably and thats all i needed

so if youre post step 2 and running on fumes and just want to know the minimum viable strategy to pass... this is what i did

what i actually used (and what i skipped)

UWorld - tried it, gave up. if you have the energy go for it but i didnt. skip if youre burnt out like i was

NBMEs - NBME 4 & 5 are the old offline versions. NBME 6 & 7 are the current ones on the NBME website and honestly these two are the highest yield. theres also 3 Free 137s, the current one on the website plus two previous versions. fair amount of overlap between them so dont freak out if you recognize questions, thats normal

ccscases.com - this is where i actually spent most of my time. like 170-180 cases total. i picked the High Yield tagged ones first and got through maybe 70% of them. CCS will straight up wreck you on exam day if you dont practice on actual software. the interface alone takes getting used to

also watched a bunch of CCS youtube videos. this one helped the most - https://www.youtube.com/watch?v=qmxWuV4psFs - notes below

understanding the two clocks

theres Real Time (actual minutes you have to solve the case, usually 10-20 min) and Simulated Time (time passing inside the virtual patients world). you fast forward hours/days/weeks with a few clicks while waiting for results. keeping track of both simultaneously is the skill

general approach from the video

when the history dialog pops up, skim and jot down 5 things on your scratch sheet - age, sex, allergies, brief PMH/chief complaint, vaccines/screening status. sounds dumb but you'll need this in the final 2 min. the system doesnt really try to trick you btw. diagnosis is usually telegraphed. whats being graded is whether you ordered the right workup to rule out differentials, not whether you "guessed right"

for physical exam - stable patient do a complete exam (eats ~15 min of simulated time), emergent patient (chest pain etc) do focused exam only, get emergent orders in first THEN finish the rest

then decide disposition (home, ER, ward, ICU) and get your emergent orders going

ok heres where my actual strategy lives. i basically built a set of mnemonics and just mechanically fired them off every case. the real exam threw curveballs i'd never seen on practice but the mechanical approach is what saved me, not pattern recognition of specific cases

routine orders i drop on basically any patient - CUBE T3

CBC/CMP/CXR, Urine analysis, BhCG (any reproductive age F), ECG, Troponin/TSH/Toxicology. noninvasive baseline, just get it in fast

emergent stabilization - VOMICAA

Vitals (set monitoring interval), Oxygen/Oximetry, Morphine/Metoclopramide/Mg, IV fluids, Cardiac monitoring, Accu-check Glucose, Acetaminophen/Aspirin. add ABG if respiratory issue. chest pain → EKG troponin aspirin. SOB → CXR ABG O2. altered mental status → glucose CT head

admitting orders when moving to inpatient - AID LUV Tubes

Activity (bed rest, bathroom privileges etc), IV Fluids maintenance, Diet (NPO/regular/etc), LMWH for DVT ppx, Urine output monitoring, Vitals at inpatient interval, Tubes (NG/Foley if needed)

pre-op if surgery is happening - TPN A CSF

Type & screen ABO, PTT/PT/INR, NPO, Antibiotic prophylaxis (usually cefazolin), Consent, Surgery name (schedule the specific procedure), Fluids peri-op

final 2 min - even if you finish early the system pulls you into this screen. this is where the scratch sheet pays off. just mechanically drop these

vaccines (P-MIST) - Pneumococcal, Meningococcal, Influenza, Shingles (50+), Tdap/Tetanus

screening (PMC) - Pap smear, Mammography, Colonoscopy

counseling (SASS) - Smoking stop, Alcohol stop, Safe sex, Seatbelt

dont forget to actually admit/discharge/upgrade to ICU. on discharge follow-up orders are mandatory

couple case examples from the video to show the flow

41 y/o F with RUQ pain + shoulder radiation after a fatty meal. screams cholecystitis. note shes 41 and a smoker so Tdap + pap are due. pain is severe so focused exam, US shows positive Murphy. IV access, glucose, NS, morphine, metoclopramide, then complete the rest of exam. CBC CMP HCG LFTs abdominal US. US confirms it. move to inpatient, pip/tazo, gen surg consult, NPO, type & screen, prophylactic cefazolin. case ends early due to improvement. final 2 min - smoking cessation alcohol counseling pap smear exercise Tdap. clean

28 y/o M with progressive headache fever neck pain. screams meningitis. focused exam, positive Kernig and Brudzinski. O2 sat IV access glucose. LP - and this is key, ordering LP alone isnt enough, you have to separately order the CSF analysis (PCR cultures etc). CT head before LP to rule out increased ICP. also CXR urine cx blood cx for fever source. cloudy CSF, move to inpatient, ID consult, empiric vanc + ceftriaxone + dexamethasone. if you order naproxen for fever pair it with GI protection or just use celecoxib. also the presenter intentionally skipped NS to demo wrong-answer feedback and sure enough the feedback panel flagged it. good example of how the grading works

practice wise i just did ccscases.com prioritizing high yield tagged cases. slow at first, gets faster with reps. drill the common patterns - chest pain, SOB, abdominal pain, fever. they show up over and over. the mnemonic based mechanical approach genuinely carried me through cases id never seen before

honestly if youre burnt out after step 2 and just need to pass, dont kill yourself trying to do everything. NBMEs + Free 137s for MCQ, ccscases for CCS, memorize the mnemonics, and trust the process. a month was enough for me. good luck yall