Exam Prep
Step 3 and the CCS Cases
by Mike
Apr 10, 2026 · 8 min read
Exam Prep
by Mike
Apr 10, 2026 · 8 min read
Step 3 is two days: a day that feels like Step 1, a day that feels like Step 2, and the CCS cases, which don't feel like anything you've done in real life. If you just want to pass, it takes less studying than you think. This is what I did, what I'd do again, and the framework I used for CCS.
UWorld is more than enough. I did about 80% of the questions, which was definitely overkill. Even 60 to 70% with a careful review of your misses covers what you need. I started studying seriously about three weeks out, mostly on my phone during downtime on the wards or at home. The UWorld questions felt very close to the real thing in style and difficulty.
In the last week, I went through the Dorian Step 3 Anki deck a few times as a fast refresher, and I think it helped. I read the First Aid biostats section and parts of the rapid review in the back of the book. I didn't do any NBME forms or practice exams, and you don't need to buy anything else.
The most IMPORTANT resource is the official USMLE Step 3 practice questions. They're by far the closest thing to the real exam, both the multiple choice and the CCS, and their CCS grading is probably the most accurate you'll find. Do them before anything else.
Day 1 is the Step 1 day: six one-hour blocks of about 40 questions. It leans on Step 1 factoids and biostats, plus some ethics, risk factors, diagnosis, and treatment. Most people find it the harder day, since it's full of facts you haven't looked at since Step 1 (unless you've been doing Step 1 Anki for some reason). Review biostats in First Aid and watch the rapid review playlist and it'll probably go fine. I didn't feel great after day 1, but it's manageable.
Day 2 is the clinical day: six blocks of 30 questions, 45 minutes each, mostly diagnosis and treatment. I found it much more straightforward, and I know several people who did all six blocks back to back without a break. Then come the CCS cases, 10 or 20 minutes each, worth about 25% of your score. Get ready to read fast and type.
If you just want to pass, take it early in the year and get it over with.
CCS is a perfect example of the USMLE being out of touch with real practice. What it wants is often not how you'd manage the patient on the wards, and plenty of things you've seen done in real life are wrong in CCS land. A few rules:
If you're short on time and fairly sure you'll pass, just do the official cases and read their grading criteria. I also walk through the framework in a video.
CCS grades you on six things:
Go through the steps below on every case.
Keep the exam focused. After the intro and vitals you'll already have a differential. Pick the relevant pieces from: physical appearance, skin, breast, lymph nodes, HEENT/neck, chest/lungs, heart/cardio, abdomen, genitalia, rectal, extremities/spine, and neuro/psych.
Order basic monitoring on everyone: cardiac monitor, pulse ox, and accucheck.
Use this at the start of every acute or emergent case.
Cast a wide net, since cost doesn't matter. Order from each group as it fits the case.
Once you have a working diagnosis and results are coming back, start treatment and admission orders.
If a procedure or surgery is indicated, go through this before you order it.
Consult whenever it applies, ideally after the patient is stable and you have a working diagnosis. The usual ones are cardiology, psychiatry, social services, surgery, GI, nutrition, and poison control.
Once the patient is better and before you end the case, always do preventive care. People forget it all the time, and it's easy points.
Vaccines, P-MIST:
Screening and counseling, PMCs-CREASS:
Location: Emergency department. Chief complaint: Chest pain.
A 58-year-old man presents with a 30-minute history of crushing chest pain radiating to the left arm, associated with shortness of breath, diaphoresis, and nausea. PMH includes possible hypertension and hyperlipidemia. Family history of cardiac disease. Pain is 8/10, not pleuritic, not relieved by Tylenol or ibuprofen.
Exam: physical appearance, chest/lungs, heart/cardio, abdomen, extremities/spine.
Stabilize (HAVOC): morphine for pain, IV access with fluids, accucheck, and ABG, vitals, oxygen and pulse ox, EKG and cardiac monitor.
Diagnostics (I BUOP Micro Toxins): CXR and TTE. CBC, BMP, cardiac enzymes (troponin), lipids, A1c, and LFTs. UA. Serum pregnancy test if it applies.
Treat and admit (ABCs-DEFGHI): aspirin, clopidogrel or ticagrelor, heparin, a beta-blocker, a statin, and nitroglycerin. Cardiac diet. Admit to the ICU or CCU with continuous monitoring.
Procedure (NICE PTS): if cath is indicated, NPO, informed consent, cefazolin, EKG, PT/PTT, type and screen, then order the cardiac cath.
Consults: cardiology.
Preventive care, once he's better: age-appropriate vaccines (P-MIST), screening (PMCs-CREASS), counseling on smoking, exercise, diet, and taking his meds, and a cardiac rehab referral.
Short answer: No.
Long answer: No, but with more words. Some fellowships look at Step 3, usually the competitive IM subspecialties, but research, letters, and connections almost always matter more. It might help a residency application a tiny bit, but programs mostly use Step 2 to decide who gets interview invites, and Step 3 barely factors in next to it.
If you wanted to crush it for some reason, you could do all of UWorld, make Anki cards from your misses, add the Dorian deck, and do every CCS case. That's complete overkill in almost every situation. Intern year is tough. I'd use your free time to recover, see your family, and take care of yourself instead.
Looking back, I studied more than I needed to. A lot of what you learned for Step 1 and Step 2 carries over, so let those scores tell you how much to study. Remember, passing is 200!
Best of luck!
Mike