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Cracking the CCS Cases: Preparing for USMLE Step 3

Dr. Christopher CarrubbaSarah Godfrey, and Dr. Patrick Curtin contributed to this post.

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 exam 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.

What do I need to know about CCS cases and Step 3?

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.

The Step 3 CCS 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.

How to prepare for the CCS cases on Step 3:

If you can only do one thing to prepare for the USMLE Step 3 CCS, complete every one of the UWorld practice cases. Doing well on CCS is mainly about putting 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 USMLE Step 3 CCS 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 examination. 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.

CCS cases teach you how to address patient conditions.

Another part of completing the CCS practice cases is that it teaches you a very crucial lesson regarding Step 3 in that it is a test on 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 to miss common medical school interview questions because of this, and the 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.

Step 3 CCS study tips:

1. First, just figure out how to use the platform.

The first step is to familiarize yourself with the CCS software because it is not the most intuitive program. Figure out how to perform a history and physical examination and how to search for common orders. Practice moving time forward (hint: usually moving to the next available result will suit your needs). Finally, figure out how and when you should be moving patients to new settings (clinic vs. ED vs. inpatient).

2. Do a case per day.

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.

CCS cases study plan: use an outline!

Have a system and use it every time.

The CCS cases have a large variety. Some are ‘textbook’ presentations of common diseases, while others are more subtle. Some may be in the specialty of your training, while others are fields you haven’t worked directly for since 3rd year of medical school.

Regardless of the case details, basic organizational needs will be the same for every case. One of the easiest ways to lose points is missing broad categories of assessments, like labs or procedures. When rushing through a case, it can be easy to jump on a diagnosis and skip key workups.

An outline helps prevent these missteps. One basic outline is below.

  • History
  • Physical
  • Orders
    • Labs
    • Imaging
    • Consults
    • Procedure
    • Counseling
    • Inpatient orders
  • Advancement of care/Reassess

Very generally speaking, the above outline can be applied to any case. The history is given as part of the case starting.

This system is very basic, but can be applied to any patient. Some students may choose to have a set pathway for clinic triage, ED patients, and inpatient/ICU so as to further taller their assessment/plans and not miss things.

How to manage treatment for CCS practice cases:

Now that you have basic CCS study tips and an outline, the next step is handling patient treatment.

1. Decide what bundles of orders you should send on every patient.

If you are already an intern, this should be similar to the admission orders you submit every day. For those who have not started residency yet, this may take a bit more thought. For example, in the emergency department, you will want to ask for pulse oximetry (which is not included in the vitals for some reason). Many patients will require cardiac monitoring and oxygen immediately upon arrival. You will also likely want a basic set of labs on most patients (such as CBC, BMP, LFTs, coagulation panel, urinalysis). Knowing common bundles of orders will save you time, if you do not have to think to remember them in each case.

2. Think about what information you need to diagnose and treat the patient.

Once you have the basic information and labs, think about what imaging or diagnostic studies you need next. You will lose points for not ordering the appropriate studies, but you can also lose points for ordering unnecessarily invasive tests (i.e. going straight to cardiac catheterization before ordering an EKG). Depending on the chief complaint, an EKG, x-ray or ultrasound can be a good starting point.

3. As soon as you know the diagnosis, start the appropriate treatment ASAP.

Order any medication you might need, including symptom management like pain control. Call for any consults you might need (though they will not offer any recommendations), and then order whatever procedure the patient might need (i.e. cholecystectomy for cholecystitis). This also includes moving the patient to the most appropriate location. If you know the patient needs surgery, admit them to the inpatient floor. If a patient in clinic is having acute chest pain with EKG changes, send them to the emergency room.

4. Don’t worry if you run out of time on the first few attempts.

Especially on the 10-minute cases, it can be hard at first to get through the whole scenario. If you work your way through all of the UWorld cases, you will get faster at knowing what to order and how to maneuver the program.

5. Don’t forget to counsel the patient!

Finally, after you finish each case, read through the grading rubric for each one. They will give you a sense of what orders will earn points and which ones will lose points. One of the most common things to forget is to counsel the patient. You can gain easy points by counseling the patient on smoking cessation, medication adherence, birth control, etc.


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