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EXCEL ON THE USMLE® STEP 1 WITH HELP FROM THE WORLD’S MOST POPULAR MEDICAL REVIEW BOOK!
Trust First Aid™ to help you score your highest on this high-stakes exam

Written by students who excelled on the Step 1 exam and reviewed by top faculty for accuracy, this indispensable guide provides you with a blueprint of all the content you’re likely to find on the exam. Packed with insider advice for students from students, First Aid for the USMLE® Step 1 2020 will help maximize your study time.

Features

A complete framework for USMLE Step 1 preparation

1,300+ must-know topics with mnemonics to focus your study
1,000+ color photos and illustrations to help you visualize processes, disorders, and clinical findings
Rapid Review section presents high-yield tables associating diseases with their clinical findings, treatments, and pathophysiology
Updated every year to ensure all content is relevant and high-yield, reflecting the most current USMLE blueprint
Year:
2020
Edition:
30th
Publisher:
McGraw-Hill Education
Language:
english
Pages:
876
ISBN 13:
9781260462050
File:
PDF, 69.34 MB
Download (pdf, 69.34 MB)

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Can you please upload the full version??
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nice veryhelpful thank you
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FIRST AID

FOR
THE®

USMLE
STEP 1
2020
TAO LE, MD, MHS

VIKAS BHUSHAN, MD

Founder, ScholarRx
Associate Clinical Professor, Department of Medicine
University of Louisville School of Medicine

Boracay

MATTHEW SOCHAT, MD

VAISHNAVI VAIDYANATHAN, MD

Fellow, Department of Hematology/Oncology
St. Louis University School of Medicine

Resident, Department of Pediatric Neurology
Barrow Neurological Institute at Phoenix Children’s Hospital

SARAH SCHIMANSKY, MB BCh BAO

JORDAN ABRAMS

Resident, Department of Ophthalmology
Royal United Hospitals Bath

St. George’s University School of Medicine
Class of 2020

KIMBERLY KALLIANOS, MD
Assistant Professor, Department of Radiology and Biomedical Imaging
University of California, San Francisco School of Medicine

New York / Chicago / San Francisco / Athens / London / Madrid / Mexico City
Milan / New Delhi / Singapore / Sydney / Toronto

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Copyright © 2020 by Tao Le and Vikas Bhushan. All rights reserved. Except as permitted under the United States Copyright Act of 1976,
no part of this publication may be reproduced or distributed in any form or by any means, or stored in a database or retrieval system,
without the prior written permission of the publisher.
ISBN: 978-1-26-046205-0
MHID:
1-26-046205-6
The material in this eBook also appears in the print version of this title: ISBN: 978-1-26-046204-3,
MHID: 1-26-046204-8.
eBook conversion by codeMantra
Version 1.0
All trademarks are trademarks of their respective owners. Rather than put a trademark symbol after every occurrence of a trademarked
name, we use names in an editorial fashion only, and to the benefit of the trademark owner, with no intention of infringement of the
trademark. Where such designations appear in this book, they have been printed with initial caps.
McGraw-Hill Education eBooks are available at special quantity discounts to use as premiums and sales promotions or for use in corporate training programs. To contact a representative, please visit the Conta; ct Us page at www.mhprofessional.com.
Notice
Medicine is an ever-changing science. As new research and clinical experience broaden our knowledge, changes in treatment and drug
therapy are required. The authors and the publisher of this work have checked with sources believed to be reliable in their efforts to
provide information that is complete and generally in accord with the standards accepted at the time of publication. However, in view
of the possibility of human error or changes in medical sciences, neither the authors nor the publisher nor any other party who has been
involved in the preparation or publication of this work warrants that the information contained herein is in every respect accurate or complete, and they disclaim all responsibility for any errors or omissions or for the results obtained from use of the information contained in
this work. Readers are encouraged to confirm the information contained herein with other sources. For example and in particular, readers
are advised to check the product information sheet included in the package of each drug they plan to administer to be certain that the
information contained in this work is accurate and that changes have not been made in the recommended dose or in the contraindications
for administration. This recommendation is of particular importance in connection with new or infrequently used drugs.
TERMS OF USE
This is a copyrighted work and McGraw-Hill Education and its licensors reserve all rights in and to the work. Use of this work is subject
to these terms. Except as permitted under the Copyright Act of 1976 and the right to store and retrieve one copy of the work, you may
not decompile, disassemble, reverse engineer, reproduce, modify, create derivative works based upon, transmit, distribute, disseminate,
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to any claim or cause whatsoever whether such claim or cause arises in contract, tort or otherwise.

Dedication
To the contributors to this and past editions, who took
time to share their knowledge, insight, and humor for the
benefit of students and physicians everywhere.

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Contents

Contributing Authors

vii

Associate Authors

viii

General Acknowledgments

xv

How to Contribute

xvii

Faculty Advisors

ix

How to Use This Book

xix

Thirtieth Anniversary Foreword

xi

Selected USMLE Laboratory Values

xx

Preface

xiii

Special Acknowledgments

xiv

``
SECTION I
Introduction
USMLE Step 1—The Basics

First Aid Checklist for the USMLE Step 1

G U I D E TO E F F I C I E N T E X A M P R E PA R AT I O N

xxii

1

2

Test-Taking Strategies

22

2

Clinical Vignette Strategies

23

Defining Your Goal

12

If You Think You Failed

24

Learning Strategies

13

Testing Agencies

24

Timeline for Study

16

References

25

Study Materials

20

``
SECTION I SUPPLEMENT

``
SECTION II

S P E C I A L S I T UAT I O N S

27

HIGH-YIELD GENERAL PRINCIPLES

29

How to Use the Database

30

Pathology

205

Biochemistry

33

Pharmacology

229

Immunology

95

Public Health Sciences

255

Microbiology

123

v

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H I G H - Y I E L D O R G A N S YS T E M S

``
SECTION III

275

Approaching the Organ Systems

276

Neurology and Special Senses

489

Cardiovascular

279

Psychiatry

553

Endocrine

325

Renal

577

Gastrointestinal

357

Reproductive

611

Hematology and Oncology

403

Respiratory

659

Musculoskeletal, Skin, and Connective Tissue

445

Rapid Review

689

``
SECTION IV

TO P - R AT E D R E V I E W R E S O U R C E S

711

How to Use the Database

712

Biochemistry

716

Question Banks and Books

714

Cell Biology and Histology

716

Web and Mobile Apps

714

Microbiology and Immunology

717

Comprehensive

715

Pathology

717

Anatomy, Embryology, and Neuroscience

715

Pharmacology

718

Behavioral Science

716

Physiology

718

Abbreviations and Symbols

719

Index

749

Image Acknowledgments

727

About the Editors

808

``

vi

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Contributing Authors
MAJED H. ALGHAMDI, MBBS

KAITLYN MELNICK, MD

Resident, Joint Program of Preventive Medicine
Jeddah, Saudi Arabia

Resident, Department of Neurological Surgery
University of Florida College of Medicine, Gainesville

LILIT ASLANYAN

MARY KATHERINE MONTES de OCA, MD

New York Institute of Technology College of Osteopathic Medicine
Class of 2020

Resident, Department of Obstetrics and Gynecology
Duke University Hospital

HUMOOD BOQAMBAR, MB BCh BAO

SCOTT MOORE, DO

Assistant Registrar, Department of Orthopaedic Surgery
Farwaniya Hospital

Assistant Professor of Medical Laboratory Sciences
Weber State University

WEELIC CHONG

VASILY OVECHKO, MD

Sidney Kimmel Medical College at Thomas Jefferson University
MD/PhD Candidate

Resident, Department of Surgery
Russian Medical Academy of Continuous Professional Education

KRISTINA DAMISCH

VIVEK PODDER

University of Iowa Carver College of Medicine
Class of 2020

MBBS Student
Tairunnessa Memorial Medical College and Hospital, Bangladesh

YUMI KOVIC, MD

CONNIE QIU

Resident, Department of Psychiatry
University of Massachusetts Medical School

Lewis Katz School of Medicine at Temple University
MD/PhD Candidate

Image and Illustration Team
CAROLINE COLEMAN

VICTOR JOSE MARTINEZ LEON, MD

Emory University School of Medicine
Class of 2020

Central University of Venezuela

MATTHEW HO ZHI GUANG
University College Dublin (MD), DFCI (PhD)
MD/PhD Candidate

ALIREZA ZANDIFAR, MD
Research Fellow
Isfahan University of Medical Sciences, Iran

vii

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Associate Authors
HUZAIFA AHMAD, MD

SARINA KOILPILLAI

Resident, Department of Medicine
Georgetown University Hospital/MedStar Washington Hospital Center

St. George’s University School of Medicine
Class of 2020

ALEXANDER R. ASLESEN

LAUREN N. LESSOR, MPH, MD

Kirksville College of Osteopathic Medicine
Class of 2020

Resident, Department of Pediatrics
Mercy Health – St. Vincent Medical Center

ANUP K. BHATTACHARYA, MD

ROHAN BIR SINGH, MD

Resident, Mallinckrodt Institute of Radiology
Washington University School of Medicine

Fellow, Department of Ophthalmology
Massachusetts Eye and Ear
Harvard Medical School

ANUP CHALISE, MBBS
Resident, Department of General Surgery
Nepal Medical College and Teaching Hospital

ASHTEN R. DUNCAN, MPH
University of Oklahoma-Tulsa School of Community Medicine
Class of 2021

Image and Illustration Team
YAMNA JADOON, MD

MITCHELL A. KATONA

Research Associate
Aga Khan University

University of Texas Health Science Center, Long School of Medicine
Class of 2020

DANA M. JORGENSON

TAYLOR MANEY, MD

Chicago College of Osteopathic Medicine
Class of 2020

Resident, Department of Anesthesiology
Brigham and Women’s Hospital

viii

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Faculty Advisors
DIANA ALBA, MD

ANTHONY L. DeFRANCO, PhD

Clinical Instructor
University of California, San Francisco School of Medicine

Professor, Department of Microbiology and Immunology
University of California, San Francisco School of Medicine

MARK A.W. ANDREWS, PhD

CHARLES S. DELA CRUZ, MD, PhD

Professor of Physiology
Lake Erie College of Osteopathic Medicine at Seton Hill

Associate Professor, Department of Pulmonary and Critical Care Medicine
Yale School of Medicine

MARIA ANTONELLI, MD

SAKINA FARHAT, MD

Assistant Professor, Division of Rheumatology
MetroHealth Medical Center, Case Western Reserve University

Consulting Gastroenterologist
State University of New York Downstate Medical Center

HERMAN SINGH BAGGA, MD

CONRAD FISCHER, MD

Urologist, Allegheny Health Network
University of Pittsburgh Medical Center Passavant

Associate Professor, Medicine, Physiology, and Pharmacology
Touro College of Medicine

SHIN C. BEH, MD

RAYUDU GOPALAKRISHNA, PhD

Assistant Professor, Department of Neurology & Neurotherapeutics
UT Southwestern Medical Center at Dallas

Associate Professor, Department of Integrative Anatomical Sciences
Keck School of Medicine of University of Southern California

JOHN R. BUTTERLY, MD

RYAN C.W. HALL, MD

Professor of Medicine
Dartmouth Geisel School of Medicine

Assistant Professor, Department of Psychiatry
University of South Florida School of Medicine

SHELDON CAMPBELL, MD, PhD

LOUISE HAWLEY, PhD

Professor of Laboratory Medicine
Yale School of Medicine

Immediate Past Professor and Chair, Department of Microbiology
Ross University School of Medicine

BROOKS D. CASH, MD

JEFFREY W. HOFMANN, MD, PhD

Professor of Medicine, Division of Gastroenterology
University of South Alabama School of Medicine

Resident, Department of Pathology
University of California, San Francisco School of Medicine

SHIVANI VERMA CHMURA, MD

CLARK KEBODEAUX, PharmD

Adjunct Clinical Faculty, Department of Psychiatry
Stanford University School of Medicine

Clinical Assistant Professor, Pharmacy Practice and Science
University of Kentucky College of Pharmacy

BRADLEY COLE, MD

KRISTINE KRAFTS, MD

Assistant Professor of Basic Sciences
Loma Linda University School of Medicine

Assistant Professor, Department of Basic Sciences
University of Minnesota School of Medicine

LINDA S. COSTANZO, PhD

MATTHEW KRAYBILL, PhD

Professor, Physiology & Biophysics
Virginia Commonwealth University School of Medicine

Clinical Neuropsychologist
Cottage Health, Santa Barbara, California

MANAS DAS, MD, MS

GERALD LEE, MD

Director, Clinical Anatomy, Embryology, and Histology
University of Massachusetts Medical School

Assistant Professor, Departments of Pediatrics and Medicine
Emory University School of Medicine

ix

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KACHIU C. LEE, MD, MPH

NATHAN W. SKELLEY, MD

Assistant Clinical Professor, Department of Dermatology
The Warren Alpert Medical School of Brown University

Assistant Professor, Department of Orthopaedic Surgery
University of Missouri, The Missouri Orthopaedic Institute

WARREN LEVINSON, MD, PhD

HOWARD M. STEINMAN, PhD

Professor, Department of Microbiology and Immunology
University of California, San Francisco School of Medicine

Assistant Dean, Biomedical Science Education
Albert Einstein College of Medicine

JAMES LYONS, MD

SUPORN SUKPRAPRUT-BRAATEN, PhD

Professor of Pathology and Family Medicine
Alabama College of Osteopathic Medicine

Director of Research, Graduate Medical Education
Unity Health, Searcy, Arkansas

PETER MARKS, MD, PhD

RICHARD P. USATINE, MD

Center for Biologics Evaluation and Research
US Food and Drug Administration

Professor, Dermatology and Cutaneous Surgery
University of Texas Health Science Center San Antonio

DOUGLAS A. MATA, MD, MPH

J. MATTHEW VELKEY, PhD

Brigham Education Institute and Brigham and Women’s Hospital
Harvard Medical School

Assistant Dean, Basic Science Education
Duke University School of Medicine

VICKI M. PARK, PhD, MS

TISHA WANG, MD

Assistant Dean
University of Tennessee College of Medicine

Associate Clinical Professor, Department of Medicine
David Geffen School of Medicine at UCLA

SOROUSH RAIS-BAHRAMI, MD

SYLVIA WASSERTHEIL-SMOLLER, PhD

Assistant Professor, Departments of Urology and Radiology
University of Alabama at Birmingham School of Medicine

Professor Emerita, Department of Epidemiology and Population Health
Albert Einstein College of Medicine

SASAN SAKIANI, MD

ADAM WEINSTEIN, MD

Fellow, Transplant Hepatology
Cleveland Clinic

Assistant Professor, Pediatric Nephrology and Medical Education
Geisel School of Medicine at Dartmouth

MELANIE SCHORR, MD

ABHISHEK YADAV, MBBS, MSc

Assistant in Medicine
Massachusetts General Hospital

Associate Professor of Anatomy
Geisinger Commonwealth School of Medicine

SHIREEN MADANI SIMS, MD

KRISTAL YOUNG, MD

Chief, Division of Gynecology, Gynecologic Surgery, and Obstetrics
University of Florida School of Medicine

Clinical Instructor, Department of Cardiology
Huntington Hospital, Pasadena, California

x

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Thirtieth Anniversary Foreword
Our exam experiences remain vivid in our minds to this day as we reflect on 30 years of First Aid. In 1989, our
big idea was to cobble together a “quick and dirty” study guide so that we would never again have to deal with the
USMLE Step 1. We passed, but in a Faustian twist, we now relive the exam yearly while preparing each new edition.
Like all students before us, we noticed that certain topics tended to appear frequently on examinations. So we
compulsively bought and rated review books and pored through a mind-numbing number of “recall” questions,
distilling each into short facts. We had a love-hate relationship with mnemonics. They went against our purist desires
for conceptual knowledge, but remained the best way to absorb the vocabulary and near-random associations that
unlocked questions and eponyms.
To pull it all together, we used a then “state-of-the-art” computer database (Paradox/MS DOS 4) that fortuitously
limited our entries to 256 characters. That length constraint (which predated Twitter by nearly two decades) imposed
extreme brevity. The three-column layout created structure—and this was the blueprint upon which First Aid was
founded.
The printed, three-column database was first distributed in 1989 at the University of California, San Francisco.
The next year, the official first edition was self-published under the title High-Yield Basic Science Boards Review: A
Student-to-Student Guide. The following year, our new publisher dismissed the High-Yield title as too confusing and
came up with First Aid for the Boards. We thought the name was a bit cheesy, but it proved memorable. Interestingly,
our “High-Yield” name resurfaced years later as the title of a competing board review series.
We lived in San Francisco and Los Angeles during medical school and residency. It was before the Web, and
before med students could afford cell phones and laptops, so we relied on AOL e-mail and bulky desktops. One of
us would drive down to the other person’s place for multiple weekends of frenetic revisions fueled by triple-Swiss
white chocolate lattes from the Coffee Bean & Tea Leaf, with R.E.M. and the Nusrat Fateh Ali Khan playing in the
background. Everything was marked up on 11- by 17-inch “tearsheets,” and at the end of the marathon weekend
we would converge at the local 24-hour Kinko’s followed by the FedEx box near LAX (10 years before these two
great institutions merged). These days we work with our online collaborative platform A.nnotate, GoToMeeting, and
ubiquitous broadband Internet, and sadly, we rarely get to see each other.
What hasn’t changed, however, is the collaborative nature of the book. Thousands of authors, editors, and
contributors have enriched our lives and made this book possible. Most helped for a year or two and moved on, but
a few, like Ted Hon, Chirag Amin, and Andi Fellows, made lasting contributions. Like the very first edition, the team
is always led by student authors who live and breathe (and fear) the exam, not professors years away from that reality.
We’re proud of the precedent that First Aid set for the many excellent student-to-student publications that followed.
More importantly, First Aid itself owes its success to the global community of medical students and international
medical graduates (IMGs) who each year contribute ideas, suggestions, and new content. In the early days, we
used book coupons and tear-out business reply mail forms. These days, we get many thousands of comments and
suggestions each year via our blog FirstAidTeam.com and A.nnotate.

xi

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At the end of the day, we don’t take any of this for granted. Students are expected to synthesize an ever increasing
amount of information, and we have a bigger challenge ahead of us to try to keep First Aid indispensable to students
and IMGs. We want and need your participation in the First Aid community. (See How to Contribute, p. xvii.) With
your help, we hope editing First Aid will continue to be just as fun and rewarding as the past 30 years have been.
Louisville Tao Le
Boracay Vikas Bhushan

First Aid for the USMLE Step 1 Through the Years

xii

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Preface
With the 30th edition of First Aid for the USMLE Step 1, we continue our commitment to providing students with
the most useful and up-to-date preparation guide for the USMLE Step 1. This edition represents an outstanding
revision in many ways, including:
ƒƒ 50 entirely new or heavily revised high-yield topics reflecting evolving trends in the USMLE Step 1.
ƒƒ Reorganization of high-yield topics in Pharmacology, Endocrine, and Reproductive chapters for improved study.
ƒƒ Extensive text revisions, new mnemonics, clarifications, and corrections curated by a team of more than 30
medical student and resident physician authors who excelled on their Step 1 examinations and verified by a team
of expert faculty advisors and nationally recognized USMLE instructors.
ƒƒ Updated with 178 new and revised diagrams and illustrations as part of our ongoing collaboration with
USMLE-Rx and ScholarRx (MedIQ Learning, LLC).
ƒƒ Updated with 75 new and revised photos to help visualize various disorders, descriptive findings, and basic
science concepts. Additionally, revised imaging photos have been labeled and optimized to show both normal
anatomy and pathologic findings.
ƒƒ Updated study tips on the opening page of each chapter.
ƒƒ Improved integration of clinical images and illustrations to better reinforce and learn key anatomic concepts.
ƒƒ Improved organization and integration of text, illustrations, clinical images, and tables throughout for focused
review of high-yield topics.
ƒƒ Revised and expanded ratings of current, high-yield review resources, with clear explanations of their relevance
to USMLE review.
ƒƒ Real-time Step 1 updates and corrections can be found exclusively on our blog, www.firstaidteam.com.
We invite students and faculty to share their thoughts and ideas to help us continually improve First Aid for the
USMLE Step 1 through our blog and collaborative editorial platform. (See How to Contribute, p. xvii.)
Louisville
Boracay
St. Louis
Phoenix
Bristol
New York City
San Francisco

Tao Le
Vikas Bhushan
Matthew Sochat
Vaishnavi Vaidyanathan
Sarah Schimansky
Jordan Abrams
Kimberly Kallianos

xiii

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Special Acknowledgments
This has been a collaborative project from the start. We gratefully acknowledge the thousands of thoughtful
comments, corrections, and advice of the many medical students, international medical graduates, and faculty who
have supported the authors in our continuing development of First Aid for the USMLE Step 1.
For support and encouragement throughout the process, we are grateful to Thao Pham, Jinky Flang, and Jonathan
Kirsch, Esq. Thanks to Louise Petersen for organizing and supporting the project. Thanks to our publisher, McGrawHill, for the valuable assistance of its staff, including Bob Boehringer, Jeffrey Herzich, and Christina Thomas.
We are also very grateful to Dr. Fred Howell and Dr. Robert Cannon of Textensor Ltd for providing us extensive
customization and support for their powerful Annotate.co collaborative editing platform (www.annotate.co), which
allows us to efficiently manage thousands of contributions. Thanks to Dr. Richard Usatine and Dr. Kristine Krafts
for their outstanding image contributions. Thanks also to Jean-Christophe Fournet (www.humpath.com), Dr. Ed
Uthman, and Dr. Frank Gaillard (www.radiopaedia.org) for generously allowing us to access some of their striking
photographs.
For exceptional editorial leadership, enormous thanks to Kathleen Naylor, Christine Diedrich and Emma
Underdown. Thank you to our USMLE-Rx/ScholarRx team of editors, Jessie Schanzle, Ruth Kaufman, Janene
Matragrano, Susan Mazik, Isabel Nogueira, Sharon Prevost, Jen Shimony, and Hannah Warnshuis. Special thanks to
our indexer Dr. Anne Fifer. We are also grateful to our medical illustrator, Hans Neuhart, for his creative work on the
new and updated illustrations. Lastly, tremendous thanks to Graphic World, especially Anne Banning, Sandy Brown,
Gary Clark, and Cindy Geiss.
Louisville
Boracay
St. Louis
Phoenix
Bristol
New York City
San Francisco

Tao Le
Vikas Bhushan
Matthew Sochat
Vaishnavi Vaidyanathan
Sarah Schimansky
Jordan Abrams
Kimberly Kallianos

xiv

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General Acknowledgments

Each year we are fortunate to receive the input of thousands of medical students and graduates who provide new
material, clarifications, and potential corrections through our website and our collaborative editing platform.
This has been a tremendous help in clarifying difficult concepts, correcting errata from the previous edition, and
minimizing new errata during the revision of the current edition. This reflects our long-standing vision of a true,
student-to-student publication. We have done our best to thank each person individually below, but we recognize
that errors and omissions are likely. Therefore, we will post an updated list of acknowledgments at our website, www.
firstaidteam.com/bonus/. We will gladly make corrections if they are brought to our attention.
For submitting contributions and corrections, many thanks to Raed Ababneh, Antara Afrin, Rasim Agaev, Vanya
Aggarwal, Ataa Ahmed, Hasan Alarouri, Basim Ali, Muhammad Faizan Ali, Moatasem Al-Janabi, Mohamed
Almahmodi, Chima Amadi, Arman Amin, Jacqueline Aredo, Ranya Baddourah, Daniel Badin, Nida Bajwa, Dileni
Bandarage, Jerrin Bawa, Esra Bayram, Craig Beavers, Jacqueline Bekhit, Matthias Bergmann, Stephanie Biecker,
Aaron Birnbaum, Prateek Bommu, Nathaniel Borochov, Susan Brands, Olivia W. Brooks, Meghan Brown, Stanley
Budzinski, Kevin Budziszewski, Pavel Burski, Elisa M. Cairns, Sergio Camba, Katie Carsky, Esteban Casasola,
Marielys Castro, Jesse Chait, Bliss Chang, Santosh Cherian, Heewon Choi, Charilaos Chourpiliadis, Maruf
Chowdhury, Matthew J. Christensen, Matthew Yat Hon Chung, Alexander Ciaramella, Dillon Clancy, Sofija Conic,
M. Marwan Dabbagh, Parag Das, Ketan Dayma, Elmer De Camps, Charles de Leeuw, Xavier De Pena, Christopher
DeAngelo, Elliott Delgado, Anthony DeMarinis, Stacy Diaz, Evan Dishion, Nicola Helen Duzak, Emily Edwards,
Alec Egan, Mohamed Elashwal, Osama El-Gabalawy, Matthew Eli, Awab Elnaeem, Sally El Sammak, Dylan Erwin,
Stephanie Estevez-Marin, Gray Evans, Najat Fadlallah, Aria Fariborzi, Richard Ferro, Adam Fletcher, Kimberly A.
Foley, Kyle Fratta, Samantha Friday, Nikhila Gandrakota, Siva Garapati, Nicolas Curi Gawlinski, Joanna Georgakas,
Beth Anne George, Ashley Ghaemi, E. Sophia Gonzalez, Justin Graff, Gabriel Graham, Donovan Griggs, David
Gruen, Gursewak Hadday, Jacqueline Hairston, Hunter Harrison, Gull Shahmir Hasnat, Maximillan Hawkins,
Grecia Haymee, Briana Hernandez, Robin Hilder, Tammy Hua, Derrek Humphries, Audrey Hunt, Nanki Hura,
Danny Ibrahim, Jyothik Varun Inampudi, Hnin Ingyin, Maham Irfan, Mina Iskandar, Kritika Iyer, Christina Jacobs,
Arpit Jain, Neil K. Jain, Ala Jamal, Natalie Jansen, Jordan Jay, Mohammad Jmasi, Colton Junod, Talia Kamdjou,
Filip Kaniski, Lydia Kaoutzani, Panagiotis Kaparaliotis, Srikrishna Karnatapu, Patrick Keller, Olivia Keller-Baruch,
Cameron Kerl, Ahmed Ali Khan, Sara Khan, Shaima Khandaker, Samir Khouzam, Sonya Klein, Elana Kleinman,
Andrew Ko, Soheil Kooraki, Anna Kukharchuk, Dennis Vu Kulp, Anil A. Kumar, Julie Kurek, Chloe Lahoud,
Mike Lawandy, Ramy Lawandy, Jessica Lazar, Andrea Leal-Lopez, Lynda Lee, Chime Lhatso, Christine Lin,
Benjamin Lodge, Soon Khai Low, Estefanía Henríquez Luthje, Lisa-Qiao MacDonald, Divya Madhavarapu, Mahir
Mameledzija, Keerer Mann, Rajver Mann, Nadeen Mansour, Yusra Mansour, Bridget Martinez, Ahmad Mashlah,
Rick Mathews, Amy McGregor, Alexandra & Joshua Medeiros & Fowler, Viviana Medina, Areeka Memon, Pedro
G. R. Menicucci, Ben Meyers, Stephan A. Miller, Fatima Mirza, Murli Mishra, Elana Molcho, Guarina Molina,
John Moon, Nayla Mroueh, Neha Mylarapu, Behnam Nabavizadeh, Moeko Nagatsuka, Ghazal Naghibzadeh, Alice
Nassar, Nadya Nee, Lucas Nelson, Zach Nelson, Monica Nemat, Kenneth Nguyen, Michael Nguyen, Christian

xv

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Nieves, Nyia Njamfa, Ahmed Noor, Kyle Nyugen, Ahamd Obeidat, Gerald Olayan, Anndres Olson, Hasaan Omar,
Daniel Ortiz, Michael O’Shea, Zonghao Pan, Vasilis Sebastian Paraschos, Christopher Parrino, Janak Patel, Vanisha
Patel, Cyril Patra, Rita Paulis, Dmytro Pavlenko, Nancy A. Pina, Alexander Polyak, Jackeline Porto, Shannon D.
Powell, Jacob Pruett, Laith Rahabneh, Kamleshun Ramphul, Janhvi Rana, Nidaa Rasheed, Abdul Sattar Raslan,
Tomas Ream, Rashelle Ripa, Amanda Michelle Ritchie, Helio Manuel Grullón Rodríguez, Sarah Rohrig, Gessel
Romero, Alexander Rose, Rachel Rose, Erica Rubin, Areesha Saati, Jeffrey Sackey, Raza H. Sagarwala, Chhavi Saini,
Sergii Sakhno, Allie Sakowicz, Shadia Saleh, Roshun Sangani, Dhruv Sarwal, Abeer Sarwar, M. Sathyanarayanan,
Neetu Scariya, Tonio Felix Schaffert, Melissa Schechter, Kathryn Scheinberg, Emma Schnuckle, Emma Schulte,
Taylor Schweigert, Lee Seifert, Sheila Serin, Deeksha Seth, Omid Shafaat, Nirav Shah, Samir K. Shah, Wasif
Nauman Shah, Muhanad Shaib, Ahmed Shakir, Purnima Sharma, Tina Sharma, Kayla Sheehan, Dr. Priya
Shenwai, Sami Shoura, Kris Sifeldeen, Akhand Singh, Manik Inder Singh, Ramzi Y. Skaik, Samantha A. Smith,
Timothy Smith, Emilie Song, Hang Song, Shichen Song, Luke Sorensen, Charles Starling, Jonathan Andrew
Stone, Nathan Stumpf, Johnny Su, Bahaa Eddine Succar, Saranya Sundaram, Steven Svoboda, Clara Sze, Olive
Tang, Brian Tanksley, Omar Tayh, Joshua Taylor, Valerie Teano, Warren Teltser, Steffanie Camilo Tertulien, Roger
Torres, Michael Trainer, Andrew Trinh, Aalap K. Trivedi, Georgeanna Tsoumas, Elizabeth Tsui, Cem Turam,
Methma Udawatta, Daramfon Udofia, Adaku Ume, Rio Varghese, Judith Vásquez, Earl Vialpando, Sagar Vinayak,
Phuong Vo, Habiba Wada, Jason Wang, Tiffany Wang, Zoe Warczak, Mitchell Waters, Rachel Watson, Elizabeth
Douglas Weigel, Rabbi Michael Weingarten, Kaystin Weisenberger, Aidan Woodthorpe, Mattia Wruble, Angela Wu,
Catherine Xie, Rebecca Xu, Nicholas Yeisley, Sammy Yeroushalmi, Melissas Yuan, Sahil Zaveri, and Yolanda Zhang.

xvi

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How to Contribute

This version of First Aid for the USMLE Step 1 incorporates thousands of contributions and improvements suggested
by student and faculty advisors. We invite you to participate in this process. Please send us your suggestions for:
ƒƒ Study and test-taking strategies for the USMLE Step 1
ƒƒ New facts, mnemonics, diagrams, and clinical images
ƒƒ High-yield topics that may appear on future Step 1 exams
ƒƒ Personal ratings and comments on review books, question banks, apps, videos, and courses
For each new entry incorporated into the next edition, you will receive up to a $20 Amazon.com gift card as well as
personal acknowledgment in the next edition. Significant contributions will be compensated at the discretion of the
authors. Also, let us know about material in this edition that you feel is low yield and should be deleted.
All submissions including potential errata should ideally be supported with hyperlinks to a dynamically updated Web
resource such as UpToDate, AccessMedicine, and ClinicalKey.
We welcome potential errata on grammar and style if the change improves readability. Please note that First Aid style
is somewhat unique; for example, we have fully adopted the AMA Manual of Style recommendations on eponyms
(“We recommend that the possessive form be omitted in eponymous terms”) and on abbreviations (no periods with
eg, ie, etc). We also avoid periods in tables unless required for full sentences. Kindly refrain from submitting “style
errata” unless you find specific inconsistencies with the AMA Manual of Style.
The preferred way to submit new entries, clarifications, mnemonics, or potential corrections with a valid,
authoritative reference is via our website: www.firstaidteam.com.
This website will be continuously updated with validated errata, new high-yield content, and a new online platform
to contribute suggestions, mnemonics, diagrams, clinical images, and potential errata.
Alternatively, you can email us at: firstaid@scholarrx.com.
Contributions submitted by May 15, 2020, receive priority consideration for the 2021 edition of First Aid for the
USMLE Step 1. We thank you for taking the time to share your experience and apologize in advance that we cannot
individually respond to all contributors as we receive thousands of contributions each year.

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``
NOTE TO CONTRIBUTORS
All contributions become property of the authors and are subject to editing and reviewing. Please verify all data and
spellings carefully. Contributions should be supported by at least two high-quality references.
Check our website first to avoid duplicate submissions. In the event that similar or duplicate entries are received,
only the first complete entry received with valid, authoritative references will be credited. Please follow the style,
punctuation, and format of this edition as much as possible.

``
JOIN THE FIRST AID TEAM
The First Aid author team is pleased to offer part-time and full-time paid internships in medical education and
publishing to motivated medical students and physicians. Internships range from a few months (eg, a summer) up
to a full year. Participants will have an opportunity to author, edit, and earn academic credit on a wide variety of
projects, including the popular First Aid series.
For 2020, we are actively seeking passionate medical students and graduates with a specific interest in improving our
medical illustrations, expanding our database of medical photographs, and developing the software that supports our
crowdsourcing platform. We welcome people with prior experience and talent in these areas. Relevant skills include
clinical imaging, digital photography, digital asset management, information design, medical illustration, graphic
design, tutoring, and software development.
Please email us at firstaid@scholarrx.com with a CV and summary of your interest or sample work.

xviii

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How to Use This Book
CONGRATULATIONS: You now possess the book that has guided nearly two million students to USMLE success
for 30 years. With appropriate care, the binding should last the useful life of the book. Keep in mind that putting
excessive flattening pressure on any binding will accelerate its failure. If you purchased a book that you believe
is defective, please immediately return it to the place of purchase. If you encounter ongoing issues, you can also
contact Customer Service at our publisher, McGraw-Hill Education, at https://www.mheducation.com/contact.html.
START EARLY: Use this book as early as possible while learning the basic medical sciences. The first semester of
your first year is not too early! Devise a study plan by reading Section I: Guide to Efficient Exam Preparation, and
make an early decision on resources to use by checking Section IV: Top-Rated Review Resources. Note that First Aid
is neither a textbook nor a comprehensive review book, and it is not a panacea for inadequate preparation.
CONSIDER FIRST AID YOUR ANNOTATION HUB: Annotate material from other resources, such as class
notes or comprehensive textbooks, into your book. This will keep all the high-yield information you need in one
place. Other tips on keeping yourself organized:
ƒƒ For best results, use fine-tipped ballpoint pens (eg, BIC Pro+, Uni-Ball Jetstream Sports, Pilot Drawing Pen,
Zebra F-301). If you like gel pens, try Pentel Slicci, and for markers that dry almost immediately, consider
Staedtler Triplus Fineliner, Pilot Drawing Pen, and Sharpies.
ƒƒ Consider using pens with different colors of ink to indicate different sources of information (eg, blue for
USMLE-Rx Step 1 Qmax, green for UWorld Step 1 Qbank).
ƒƒ Choose highlighters that are bright and dry quickly to minimize smudging and bleeding through the page
(eg, Tombow Kei Coat, Sharpie Gel).
ƒƒ Many students de-spine their book and get it 3-hole-punched. This will allow you to insert materials from other
sources, including curricular materials.
INTEGRATE STUDY WITH CASES, FLASH CARDS, AND QUESTIONS: To broaden your learning strategy,
consider integrating your First Aid study with case-based reviews (eg, First Aid Cases for the USMLE Step 1), flash
cards (eg, First Aid Flash Facts), and practice questions (eg, the USMLE-Rx Step 1 Qmax). Read the chapter in the
book, then test your comprehension by using cases, flash cards, and questions that cover the same topics. Maintain
access to more comprehensive resources (eg, First Aid for the Basic Sciences: General Principles and Organ Systems
and First Aid Express videos) for deeper review as needed.
PRIME YOUR MEMORY: Return to your annotated Sections II and III several days before taking the USMLE
Step 1. The book can serve as a useful way of retaining key associations and keeping high-yield facts fresh in your
memory just prior to the exam. The Rapid Review section includes high-yield topics to help guide your studying.
CONTRIBUTE TO FIRST AID: Reviewing the book immediately after your exam can help us improve the next
edition. Decide what was truly high and low yield and send us your comments. Feel free to send us scanned images
from your annotated First Aid book as additional support. Of course, always remember that all examinees are under
agreement with the NBME to not disclose the specific details of copyrighted test material.

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Selected USMLE Laboratory Values
* = Included in the Biochemical Profile (SMA-12)
Blood, Plasma, Serum

Reference Range

SI Reference Intervals

*Alanine aminotransferase (ALT, GPT at 30°C)

8–20 U/L

8­–20 U/L

25–125 U/L

25–125 U/L

8–20 U/L

8–20 U/L

0.1–1.0 mg/dL // 0.0–0.3 mg/dL

2–17 µmol/L // 0–5 µmol/L

*Calcium, serum (Total)

8.4–10.2 mg/dL

2.1–2.8 mmol/L

*Cholesterol, serum (Total)

Rec: < 200 mg/dL

< 5.2 mmol/L

*Creatinine, serum (Total)

0.6–1.2 mg/dL

53–106 µmol/L

Electrolytes, serum
Sodium (Na+)
Chloride (Cl–)
+
* Potassium (K )
Bicarbonate (HCO3–)
Magnesium (Mg2+)

136–145 mEq/L
95–105 mEq/L
3.5–5.0 mEq/L
22–28 mEq/L
1.5–2 mEq/L

136–145 mmol/L
95–105 mmol/L
3.5–5.0 mmol/L
22–28 mmol/L
0.75–1.0 mmol/L

75–105 mm Hg
33–45 mm Hg
7.35–7.45

10.0–14.0 kPa
4.4–5.9 kPa
[H+] 36–44 nmol/L

Fasting: 70–110 mg/dL
2-h postprandial: < 120 mg/dL

3.8–6.1 mmol/L
< 6.6 mmol/L

Growth hormone − arginine stimulation

Fasting: < 5 ng/mL
provocative stimuli: > 7 ng/mL

< 5 µg/L
> 7 µg/L

Osmolality, serum

275–295 mOsm/kg

275–295 mOsm/kg

*Phosphatase (alkaline), serum (p-NPP at 30°C)

20–70 U/L

20–70 U/L

*Phosphorus (inorganic), serum

3.0–4.5 mg/dL

1.0–1.5 mmol/L

< 20 ng/mL

< 20 µg/L

6.0–7.8 g/dL
3.5–5.5 g/dL
2.3–3.5 g/dL

60–78 g/L
35–55 g/L
23–35 g/L

0.5–5.0 µU/mL

0.5–5.0 mU/L

*Urea nitrogen, serum (BUN)

7–18 mg/dL

1.2–3.0 mmol/L

*Uric acid, serum

3.0–8.2 mg/dL

0.18–0.48 mmol/L

Amylase, serum
*Aspartate aminotransferase (AST, GOT at 30°C)
Bilirubin, serum (adult)
Total // Direct

Gases, arterial blood (room air)
PO
PCO
pH
2

2

*Glucose, serum

Prolactin, serum (hPRL)
*Proteins, serum
Total (recumbent)
Albumin
Globulins
Thyroid-stimulating hormone, serum or plasma

(continues)

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Cerebrospinal Fluid

Glucose

Reference Range

SI Reference Intervals

40–70 mg/dL

2.2–3.9 mmol/L

Erythrocyte count

Male: 4.3–5.9 million/mm3
Female: 3.5–5.5 million/mm3

4.3–5.9 × 1012/L
3.5–5.5 × 1012/L

Erythrocyte sedimentation rate (Westergen)

Male: 0–15 mm/h
Female: 0–20 mm/h

0–15 mm/h
0–20 mm/h

Hematocrit

Male: 41–53%
Female: 36–46%

0.41–0.53
0.36–0.46

Hemoglobin, blood

Male: 13.5–17.5 g/dL
Female: 12.0–16.0 g/dL

2.09–2.71 mmol/L
1.86–2.48 mmol/L

Hemoglobin, plasma

1–4 mg/dL

0.16–0.62 µmol/L

Leukocyte count and differential
  Leukocyte count
    Segmented neutrophils
    Band forms
    Eosinophils
    Basophils
    Lymphocytes
    Monocytes

4,500–11,000/mm3
54–62%
3–5%
1–3%
0–0.75%
25–33%
3–7%

4.5–11.0 × 109/L
0.54–0.62
0.03–0.05
0.01–0.03
0–0.0075
0.25–0.33
0.03–0.07

Mean corpuscular hemoglobin

25.4–34.6 pg/cell

0.39–0.54 fmol/cell

Mean corpuscular volume

80–100 μm

80–100 fL

Partial thromboplastin time (activated)

25–40 seconds

Platelet count

150,000–400,000/mm

150–400 × 109/L

Prothrombin time

11–15 seconds

11–15 seconds

Reticulocyte count

0.5–1.5% of red cells

0.005–0.015

0–35 mmol/L

0–35 mmol/L

Hematologic

3

25–40 seconds
3

Sweat

Chloride
Urine

Creatinine clearance

Male: 97–137 mL/min
Female: 88–128 mL/min

Osmolality

50–1,400 mOsmol/kg H2O

Proteins, total

< 150 mg/24 h

< 0.15 g/24 h

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First Aid
Checklist
First Aid Checklist
for the
USMLEfor
Stepthe
1 USMLE Step 1

This is an example of how you might use the information in Section I to prepare for the USMLE Step 1.
This
example oftopics
how you
might Iuse
in Section I to prepare for the USMLE
Referistoan
corresponding
in Section
for the
moreinformation
details.
Step 1. Refer to corresponding topics in Section I for more details.

Years Prior

Use top-rated review resources for first-year medical school courses.
Ask for advice from those who have recently taken the USMLE Step 1.

Months Prior

Review computer test format and registration information.
Register six months in advance.
Carefully verify name and address printed on scheduling permit. Make sure
the name on scheduling permit matches the name printed on your photo ID.
Go online for test date ASAP.
Define your exam goals (pass comfortably, beat the mean, ace the test)
Set up a realistic timeline for study. Cover less crammable subjects first.
Evaluate and choose study materials (review books, question banks).
Use a question bank to simulate the USMLE Step 1 to pinpoint strengths and
weaknesses in knowledge and test-taking skills.

Weeks Prior

Do another test simulation in a question bank.
Assess how close you are to your goal.
Pinpoint remaining weaknesses. Stay healthy (exercise, sleep).
Verify information on admission ticket (eg, location, date).

One Week Prior

One Day Prior

Day of Exam

After Exam

Remember comfort measures (loose clothing, earplugs, etc).
Work out test site logistics (eg, location, transportation, parking, lunch).
Print or download your Scheduling Permit and Scheduling Confirmation
to your phone.
Relax.
Lightly review short-term material if necessary. Skim high-yield facts.
Get a good night’s sleep.
Relax.
Eat breakfast.
Minimize bathroom breaks during exam by avoiding excessive morning
caffeine.
Celebrate, regardless of how well you feel you did.
Send feedback to us on our website at www.firstaidteam.com.

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SECTION I

Guide to Efficient
Exam Preparation
“I don’t love studying. I hate studying. I like learning. Learning is
beautiful.”
—Natalie Portman

“Finally, from so little sleeping and so much reading, his brain dried up
and he went completely out of his mind.”
—Miguel de Cervantes Saavedra, Don Quixote

“Sometimes the questions are complicated and the answers are simple.”
—Dr. Seuss

“He who knows all the answers has not been asked all the questions.”
—Confucius

“The expert in anything was once a beginner.”
—Helen Hayes

“It always seems impossible until it’s done.”
—Nelson Mandela

``Introduction2
``USMLE Step 1—The
Basics2
``Defining Your Goal

12

``Learning Strategies

13

``Timeline for Study

16

``Study Materials

20

``Test-Taking
Strategies22
``Clinical Vignette
Strategies23
``If You Think You
Failed24
``Testing Agencies

24

``References25

1
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2

SECTION I

Guide to Efficient Exam Preparation

``
INTRODUCTION
Relax.
This section is intended to make your exam preparation easier, not harder.
Our goal is to reduce your level of anxiety and help you make the most
of your efforts by helping you understand more about the United States
Medical Licensing Examination, Step 1 (USMLE Step 1). As a medical
student, you are no doubt familiar with taking standardized examinations
and quickly absorbing large amounts of material. When you first confront
the USMLE Step 1, however, you may find it all too easy to become
sidetracked from your goal of studying with maximal effectiveness. Common
mistakes that students make when studying for Step 1 include the following:

`` The test at a glance:
ƒƒ 8-hour exam
ƒƒ Up to a total of 280 multiple choice items
ƒƒ 7 test blocks (60 min/block)
ƒƒ Up to 40 test items per block
ƒƒ 45 minutes of break time, plus another 15
if you skip the tutorial

ƒƒ
ƒƒ
ƒƒ
ƒƒ
ƒƒ
ƒƒ
ƒƒ
ƒƒ
ƒƒ
ƒƒ
ƒƒ
ƒƒ
ƒƒ
ƒƒ
ƒƒ

Starting to study (including First Aid) too late
Starting to study intensely too early and burning out
Starting to prepare for boards before creating a knowledge foundation
Using inefficient or inappropriate study methods
Buying the wrong resources or buying too many resources
Buying only one publisher’s review series for all subjects
Not using practice examinations to maximum benefit
Not understanding how scoring is performed or what the score means
Not using review books along with your classes
Not analyzing and improving your test-taking strategies
Getting bogged down by reviewing difficult topics excessively
Studying material that is rarely tested on the USMLE Step 1
Failing to master certain high-yield subjects owing to overconfidence
Using First Aid as your sole study resource
Trying to prepare for it all alone

In this section, we offer advice to help you avoid these pitfalls and be more
productive in your studies.

``
USMLE STEP 1—THE BASICS
The USMLE Step 1 is the first of three examinations that you must pass in
order to become a licensed physician in the United States. The USMLE
is a joint endeavor of the National Board of Medical Examiners (NBME)
and the Federation of State Medical Boards (FSMB). The USMLE serves
as the single examination system for US medical students and international
medical graduates (IMGs) seeking medical licensure in the United States.

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Guide to Efficient Exam Preparation

3

SECTION I

The Step 1 exam includes test items that can be grouped by the organizational constructs outlined in Table 1 (in order of tested frequency).
T A B L E 1 . Frequency of Various Constructs Tested on the USMLE Step 1.*

Competency

Range, %

System

Range, %

Medical knowledge: applying foundational
science concepts

52–62

General principles

Patient care: diagnosis

20–30

Behavioral health & nervous systems/special senses

9–13

13–17

Patient care: management

7–12

Respiratory & renal/urinary systems

9–13

Practice-based learning & improvement

5–7

Reproductive & endocrine systems

9–13

Communication/professionalism

2–5

Blood & lymphoreticular/immune systems

7–11

Multisystem processes & disorders

7–11

Discipline

Range, %

Pathology

45–52

Musculoskeletal, skin & subcutaneous tissue

6–10

Physiology

26–34

Cardiovascular system

6–10

Pharmacology

16–23

Gastrointestinal system

5–9

Biochemistry & nutrition

14–24

Biostatistics & epidemiology/population health

5–7

Microbiology & immunology

15–22

Social sciences: communication skills/ethics

3–5

Gross anatomy & embryology

11–15

Histology & cell biology

9–13

Behavioral sciences

8–12

Genetics

5–9

*Percentages are subject to change at any time. www.usmle.org

How Is the Computer-Based Test (CBT) Structured?

The CBT Step 1 exam consists of one “optional” tutorial/simulation block
and seven “real” question blocks of up to 40 questions per block with no
more than 280 questions in total, timed at 60 minutes per block. A short
11-question survey follows the last question block. The computer begins the
survey with a prompt to proceed to the next block of questions.
Once an examinee finishes a particular question block on the CBT, he or
she must click on a screen icon to continue to the next block. Examinees
cannot go back and change their answers to questions from any previously
completed block. However, changing answers is allowed within a block of
questions as long as the block has not been ended and if time permits.
What Is the CBT Like?

Given the unique environment of the CBT, it’s important that you become
familiar ahead of time with what your test-day conditions will be like. You
can access a 15-minute tutorial and practice blocks at http://orientation.
nbme.org/Launch/USMLE/STPF1. This tutorial interface is very similar to
the one you will use in the exam; learn it now and you can skip taking it
during the exam, giving you up to 15 extra minutes of break time. You can
gain experience with the CBT format by taking the 120 practice questions
(3 blocks with 40 questions each) available online or by signing up for a
practice session at a test center for a fee.

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4

SECTION I

Guide to Efficient Exam Preparation
For security reasons, examinees are not allowed to bring any personal
electronic equipment into the testing area. This includes both digital and
analog watches, iPods, tablets, calculators, cell phones, and electronic paging
devices. Examinees are also prohibited from carrying in their books, notes,
pens/pencils, and scratch paper. Food and beverages are also prohibited
in the testing area. The testing centers are monitored by audio and video
surveillance equipment. However, most testing centers allot each examinee
a small locker outside the testing area in which he or she can store snacks,
beverages, and personal items.

`` Keyboard shortcuts:
ƒƒ A, B, etc—letter choices
ƒƒ Enter or spacebar—move to next
question
ƒƒ Esc—exit pop-up Calculator and Notes
windows

`` Heart sounds are tested via media questions.
Make sure you know how different heart
diseases sound on auscultation.

`` Be sure to test your headphones during the
tutorial.

`` Familiarize yourself with the commonly
tested lab values (eg, Hgb, WBC, platelets,
Na+, K+).

`` Illustrations on the test include:
ƒƒ Gross specimen photos
ƒƒ Histology slides
ƒƒ Medical imaging (eg, x-ray, CT, MRI)
ƒƒ Electron micrographs
ƒƒ Line drawings

`` Ctrl-Alt-Delete are the keys of death during
the exam. Don’t touch them at the same time!

FAS1_2019_00_Section_I.indd 4

Questions are typically presented in multiple choice format, with 4–5
possible answer options. There is a countdown timer on the lower left corner
of the screen as well. There is also a button that allows the examinee to
mark a question for review. If a given question happens to be longer than
the screen (which occurs very rarely), a scroll bar will appear on the right,
allowing the examinee to see the rest of the question. Regardless of whether
the examinee clicks on an answer choice or leaves it blank, he or she must
click the “Next” button to advance to the next question.
The USMLE features a small number of media clips in the form of audio
and/or video. There may even be a question with a multimedia heart sound
simulation. In these questions, a digital image of a torso appears on the
screen, and the examinee directs a digital stethoscope to various auscultation
points to listen for heart and breath sounds. The USMLE orientation
materials include several practice questions in these formats. During the
exam tutorial, examinees are given an opportunity to ensure that both the
audio headphones and the volume are functioning properly. If you are
already familiar with the tutorial and planning on skipping it, first skip ahead
to the section where you can test your headphones. After you are sure the
headphones are working properly, proceed to the exam.
The examinee can call up a window displaying normal laboratory values.
In order to do so, he or she must click the “Lab” icon on the top part of
the screen. Afterward, the examinee will have the option to choose between
“Blood,” “Cerebrospinal,” “Hematologic,” or “Sweat and Urine.” The
normal values screen may obscure the question if it is expanded. The
examinee may have to scroll down to search for the needed lab values. You
might want to memorize some common lab values so you spend less time on
questions that require you to analyze these.
The CBT interface provides a running list of questions on the left part of the
screen at all times. The software also permits examinees to highlight or cross
out information by using their mouse. There is a “Notes” icon on the top
part of the screen that allows students to write notes to themselves for review
at a later time. Finally, the USMLE has recently added new functionality
including text magnification and reverse color (white text on black
background). Being familiar with these features can save time and may help
you better view and organize the information you need to answer a question.

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For those who feel they might benefit, the USMLE offers an opportunity
to take a simulated test, or “CBT Practice Session” at a Prometric center.
Students are eligible to register for this three-and-one-half-hour practice
session after they have received their scheduling permit.
The same USMLE Step 1 sample test items (120 questions) available on
the USMLE website, www.usmle.org, are used at these sessions. No new
items will be presented. The practice session is available at a cost of $75
(or more if taken outside of the US and Canada) and is divided into a short
tutorial and three 1-hour blocks of ~40 test items each. Students receive a
printed percent-correct score after completing the session. No explanations
of questions are provided.

`` You can take a shortened CBT practice test at
a Prometric center.

You may register for a practice session online at www.usmle.org. A separate
scheduling permit is issued for the practice session. Students should allow
two weeks for receipt of this permit.
How Do I Register to Take the Exam?

Prometric test centers offer Step 1 on a year-round basis, except for the
first two weeks in January and major holidays. The exam is given every day
except Sunday at most centers. Some schools administer the exam on their
own campuses. Check with the test center you want to use before making
your exam plans.

`` The Prometric website will display a calendar
with open test dates.

US students can apply to take Step 1 at the NBME website. This application
allows you to select one of 12 overlapping three-month blocks in which to be
tested (eg, April–May–June, June–July–August). Choose your three-month
eligibility period wisely. If you need to reschedule outside your initial threemonth period, you can request a one-time extension of eligibility for the next
contiguous three-month period, and pay a rescheduling fee. The application
also includes a photo ID form that must be certified by an official at your
medical school to verify your enrollment. After the NBME processes your
application, it will send you a scheduling permit.
The scheduling permit you receive from the NBME will contain your USMLE
identification number, the eligibility period in which you may take the exam,
and two additional numbers. The first of these is known as your “scheduling
number.” You must have this number in order to make your exam appointment
with Prometric. The second number is known as the “candidate identification
number,” or CIN. Examinees must enter their CINs at the Prometric
workstation in order to access their exams. However, you will not be allowed
to bring your permit into the exam and will be asked to copy your CIN onto
your scratch paper. Prometric has no access to the codes. Make sure to bring
a paper or electronic copy of your permit with you to the exam! Also bring
an unexpired, government-issued photo ID that includes your signature (such
as a ­driver’s license or passport). Make sure the name on your photo ID exactly
matches the name that appears on your scheduling permit.

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`` The confirmation emails that Prometric
and NBME send are not the same as the
scheduling permit.

`` Test scheduling is done on a “first-come,
first-served” basis. It’s important to schedule
an exam date as soon as you receive your
scheduling permit.

Once you receive your scheduling permit, you may access the Prometric
website or call Prometric’s toll-free number to arrange a time to take the
exam. You may contact Prometric two weeks before the test date if you
want to confirm identification requirements. Although requests for taking
the exam may be completed more than six months before the test date,
examinees will not receive their scheduling permits earlier than six months
before the eligibility period. The eligibility period is the three-month period
you have chosen to take the exam. Most medical students choose the April–
June or June–August period. Because exams are scheduled on a “first-come,
first-served” basis, it is recommended that you book an exam date on the
Prometric website as soon as you receive your permit. Prometric will provide
appointment confirmation on a print-out and by email. Be sure to read the
latest USMLE Bulletin of Information for further details.
What If I Need to Reschedule the Exam?

You can change your test date and/or center by contacting Prometric at
1-800-MED-EXAM (1-800-633-3926) or www.prometric.com. Make sure to
have your CIN when rescheduling. If you are rescheduling by phone, you
must speak with a Prometric representative; leaving a voicemail message will
not suffice. To avoid a rescheduling fee, you will need to request a change
at least 31 calendar days before your appointment. Please note that your
rescheduled test date must fall within your assigned three-month eligibility
period.

`` Register six months in advance for seating
and scheduling preference.

When Should I Register for the Exam?

You should plan to register as far in advance as possible ahead of your
desired test date (eg, six months), but, depending on your particular test
center, new dates and times may open closer to the date. Scheduling early
will guarantee that you will get either your test center of choice or one
within a 50-mile radius of your first choice. For most US medical students,
the desired testing window is in June, since most medical school curricula
for the second year end in May or June. Thus, US medical students should
plan to register before January in anticipation of a June test date. The timing
of the exam is more flexible for IMGs, as it is related only to when they
finish exam preparation. Talk with upperclassmen who have already taken
the test so you have real-life experience from students who went through a
similar curriculum, then formulate your own strategy.
Where Can I Take the Exam?

Your testing location is arranged with Prometric when you book your test
date (after you receive your scheduling permit). For a list of Prometric
locations nearest you, visit www.prometric.com.

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SECTION I

How Long Will I Have to Wait Before I Get My Scores?

The USMLE reports scores in three to four weeks, unless there are delays
in score processing. Examinees will be notified via email when their scores
are available. By following the online instructions, examinees will be able to
view, download, and print their score report online for ~120 days after score
notification, after which scores can only be obtained through requesting an
official USMLE transcript. Additional information about score timetables
and accessibility is available on the official USMLE website.
What About Time?

Time is of special interest on the CBT exam. Here’s a breakdown of the
exam schedule:

`` Gain extra break time by skipping the tutorial
or finishing a block early.

15 minutes 	Tutorial (skip if familiar with test format and features)
7 hours
Seven 60-minute question blocks
45 minutes
Break time (includes time for lunch)
The computer will keep track of how much time has elapsed on the exam.
However, the computer will show you only how much time you have
remaining in a given block. Therefore, it is up to you to determine if you
are pacing yourself properly (at a rate of approximately one question per 90
seconds).
The computer does not warn you if you are spending more than your
allotted time for a break. You should therefore budget your time so that
you can take a short break when you need one and have time to eat. You
must be especially careful not to spend too much time in between blocks
(you should keep track of how much time elapses from the time you finish a
block of questions to the time you start the next block). After you finish one
question block, you’ll need to click to proceed to the next block of questions.
If you do not click within 30 seconds, you will automatically be entered into
a break period.
Break time for the day is 45 minutes, but you are not required to use all of
it, nor are you required to use any of it. You can gain extra break time (but
not extra time for the question blocks) by skipping the tutorial or by finishing
a block ahead of the allotted time. Any time remaining on the clock when
you finish a block gets added to your remaining break time. Once a new
question block has been started, you may not take a break until you have
reached the end of that block. If you do so, this will be recorded as an
“unauthorized break” and will be reported on your final score report.

`` Be careful to watch the clock on your break
time.

Finally, be aware that it may take a few minutes of your break time to “check
out” of the secure resting room and then “check in” again to resume testing,
so plan accordingly. The “check-in” process may include fingerprints,
pocket checks, and metal detector scanning. Some students recommend
pocketless clothing on exam day to streamline the process.

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If I Freak Out and Leave, What Happens to My Score?

Your scheduling permit shows a CIN that you will need to enter to start
your exam. Entering the CIN is the same as breaking the seal on a test book,
and you are considered to have started the exam when you do so. However,
no score will be reported if you do not complete the exam. In fact, if you
leave at any time from the start of the test to the last block, no score will be
reported. The fact that you started but did not complete the exam, however,
will appear on your USMLE score transcript. Even though a score is not
posted for incomplete tests, examinees may still get an option to request that
their scores be calculated and reported if they desire; unanswered questions
will be scored as incorrect.
The exam ends when all question blocks have been completed or when
their time has expired. As you leave the testing center, you will receive a
printed test-completion notice to document your completion of the exam.
To receive an official score, you must finish the entire exam.
What Types of Questions Are Asked?
`` Nearly three fourths of Step 1 questions begin
with a description of a patient.

All questions on the exam are one-best-answer multiple choice items.
Most questions consist of a clinical scenario or a direct question followed
by a list of five or more options. You are required to select the single best
answer among the options given. There are no “except,” “not,” or matching
questions on the exam. A number of options may be partially correct, in
which case you must select the option that best answers the question or
completes the statement. Additionally, keep in mind that experimental
questions may appear on the exam, which do not affect your score.
How Is the Test Scored?

Each Step 1 examinee receives an electronic score report that includes the
examinee’s pass/fail status, a three-digit test score, a bar chart comparing the
examinee’s performance to that of other examinees’, and a graphic depiction
of the examinee’s performance by physician task, discipline and organ
system.
The USMLE score report highlights the examinee’s strength and weaknesses
by providing an overview of their performance by physician task, discipline
and organ system compared to their overall performance on the exam.
Each of the questions (minus experimental questions) is tagged according
to any or all relevant content areas. Yellow-colored boxes (lower, same,
higher) on your score report indicate your performance in each specific
content area relative to your overall performance on the exam. This is often
a direct consequence of the total number of questions for each physician
task, discipline or system, which is indicated by percentage range after each
specified content area on the score report (see Figure 1).

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SECTION I

F I G U R E 1 . Samples from the USMLE Step 1 Performance Profile.

The NBME provides a three-digit test score based on the total number of
items answered correctly on the examination, which corresponds to a
particular percentile (see Figure 2). Your three-digit score will be qualified
by the mean and standard deviation of US and Canadian medical school
first-time examinees.
Since some questions may be experimental and are not counted, it is
possible to get different scores for the same number of correct answers. In
2018, the mean score was 230 with a standard deviation of 19.

`` The mean Step 1 score for US medical
students continues to rise, from 200 in 1991
to 230 in 2018.

The passing score for Step 1 is 194. The NBME does not report the
minimum number of correct responses needed to pass, but estimates that it
is roughly 60–70%. The NBME may adjust the minimum passing score in
the future, so please check the USMLE website or www.firstaidteam.com for
updates.
According to the USMLE, medical schools receive a listing of total scores
and pass/fail results plus group summaries by discipline and organ system.
Students can withhold their scores from their medical school if they wish.
Official USMLE transcripts, which can be sent on request to residency
programs, include only total scores, not performance profiles.

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Guide to Efficient Exam Preparation
F I G U R E 2 . Score and Percentile for First-time Step 1 Takers.

100

Percentile

80
60
40
20

Minimum
passing score

0
150

175

200

225

250

275

300

USMLE Step 1 Score
N=72,473 including US and Canadian medical school students testing between January 1, 2016–December 31, 2018.
www.usmle.org.

Consult the USMLE website or your medical school for the most current
and accurate information regarding the examination.
What Does My Score Mean?

The most important point with the Step 1 score is passing versus failing.
Passing essentially means, “Hey, you’re on your way to becoming a fully
licensed doc.” As Table 2 shows, the majority of students pass the exam, so
remember, we told you to relax.
T A B L E 2 . Passing Rates for the 2017–2018 USMLE Step 1.2

2017

2018

No. Tested

% Passing

No. Tested

% Passing

20,353

96%

20,670

96%

Repeaters

1,029

67%

941

67%

Allopathic total

21,382

94%

21,611

95%

3,786

95%

4,092

96%

49

76%

44

73%

3,835

95%

4,136

96%

Total US/Canadian

25,217

94%

25,747

94%

IMG 1st takers

14,900

78%

14,332

80%

2,303

41%

2,111

44%

IMG total

17,203

73%

16,443

75%

Total Step 1 examinees

42,420

85%

42,190

86%

Allopathic 1st takers­­­­

Osteopathic 1st takers
Repeaters
Osteopathic total

Repeaters

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Guide to Efficient Exam Preparation
Beyond that, the main point of having a quantitative score is to give you
a sense of how well you’ve done on the exam and to help schools and
residencies rank their students and applicants, respectively.
Official NBME/USMLE Resources

The NBME offers a Comprehensive Basic Science Examination (CBSE) for
practice that is a shorter version of the Step 1. The CBSE contains four blocks
of 50 questions each and covers material that is typically learned during the
basic science years. Scores range from 45 to 95 and correlate with a Step 1
equivalent (see Table 3). The standard error of measurement is approximately
3 points, meaning a score of 80 would estimate the student’s proficiency is
somewhere between 77 and 83. In other words, the actual Step 1 score could be
predicted to be between 218 and 232. Of course, these values do not correlate
exactly, and they do not reflect different test preparation methods. Many schools
use this test to gauge whether a student is expected to pass Step 1. If this test
is offered by your school, it is usually conducted at the end of regular didactic
time before any dedicated Step 1 preparation. If you do not encounter the
CBSE before your dedicated study time, you need not worry about taking it.
Use the information to help set realistic goals and timetables for your success.
The NBME also offers six forms of Comprehensive Basic Science SelfAssessment (CBSSA). Students who prepared for the exam using this webbased tool reported that they found the format and content highly indicative
of questions tested on the actual exam. In addition, the CBSSA is a fair
predictor of USMLE performance (see Table 4). The test interface, however,
does not match the actual USMLE test interface, so practicing with these
forms alone is not advised.
The CBSSA exists in two formats: standard-paced and self-paced, both of
which consist of four sections of 50 questions each (for a total of 200 multiple
choice items). The standard-paced format allows the user up to 75 minutes
to complete each section, reflecting time limits similar to the actual exam.
By contrast, the self-paced format places a 5-hour time limit on answering
all multiple choice questions. Every few years, a new form is released and an
older one is retired, reflecting changes in exam content. Therefore, the newer
exams tend to be more similar to the actual Step 1, and scores from these
exams tend to provide a better estimation of exam day performance.
Keep in mind that this bank of questions is available only on the web. The
NBME requires that users start and complete the exam within 90 days of
purchase. Once the assessment has begun, users are required to complete
the sections within 20 days. Following completion of the questions, the
CBSSA provides a performance profile indicating the user’s relative
strengths and weaknesses, much like the report profile for the USMLE Step
1 exam. The profile is scaled with an average score of 500 and a standard
deviation of 100. In addition to the performance profile, examinees will be
informed of the number of questions answered incorrectly. You will have the
ability to review the text of the incorrect question with the correct answer.

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SECTION I

T A B L E 3 . CBSE to USMLE Score

Prediction.

CBSE
Score

Step 1
Equivalent

≥ 94

≥ 260

  92

  255

  90

  250

  88

  245

  86

  240

  84

  235

  82

  230

  80

  225

  78

  220

  76

  215

  74

  210

  72

  205

  70

  200

  68

  195

  66

  190

  64

  185

  62

  180

  60

  175

  58

  170

  56

  165

  54

  160

  52

  155

  50

  150

  48

  145

  46

  140

≤ 44

≤ 135

`` Practice questions may be easier than the
actual exam.

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T A B L E 4 . CBSSA to USMLE Score

Prediction.

CBSSA
Score

Approximate
USMLE Step 1 Score

150

155

200

165

250

175

300

186

350

196

400

207

450

217

500

228

550

238

600

248

650

259

700

269

750

280

800

290

Explanations for the correct answer, however, will not be provided. The
NBME charges $60 for assessments with expanded feedback. The fees are
payable by credit card or money order. For more information regarding the
CBSE and the CBSSA, visit the NBME’s website at www.nbme.org.
The NBME scoring system is weighted for each assessment exam. While
some exams seem more difficult than others, the score reported takes into
account these inter-test differences when predicting Step 1 performance.
Also, while many students report seeing Step 1 questions “word-for-word”
out of the assessments, the NBME makes special note that no live USMLE
questions are shown on any NBME assessment.
Lastly, the International Foundations of Medicine (IFOM) offers a Basic
Science Examination (BSE) practice exam at participating Prometric test
centers for $200. Students may also take the self-assessment test online for
$35 through the NBME’s website. The IFOM BSE is intended to determine
an examinee’s relative areas of strength and weakness in general areas of
basic science—not to predict performance on the USMLE Step 1 exam—
and the content covered by the two examinations is somewhat different.
However, because there is substantial overlap in content coverage and many
IFOM items were previously used on the USMLE Step 1, it is possible to
roughly project IFOM performance onto the USMLE Step 1 score scale.
More information is available at http://www.nbme.org/ifom/.

``
DEFINING YOUR GOAL
It is useful to define your own personal performance goal when approaching
the USMLE Step 1. Your style and intensity of preparation can then be
matched to your goal. Furthermore, your goal may depend on your school’s
requirements, your specialty choice, your grades to date, and your personal
assessment of the test’s importance. Do your best to define your goals early
so that you can prepare accordingly.
`` Some competitive residency programs place
more weight on Step 1 scores when choosing
candidates to interview.

`` Fourth-year medical students have the best
feel for how Step 1 scores factor into the
residency application process.

FAS1_2019_00_Section_I.indd 12

The value of the USMLE Step 1 score in selecting residency applicants
remains controversial, and some have called for less emphasis to be placed
on the score when selecting or screening applicants.3 For the time being,
however, it continues to be an important part of the residency application, and
it is not uncommon for some specialties to implement filters that screen out
applicants who score below a certain cutoff. This is more likely to be seen in
competitive specialties (eg, orthopedic surgery, ophthalmology, dermatology,
otolaryngology). Independent of your career goals, you can maximize your
future options by doing your best to obtain the highest score possible (see
Figure 3). At the same time, your Step 1 score is only one of a number of
factors that are assessed when you apply for residency. In fact, many residency
programs value other criteria such as letters of recommendation, third-year
clerkship grades, honors, and research experience more than a high score
on Step 1. Fourth-year medical students who have recently completed the
residency application process can be a valuable resource in this regard.

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SECTION I

F I G U R E 3 . Median USMLE Step 1 Score by Specialty for Matched US Seniors.a,b
260
250

246

240
233

230

226

220

220

225

230

227

231

232

233

233

233

236

235

236

240

245

248

247

248

249

245

249

210
200

Fam

ily
m

ed
icin
e
Psy
chi
P
atr
an hysic
y
d r al
eh m
ab ed
ilit icin
a
Ch tion e
ild
ne
uro
log
y
Ob
ste
gy tric
ne s a
col nd
og
y
Pe
dia
tric
s
Ne
uro
log
y
An
est
he
sio
Em
log
erg
y
en
cy
me
dic
ine
Int
ern
al
me
dic
ine
Pa
tho
log
Ge
y
ne
ral
sur
ge
Int
ry
ern
al
me
Pe dic
d in
Va iatric e/
scu s
lar
sur
Dia
ge
gn
ry
ost
i
c
Int
rad
erv
iol
og
en
y
tio
na
l ra
dio
log
Op
y
hth
alm
olo
Or
gy
tho
pe
dic
sur
Ra
ge
dia
ry
tio
no
n co
log
y
Oto
lar
yn
go
log
y
De
rm
ato
Ne
log
uro
y
log
ica
l su
rge
ry
Pla
sti
cs
urg
ery

190

aVertical lines show

interquartile range.

bData from National Resident Matching Program. Charting outcomes in the match. http://www.nrmp.org/wp-content/uploads/2018/06/Charting-Outcomes-in-the-Match-2018-Seniors.pdf. Published July 2018.

``
LEARNING STRATEGIES
Many students feel overwhelmed during the preclinical years and struggle to
find an effective learning strategy. Table 5 lists several learning strategies you
can try and their estimated effectiveness for Step 1 preparation based on the
literature (see References). These are merely suggestions, and it’s important
to take your learning preferences into account. Your comprehensive
learning approach will contain a combination of strategies (eg, elaborative
interrogation followed by practice testing, mnemonics review using spaced
repetition, etc). Regardless of your choice, the foundation of knowledge
you build during your basic science years is the most important resource for
success on the USMLE Step 1.

`` The foundation of knowledge you build
during your basic science years is the most
important resource for success on the USMLE
Step 1.

HIGH EFFICACY
Practice Testing

Also called “retrieval practice,” practice testing has both direct and indirect
benefits to the learner.4 Effortful retrieval of answers does not only identify
weak spots—it directly strengthens long-term retention of material.5 The
more effortful the recall, the better the long-term retention. This advantage
has been shown to result in higher test scores and GPAs.6 In fact, research
has shown a positive correlation between the number of boards-style practice
questions completed and Step 1 scores among medical students.7

`` Research has shown a positive correlation
between the number of boards-style practice
questions completed and Step 1 scores
among medical students.

Practice testing should be done with “interleaving” (mixing of questions
from different topics in a single session). Question banks often allow you to
intermingle topics. Interleaved practice helps learners develop their ability to
focus on the relevant concept when faced with many possibilities. Practicing
topics in massed fashion (eg, all cardiology, then all dermatology) may seem
intuitive, but there is strong evidence that interleaving correlates with longer-

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TA B L E 5 .

Effective Learning Strategies.

EFFICACY

STRATEGY

EXAMPLE RESOURCES

High efficacy

Practice testing
(retrieval practice)

UWorld Qbank
NBME Self-Assessments
USMLE-Rx QMax
Kaplan Qbank

Distributed practice

USMLE-Rx Flash Facts
Anki
Firecracker
Memorang
Osmosis

Mnemonics

Pre-made:
SketchyMedical
Picmonic
Self-made:
Mullen Memory

Moderate
efficacy

Elaborative interrogation/
self-explanation
Concept mapping

Low efficacy

Coggle
FreeMind
XMind
MindNode

Rereading
Highlighting/underlining
Summarization

term retention and increased student achievement, especially on tasks that
involve problem solving.5
In addition to using question banks, you can test yourself by arranging your
notes in a question-answer format (eg, via flash cards). Testing these Q&As in
random order allows you to reap the benefit of interleaved practice. Bear in
mind that the utility of practice testing comes from the practice of information
retrieval, so simply reading through Q&As will attenuate this benefit.
Distributed Practice

Also called “spaced repetition,” distributed practice is the opposite of massed
practice or “cramming.” Learners review material at increasingly spaced out
intervals (days to weeks to months). Massed learning may produce more
short-term gains and satisfaction, but learners who use distributed practice
have better mastery and retention over the long term.5,9
Flash cards are a simple way to incorporate both distributed practice and
practice testing. Studies have linked spaced repetition learning with flash

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Guide to Efficient Exam Preparation
cards to improved long-term knowledge retention and higher exam scores.6,8,10
Apps with automated spaced-repetition software (SRS) for flash cards exist for
smartphones and tablets, so the cards are accessible anywhere. Proceed with
caution: there is an art to making and reviewing cards. The ease of quickly
downloading or creating digital cards can lead to flash card overload (it is
unsustainable to make 50 flash cards per lecture!). Even at a modest pace,
the thousands upon thousands of cards are too overwhelming for Step 1
preparation. Unless you have specific high-yield cards (and have checked
the content with high-yield resources), stick to pre-made cards by reputable
sources that curate the vast amount of knowledge for you.

15

SECTION I

`` Studies have linked spaced repetition
learning with flash cards to improved longterm knowledge retention and higher exam
scores.

If you prefer pen and paper, consider using a planner or spreadsheet to
organize your study material over time. Distributed practice allows for
some forgetting of information, and the added effort of recall over time
strengthens the learning.
MODERATE EFFICACY
Mnemonics

A “mnemonic” refers to any device that assists memory, such as acronyms,
mental imagery (eg, keywords with or without memory palaces), etc. Keyword
mnemonics have been shown to produce superior knowledge retention
when compared with rote memorization in many scenarios. However, they
are generally more effective when applied to memorization-heavy, keywordfriendly topics and may not be broadly suitable.5 Keyword mnemonics may
not produce long-term retention, so consider combining mnemonics with
distributed, retrieval-based practice (eg, via flash cards with SRS).
Self-made mnemonics may have an advantage when material is simple and
keyword friendly. If you can create your own mnemonic that accurately
represents the material, this will be more memorable. When topics are
complex and accurate mnemonics are challenging to create, pre-made
mnemonics may be more effective, especially if you are inexperienced at
creating mnemonics.11
Elaborative Interrogation/Self-Explanation

Elaborative interrogation (“why” questions) and self-explanation (general
questioning) prompt learners to generate explanations for facts. When
reading passages of discrete facts, consider using these techniques, which
have been shown to be more effective than rereading (eg, improved recall
and better problem-solving/diagnostic performance).5,12,13

`` Elaborative interrogation and selfexplanation prompt learners to generate
explanations for facts, which improves recall
and problem solving.

Concept Mapping

Concept mapping is a method for graphically organizing knowledge, with
concepts enclosed in boxes and lines drawn between related concepts.

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Creating or studying concept maps may be more effective than other
activities (eg, writing or reading summaries/outlines). However, studies have
reached mixed conclusions about its utility, and the small size of this effect
raises doubts about its authenticity and pedagogic significance.14
LOW EFFICACY
Rereading

While the most commonly used method among surveyed students,
rereading has not been shown to correlate with grade point average.9 Due to
its popularity, rereading is often a comparator in studies on learning. Other
strategies that we have discussed (eg, practice testing) have been shown to be
significantly more effective than rereading.
Highlighting/Underlining

Because this method is passive, it tends to be of minimal value for learning
and recall. In fact, lower-performing students are more likely to use these
techniques.9 Students who highlight and underline do not learn how
to actively recall learned information and thus find it difficult to apply
knowledge to exam questions.
Summarization

While more useful for improving performance on generative measures (eg,
free recall or essays), summarization is less useful for exams that depend on
recognition (eg, multiple choice). Findings on the overall efficacy of this
method have been mixed.5

``
TIMELINE FOR STUDY
Before Starting

Your preparation for the USMLE Step 1 should begin when you enter
medical school. Organize and commit to studying from the beginning so
that when the time comes to prepare for the USMLE, you will be ready with
a strong foundation.
Make a Schedule

After you have defined your goals, map out a study schedule that is consistent
with your objectives, your vacation time, the difficulty of your ongoing
coursework, and your family and social commitments (see Figure 4).
Determine whether you want to spread out your study time or concentrate it
into 14-hour study days in the final weeks. Then factor in your own history in

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17

SECTION I

F I G U R E 4 . Typical Timeline for the USMLE Step 1.

Register
for
USMLE
Step 1

Schedule
test date
and
location

Nov Dec Jan Feb
2019
2020

Typical
period
to take
exam

Mar

Apr

May June July Aug

Sept

`` Customize your schedule. Tackle your weakest
section first.

preparing for standardized examinations (eg, SAT, MCAT). Talk to students at
your school who have recently taken Step 1. Ask them for their study schedules,
especially those who have study habits and goals similar to yours. Sample
schedules can be found at https://firstaidteam.com/schedules/.
Typically, US medical schools allot between four and eight weeks for
dedicated Step 1 preparation. The time you dedicate to exam preparation
will depend on your target score as well as your success in preparing yourself
during the first two years of medical school. Some students reserve about a
week at the end of their study period for final review; others save just a few
days. When you have scheduled your exam date, do your best to adhere to it.
Studies show that a later testing date does not translate into a higher score, so
avoid pushing back your test date without good reason.15
Make your schedule realistic, and set achievable goals. Many students make
the mistake of studying at a level of detail that requires too much time for a
comprehensive review—reading Gray’s Anatomy in a couple of days is not a
realistic goal! Have one catch-up day per week of studying. No matter how
well you stick to your schedule, unexpected events happen. But don’t let
yourself procrastinate because you have catch-up days; stick to your schedule
as closely as possible and revise it regularly on the basis of your actual
progress. Be careful not to lose focus. Beware of feelings of inadequacy when
comparing study schedules and progress with your peers. Avoid others who
stress you out. Focus on a few top-rated resources that suit your learning
style—not on some obscure books your friends may pass down to you.
Accept the fact that you cannot learn it all.
You will need time for uninterrupted and focused study. Plan your
personal affairs to minimize crisis situations near the date of the test. Allot
an adequate number of breaks in your study schedule to avoid burnout.
Maintain a healthy lifestyle with proper diet, exercise, and sleep.

`` Avoid burnout. Maintain proper diet, exercise,
and sleep habits.

Another important aspect of your preparation is your studying environment.
Study where you have always been comfortable studying. Be sure to
include everything you need close by (review books, notes, coffee, snacks,
etc). If you’re the kind of person who cannot study alone, form a study group
with other students taking the exam. The main point here is to create a
comfortable environment with minimal distractions.

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Year(s) Prior

`` Buy review books early (first year) and use
while studying for courses.

The knowledge you gained during your first two years of medical school and
even during your undergraduate years should provide the groundwork on
which to base your test preparation. Student scores on NBME subject tests
(commonly known as “shelf exams”) have been shown to be highly correlated
with subsequent Step 1 scores.16 Moreover, undergraduate science GPAs
as well as MCAT scores are strong predictors of performance on the Step 1
exam.17
We also recommend that you buy highly rated review books early in your first
year of medical school and use them as you study throughout the two years.
When Step 1 comes along, these books will be familiar and personalized to the
way in which you learn. It is risky and intimidating to use unfamiliar review
books in the final two or three weeks preceding the exam. Some students find
it helpful to personalize and annotate First Aid throughout the curriculum.
Months Prior

Review test dates and the application procedure. Testing for the USMLE
Step 1 is done on a year-round basis. If you have disabilities or special
circumstances, contact the NBME as early as possible to discuss test
accommodations (see the Section I Supplement at www.firstaidteam.com/
bonus).
`` Simulate the USMLE Step 1 under “real”
conditions before beginning your studies.

Use this time to finalize your ideal schedule. Consider upcoming breaks
and whether you want to relax or study. Work backward from your test date
to make sure you finish at least one question bank. Also add time to redo
missed or flagged questions (which may be half the bank). This is the time to
build a structured plan with enough flexibility for the realities of life.
Begin doing blocks of questions from reputable question banks under “real”
conditions. Don’t use tutor mode until you’re sure you can finish blocks
in the allotted time. It is important to continue balancing success in your
normal studies with the Step 1 test preparation process.
Weeks Prior (Dedicated Preparation)

`` In the final two weeks, focus on review,
practice questions, and endurance. Stay
confident!

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Your dedicated prep time may be one week or two months. You should have
a working plan as you go into this period. Finish your schoolwork strong, take
a day off, and then get to work. Start by simulating a full-length USMLE
Step 1 if you haven’t yet done so. Consider doing one NBME CBSSA and
the free questions from the NBME website. Alternatively, you could choose 7
blocks of randomized questions from a commercial question bank. Make sure
you get feedback on your strengths and weaknesses and adjust your studying
accordingly. Many students study from review sources or comprehensive
programs for part of the day, then do question blocks. Also, keep in mind that
reviewing a question block can take upward of two hours. Feedback from
CBSSA exams and question banks will help you focus on your weaknesses.

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One Week Prior

Make sure you have your CIN (found on your scheduling permit) as well
as other items necessary for the day of the examination, including a current
driver’s license or another form of photo ID with your signature (make sure
the name on your ID exactly matches that on your scheduling permit).
Confirm the Prometric testing center location and test time. Work out how
you will get to the testing center and what parking and traffic problems you
might encounter. Drive separately from other students taking the test on
the same day, and exchange cell phone numbers in case of emergencies.
If possible, visit the testing site to get a better idea of the testing conditions
you will face. Determine what you will do for lunch. Make sure you have
everything you need to ensure that you will be comfortable and alert at the
test site. It may be beneficial to adjust your schedule to start waking up at
the same time that you will on your test day. And of course, make sure to
maintain a healthy lifestyle and get enough sleep.

`` One week before the test:
ƒƒ Sleep according to the same schedule you’ll
use on test day
ƒƒ Review the CBT tutorial one last time
ƒƒ Call Prometric to confirm test date and time

One Day Prior

Try your best to relax and rest the night before the test. Double-check your
admissions and test-taking materials as well as the comfort measures discussed
earlier so that you will not have to deal with such details on the morning of
the exam. At this point it will be more effective to review short-term memory
material that you’re already familiar with than to try to learn new material.
The Rapid Review section at the end of this book is high yield for last-minute
studying. Remember that regardless of how hard you have studied, you cannot
know everything. There will be things on the exam that you have never even
seen before, so do not panic. Do not underestimate your abilities.
Many students report difficulty sleeping the night prior to the exam. This
is often exacerbated by going to bed much earlier than usual. Do whatever
it takes to ensure a good night’s sleep (eg, massage, exercise, warm milk,
no back-lit screens at night). Do not change your daily routine prior to the
exam. Exam day is not the day for a caffeine-withdrawal headache.
Morning of the Exam

On the morning of the Step 1 exam, wake up at your regular time and
eat a normal breakfast. If you think it will help you, have a close friend or
family member check to make sure you get out of bed. Make sure you have
your scheduling permit admission ticket, test-taking materials, and comfort
measures as discussed earlier. Wear loose, comfortable clothing. Plan for a
variable temperature in the testing center. Arrive at the test site 30 minutes
before the time designated on the admission ticket; however, do not come
too early, as doing so may intensify your anxiety. When you arrive at the
test site, the proctor should give you a USMLE information sheet that will
explain critical factors such as the proper use of break time. Seating may be
assigned, but ask to be reseated if necessary; you need to be seated in an area

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`` No notes, books, calculators, pagers, cell
phones, recording devices, or watches of any
kind are allowed in the testing area, but they
are allowed in lockers.

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`` Arrive at the testing center 30 minutes before
your scheduled exam time. If you arrive
more than half an hour late, you will not be
allowed to take the test.

that will allow you to remain comfortable and to concentrate. Get to know
your testing station, especially if you have never been in a Prometric testing
center before. Listen to your proctors regarding any changes in instructions
or testing procedures that may apply to your test site.
Finally, remember that it is natural (and even beneficial) to be a little
nervous. Focus on being mentally clear and alert. Avoid panic. When you
are asked to begin the exam, take a deep breath, focus on the screen, and
then begin. Keep an eye on the timer. Take advantage of breaks between
blocks to stretch, maybe do some jumping jacks, and relax for a moment
with deep breathing or stretching.
After the Test

After you have completed the exam, be sure to have fun and relax regardless
of how you may feel. Taking the test is an achievement in itself. Remember,
you are much more likely to have passed than not. Enjoy the free time
you have before your clerkships. Expect to experience some “reentry”
phenomena as you try to regain a real life. Once you have recovered
sufficiently from the test (or from partying), we invite you to send us your
feedback, corrections, and suggestions for entries, facts, mnemonics,
strategies, resource ratings, and the like (see p. xvii, How to Contribute).
Sharing your experience will benefit fellow medical students and IMGs.

``
STUDY MATERIALS
Quality Considerations

Although an ever-increasing number of review books and software are now
available on the market, the quality of such material is highly variable. Some
common problems are as follows:
ƒƒ Certain review books are too detailed to allow for review in a reasonable
amount of time or cover subtopics that are not emphasized on the exam.
ƒƒ Many sample question books were originally written years ago and have
not been adequately updated to reflect recent trends.
ƒƒ Some question banks test to a level of detail that you will not find on the
exam.
`` If a given review book is not working for you,
stop using it no matter how highly rated it
may be or how much it costs.

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Review Books

In selecting review books, be sure to weigh different opinions against each
other, read the reviews and ratings in Section IV of this guide, examine the
books closely in the bookstore, and choose carefully. You are investing not
only money but also your limited study time. Do not worry about finding
the “perfect” book, as many subjects simply do not have one, and different
students prefer different formats. Supplement your chosen books with personal
notes from other sources, including what you learn from question banks.

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Guide to Efficient Exam Preparation
There are two types of review books: those that are stand-alone titles and
those that are part of a series. Books in a series generally have the same style,
and you must decide if that style works for you. However, a given style is not
optimal for every subject.

SECTION I

21

`` Charts and diagrams may be the best
approach for physiology and biochemistry,
whereas tables and outlines may be
preferable for microbiology.

You should also find out which books are up to date. Some recent editions
reflect major improvements, whereas others contain only cursory changes.
Take into consideration how a book reflects the format of the USMLE Step 1.
Apps

With the explosion of smartphones and tablets, apps are an increasingly
popular way to review for the Step 1 exam. The majority of apps are
compatible with both iOS and Android. Many popular Step 1 review
resources (eg, UWorld, USMLE-Rx) have apps that are compatible with
their software. Many popular web references (eg, UpToDate) also now offer
app versions. All of these apps offer flexibility, allowing you to study while
away from a computer (eg, while traveling).
Practice Tests

Taking practice tests provides valuable information about potential strengths
and weaknesses in your fund of knowledge and test-taking skills. Some
students use practice examinations simply as a means of breaking up the
monotony of studying and adding variety to their study schedule, whereas
other students rely almost solely on practice. You should also subscribe to
one or more high-quality question banks. In addition, students report that
many current practice-exam books have questions that are, on average,
shorter and less clinically oriented than those on the current USMLE Step 1.

`` Most practice exams are shorter and less
clinical than the real thing.

Additionally, some students preparing for the Step 1 exam have started to
incorporate case-based books intended primarily for clinical students on the
wards or studying for the Step 2 CK exam. First Aid Cases for the USMLE
Step 1 aims to directly address this need.
After taking a practice test, spend time on each question and each answer
choice whether you were right or wrong. There are important teaching
points in each explanation. Knowing why a wrong answer choice is incorrect
is just as important as knowing why the right answer is correct. Do not panic
if your practice scores are low as many questions try to trick or distract you to
highlight a certain point. Use the questions you missed or were unsure about
to develop focused plans during your scheduled catch-up time.

`` Use practice tests to identify concepts and
areas of weakness, not just facts that you
missed.

Textbooks and Course Syllabi

Limit your use of textbooks and course syllabi for Step 1 review. Many
textbooks are too detailed for high-yield review and include material that
is generally not tested on the USMLE Step 1 (eg, drug dosages, complex
chemical structures). Syllabi, although familiar, are inconsistent across

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medical schools and frequently reflect the emphasis of individual faculty,
which often does not correspond to that of the USMLE Step 1. Syllabi also
tend to be less organized than top-rated books and generally contain fewer
diagrams and study questions.

``
TEST-TAKING STRATEGIES
`` Practice! Develop your test-taking skills and
strategies well before the test date.

Your test performance will be influenced by both your knowledge and your
test-taking skills. You can strengthen your performance by considering each
of these factors. Test-taking skills and strategies should be developed and
perfected well in advance of the test date so that you can concentrate on the
test itself. We suggest that you try the following strategies to see if they might
work for you.
Pacing

`` Time management is an important skill for
exam success.

You have seven hours to complete up to 280 questions. Note that each onehour block contains up to 40 questions. This works out to approximately
90 seconds per question. We recommend following the “1 minute rule” to pace
yourself. Spend no more than 1 minute on each question. If you are still unsure
about the answer after this time, mark the question, make an educated guess,
and move on. Following this rule, you should have approximately 20 minutes
left after all questions are answered, which you can use to revisit all of your
marked questions. Remember that some questions may be experimental
and do not count for points (and reassure yourself that these experimental
questions are the ones that are stumping you). In the past, pacing errors have
been detrimental to the performance of even highly prepared examinees. The
bottom line is to keep one eye on the clock at all times!
Dealing with Each Question

There are several established techniques for efficiently approaching
multiple choice questions; find what works for you. One technique begins
with identifying each question as easy, workable, or impossible. Your goal
should be to answer all easy questions, resolve all workable questions in a
reasonable amount of time, and make quick and intelligent guesses on all
impossible questions. Most students read the stem, think of the answer,