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FIRST AID FOR
THE®
USMLE
STEP 1
2020
TAO LE, MD, MHS VIKAS BHUSHAN, MD
Founder, ScholarRx Boracay
Associate Clinical Professor, Department of Medicine
University of Louisville School of Medicine
MATTHEW SOCHAT, MD VAISHNAVI VAIDYANATHAN, MD

Fellow, Department of Hematology/Oncology Resident, Department of Pediatric Neurology
St. Louis University School of Medicine Barrow Neurological Institute at Phoenix Children’s Hospital
SARAH SCHIMANSKY, MB BCh BAO JORDAN ABRAMS

Resident, Department of Ophthalmology St. George’s University School of Medicine
Royal United Hospitals Bath 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
FAS1_2019_00_Frontmatter.indd 1 11/14/19 4:35 PM

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.
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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.

This page intentionally left blank

Contents
Contributing Authors vii General Acknowledgments xv

Associate Authors viii How to Contribute xvii
Faculty Advisors ix How to Use This Book xix
Thirtieth Anniversary Foreword xi Selected USMLE Laboratory Values xx
Preface xiii First Aid Checklist for the USMLE Step 1 xxii
Special Acknowledgments xiv
SECTION I
`` 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 1
Introduction 2 Test-Taking Strategies 22

USMLE Step 1—The Basics 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
`` S P E C I A L S I T UAT I O N S 27
SECTION II
`` 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

SECTION III
`` H I G H - Y I E L D O R G A N S YS T E M S 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 71 1
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

Contributing Authors
MAJED H. ALGHAMDI, MBBS KAITLYN MELNICK, MD

Resident, Joint Program of Preventive Medicine Resident, Department of Neurological Surgery
Jeddah, Saudi Arabia University of Florida College of Medicine, Gainesville
LILIT ASLANYAN MARY KATHERINE MONTES de OCA, MD

New York Institute of Technology College of Osteopathic Medicine Resident, Department of Obstetrics and Gynecology
Class of 2020 Duke University Hospital
HUMOOD BOQAMBAR, MB BCh BAO SCOTT MOORE, DO

Assistant Registrar, Department of Orthopaedic Surgery Assistant Professor of Medical Laboratory Sciences
Farwaniya Hospital Weber State University
WEELIC CHONG VASILY OVECHKO, MD

Sidney Kimmel Medical College at Thomas Jefferson University Resident, Department of Surgery
MD/PhD Candidate Russian Medical Academy of Continuous Professional Education
KRISTINA DAMISCH VIVEK PODDER

University of Iowa Carver College of Medicine MBBS Student
Class of 2020 Tairunnessa Memorial Medical College and Hospital, Bangladesh
YUMI KOVIC, MD CONNIE QIU

Resident, Department of Psychiatry Lewis Katz School of Medicine at Temple University
University of Massachusetts Medical School MD/PhD Candidate
Image and Illustration Team
CAROLINE COLEMAN VICTOR JOSE MARTINEZ LEON, MD

Emory University School of Medicine Central University of Venezuela
Class of 2020
ALIREZA ZANDIFAR, MD
MATTHEW HO ZHI GUANG Research Fellow
University College Dublin (MD), DFCI (PhD) Isfahan University of Medical Sciences, Iran
MD/PhD Candidate
vii

Associate Authors
HUZAIFA AHMAD, MD SARINA KOILPILLAI

Resident, Department of Medicine St. George’s University School of Medicine
Georgetown University Hospital/MedStar Washington Hospital Center Class of 2020
ALEXANDER R. ASLESEN LAUREN N. LESSOR, MPH, MD

Kirksville College of Osteopathic Medicine Resident, Department of Pediatrics
Class of 2020 Mercy Health – St. Vincent Medical Center
ANUP K. BHATTACHARYA, MD ROHAN BIR SINGH, MD

Resident, Mallinckrodt Institute of Radiology Fellow, Department of Ophthalmology
Washington University School of Medicine 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 University of Texas Health Science Center, Long School of Medicine
Aga Khan University Class of 2020
DANA M. JORGENSON TAYLOR MANEY, MD

Chicago College of Osteopathic Medicine Resident, Department of Anesthesiology
Class of 2020 Brigham and Women’s Hospital
viii

Faculty Advisors
DIANA ALBA, MD ANTHONY L. DeFRANCO, PhD

Clinical Instructor Professor, Department of Microbiology and Immunology
University of California, San Francisco School of Medicine University of California, San Francisco School of Medicine
MARK A.W. ANDREWS, PhD CHARLES S. DELA CRUZ, MD, PhD

Professor of Physiology Associate Professor, Department of Pulmonary and Critical Care Medicine
Lake Erie College of Osteopathic Medicine at Seton Hill Yale School of Medicine
MARIA ANTONELLI, MD SAKINA FARHAT, MD

Assistant Professor, Division of Rheumatology Consulting Gastroenterologist
MetroHealth Medical Center, Case Western Reserve University State University of New York Downstate Medical Center
HERMAN SINGH BAGGA, MD CONRAD FISCHER, MD

Urologist, Allegheny Health Network Associate Professor, Medicine, Physiology, and Pharmacology
University of Pittsburgh Medical Center Passavant Touro College of Medicine
SHIN C. BEH, MD RAYUDU GOPALAKRISHNA, PhD

Assistant Professor, Department of Neurology & Neurotherapeutics Associate Professor, Department of Integrative Anatomical Sciences
UT Southwestern Medical Center at Dallas Keck School of Medicine of University of Southern California
JOHN R. BUTTERLY, MD RYAN C.W. HALL, MD

Professor of Medicine Assistant Professor, Department of Psychiatry
Dartmouth Geisel School of Medicine University of South Florida School of Medicine
SHELDON CAMPBELL, MD, PhD LOUISE HAWLEY, PhD

Professor of Laboratory Medicine Immediate Past Professor and Chair, Department of Microbiology
Yale School of Medicine Ross University School of Medicine
BROOKS D. CASH, MD JEFFREY W. HOFMANN, MD, PhD

Professor of Medicine, Division of Gastroenterology Resident, Department of Pathology
University of South Alabama School of Medicine University of California, San Francisco School of Medicine
SHIVANI VERMA CHMURA, MD CLARK KEBODEAUX, PharmD

Adjunct Clinical Faculty, Department of Psychiatry Clinical Assistant Professor, Pharmacy Practice and Science
Stanford University School of Medicine University of Kentucky College of Pharmacy
BRADLEY COLE, MD KRISTINE KRAFTS, MD

Assistant Professor of Basic Sciences Assistant Professor, Department of Basic Sciences
Loma Linda University School of Medicine University of Minnesota School of Medicine
LINDA S. COSTANZO, PhD MATTHEW KRAYBILL, PhD

Professor, Physiology & Biophysics Clinical Neuropsychologist
Virginia Commonwealth University School of Medicine Cottage Health, Santa Barbara, California
MANAS DAS, MD, MS GERALD LEE, MD

Director, Clinical Anatomy, Embryology, and Histology Assistant Professor, Departments of Pediatrics and Medicine
University of Massachusetts Medical School Emory University School of Medicine
ix

KACHIU C. LEE, MD, MPH NATHAN W. SKELLEY, MD
Assistant Clinical Professor, Department of Dermatology Assistant Professor, Department of Orthopaedic Surgery
The Warren Alpert Medical School of Brown University University of Missouri, The Missouri Orthopaedic Institute
WARREN LEVINSON, MD, PhD HOWARD M. STEINMAN, PhD

Professor, Department of Microbiology and Immunology Assistant Dean, Biomedical Science Education
University of California, San Francisco School of Medicine Albert Einstein College of Medicine
JAMES LYONS, MD SUPORN SUKPRAPRUT-BRAATEN, PhD

Professor of Pathology and Family Medicine Director of Research, Graduate Medical Education
Alabama College of Osteopathic Medicine Unity Health, Searcy, Arkansas
PETER MARKS, MD, PhD RICHARD P. USATINE, MD

Center for Biologics Evaluation and Research Professor, Dermatology and Cutaneous Surgery
US Food and Drug Administration 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 Assistant Dean, Basic Science Education
Harvard Medical School Duke University School of Medicine
VICKI M. PARK, PhD, MS TISHA WANG, MD

Assistant Dean Associate Clinical Professor, Department of Medicine
University of Tennessee College of Medicine David Geffen School of Medicine at UCLA
SOROUSH RAIS-BAHRAMI, MD SYLVIA WASSERTHEIL-SMOLLER, PhD

Assistant Professor, Departments of Urology and Radiology Professor Emerita, Department of Epidemiology and Population Health
University of Alabama at Birmingham School of Medicine Albert Einstein College of Medicine
SASAN SAKIANI, MD ADAM WEINSTEIN, MD

Fellow, Transplant Hepatology Assistant Professor, Pediatric Nephrology and Medical Education
Cleveland Clinic Geisel School of Medicine at Dartmouth
MELANIE SCHORR, MD ABHISHEK YADAV, MBBS, MSc

Assistant in Medicine Associate Professor of Anatomy
Massachusetts General Hospital Geisinger Commonwealth School of Medicine
SHIREEN MADANI SIMS, MD KRISTAL YOUNG, MD

Chief, Division of Gynecology, Gynecologic Surgery, and Obstetrics Clinical Instructor, Department of Cardiology
University of Florida School of Medicine Huntington Hospital, Pasadena, California

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

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

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:
50 entirely new or heavily revised high-yield topics reflecting evolving trends in the USMLE Step 1.
Reorganization of high-yield topics in Pharmacology, Endocrine, and Reproductive chapters for improved study.
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.
Updated with 178 new and revised diagrams and illustrations as part of our ongoing collaboration with
USMLE-Rx and ScholarRx (MedIQ Learning, LLC).
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.
Updated study tips on the opening page of each chapter.
Improved integration of clinical images and illustrations to better reinforce and learn key anatomic concepts.
Improved organization and integration of text, illustrations, clinical images, and tables throughout for focused
review of high-yield topics.
Revised and expanded ratings of current, high-yield review resources, with clear explanations of their relevance
to USMLE review.
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 Tao Le
St. Louis Matthew Sochat
Phoenix Vaishnavi Vaidyanathan
Bristol Sarah Schimansky
New York City Jordan Abrams
San Francisco Kimberly Kallianos
xiii

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, McGraw-
Hill, 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 Tao Le
St. Louis Matthew Sochat
Phoenix Vaishnavi Vaidyanathan
Bristol Sarah Schimansky
New York City Jordan Abrams
San Francisco Kimberly Kallianos
xiv

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

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

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:
Study and test-taking strategies for the USMLE Step 1
New facts, mnemonics, diagrams, and clinical images
High-yield topics that may appear on future Step 1 exams
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.
xvii

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

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:
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.
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).
Choose highlighters that are bright and dry quickly to minimize smudging and bleeding through the page
(eg, Tombow Kei Coat, Sharpie Gel).
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.
xix

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

Amylase, serum 25–125 U/L 25–125 U/L
*Aspartate aminotransferase (AST, GOT at 30°C) 8–20 U/L 8–20 U/L
Bilirubin, serum (adult)
Total // Direct 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+) 136–145 mEq/L 136–145 mmol/L
Chloride (Cl–) 95–105 mEq/L 95–105 mmol/L
* Potassium (K ) 3.5–5.0 mEq/L 3.5–5.0 mmol/L
+
Bicarbonate (HCO3–) 22–28 mEq/L 22–28 mmol/L

Magnesium (Mg2+) 1.5–2 mEq/L 0.75–1.0 mmol/L
Gases, arterial blood (room air)
PO 2
75–105 mm Hg 10.0–14.0 kPa
PCO 2
33–45 mm Hg 4.4–5.9 kPa
pH 7.35–7.45 [H+] 36–44 nmol/L
*Glucose, serum Fasting: 70–110 mg/dL 3.8–6.1 mmol/L
2-h postprandial: < 120 mg/dL < 6.6 mmol/L
Growth hormone − arginine stimulation Fasting: < 5 ng/mL < 5 µg/L
provocative stimuli: > 7 ng/mL > 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
Prolactin, serum (hPRL) < 20 ng/mL < 20 µg/L
*Proteins, serum
Total (recumbent) 6.0–7.8 g/dL 60–78 g/L
Albumin 3.5–5.5 g/dL 35–55 g/L
Globulins 2.3–3.5 g/dL 23–35 g/L
Thyroid-stimulating hormone, serum or plasma 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
(continues)
xx

Cerebrospinal Fluid Reference Range SI Reference Intervals
Glucose 40–70 mg/dL 2.2–3.9 mmol/L

Hematologic
Erythrocyte count Male: 4.3–5.9 million/mm3 4.3–5.9 × 1012/L

Female: 3.5–5.5 million/mm3 3.5–5.5 × 1012/L
Erythrocyte sedimentation rate (Westergen) Male: 0–15 mm/h 0–15 mm/h
Female: 0–20 mm/h 0–20 mm/h
Hematocrit Male: 41–53% 0.41–0.53
Female: 36–46% 0.36–0.46
Hemoglobin, blood Male: 13.5–17.5 g/dL 2.09–2.71 mmol/L
Female: 12.0–16.0 g/dL 1.86–2.48 mmol/L
Hemoglobin, plasma 1–4 mg/dL 0.16–0.62 µmol/L
Leukocyte count and differential
Leukocyte count 4,500–11,000/mm3 4.5–11.0 × 109/L
Segmented neutrophils 54–62% 0.54–0.62
Band forms 3–5% 0.03–0.05
Eosinophils 1–3% 0.01–0.03
Basophils 0–0.75% 0–0.0075
Lymphocytes 25–33% 0.25–0.33
Monocytes 3–7% 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 3
80–100 fL
Partial thromboplastin time (activated) 25–40 seconds 25–40 seconds
Platelet count 150,000–400,000/mm 3
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
Sweat
Chloride 0–35 mmol/L 0–35 mmol/L

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
xxi

First Aid
First Aid Checklist 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
Referistoan example oftopics
corresponding how you might Iuse
in Section for the
moreinformation
details. in Section I to prepare for the USMLE
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 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.
One Day Prior Relax.

Lightly review short-term material if necessary. Skim high-yield facts.
Get a good night’s sleep.
Day of Exam Relax.

Eat breakfast.
Minimize bathroom breaks during exam by avoiding excessive morning
caffeine.
After Exam Celebrate, regardless of how well you feel you did.
Send feedback to us on our website at www.firstaidteam.com.
xxii

SECTION I
Guide to Efficient
Exam Preparation
“I don’t love studying. I hate studying. I like learning. Learning is `Ìntroduction2

beautiful.”
—Natalie Portman `ÙSMLE Step 1—The
Basics2
“Finally, from so little sleeping and so much reading, his brain dried up
and he went completely out of his mind.” ``Defining Your Goal 12
—Miguel de Cervantes Saavedra, Don Quixote
``Learning Strategies 13
“Sometimes the questions are complicated and the answers are simple.”
—Dr. Seuss ``Timeline for Study 16
“He who knows all the answers has not been asked all the questions.” ``Study Materials 20
—Confucius
``Test-Taking
“The expert in anything was once a beginner.”
Strategies22
—Helen Hayes
“It always seems impossible until it’s done.” ``Clinical Vignette

Strategies23
—Nelson Mandela
`Ìf You Think You

Failed24
``Testing Agencies 24
``References25
FAS1_2019_00_Section_I.indd 1 11/7/19 2:48 PM

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:
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
`` The test at a glance: Not using review books along with your classes
8-hour exam Not analyzing and improving your test-taking strategies
Up to a total of 280 multiple choice items Getting bogged down by reviewing difficult topics excessively
7 test blocks (60 min/block) Studying material that is rarely tested on the USMLE Step 1
Up to 40 test items per block Failing to master certain high-yield subjects owing to overconfidence
45 minutes of break time, plus another 15 Using First Aid as your sole study resource
if you skip the tutorial 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.

Guide to Efficient Exam Preparation SECTION I 3
The Step 1 exam includes test items that can be grouped by the organiza-
tional 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 52–62 General principles 13–17
science concepts
Patient care: diagnosis 20–30 Behavioral health & nervous systems/special senses 9–13
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
Discipline Range, % Multisystem processes & disorders 7–11
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.

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:
Questions are typically presented in multiple choice format, with 4–5
A, B, etc—letter choices
possible answer options. There is a countdown timer on the lower left corner
Enter or spacebar—move to next
of the screen as well. There is also a button that allows the examinee to
question
mark a question for review. If a given question happens to be longer than
Esc—exit pop-up Calculator and Notes
the screen (which occurs very rarely), a scroll bar will appear on the right,
windows
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
`` Heart sounds are tested via media questions. and/or video. There may even be a question with a multimedia heart sound
Make sure you know how different heart simulation. In these questions, a digital image of a torso appears on the
diseases sound on auscultation. 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
`` Be sure to test your headphones during the
audio headphones and the volume are functioning properly. If you are
tutorial.
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.
`` Familiarize yourself with the commonly

The examinee can call up a window displaying normal laboratory values.
tested lab values (eg, Hgb, WBC, platelets,
In order to do so, he or she must click the “Lab” icon on the top part of
Na+, K+).
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
`` Illustrations on the test include: might want to memorize some common lab values so you spend less time on
Gross specimen photos questions that require you to analyze these.
Histology slides
The CBT interface provides a running list of questions on the left part of the
Medical imaging (eg, x-ray, CT, MRI)
screen at all times. The software also permits examinees to highlight or cross
Electron micrographs
out information by using their mouse. There is a “Notes” icon on the top
Line drawings
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
`` Ctrl-Alt-Delete are the keys of death during background). Being familiar with these features can save time and may help
the exam. Don’t touch them at the same time! you better view and organize the information you need to answer a question.

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 `` You can take a shortened CBT practice test at
the USMLE website, www.usmle.org, are used at these sessions. No new a Prometric center.
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 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 `` The Prometric website will display a calendar
first two weeks in January and major holidays. The exam is given every day with open test dates.
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.
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 three-
month 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.

`` The confirmation emails that Prometric Once you receive your scheduling permit, you may access the Prometric
and NBME send are not the same as the website or call Prometric’s toll-free number to arrange a time to take the
scheduling permit. 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,
`` Test scheduling is done on a “first-come,
first-served” basis, it is recommended that you book an exam date on the
first-served” basis. It’s important to schedule
Prometric website as soon as you receive your permit. Prometric will provide
an exam date as soon as you receive your
appointment confirmation on a print-out and by email. Be sure to read the
scheduling permit.
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.
When Should I Register for the Exam?

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

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?

`` Gain extra break time by skipping the tutorial
Time is of special interest on the CBT exam. Here’s a breakdown of the or finishing a block early.
exam schedule:
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
`` Be careful to watch the clock on your break
a block ahead of the allotted time. Any time remaining on the clock when
time.
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.
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.

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

All questions on the exam are one-best-answer multiple choice items.
with a description of a patient.
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).

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.
`` The mean Step 1 score for US medical
Since some questions may be experimental and are not counted, it is
students continues to rise, from 200 in 1991
possible to get different scores for the same number of correct answers. In
to 230 in 2018.
2018, the mean score was 230 with a standard deviation of 19.
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.

F I G U R E 2 . Score and Percentile for First-time Step 1 Takers.
100
80
60
Percentile
40
Minimum
passing score
20
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
Allopathic 1st takers 20,353 96% 20,670 96%
Repeaters 1,029 67% 941 67%
Allopathic total 21,382 94% 21,611 95%
Osteopathic 1st takers 3,786 95% 4,092 96%
Repeaters 49 76% 44 73%
Osteopathic total 3,835 95% 4,136 96%
Total US/Canadian 25,217 94% 25,747 94%
IMG 1st takers 14,900 78% 14,332 80%
Repeaters 2,303 41% 2,111 44%
IMG total 17,203 73% 16,443 75%
Total Step 1 examinees 42,420 85% 42,190 86%

Beyond that, the main point of having a quantitative score is to give you T A B L E 3 . CBSE to USMLE Score
a sense of how well you’ve done on the exam and to help schools and Prediction.
residencies rank their students and applicants, respectively. CBSE Step 1
Score Equivalent
≥ 94 ≥ 260
Official NBME/USMLE Resources
92 255
The NBME offers a Comprehensive Basic Science Examination (CBSE) for 90 250
practice that is a shorter version of the Step 1. The CBSE contains four blocks
88 245
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 86 240
equivalent (see Table 3). The standard error of measurement is approximately 84 235
3 points, meaning a score of 80 would estimate the student’s proficiency is 82 230
somewhere between 77 and 83. In other words, the actual Step 1 score could be 80 225
predicted to be between 218 and 232. Of course, these values do not correlate 78 220
exactly, and they do not reflect different test preparation methods. Many schools
76 215
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 74 210
time before any dedicated Step 1 preparation. If you do not encounter the 72 205
CBSE before your dedicated study time, you need not worry about taking it. 70 200
Use the information to help set realistic goals and timetables for your success. 68 195
The NBME also offers six forms of Comprehensive Basic Science Self- 66 190
Assessment (CBSSA). Students who prepared for the exam using this web- 64 185
based tool reported that they found the format and content highly indicative 62 180
of questions tested on the actual exam. In addition, the CBSSA is a fair 60 175
predictor of USMLE performance (see Table 4). The test interface, however,
58 170
does not match the actual USMLE test interface, so practicing with these
forms alone is not advised. 56 165
54 160
The CBSSA exists in two formats: standard-paced and self-paced, both of 52 155
which consist of four sections of 50 questions each (for a total of 200 multiple
50 150
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. 48 145
By contrast, the self-paced format places a 5-hour time limit on answering 46 140
all multiple choice questions. Every few years, a new form is released and an ≤ 44 ≤ 135
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
`` Practice questions may be easier than the
deviation of 100. In addition to the performance profile, examinees will be
actual exam.
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.

T A B L E 4 . CBSSA to USMLE Score

Explanations for the correct answer, however, will not be provided. The
Prediction. NBME charges $60 for assessments with expanded feedback. The fees are
CBSSA Approximate payable by credit card or money order. For more information regarding the
Score USMLE Step 1 Score CBSE and the CBSSA, visit the NBME’s website at www.nbme.org.
150 155
The NBME scoring system is weighted for each assessment exam. While
200 165 some exams seem more difficult than others, the score reported takes into
250 175 account these inter-test differences when predicting Step 1 performance.
300 186 Also, while many students report seeing Step 1 questions “word-for-word”
350 196 out of the assessments, the NBME makes special note that no live USMLE
questions are shown on any NBME assessment.
400 207
450 217 Lastly, the International Foundations of Medicine (IFOM) offers a Basic
500 228 Science Examination (BSE) practice exam at participating Prometric test
centers for $200. Students may also take the self-assessment test online for
550 238
$35 through the NBME’s website. The IFOM BSE is intended to determine
600 248
an examinee’s relative areas of strength and weakness in general areas of
650 259 basic science—not to predict performance on the USMLE Step 1 exam—
700 269 and the content covered by the two examinations is somewhat different.
750 280 However, because there is substantial overlap in content coverage and many
800 290 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.
The value of the USMLE Step 1 score in selecting residency applicants

`` Some competitive residency programs place
remains controversial, and some have called for less emphasis to be placed
more weight on Step 1 scores when choosing
on the score when selecting or screening applicants.3 For the time being,
candidates to interview.
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,
`` Fourth-year medical students have the best otolaryngology). Independent of your career goals, you can maximize your
feel for how Step 1 scores factor into the future options by doing your best to obtain the highest score possible (see
residency application process. 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.

F I G U R E 3 . Median USMLE Step 1 Score by Specialty for Matched US Seniors.a,b
260
250 248 248 249 249
246 245 247 245
240 240
236 235 236
233 232 233 233 233
230 230 231
226 225 227
220 220
210
200
190
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y
ry
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y
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ry
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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 `` The foundation of knowledge you build
repetition, etc). Regardless of your choice, the foundation of knowledge during your basic science years is the most
you build during your basic science years is the most important resource for important resource for success on the USMLE
success on the USMLE Step 1. 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 `` Research has shown a positive correlation
has been shown to result in higher test scores and GPAs.6 In fact, research between the number of boards-style practice
has shown a positive correlation between the number of boards-style practice questions completed and Step 1 scores
questions completed and Step 1 scores among medical students.7 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-

TA B L E 5 . Effective Learning Strategies.

EFFICACY STRATEGY EXAMPLE RESOURCES
High efficacy Practice testing UWorld Qbank
(retrieval practice) NBME Self-Assessments
USMLE-Rx QMax
Kaplan Qbank
Distributed practice USMLE-Rx Flash Facts
Anki
Firecracker
Memorang
Osmosis
Moderate Mnemonics Pre-made:
efficacy SketchyMedical
Picmonic
Self-made:
Mullen Memory
Elaborative interrogation/
self-explanation
Concept mapping Coggle
FreeMind
XMind
MindNode
Low efficacy 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

cards to improved long-term knowledge retention and higher exam scores.6,8,10 `` Studies have linked spaced repetition
Apps with automated spaced-repetition software (SRS) for flash cards exist for learning with flash cards to improved long-
smartphones and tablets, so the cards are accessible anywhere. Proceed with term knowledge retention and higher exam
caution: there is an art to making and reviewing cards. The ease of quickly scores.
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.
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, keyword-
friendly 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 `` Elaborative interrogation and self-
questioning) prompt learners to generate explanations for facts. When explanation prompt learners to generate
reading passages of discrete facts, consider using these techniques, which explanations for facts, which improves recall
have been shown to be more effective than rereading (eg, improved recall and problem solving.
and better problem-solving/diagnostic performance).5,12,13
Concept Mapping
Concept mapping is a method for graphically organizing knowledge, with

concepts enclosed in boxes and lines drawn between related concepts.

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

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

for test date period
USMLE and to take
Step 1 location exam
Nov Dec Jan Feb Mar Apr May June July Aug Sept
`` Customize your schedule. Tackle your weakest
2019 2020
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 `` Avoid burnout. Maintain proper diet, exercise,
personal affairs to minimize crisis situations near the date of the test. Allot and sleep habits.
an adequate number of breaks in your study schedule to avoid burnout.
Maintain a healthy lifestyle with proper diet, exercise, and sleep.
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.

Year(s) Prior
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
`` Buy review books early (first year) and use
with subsequent Step 1 scores.16 Moreover, undergraduate science GPAs
while studying for courses.
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” Use this time to finalize your ideal schedule. Consider upcoming breaks
conditions before beginning your studies. 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,

Your dedicated prep time may be one week or two months. You should have
practice questions, and endurance. Stay
a working plan as you go into this period. Finish your schoolwork strong, take
confident!
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.

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 `` One week before the test:
you will face. Determine what you will do for lunch. Make sure you have Sleep according to the same schedule you’ll
everything you need to ensure that you will be comfortable and alert at the use on test day
test site. It may be beneficial to adjust your schedule to start waking up at Review the CBT tutorial one last time
the same time that you will on your test day. And of course, make sure to Call Prometric to confirm test date and time
maintain a healthy lifestyle and get enough sleep.
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

`` No notes, books, calculators, pagers, cell
On the morning of the Step 1 exam, wake up at your regular time and phones, recording devices, or watches of any
eat a normal breakfast. If you think it will help you, have a close friend or kind are allowed in the testing area, but they
family member check to make sure you get out of bed. Make sure you have are allowed in lockers.
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

`` Arrive at the testing center 30 minutes before that will allow you to remain comfortable and to concentrate. Get to know
your scheduled exam time. If you arrive your testing station, especially if you have never been in a Prometric testing
more than half an hour late, you will not be center before. Listen to your proctors regarding any changes in instructions
allowed to take the test. 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,
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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
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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.
Many sample question books were originally written years ago and have
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Some question banks test to a level of detail that you will not find on the
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whom the rising opposition hoped to make the spokesman of their
protest against the Commune and the Terror alike.
Danton, like so many of his contemporaries, had soon wearied of the
system of the Terror. He watched with repugnance the ruin which it
spread. He had no liking for political intrigue. He felt strongly the
need of stability and order, if there were ever again to be a settled
government in France. It is true that in the earlier days Danton had
taken a chief part in securing the Jacobin triumph. In the heat of the
revolutionary struggle, in the moment of national danger, no one had
been readier to act. He had encouraged and organised the
insurrection of the 10th August. He had grasped the helm of State
during the perilous days which followed. Many of the characteristic
Jacobin measures—the wholesale arrest of the suspected in
September, the foundation of the Committee of Public Safety, the
establishment of the Revolutionary Tribunal, of the Maximum and of
the tax on the rich, the formation of the Revolutionary Army, the
proclamation of the Terror, the conscription and the defence of
France—had been largely due to his initiative or support. In common
with the rest of his party, Danton had opposed the declaration of war,
but as soon as the invaders appeared upon the frontier, he had
thrown himself into the battle heart and soul. He cared little for party
jangles; but he cared intensely for the honour and greatness of his
country. Free alike from narrow theories, from absorbing jealousies
and from morbid ambition, Danton had always viewed events with a
statesman's eye. He had seen Dumouriez' failings, but he had seen
also his conspicuous ability, and he had supported him staunchly to
the end. He had seen, as Mirabeau had seen before him, that the
government of the country could never prosper until a strong
Executive were formed, and accordingly, like Mirabeau, he had
endeavoured to induce the Convention to give the Ministers seats in
the House. Only when that scheme had failed, had he fallen back on
the device of a powerful committee. He had realised much sooner
than his colleagues the folly of the reckless decree by which, in
November, 1792, the Convention had declared war on all the kings
of Europe, and four months later he had secured its repeal. He had
discerned the uses of diplomacy, had negotiated the withdrawal of
Brunswick, had tried to detach Prussia from the coalition, had
secured an alliance with Sweden, and had steadily laboured, in spite
of the wild talk of his colleagues, to bring France back into the comity
of nations. From the time of the king's death, Danton had done all
that eloquent persuasion could do to heal divisions and to unite
parties in the work of defending the Republic. He would gladly have
worked with the Girondists, had they not driven him by their
intemperate charges into the opposing camp. 'If we must shed
blood,' he once pleaded nobly, 'let us shed the blood of the enemies
of our country.'
But when the danger of invasion passed away, Danton's energies
passed with it. When the Jacobins had conquered and the State was
saved, he felt that he had no employment left. He had little sympathy
with the Government of the Terror. He wearied of the long tale of
violence and outrage. Unscrupulous and hardened as he was, he
turned disgusted from the methods of Carrier and Hébert. After his
second marriage, in June, 1793, his young wife and the delights of
home called him away to purer things than politics. He knew the
limits of his own capacity, and that he could not bring to the work of
political manœuvring the irresistible vigour and conviction by which
he had roused the country and had swept his colleagues into power.
Even to the last, when Philippeaux and Desmoulins forced him to the
front, and made him the unwilling leader round whom the party of
reaction gathered, he was inclined to urge them to put up their
weapons, and to fall back on his old plea for unity. He hated personal
animosities and was not made to be a faction chief. But he was too
conspicuous and too honest to remain altogether in the background,
when his comrades were risking their lives in a cause which he knew
to be the cause of mercy, and believed to be the cause of France.
Between Hébert and his adherents in the Commune, and the party
which gradually ranged itself behind Danton in opposition to the
whole system of the Terror, there stood, as a third party, the
Government of the day. The Government, that is the Committee of
Public Safety, was not, it is true, entirely united. Some of its
members, like Collot d'Herbois and in a lesser degree Billaud-
Varennes, approved of the methods of the Commune, and were
closely leagued with its chiefs. On the other hand, Robespierre
detested the brutal license of many of the Communist party, and his
feelings were shared by Couthon and St. Just. Others, again, like
Carnot, had little liking for either Robespierre or Hébert. Hérault de
Séchelles was a friend of Danton and sympathised with his ideas.
But, divided as they were, most of the members of the Committee
felt that things were going too far. They were responsible for the
government of the country, and they could not, therefore, view with
unconcern the anarchy and public plunder which marked the course
of the agents of the Commune. They were for the moment kings of
France, and they had no intention of surrendering their throne to the
ambitious municipality of Paris, or of permitting any reaction in the
Convention which would deprive them of the power which it had
suffered them to usurp.
Accordingly, in the month of November, when Collot d'Herbois was
absent in Lyons, a decided movement against the Commune
appeared. Robespierre, with his strong sense of decorum and his
reverence for the sentimental theology of Rousseau, was shocked
by the excesses of the materialist party, and encouraged by the
signs of opposition in the Convention, he began to make his opinions
felt. As usual, he proceeded with great caution, but by significant
hints and phrases he showed his resentment at the conduct of
Hébert. On the 17th November, in a long report upon the foreign
policy of France, he took occasion to denounce both the 'cruel
moderantism and the systematic exaggeration of false patriots.' Four
days later, at the Jacobin Club, in answer to a challenge from
Hébert, he delivered a singular speech on the religious question, and
ended by proposing the purging of the Club. The grounds on which
Robespierre attacked his enemies were characteristically circuitous
and astute. 'Atheism,' he argued, 'is aristocratic. The idea of a
Supreme Being, who watches over oppressed innocence and
punishes triumphant crime, is essentially the idea of the people.'
Cautious as Robespierre's action was, the majority quickly rallied
round him. Danton returned to Paris and ranged himself at
Robespierre's side. 'We did not destroy superstition,' he cried, 'in
order to establish the rule of the atheist.' In the Convention he
pleaded for milder measures, and urged that the sword of the Terror
should be pointed only at those convicted of crime. As the scrutiny at
the Jacobins proceeded, the victory of the opponents of the
Commune became more distinct. The attacks made upon Danton
and Desmoulins collapsed. Robespierre defended them with spirit
and enthusiasm, and asked to be judged by Danton's side. On the
4th December, a new law was adopted by the Convention,
consolidating the power of the Committee of Public Safety, bringing
all constituted authorities more directly under its control, suppressing
the revolutionary armies and the agents of the Commune in the
departments, forbidding the raising of taxes except by decree of the
Assembly, and extending the Government's supervision over the
committees in the Sections of Paris. The effect of this decisive
measure was largely to increase the authority of the Committee, and
to diminish the influence of the Commune both in the provinces and
in the capital itself.
The reaction against the Commune had unmistakably begun. On the
day after the decree of the Convention the first number of the Vieux
Cordelier appeared. The Hébertists, defeated in the Jacobins, had
made their headquarters at the Cordeliers Club; and in order to
emphasise the difference between the new doctrines and the spirit
which had inspired the Cordeliers in their earlier days, Camille
Desmoulins gave to his protest the title of the club, where his wit and
Danton's eloquence had once held undisputed sway. Danton and his
friends were known to sympathise with the opinions of the new
journal. Robespierre corrected the first number in proof. Desmoulins
began by denouncing the Hébertists, but as the tide of reaction rose
and the friends of moderation gathered courage, he passed on to
attack the whole system of the Terror, and in the famous third
number of his paper he boldly arraigned its tyranny and crimes. Two
days later, on the 17th December, the Convention, on the motion of
Danton's adherents, decreed the arrest of three agents of the
Commune, Vincent, Ronsin and Maillard. Proposals were freely put
forward for renewing and remodelling the Government itself. Bodies
of petitioners appeared at the bar of the Convention asking for mercy
towards the suspects. Robespierre proposed the appointment of a
commission to consider all cases of unjust arrest. Camille
Desmoulins appealed to Robespierre and passionately urged the
cause of mercy. 'The liberty I worship is no unknown God.... It is
happiness, reason, equality, justice.... Robespierre, friend and
comrade of my schooldays, whose eloquent words our children will
read often, recall the history and philosophy that we learned.
Remember that love is stronger and lives longer than fear, that
reverence and religion spring from kindly treatment ... and that no
men can mount on blood-stained steps to heaven. Why,' cried the
writer bitterly, as he wound up his powerful appeal, 'why has
compassion become a crime in France?'
To such a height had the reaction attained, when, on the 21st
December, Collot d'Herbois suddenly arrived in Paris. He was
welcomed by the Hébertists as a deliverer. 'The giant has arrived,'
cried Hébert gladly, 'the faithful defender of the Sansculottes,' and
Collot at once espoused the cause of his allies. Full of vigour and
self-confidence, the executioner of Lyons entertained no scruples
about the Terror. He denounced all ideas of moderation. His
presence reanimated the Committee, cheered the party of the
Commune, and abashed the hopes of the reaction. The capture of
Toulon, which occurred about the same time, served to increase the
prestige of the Government. Many who had welcomed Desmoulins'
appeal began to feel that they had been too precipitate. The
Commune, gathering courage, demanded and obtained the release
of its imprisoned agents. The commission to enquire into cases of
unjust arrest was cancelled. Collot d'Herbois quickly made his
influence felt at the Jacobins and in the Committee, and all the
waverers, as usual, rallied to the stronger side. Robespierre,
alarmed at the turn events were taking, began to dissociate himself
from his new allies, lamented the bitterness of party feeling, and
declared that his object was 'to overwhelm factions, foreigners and
moderates, but not to ruin patriots.' Even Danton took occasion to
declare his loyalty to the Government, and endeavoured to restrain
the incautious declarations of his friends.
All through January and February, 1794, the struggle of parties
continued, and the fiercest animosities prevailed. At the Jacobins,
Desmoulins' colleagues renewed their onslaught on the followers of
Hébert, but no longer with the same success. Robespierre laboured
steadily by perpetual speeches to secure his ascendency in the club,
and studiously avoided committing himself to either side. But his
position changed. He began to display undisguised hostility towards
Philippeaux and Fabre d'Églantine, the most outspoken members of
the moderate party. He assumed a tone of paternal reproach
towards Camille Desmoulins, and proposed that the Vieux Cordelier,
which he had once cordially welcomed, should be burned. Danton,
disheartened, and embarrassed, relapsed into listless inactivity, and
contented himself with deprecating personal attacks. The chances of
a reaction against the Terror passed away, and the Government daily
offered a stronger front to the enmity of Hébertists and Dantonists
alike.
At last, after many weeks of struggle and intrigue, the crisis came. At
the end of February, St. Just returned to Paris from a mission in the
provinces, and brought a new influence to bear upon events. St. Just
was the loyal disciple of Robespierre, but he possessed far more
energy and decision than his chief. He shared Robespierre's dislike
of Hébert, but he did not share his kindly feeling towards Danton.
Desmoulins had ridiculed the stiff pomposity of the young
Committee-man's demeanour, and to St. Just ridicule was an
unpardonable wrong. While Robespierre pleaded indisposition and
held aloof from the meetings of the Committee, St. Just declared
himself without disguise. He proposed to enforce the authority of the
Government by sacrificing Dantonists and Hébertists alike. He
denounced significantly 'the greatest criminals, who are only trying to
destroy the scaffold because they dread the prospect of mounting it
themselves.' His presence seems to have roused his colleagues, as
the arrival of Collot had roused them before. The Commune was
once more made to feel the weight of the Committee's authority. A
decree of the Convention confiscated the property of the suspects in
order to provide for destitute patriots, and by this great bribe
diminished the influence which the Commune enjoyed with the
needy poor. The Hébertists, now thoroughly alarmed, made a last
effort to assert themselves. They held stormy meetings at the
Cordeliers Club, and indulged in reckless schemes of insurrection.
But even Collot d'Herbois seems to have felt that the leaders of the
Commune had gone too far, and he gave his consent to the policy of
the Committee. St. Just took the lead in the attack. On the night of
the 13th March, Hébert and his principal colleagues were arrested.
Next day, Robespierre reappeared in the Convention and resumed
his place at the Jacobin Club. For the first time in the history of the
Revolution the less extreme party, with legitimate authority behind it,
had asserted itself against the forces of insurrection, had assumed
the offensive and had won the day.
On the one side the enemies of the Government had fallen. It only
remained for them to dispose of the rest. The extreme Terrorists had
consented to allow their friends in the Commune to perish, but only
on condition that the advocates of mercy should perish too. The
moderate party had many supporters in the Convention, and were a
serious danger to the supremacy of the Committee. They counted on
the support of Danton, and though Danton gave them little
encouragement, they used his great name to forward their designs.
'Danton sleeps,' said Desmoulins, as he took up his pen again to
attack the system and the agents of the Terror, 'Danton sleeps, but it
is the sleep of a lion, and he will wake to defend us.' But Danton's
power and energy seemed destined never to wake again. Heartily
weary of conspiracies and factions, discerning plainly enough the
danger which confronted him but unable to rouse himself to avert it,
disdaining to take measures to defend himself or to fight his
opponents with their own weapons of intrigue, Danton remained
undecided and inert. He would not compass his enemies'
destruction, and he did not believe that his enemies would dare to
compass his. Perhaps he relied on Robespierre's friendship, and
forgot that Robespierre was not the man to risk his own ascendency
in order to save another's life. At any rate when the crisis came,
Robespierre swallowed any scruples that he felt, and consented to
unite the Government by abandoning Danton to his opponents. On
the night of the 30th March, Danton, Desmoulins and their
colleagues were arrested, and next day Robespierre came forward
and denounced the 'broken idol' in the Convention. Danton's bearing
before the Revolutionary Tribunal was marked by his habitual
scornful courage. 'My abode,' he said, in answer to the judge's
questions, 'will soon be in eternity; my name you will find in the
Pantheon of history.' He defended himself hotly and proudly against
the ridiculous charges of royalist conspiracy. His vigorous eloquence
created so profound an impression that his accusers trembled for the
consequences, and took exceptional measures to cut the trial short.
On the 5th April, Danton was guillotined. 'I see now,' he said, 'that in
times of Revolution, power falls ultimately to the greatest
scoundrels.... Ah, better be a poor fisherman than meddle with the
governing of men!'
The fall of Danton left Robespierre by far the most conspicuous man
in France. For character and reputation he had no rival in the
Committees, and it was largely on his popularity that the
Government rested for support. In some points Robespierre
compared favourably with his colleagues. His life was frugal, pure
and decent. His dress was always neat. His sense of decorum never
deserted him. His devotion to his principles and his hatred of license
and irreverence were sincere. He represented admirably the
complacent Philistinism of a certain type of French bourgeois. His
language breathed of virtue and emotion. His long-winded, didactic
generalities, his perpetual appeals to morality and conscience
imposed on well-intentioned, narrow minds, and, no doubt, imposed
upon his own. Robespierre's followers, women especially, with whom
his influence was great, took him at his own valuation. They did not
discover his amazing egotism. They did not resent the qualities
which make him appear to us the typical prig of history. They liked
the long abstract discourses, which were the fashion of his time and
sect. They liked his plain respectability. They liked his war upon
corruption. They liked his feeling for religion and his copious
sentiment. They were charmed by his high-sounding and unpractical
ideals. They marvelled when he recited, as he never tired of doing,
the tale of his own virtues. Robespierre was essentially a priest, and
he exercised a priest's fascination, preaching unceasingly and
claiming without scruple the admiration of his flock. 'I have never
bowed,' he cried, 'beneath the yoke of baseness and corruption.'
'Surrounded by assassins, I have little to reconcile me to life except
my love for my country and my thirst for justice.' 'I am a living martyr
to the Republic, at once the victim and the enemy of crime.' 'If such
truths must be dissembled, then bring me the hemlock.' He was for
ever proclaiming himself the champion of morality, for ever protesting
his readiness to die in its cause. He reiterated it so often, and he
believed it so intensely, that he made his followers believe it too.
Moreover, Robespierre's sentiment was genuine. He had brought
with him from Arras the reputation of a young provincial lawyer,
upright, industrious and tender-hearted, fond of indifferent verse and
of pet-birds. In his early days he had resigned an honourable office
rather than condemn a man to death. He had from the first figured as
the friend of humanity, as the defender of the unfortunate and the
oppressed. If any question arose of suppressing disorder, he had
always raised his voice against severity. He had pleaded for the
abolition of the penalty of death. He had championed the cause of
coloured men. He had more than once shown his sympathy for
priests. Later on, he had defended the seventy-three members of the
Convention, who were attacked for protesting against the arrest of
the Gironde. He was known to have resented the treatment of
Madame Elizabeth and the insults offered by Hébert to the Queen.
He had taken no part personally in the enormities of the proconsuls
of the Terror. He had repudiated the immorality and materialism of
the leaders of the Commune. He had helped to secure the recall of
Carrier. Conscious cruelty had no place in his speeches or ideals.
But when one turns from Robespierre's speeches to his actions, a
different tale is told. In vain his apologists recapitulate his language,
and dwell on his protestations of virtue, on his ceaseless iteration of
benevolent designs. His career stands out in flagrant contrast to his
oft-repeated principles, and the record of his career no apologies can
explain away. The most noticeable characteristics of Robespierre's
public life were his lack of initiative, his disingenuous reserve, and
his profound incompetence as a practical politician. There is hardly a
single great measure of the Terror, except the development of the
Revolutionary Tribunal, in which Robespierre took a leading part. His
method was to combat every proposal and every party, but rarely to
make a proposal himself. If a critical occasion came, Robespierre
always waited to see the issue before he declared himself. He never
threw off his nervous hesitation. He never committed himself to
violent risks, or took the initiative in violent courses. These
characteristics are illustrated at each stage of his career. In the
difficult days of July, 1791, at the time of the 'Massacre of the Champ
de Mars,' he conducted himself with exemplary caution. A year later,
on the 10th August, he remained in the background till the battle was
decided, but he joined the Commune openly on the 11th, when the
victory was won. Later still, though he detested the doctrines of the
Hébertists, he did not venture to attack them straightforwardly. He
only threw out hints against them until he saw which way the tide
was running, and then he tried to discredit them by arguing that
atheism was an aristocratic idea! He was absent, on the plea of
illness, while their fate was being decided in the Committee, but he
was well enough to re-appear in public the morning after their arrest.
He encouraged Desmoulins cordially in his crusade against the
Commune; but he changed his tone as soon as Collot d'Herbois'
reappearance turned the scale against Desmoulins' views, and he
finally threw over without a struggle the man who had been for years
his warm admirer and friend. With equal treachery he sacrificed
Danton as soon as it was evident that the strongest party was bent
on Danton's destruction, and directly the arrest was made, he came
forward to denounce a colleague, at whose side, only a few weeks
before, he had proudly asked to stand. Of course it is possible that
Robespierre was able, with his remarkable faculty of self-deception,
to persuade his conscience in every case that he was acting as the
interests of virtue required. But it is difficult by any sophisms to
excuse such heartless opportunism, and to avoid the conviction that,
whoever fell, Robespierre was determined to be upon the winning
side.
Hardly less noticeable than his tortuous manœuvring was his
incompetence in practical affairs. His speeches were treatises full of
vague and abstract speculation, in which the same forms and
phrases constantly appeared, but singularly lacking in definiteness
and meaning, with very little bearing upon facts, and generally
without any practical conclusions or result. He seemed to talk for the
sake of talking, but the listeners, who accepted his theory as their
gospel, never seemed to tire of the voice of the priest. At the height
of the struggle between the rival parties in January, 1794,
Robespierre solemnly invited the Jacobins to consider 'the crimes of
the English Government and the vices of the British Constitution.' At
another time of stirring interest and activity, he busied himself with
drawing up a lengthy indictment of the monarchs of the world. At
another time, he contributed to a practical discussion some luminous
remarks, in which he insisted that the outbreak of the Revolution had
been largely due to the determination of 'the London Cabinet ... to
place the Duke of York on the throne of Louis XVI,' and that Pitt was
'an imbecile ... who, abusing the influence acquired by him on an
island placed haphazard in the ocean,' conceived plans only worthy
of a madhouse. It is no wonder if his colleagues in the Government,
who were nearly all of them vigorous men of action, came to regard
him with something like contempt. All through the Revolution
Robespierre's attitude was the same. He never displayed much
practical ability. The overthrow of the monarchy, the establishment of
the Republic, the defeat of the invaders, the triumph of the
Revolutionary Government, the organisation of the national defence,
owed little to him. On the Committee of Public Safety his services,
apart from matters of police, were unimportant. He did little useful
work himself, and his jealous interference only hampered and
embarrassed those who did. He never went on mission. The
equipment of the army and navy, the management of the food
supply, the control of the proconsuls, the administration of the
country, the heroic labours of the terrible Committee, rested in other
hands. Robespierre was only its tireless rhetorician, watching,
manœuvring, expatiating incessantly on his ideals, his virtues and
himself. Even after the fall of Danton, when he had ample scope for
his designs, all that he contributed as a practical reformer to the
Utopia which he had described a hundred times, was a masquerade
to the discredit of religion and the most sanguinary police-law which
the world has seen.
But wrapped as Robespierre was in self-complacency, he was
always sufficiently awake to suspect and envy others. The doctrine
of mistrust was a part of the Jacobin creed. The habit of suspecting
others seemed to grow upon all those who professed the faith, and
gradually to distort their views and to discolour their judgment. The
Robespierre of 1794, the jealous, nervous, inflated fanatic, was a
very different being from the earnest, narrow-minded lawyer, who
had set out from Arras five years before to take his part in
regenerating France. As Marat had developed, under the influence
of the Jacobin theory and amid the desperate excitements of the
time, from a soured idealist into the furious advocate of murder, so
Robespierre had developed too. The mania of panic and suspicion
had settled upon him. The peril which he and his colleagues
encountered had convinced him that he was a martyr, and that all
who did not recognise his virtues were conspirators seeking for his
death. 'Gazing on the multitude of vices which the torrent of the
Revolution has rolled down,' he cried in his last great speech in the
Convention, 'I have sometimes trembled lest I should be soiled by
the impure neighbourhood of wicked men.... I know that it is easy for
the leagued tyrants of the world to overwhelm a single individual; but
I know also what is the duty of a man who can die in defence of
humanity.' In the latter part of Robespierre's career it seemed that
nothing was too innocent for him to mistrust or too improbable for
him to suspect. 'I am not obliged to reflect,' he told Garat, 'I always
rely on first impressions.' He believed that his instinct could not err,
and his instinct always was to think the worst. 'Evidently,' he said one
day to Garat, early in the spring of 1793, 'the Girondists are
conspiring.' 'Where?' asked Garat. 'Everywhere,' answered
Robespierre. He needed no facts to prove it. His virtue, the
watchdog of the Republic, told him it was true. At one moment
Lafayette was the traitor, at another Brissot, at another Dumouriez,
at another Hébert. Servan, he insisted, was given a command in the
Pyrenees, in order to hand over the keys of France to Spain. 'Is
there no doubt of this in your mind?' asked Garat. 'None whatever,'
replied the infallible pedant. Again and again Robespierre
denounced mysterious conspiracies and treasons in Paris, in the
departments, in the Commune, in the Convention. He had no doubt
whatever that he was unmasking traitors, and traitors he could not
scruple to send to the guillotine. In particular, the generals of the
Republic were singled out by Robespierre as objects of alarm. It was
he who sent Custine to the scaffold, and scouted the suggestion that
it was necessary to offer written proofs of his guilt. It was he who
took the chief part in denouncing Houchard and in consigning him to
a similar fate. It was he who first threw doubts on the good faith of
Kellermann. It was he who, upon no evidence whatever, ordered the
arrest of Hoche upon a charge of treason[11].
The growth of this fever of suspicion, which was common to most of
the Jacobin party, but which was specially marked in Marat and in
Robespierre, enables one to understand how a man naturally neither
cruel nor unprincipled became so largely responsible for the
bloodshed of the Terror. Robespierre's apologists have vainly
endeavoured to defend him against this reproach, and to maintain
that he always wished to stop it. But even their defence of
Robespierre contains conclusive evidence of his guilt. His position,
after the fall of Danton, was unquestionably strong. In the two
governing Committees, though he had enemies and critics, he was
closely supported by Couthon and St. Just. His popularity in Paris
was considerable. His reputation within his own party stood higher
than that of any of his colleagues. The Jacobin Club was his
stronghold. On the triumph of the Committee in March, 1794, the
Commune had been reconstituted, and its new heads, Fleuriot and
Payan, were devoted to Robespierre's interest. The Revolutionary
Army of the capital had been dissolved, but Hanriot, Robespierre's
firm friend, retained his command in the National Guard, and was
zealous in Robespierre's service. The ministries also had been
suppressed. Twelve new commissions had been appointed to
administer affairs in their place, and in the appointments to these
commissions Robespierre's influence was naturally large. Had
Robespierre really cared to use his power to mitigate the Terror, it is
difficult to believe that he could not have done so with success. In
the existing state of public opinion he could, for such an enterprise,
have commanded overwhelming support. The great majority of the
Convention, as their conduct both before and after proved, were only
waiting for an opportunity to throw their weight into the scale of
mercy.
But the fact is that Robespierre's influence was used throughout in
the opposite direction. He detested, it is true, the disorderly excesses
that had accompanied the Terror in the departments. He wished to
centralise and regulate the system, to make it uniform, moral and
decorous, to take the power of the sword out of the hands of men
whom he distrusted and disliked. But he did not wish to end it. The
police-law of April, 1794, which directed that all conspirators should
be brought to Paris for trial, and the establishment of a new Bureau
of police under the supervision of St. Just and of Robespierre
himself, were designed to prevent the occurrence of enormities like
those of Carrier in the provinces, and to deprive Robespierre's
opponents in the Committee of General Security of their monopoly in
matters of police. But they were not measures of compassion. From
the first, Robespierre had taken a prominent part in founding and
developing the Revolutionary Tribunal. Again and again he had
protested against its delays and its unnecessary forms. When he
attained the climax of his power, he swept those forms away. In the
Revolutionary Tribunal he had staunch adherents. His work in the
Committee of Public Safety was always largely concerned with
questions of police. The Terror was an essential part of his system.
He honestly believed that his Utopia could not flourish until he had
consumed the wicked, and against the wicked accordingly he
sharpened the sword of death.
With this crusade against the enemies of his ideal he mingled
schemes of arbitrary benevolence. Both St. Just and Robespierre
were determined to found the State which Rousseau had conceived,
wherein all should be equal, virtuous, enlightened, without poverty or
riches, irreverence or sin. As a step towards it they determined to
establish Rousseau's Church. On the 18th Floréal (7th May),
Robespierre induced the Convention to decree its belief in a
Supreme Being and in the immortality of the soul. On the 20th
Prairial (8th June), he celebrated, in one of the strangest pageants of
history, the festival of the new Deity in France. Arrayed in a brilliant
uniform, and carrying a bouquet of flowers and corn sheaves,
Robespierre marched at the head of a procession out to the Champ
de Mars, burned the symbols of Atheism and Vice, and inaugurated
the new religion. 'Here,' he cried, 'is the Universe assembled. O
Nature, how sublime, how exquisite, thy power! How tyrants will pale
at the tidings of our feast.' And within two days of this ideal festival
he set to work to re-organise the machinery of the guillotine. A few
weeks before he had taken a chief part in establishing, on the
demand of his adherent Maignet, an extraordinary tribunal at Orange
in the South, and had drawn up with his own hand a paper of
instructions, which laid it down that the conscience of the judges was
to be the only test of the guilt of the accused. In the law of the 22nd
Prairial this monstrous principle was carried further. The decree
provided that the Revolutionary Tribunal should be divided into four
sections to expedite its work, that prisoners should thenceforward be
tried in batches, that they should no longer have counsel to defend
them or be allowed to call witnesses for their defence, and that the
question of their guilt should be left to the enlightened conscience of
the jury! The results of this proposal were that, in the six or seven
weeks which followed, the number of victims guillotined mounted to
over thirteen hundred, a number considerably exceeding the total
reached during the first fifteen months of the tribunal's existence. In
face of this measure, which was unquestionably Robespierre's work,
it is idle to pretend that he wished to check the Terror. No doubt he
disliked its extravagance and license. No doubt he wished to strike
some of the Terrorists. But apart from that there is no evidence that
he attempted to stop it, and against him there is the whole tenour of
his policy and the testimony of this nefarious decree.
But Robespierre's ascendency was destined to be brief. The majority
of his colleagues had begun to dread him. They knew that he was
jealous of their authority. After the 10th June he held himself more
and more aloof[12]. He did not resign his place on the Committee; but
finding that he could not make its members accept his ascendency,
he began to form schemes for purging the Government afresh, to
dissociate himself from his colleagues, and to concentrate his forces
in the Commune and at the Jacobin Club. At last, aware that a
breach was inevitable, St. Just and others urged him to take
vigorous measures against his opponents. But Robespierre, always
incapable of decisive action, preferred to confine himself to
speeches and to vague hints of conspiracy and treason. On the 8th
Thermidor (26th July), in a long and mysterious speech, marked by
his habitual and astonishing egotism, he denounced the plots
against the Convention, and demanded the punishment of evil men.
But he named no one, and his threats frightened all. That night the
combination which had been gradually forming against him came to
a head. Tallien, Billaud, Bourdon and others, Dantonists and
Hébertists, all parties alike determined to unite, to save their lives.
On the morrow, the 9th Thermidor, the crisis came, and the
Convention, for once acting with unanimity and vigour, rejected
Robespierre's appeal and boldly ordered his arrest. For a few hours
the issue of the struggle hung doubtful. The Commune rallied to
Robespierre's defence. He was delivered from prison and carried to
the Hôtel de Ville in triumph. Hanriot summoned his artillerymen to
the rescue, and once again the Commune proposed to raise an
insurrection. But the name of the Commune was no longer a
watchword in the capital. The Convention held its ground with
unusual courage. It outlawed all the chief conspirators. It took prompt
measures to organise resistance, to rouse Paris, to summon the
forces of the Sections to its aid. The prestige of the National
Assembly, when united, was still redoubtable, and Hanriot's troops
hesitated to attack it. Early in the dawn of the following day the
Conventional forces assumed the offensive, and marched on the
Hôtel de Ville. The insurrection collapsed, and Robespierre and his
confederates died. At last the lawful authority in France, so long
paralysed and broken, had dared to act decisively, and to use force
to make itself obeyed. From the moment that its vigour revived its
triumph was assured, and with its triumph the reaction began.
FOOTNOTES:
[11] Even M. Hamel admits this (Hist. de Robespierre, III. p. 499
et seq.), although he endeavours, in a manner that is not
convincing, to throw the responsibility on to Carnot. Carnot
claimed to have saved Hoche's life. He certainly joined in ordering
his release from prison almost immediately after Robespierre's
fall.
[12] Robespierre himself said, on the 8th Thermidor, that for the
last six weeks he had 'absolutely abandoned his functions as a
member of the Committee of Public Safety.' Louis Blanc argues
that he was therefore not responsible for the Terror. But another
of Robespierre's admirers, Hamel, has taken pains to prove that
Robespierre was constantly present at the Committee's meetings
up to the 9th Thermidor, and decides that his alleged retirement
must consequently have been 'toute morale' (vol. III. pp. 594-
601).
CHAPTER XI.
The Reaction.
With the fall of Robespierre the Terror came to an end. The men
who overthrew him were many of them worse men than he. They did
not intend to repudiate his system. They had acted from personal
motives, from a desire to save their lives and to maintain themselves
in power. But without Robespierre the Terror could not continue. It
was his reputation for moral earnestness and for disinterested
conviction which alone had reconciled to it many honest, narrow-
minded men, who accepted his theory, believed in his sincerity, and
had not the capacity to criticise his actions. In him and his associates
the principles of the Terror perished. There remained no one to throw
over the system the veil of sentimental virtue, and without that veil its
uglier aspects stood disclosed. Men who to the last had respected
Robespierre could not respect Collot d'Herbois or Billaud-Varennes.
The Convention which had revolted against Robespierre was not
likely, when once it had tasted freedom, to replace on its neck the
yoke of his colleagues. The Committee of Public Safety had
appeared irresistible so long as it was undivided. But when it broke
up into parties and appealed to the Convention to protect it, its
dictatorship necessarily expired.
Accordingly, in the weeks which followed the 9th Thermidor, a
number of measures testified to the growing reaction. The
Committee of Public Safety was remodelled, and a system was
enforced under which three of its members retired, without the right
of re-election, every month. The Convention and its Committees
resumed the powers of government. The Revolutionary Tribunal was
reconstituted and the law of the 22nd Prairial repealed. The
redoubtable Commune was abolished, and for purposes of local
government Paris was placed under the authority of the Department
of the Seine. The staff of the National Guard was reorganised. The
Revolutionary Committees in Paris and elsewhere were reduced in
number and shorn of their powers. The meetings of the Sections
were limited to three a month, and the decree which provided a
payment of forty sous for all citizens who attended them was
repealed. In the departments the officials of the Communes and of
the Clubs were sifted and replaced. Everywhere the prison doors
were opened and hundreds of prisoners were set free. Before the
end of August, voices were raised in the Convention against the
Terrorists who continued in the Government, and at the beginning of
September, Billaud-Varennes, Collot d'Herbois and the remaining
Terrorists retired.
As the autumn went on, the pace of the reaction increased. The
Jacobins, it is true, were still numerous and active. Although the
reputation of the leading Terrorists was shaken, the Mountain was
still a force in the Convention. Besides the members of the old
Committees, many deputies, like Romme and Soubrany, Goujon and
Bourbotte, maintained without flinching extreme Jacobin views.
Others, like Thuriot and Cambon, were not prepared to go too far
with the reaction. The Jacobin Club, though weakened by the fall of
Robespierre, had resumed its old activity, and, supported by some of
its confederates in the provinces, determined not to surrender its
power without a struggle. Billaud-Varennes declared passionately
that the old lion was not dead. But the tide flowed heavily against the
Mountain. The majority of the Convention was determined at all
costs to break with the system of the Terror. The deputies of the
Right and of the Centre recovered their voices under the courageous
leadership of Boissy-d'Anglas and Thibeaudeau. The Thermidorians,
under Tallien and Fréron, rallied to the side of the moderate
members, and gathered round them many old Dantonists and many
old adherents of the Mountain, Legendre, Lecointre and Bourdon de
l'Oise, Merlin of Thionville and Merlin of Douai, Cambacères, and
André Dumont. Sieyès, released from the necessity of silence,
brought to the same side his affectation of inscrutable wisdom.
Encouraged by the divisions in the Assembly, public opinion
expressed itself outside. The independence of the Press revived.
Fréron's paper, the Orateur du Peuple boldly took the lead of the
reactionary journals. The trial of the prisoners sent up from Nantes to
be tried at Paris revealed for the first time to the public the worst
iniquities of Carrier's rule, and in the weeks and months which
followed, evidence began to pour in against the agents of the Terror.
The indignation against the Terrorists in Paris increased every day.
Reactionary feeling showed itself overwhelmingly strong in the
Sections, in the cafés, in the streets. Bodies of young men, some of
them men of family and wealth, but most of them drawn from the
ranks of tradesmen, clerks and artisans, representing the great
majority of respectable people which had allowed itself to be
tyrannised over so long, and which had shown its readiness to rise
as early as May, 1793, gathering in the Palais Royal, once the
headquarters of revolutionary agitation, organised themselves into
an effective force, armed themselves with short and heavy sticks,
and led by Lacretelle and encouraged by Fréron and Tallien, began
to parade the streets, to suppress Jacobin speakers and meetings,
to pour contempt on Jacobin opinions, and to wage war against
Jacobinism in whatever shape it might be found. Extravagant and
ridiculous in some respects the 'Jeunes Gens' were, and in later
days it suited the Thermidorians to turn their affectation into ridicule,
and to denounce them as 'Jeunesse Dorée,' as 'Elégants' and
Muscadins.' But in their origin at any rate they represented a genuine
popular movement, and up to April, 1795, they acted cordially with
the moderate party, and rendered valuable service in destroying the
terrorism which the Jacobins had established in Paris. With the new
movement a new song came into fashion, and the Jeunes Gens,
rejecting the Marseillaise, sang in the streets the 'Réveil du Peuple':
—
'Quelle est cette lenteur barbare?
Hâte-toi, peuple souverain,
De rendre aux monstres de Ténare
Tous ces buveurs de sang humain.'
The reaction in Paris soon made itself felt in the Assembly. The
attacks upon the Terrorists and their supporters redoubled. In
October a law was passed forbidding the federation of popular clubs.
On the 12th November, the Committee of Public Safety announced
that it had closed the Jacobin Club. In the same month Carrier was
arrested. He was sent for trial before the Revolutionary Tribunal and
a few weeks later to the scaffold. On the 8th December, the seventy-
three deputies who had been imprisoned for protesting against the
expulsion of the Gironde, were readmitted to their places in the
Convention. At the end of that month the Assembly decided that
there was ground for investigating the charges against Billaud-
Varennes, Collot d'Herbois, Vadier and Barère. As the winter went
on, the members of the Right, reinforced by the seventy-three, and
determined to undo the work of the Terror, demanded a
reconsideration of the laws against Emigrants and priests, and the
restoration in certain cases of property confiscated for political
offences. In February, 1795, the Convention decreed the freedom of
all forms of religious opinion; but at the same time it continued the
penal enactments against non-juring priests, imposed a variety of
restrictions on the exercise of public worship, and, while refusing to
contribute towards the maintenance of any religion, retained its hold
upon the buildings and property of the old Church. A further advance
made in June towards the principles of complete toleration was
afterwards repealed by the influence of the Left. On the 2nd March,
Legendre carried a motion for the arrest of Billaud-Varennes, Collot
d'Herbois, Vadier and Barère. On the 8th, the survivors of the
Girondist leaders proscribed on the 31st May, including Isnard,
Lanjuinais and Louvet, were recalled to their seats in the Assembly.
The triumph of the reaction seemed to be assured.
But the Jacobins were not to fall without a struggle. They had more
than once secured the victory by appealing to the physical
necessities of the poor, and it was by that means that they
endeavoured to conquer again. In the spring of 1795 the distress in
Paris was exceptionally keen. With the political reaction an economic
reaction had begun. After Thermidor it became evident that the
economic system of the Terror could not stand. Its drastic laws were
on all sides disregarded. No penalties or prohibitions could force
men to observe laws which they were resolutely determined to
infringe. The State might fix the price of food, but the producers
would not produce it at that price, and when the guillotine had
ceased to compel submission, the vain attempts of the State to fix
prices broke down. Economic causes more powerful than any laws
overthrew the Maximum, and at last, towards the end of December,
the Convention recognised the fact and repealed the Maximum
decrees. With the repeal of the Maximum the whole system of
Terrorist finance collapsed. The practice of requisition was
abandoned. The restrictions upon foreign trade and upon the
exportation of specie were removed. In a short time the Bourse was
reopened. The intrepid experiment by which the economists of the
Terror had endeavoured to concentrate in the hands of the
Government the whole commercial system of the country, fell to the
ground, and the old methods of monopoly and competition, which
the Terrorists had so constantly denounced, and which they had so
boldly but recklessly attacked, reasserted their sway and exacted
their penalty. The financial system of the Terror was ruinously
mistaken, but by its draconian methods it had to some extent
checked the rise in prices, and had perhaps saved from extinction
the vanishing credit of the Assignats. Yet even under the Terror the
Assignats had deteriorated in value. In spite of the imperious
demands of the Terrorist Exchequer, in spite of its forced loans and
wholesale confiscations, in spite of the plunder which it drew from its
victims and of the money which, as Barère boasted, it coined on the
Place de la Révolution, the Jacobin Government had never been
free from financial troubles. The non-payment of taxes, the
peculation of local authorities, the failure of the forced loans to bring
in anything like the sum expected, the depreciation in value of
national property, the ignorance of economics which prevailed
among the ruling party, and above all the enormous expenses of the
war, of the administration, and of supplying Paris and the great
towns with food, had created a perpetual deficit. 'The Revolution and
the war,' said Cambon, the chief financier of the Terror, in a report of
January, 1795, 'have cost in four years five thousand three hundred
and fifty millions above the ordinary expenses;' and Cambon's
estimate was probably much below the fact. In vain had Cambon by
a partial bankruptcy put out of circulation fifteen hundred million
francs of Assignats which bore the image of the King. In vain had the
Convention, in August 1794, decreed, on Cambon's proposal, the
Republicanisation of the National Debt, ordered all the creditors of
the State to send in their claims, entered their titles in a Great Ledger
of the Public Debt, declared the capital borrowed by the State to be
irrecoverable, and, regardless of all engagements entered into and
of all promises of high interest previously made, informed them that
in future the State would pay five per cent interest to all its creditors
alike. This summary method of escaping liabilities had introduced, it
is true, some order into the finances, but it had not improved the
credit of the State. The chief resource of the Government had
continued to be the Assignats, and not even the drastic legislation of
the Terror had been able to keep their credit up.
The repeal of that drastic legislation and the financial policy of the
Convention in the winter of 1794-95 accelerated their decline[13].
Prices, no longer fixed by law, rose rapidly, as the value of the paper
money fell. The Government, no longer able to rely on the methods
which the Terrorists had used to swell their income, and face to face
with high prices and diminishing credit, could think of no better
resource than to issue Assignats faster than before; and of course
with every fresh issue the depreciation increased. At the end of
1794, some seven thousand million francs of Assignats were in
circulation. In May, 1795, these had risen to ten thousand millions, in
the August following, to sixteen thousand millions, and in the
October following that, to many thousand millions more. In proportion
to these enormous issues, the value of the currency declined. At the
end of the reign of Terror, Assignats had been worth 33 or 34 per
cent of their nominal value. In December, 1794, they had fallen to 22
per cent. In the ensuing May they stood at 7 per cent, and in the
months which followed they fell to 4, to 2, and even to less than 1
per cent. In vain different members of the Convention proposed
schemes for diminishing the number. The Government had no other
resource to look to, and its expenses seemed daily to increase, as
claims for compensation poured in upon it from those who had
suffered under the Terror. With the fall of the Assignats, prices rose
to an alarming height. All wage-earners who could not raise their
wages in proportion to the rapid rise in prices, all who lived upon
fixed incomes, all who depended on the paper-money and whose
small savings consisted of Assignats, suffered acutely from the
economic crisis. A certain number of people, tenant farmers for
instance, who paid their rent in Assignats, and who made it many
times over by the high prices fetched by corn, debtors who could pay
off long-standing debts in Assignats at their nominal value, and
speculators, who sprang up on all sides to traffic in the fluctuations of
the currency, made heavy profits and enriched themselves. But to
the great majority of people the fall of the Assignats meant grave
distress. The prices of bread, of meat, of fuel, of all the necessaries
of life, rose as in a siege. One reads of the most fantastic payments,
of thousands of francs paid for a dinner, a cab-fare or a load of
wood. The sense of the value of money vanished, when its
purchasing power declined every day. But it was only those who had
plenty of it who possessed the power to purchase at all.
There is overwhelming evidence of the general distress in the winter
of 1794-95. From all sides complaints came in of the exorbitant
dearness of food, and that trouble was aggravated by the intense
cold. In Paris and many great cities the authorities bought up food at
ruinous prices and distributed it in meagre rations to the poor. But as
the year advanced, these rations constantly diminished. The country
districts bitterly complained that they were starved in order that the
big towns might be fed. 'Many families, entire communes,' wrote an
official from Laon, in the summer of 1795, 'have been without bread
two or three months and are living on bran or herbs.' Around Caen
the peasants were living on unripe peas, beans and green barley. In
Picardy 'the great majority of people' overran the woods for food.
From all sides the same reports poured in upon the Government.
'Yesterday,' wrote the authorities of Montreuil-sur-Mer, 'more than
two hundred of our citizens set out to beg in the country;' and those
who could not get food in other ways took it by force. Nor, in spite of
the efforts of the authorities, were the large towns better off. Lyons,
in January, was without bread 'for five full days.' At Troyes, in March,
the public distribution of bread fell to two ounces a day. At Amiens, a
few months later, it ceased altogether. At Nancy a traveller noticed a
crowd of 'three thousand persons imploring in vain a few pounds of
flour.' In Paris the police reported case after case of misery and
starvation. 'Every day,' wrote a friend to Mallet du Pan, 'I see people
of the poorer class dying of starvation in the streets.... Workmen
generally have to work short time, owing to the weakness and
exhaustion caused by want of food.'
It is no wonder if this acute distress resulted in an outbreak. Many of
those who suffered the most had sympathised with the Jacobin party,
and the arrest of the Terrorist leaders gave a certain political colour
to the agitation which famine had produced. But in the main the
insurrection which broke out on the 12th Germinal (1st April), which
for a time threatened the safety of the Convention, and which joined
to its demand for bread a demand for the Constitution of '93, was a
spontaneous movement due to the pressure of starvation rather than
to political intrigue. The leaders of the Mountain failed to turn it to
account. The Jeunes Gens and the battalions of the Sections
enabled the Government to win an easy victory, and the failure of the
rising helped the reaction on. Motions were quickly passed for the
transportation of Billaud-Varennes, Collot d'Herbois, Vadier and
Barère, and for the arrest of Cambon, Thuriot, Amar, and other
prominent members of the Mountain. Pichegru restored order in the
streets. The Convention decreed the disarming of the Terrorists and
the reorganisation of the National Guard. The officials of the
Departments and of the Districts were restored to their old authority.
The State, which had already undertaken to pay the debts of
Emigrants whose possessions it had confiscated, now resolved to
restore to the families of the victims the property of all persons who
had been executed for political offences since the 10th March, 1793.
A commission of eleven members was appointed to consider the
bases of a new constitution. Early in May, Fouquier-Tinville and
several of his associates in the old Tribunal were sent to the
guillotine.
But the Jacobins were not yet silenced. The rapid progress of the
reaction disquieted many. The reappearance of Emigrants and of
non-juring priests, the extravagance of the Jeunes Gens, the revival
of Royalist opinions in Paris, the terrible excesses which began to
stain the reaction in the South-East of France, and which, under the
direction of the 'Compagnies de Jésus' and the 'Compagnies du Sol,'
had already made Lyons the scene of murder and of civil war,
alarmed the Thermidorians and many other members of the
Convention. The majority oscillated from day to day between their
fear of the Mountain and their fear of a Royalist reaction, and
displayed to all the world the vacillation and weakness of the ruling
powers in France. At the beginning of May, the Jacobins so far
prevailed as to carry a decree for the immediate arrest of returned
Emigrants and refractory priests, and for the prosecution of Royalist
publications. The disarming of Terrorists practically ceased. The high
prices of food and the distress which they occasioned became more
serious every day, and Jacobin agents laboured persistently to rouse
the workmen to another insurrection. On the 1st Prairial (20th May),
their efforts succeeded. A second rising, more formidable and better
organised than that of Germinal, confronted the Government, and
the Convention, after a sharp struggle, only saved itself by yielding to
the demands of the insurrectionary leaders. Fair promises, however,
gained the Assembly time to bring up troops for its defence. On the
evening of the 22nd May, a strong force of cavalry and infantry
arrived in Paris. The next day, the Faubourg St. Antoine was
besieged and compelled to surrender at discretion. Numerous
arrests were made. The disarming of the Terrorists was completed.
All pikes were seized. The reorganisation of the National Guard was
accomplished, and the right of serving in it was once more restricted
to members of the bourgeois class. A temporary military commission
was established to try those accused of complicity in the
insurrection, and the Revolutionary Tribunal was abolished. Six
prominent deputies of the Mountain, including Goujon, Romme,
Soubrany and Bourbotte, were sent to the scaffold. Lebon, long
since put under arrest, Panis, almost forgotten, Lindet, Jean Bon St.
André, Guffroy and Rühl, all except three of the members of the two
redoubtable Committees, Pache, Bouchotte, and several of their
associates in the former Ministry of War, shared in the proscription of
their party. The influence of the extreme Jacobins was finally
destroyed, and once again the policy of the reaction triumphed.
The decisive success of the moderate party was not without its effect
upon European politics. At the time of the insurrection of Prairial, the
French arms were completely victorious and many had begun to
hope for the cessation of the war. The history of the revolutionary
armies is the finest part of the French Revolution. There the spirit
which the Revolution had inspired, and which had spent itself so
fruitlessly in Paris, was seen at its best in the enthusiasm, the
devotion and the gallantry of the troops. There too the high qualities
of the Jacobin administrators appeared, their determined patriotism,
their dauntless vigour and resource. There the Government which in
Paris seemed to be only a Government of tyrants, revealed itself as
a Government of heroes. There the politicians and intriguers of the
Terror turned to the nobler work of national defence. Carnot and St.
Just, Merlin of Thionville, Rewbell and Barras, Milhaud and
Soubrany, Richard, Drouet, Cavaignac and Fabre d'Hérault are only
some among the many brave men who, as Representatives on
Mission with the armies, inspired the French troops with their own
lofty courage, and both by precept and example taught them the
impossibility of defeat. The enthusiasm which political intrigues had
wasted found a deeper expression in the war, and the levelling
freedom of the Republic threw open to all ranks alike the prospects
of a great career. In the campaigns of 1793-94, Hoche, Pichegru and
Jourdan had already reached the highest place, and Moreau and
Kléber, Bernadotte, Ney, Davoût, Augereau and Victor, Soult,
Masséna, Bonaparte were winning their way to notice and
command. It is true that at the first the French levies were ill-
organised and ill-disciplined, and that their earlier successes were
due chiefly to the disunion or incapacity of their opponents. But the
progress of the war and the vigorous measures of the Jacobin
Government soon produced a remarkable change. There was no
lack of material upon which to draw. To the old royal army there had
in turn been added the battalions of national guards, the volunteers
raised in 1792, the levée en masse of the same year, which was,
however, of very little use, the levy of 300,000 men formed, largely
by conscription, in the spring of 1793, and the forces raised in the
following summer by the imperious decrees of the Government,
which claimed the services of all men between the ages of eighteen
and twenty-five. On this material the Convention set to work, and the
efforts of Dubois-Crancé and Carnot, seconded by their able
advisers, and perfected by the strenuous action and wide powers of
the great Committee, met with complete success. To Dubois-Crancé
especially belongs the credit. It was he who, in the winter of 1793-94,
at last carried through the Convention the great scheme for the
reorganisation of the army which he had advocated so long, who
committed the Government to the principle of conscription and to the
amalgamation of the regulars with the volunteers, and who fused the
two elements together by dividing the army into demi-brigades made
up of one battalion of regulars and four of volunteers. The result of
these measures appeared before long in the formation of a
magnificent army, which for numbers, discipline and the spirit of its
troops, was a match for the united forces of Europe.
The campaign of 1793, which at one time threatened France with
serious danger, ended in complete success. The valuable victories of
Houchard and of Jourdan on the North-Eastern frontier in September
and October, drove the Allies back upon Belgium. The equally
notable successes of Hoche and Pichegru, which followed in Alsace,
drove the victorious Austrians and Prussians again across the Rhine.
The brave insurgents of La Vendée found themselves at last
opposed by a powerful army under a general of high ability, and
were defeated by Kléber at Chollet in October, and subsequently
routed at Le Mans. By the end of the year France had ten armies for
service in the field and an effective force of some six hundred
thousand men. On the North-East, four armies, those of the Rhine,
of the Moselle, of the Ardennes, and of the North, stretched from
Strasbourg to the sea. Further to the South, the army of the Alps
occupied Savoy, and the army of Italy, which had just reduced
Toulon, waited for a new commander to launch it on an illustrious
career. In the West, two more armies held the Pyrenees, and a third
watched the insurgents of La Vendée; while on the Northern coast,
the army of Normandy, not yet organised into a definite force,
guarded the sea-board and dreamed vainly of invading England.
With these resources the Allies could not compete. But even had the
troops been forthcoming, their disunion would have rendered victory
impossible. In 1794, when France was preparing with the brightest
prospects to reopen the campaign, the long-standing jealousy
between Austria and Prussia reached its climax. Thugut, the Austrian
minister, disliked his Prussian allies even more than his French
enemies, and carrying to an extreme pitch the traditional selfishness
of Austrian policy, intrigued on all sides for territorial
aggrandisement, and meditated schemes for extending the Austrian
dominions in every quarter of Europe, in Flanders and Alsace, in
Turkey and Poland, in Bavaria and Venice. In the North, Russia drew
nearer every day to the completion of her long-prepared attack on
Polish freedom, and Prussia, determined not to be left aside when
her rivals shared the spoils of Poland, turned her attention and her
energies towards the Vistula, when the sympathies of her king would
gladly have turned towards the Rhine. In vain the English
Government threw itself with fresh energy into the war, laboured to
draw the coalition together, and promised generous supplies. In
April, 1794, at the very moment when Malmesbury, the English
envoy at the Hague, was pledging England, Holland and Prussia to
renewed efforts in the war with France, the Polish revolt broke out at
Warsaw, and Kosciusko's brave struggle for freedom diverted the
attention of the Central Powers. It was evident that until the Polish
question was settled, neither Prussia nor Austria would act with
vigour against the French. Accordingly, the French armies on the
North-Eastern frontier, now under the command of Pichegru and
Jourdan, advanced against the divided Allies, defeated them at
Turcoign and Fleurus, and entered Brussels on the 11th July. The
conquest of Belgium and the invasion of Holland followed. While
Suvórof stamped out the insurrection in Poland, and Austria and
Russia drew up plans for the partition of that unhappy country, to
which Prussia was afterwards compelled to accede, the French
troops advanced into Holland, drove the Prince of Orange into flight
and occupied the Hague and Amsterdam. At last Prussia, isolated
and alarmed, consented to open negotiations, and on the 5th April,
she definitely separated herself from Austria, and made peace with
France in the Treaty of Bâle.
There were many who hoped that the Treaty of Bâle might prove the
beginning of a general peace, and so prepare the way for a Royalist
restoration. The fresh disturbances among the peasants of La
Vendée and their allies the Chouans of Brittany, which had been
provoked in 1794 by the merciless policy of the Republic, by
Turreau's 'Hellish Columns' and by Carrier's tyranny at Nantes, had
been quieted, in the spring of 1795, by the conciliatory policy of the
Republican generals, and the long struggle in the West seemed to
be drawing to a close. In the Pyrenees the advance of the French
brought the Spanish Government to terms, and a peace between
France and Spain was concluded in July. In Paris the suppression of
the insurrection of Prairial had raised very high the hopes of the
Royalists. Many things seemed to point towards the restoration of
the Constitution of '91, which at that time, as at an earlier date,
would probably have satisfied the wishes of the majority of the
nation. But events ordered otherwise. The high demands of the
French Government, the vigour of English diplomacy, and the
settlement of the Polish difficulty, which left the Emperor free to act,
disappointed the expectations of a general peace. In the summer of
1795, England, Russia and Austria drew closer together and formed
a fresh alliance for the prosecution of the war. Early in June, the
unhappy little Dauphin died in prison, and his death dealt a heavy
blow to the hopes of the Constitutional party. Many who would have
welcomed the son of Louis XVI as Constitutional King, could not
reconcile themselves to the restoration of the Comte de Provence,
the chief of the Emigrants in arms against France, the prince who,
learning nothing from adversity, still condemned in the bitterest
language all the changes which the Revolution had introduced, and
still denounced as an enemy of the Bourbons every advocate of
moderation or of liberal ideas. The French people had not made the
Revolution in order to restore the Ancien Régime. The attempt of the
Emigrants to renew the war in the West by an ill-timed descent upon
Quiberon, although stamped out by Hoche in July, and punished with
terrible severity by the Convention, revived the deep-seated hostility
which all friends of the Revolution entertained towards the
Emigrants. The fresh tidings which came in from the South of terrible
excesses committed in the name of the reaction at Marseilles and
Avignon, Tarascon and Aix, tended to check the flowing tide. The
rapid advance of Royalist opinions in Paris, and the threatening
demeanour of the Jeunes Gens and of the Sections at length
alarmed the Thermidorians. The members of the Convention
recalled to themselves that they were committed to the measures of
the Revolution, and began to fear lest the march of events should
carry them too far and involve them in a policy perilous to
themselves.
Finally the Convention chose a middle course. The Constitution of
1795 retained the Republican form, and divided the supreme
executive power among a Directory of five persons. The legislative
power it committed to a Parliament consisting of two Houses, a
Council of Five Hundred, who must be over thirty years of age, and a
Council of Ancients, who must be over forty. The Parliament was to
elect the Directory, but the functions of each were strictly defined; the
legislative and the executive powers were kept jealously distinct, and
cordial co-operation between them was rendered almost impossible.
The Convention had learned from the experience of the past the
necessity of making the Executive strong, but it had not yet learned
the folly of making the legislature and the Executive independent
rivals instead of harmonious allies. The new Parliament was to last
for three years, but one-third of its members were renewable yearly.
Apart from these new regulations, the Convention, rejecting a series
of fantastic proposals brought forward by Sieyès, adhered to the
main lines of the Constitution of 1791. The system of double election
was re-established. The franchise was limited by a slight property
qualification. In the local administration the division into Departments
and Communes was retained. But the Communes were strictly
subordinated to the Departments, the Districts were abolished
altogether, and the numbers and powers of the officials were so
reduced, as to simplify the whole system, and to increase the
authority of the central Government. Other articles established
freedom of worship, the freedom of labour, and the freedom of the
Press, prohibited political clubs and federations, and forbade the
return of the Emigrants to France.
But although the majority of the Convention yielded to the demand
for the establishment of a settled Government, they had no wish to
extinguish themselves. They knew that in the existing temper of the
nation they had little chance of being returned to power, and they
feared the lengths to which the reaction might run. Accordingly, they
proceeded to apply at once the principles laid down by the new
constitution for the renewal of the legislative body, and by the

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First Aid For the USMLE Step 1 2020,

Thirtieth Edition 30th Edition - eBook

MATTHEW SOCHAT, MD VAISHNAVI VAIDYANATHAN, MD

SARAH SCHIMANSKY, MB BCh BAO JORDAN ABRAMS

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eBook conversion by codeMantra

To the contributors to this and past editions, who took

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Contributing Authors vii General Acknowledgments xv

Introduction 2 Test-Taking Strategies 22

How to Use the Database 30 Pathology 205

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How to Use the Database 712 Biochemistry 716

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MAJED H. ALGHAMDI, MBBS KAITLYN MELNICK, MD

LILIT ASLANYAN MARY KATHERINE MONTES de OCA, MD

HUMOOD BOQAMBAR, MB BCh BAO SCOTT MOORE, DO

WEELIC CHONG VASILY OVECHKO, MD

KRISTINA DAMISCH VIVEK PODDER

YUMI KOVIC, MD CONNIE QIU

Image and Illustration Team

CAROLINE COLEMAN VICTOR JOSE MARTINEZ LEON, MD

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HUZAIFA AHMAD, MD SARINA KOILPILLAI

ALEXANDER R. ASLESEN LAUREN N. LESSOR, MPH, MD

ANUP K. BHATTACHARYA, MD ROHAN BIR SINGH, MD

ASHTEN R. DUNCAN, MPH

Image and Illustration Team

YAMNA JADOON, MD MITCHELL A. KATONA

DANA M. JORGENSON TAYLOR MANEY, MD

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DIANA ALBA, MD ANTHONY L. DeFRANCO, PhD

MARK A.W. ANDREWS, PhD CHARLES S. DELA CRUZ, MD, PhD

MARIA ANTONELLI, MD SAKINA FARHAT, MD

HERMAN SINGH BAGGA, MD CONRAD FISCHER, MD

SHIN C. BEH, MD RAYUDU GOPALAKRISHNA, PhD

JOHN R. BUTTERLY, MD RYAN C.W. HALL, MD

SHELDON CAMPBELL, MD, PhD LOUISE HAWLEY, PhD

BROOKS D. CASH, MD JEFFREY W. HOFMANN, MD, PhD

SHIVANI VERMA CHMURA, MD CLARK KEBODEAUX, PharmD

BRADLEY COLE, MD KRISTINE KRAFTS, MD

LINDA S. COSTANZO, PhD MATTHEW KRAYBILL, PhD

MANAS DAS, MD, MS GERALD LEE, MD

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WARREN LEVINSON, MD, PhD HOWARD M. STEINMAN, PhD

JAMES LYONS, MD SUPORN SUKPRAPRUT-BRAATEN, PhD

PETER MARKS, MD, PhD RICHARD P. USATINE, MD

DOUGLAS A. MATA, MD, MPH J. MATTHEW VELKEY, PhD

VICKI M. PARK, PhD, MS TISHA WANG, MD

SOROUSH RAIS-BAHRAMI, MD SYLVIA WASSERTHEIL-SMOLLER, PhD

SASAN SAKIANI, MD ADAM WEINSTEIN, MD

MELANIE SCHORR, MD ABHISHEK YADAV, MBBS, MSc

SHIREEN MADANI SIMS, MD KRISTAL YOUNG, MD

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First Aid for the USMLE Step 1 Through the Years

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 Study and test-taking strategies for the USMLE Step 1

Study and test-taking strategies for the USMLE Step 1

New facts, mnemonics, diagrams, and clinical images

High-yield topics that may appear on future Step 1 exams

*Alanine aminotransferase (ALT, GPT at 30°C) 8–20 U/L 8–20 U/L

“I don’t love studying. I hate studying. I like learning. Learning is ``Introduction2

Starting to study (including First Aid) too late

15 minutes Tutorial (skip if familiar with test format and features)