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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.

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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 711
How to Use the Database 712 Biochemistry 716

Question Banks and Books 714 Cell Biology and Histology 716
Web and Mobile Apps 714 Microbiology and Immunology 717
Comprehensive 715 Pathology 717
Anatomy, Embryology, and Neuroscience 715 Pharmacology 718
Behavioral Science 716 Physiology 718
``
Abbreviations and Symbols 719 Index 749
Image Acknowledgments 727 About the Editors 808
vi

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
ine
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y
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ry
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,
strategies, resource ratings, and the like (see p. xvii, How to Contribute).
Sharing your experience will benefit fellow medical students and IMGs.
STUDY MATERIALS
``
Quality Considerations
Although an ever-increasing number of review books and software are now

available on the market, the quality of such material is highly variable. Some
common problems are as follows:
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
not been adequately updated to reflect recent trends.
Some question banks test to a level of detail that you will not find on the
exam.
`` If a given review book is not working for you,
stop using it no matter how highly rated it Review Books
may be or how much it costs.
In selecting review books, be sure to weigh different opinions against each
other, read the reviews and ratings in Section IV of this guide, examine the
books closely in the bookstore, and choose carefully. You are investing not
only money but also your limited study time. Do not worry about finding
the “perfect” book, as many subjects simply do not have one, and different
students prefer different formats. Supplement your chosen books with personal
notes from other sources, including what you learn from question banks.

There are two types of review books: those that are stand-alone titles and `` Charts and diagrams may be the best
those that are part of a series. Books in a series generally have the same style, approach for physiology and biochemistry,
and you must decide if that style works for you. However, a given style is not whereas tables and outlines may be
optimal for every subject. preferable for microbiology.
You should also find out which books are up to date. Some recent editions
reflect major improvements, whereas others contain only cursory changes.
Take into consideration how a book reflects the format of the USMLE Step 1.
Apps
With the explosion of smartphones and tablets, apps are an increasingly

popular way to review for the Step 1 exam. The majority of apps are
compatible with both iOS and Android. Many popular Step 1 review
resources (eg, UWorld, USMLE-Rx) have apps that are compatible with
their software. Many popular web references (eg, UpToDate) also now offer
app versions. All of these apps offer flexibility, allowing you to study while
away from a computer (eg, while traveling).
Practice Tests
Taking practice tests provides valuable information about potential strengths

and weaknesses in your fund of knowledge and test-taking skills. Some
students use practice examinations simply as a means of breaking up the
`` Most practice exams are shorter and less
monotony of studying and adding variety to their study schedule, whereas
clinical than the real thing.
other students rely almost solely on practice. You should also subscribe to
one or more high-quality question banks. In addition, students report that
many current practice-exam books have questions that are, on average,
shorter and less clinically oriented than those on the current USMLE Step 1.
Additionally, some students preparing for the Step 1 exam have started to
incorporate case-based books intended primarily for clinical students on the
wards or studying for the Step 2 CK exam. First Aid Cases for the USMLE
Step 1 aims to directly address this need.
After taking a practice test, spend time on each question and each answer
choice whether you were right or wrong. There are important teaching
points in each explanation. Knowing why a wrong answer choice is incorrect
is just as important as knowing why the right answer is correct. Do not panic `` Use practice tests to identify concepts and
if your practice scores are low as many questions try to trick or distract you to areas of weakness, not just facts that you
highlight a certain point. Use the questions you missed or were unsure about missed.
to develop focused plans during your scheduled catch-up time.
Textbooks and Course Syllabi
Limit your use of textbooks and course syllabi for Step 1 review. Many
textbooks are too detailed for high-yield review and include material that
is generally not tested on the USMLE Step 1 (eg, drug dosages, complex
chemical structures). Syllabi, although familiar, are inconsistent across

medical schools and frequently reflect the emphasis of individual faculty,

which often does not correspond to that of the USMLE Step 1. Syllabi also
tend to be less organized than top-rated books and generally contain fewer
diagrams and study questions.
TEST-TAKING STRATEGIES
``
`` Practice! Develop your test-taking skills and

Your test performance will be influenced by both your knowledge and your
strategies well before the test date.
test-taking skills. You can strengthen your performance by considering each
of these factors. Test-taking skills and strategies should be developed and
perfected well in advance of the test date so that you can concentrate on the
test itself. We suggest that you try the following strategies to see if they might
work for you.
Pacing
You have seven hours to complete up to 280 questions. Note that each one-
hour block contains up to 40 questions. This works out to approximately
90 seconds per question. We recommend following the “1 minute rule” to pace
yourself. Spend no more than 1 minute on each question. If you are still unsure
about the answer after this time, mark the question, make an educated guess,
and move on. Following this rule, you should have approximately 20 minutes
left after all questions are answered, which you can use to revisit all of your
marked questions. Remember that some questions may be experimental
and do not count for points (and reassure yourself that these experimental
questions are the ones that are stumping you). In the past, pacing errors have
`` Time management is an important skill for
been detrimental to the performance of even highly prepared examinees. The
exam success.
bottom line is to keep one eye on the clock at all times!
Dealing with Each Question
There are several established techniques for efficiently approaching

multiple choice questions; find what works for you. One technique begins
with identifying each question as easy, workable, or impossible. Your goal
should be to answer all easy questions, resolve all workable questions in a
reasonable amount of time, and make quick and intelligent guesses on all
impossible questions. Most students read the stem, think of the answer, and
turn immediately to the choices. A second technique is to first skim the
answer choices to get a context, then read the last sentence of the question
(the lead-in), and then read through the passage quickly, extracting only
information relevant to answering the question. This can be particularly
helpful for questions with long clinical vignettes. Try a variety of techniques
on practice exams and see what works best for you. If you get overwhelmed,
remember that a 30-second time out to refocus may get you back on track.

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Green's. Further on they saw Luther Williams and stopped to speak
to him. "Isn't it the most wonderful evening?" said Gwen, her face
aglow. "We've had the loveliest of trips coming home on the boat."
"She's rather late to-night," said Mr. Williams.
"Is she?" returned Gwen innocently. "I thought the time unusually
short." Then she colored and laughed softly. "I shall see you to-
morrow, dear Daddy Lu," she whispered.
At the porch Kenneth lingered. "May I bring you the picture in the
morning?" he asked.
"Will you? I hope you will, for I shall not feel quite safe till you do."
"How safe?"
"In my belief that we are friends again."
He bent his head, softly kissed her fingers and said, "Hereby I set
my seal of eternal devotion."
"To our friendship," added Gwen tremulously. She must not let him
say more, and he understood, though he kissed her fingers again,
this time with a swift eagerness which denied mere friendship, and
then they parted.
"Tired, little girl?" said her aunt as she came in. "I have kept your
supper hot. It has been a long day for you, I'm afraid."
"Not so very long," returned Gwen, "and you know I love the coming
home part. It was glorious on the water this evening."
"I must say you don't look particularly dejected," said Miss Elliott,
pouring out a cup of chocolate for her.
Gwen laughed, a low happy laugh. "Who could feel dejected on such
an evening?" she said.
"I didn't remark that it was anything very unusual."
"It was on the boat," replied the girl. She was restless for the next
hour and made the excuse of her early start that morning to account
for her eagerness to go to her room. "For to-morrow, to-morrow," she
whispered to herself, as she went up stairs. "And after that other to-
morrows. How glad I am to be alive." Before she drew her curtains
she looked out, and against the starlit sky, she saw a well-known
figure standing a little distance off, upon the rocks. When she had
blown out her candle she looked once more, and saw the man walk
slowly away. "The darling!" she murmured, "he has been watching
my light. It will be a long time to wait, but we are young, and oh dear
God, I am so thankful he has come back to me."
CHAPTER XVI
"'TWIXT TIDE AND TIDE'S RETURNING"
But there was no happy talk with Luther Williams the next day, for
sad news came to the island, and at Cap'n Ben's house there was a
grief-stricken girl, widowed while scarcely more than a child. It was
an incoming vessel which brought the tidings of the loss of one of the
Mary Lizzie's crew. Happy, careless, pleasure-loving Manny Green
had been drowned during a heavy gale. Like most of the other
fishermen, he could not swim, and had sunk for the last time before
help could reach him. It was while trying to soothe Ora that Miss
Phosie learned for the first time that the girl and her lover were
married on the day when Ora had started for Bangor. Manny had
met her on the boat, they had gone to the nearest clergyman to have
the ceremony performed and Manny had taken his little bride on a
long trolley ride for a wedding trip. They had spent a couple of days
in a quiet inland town, and then Ora had gone on to Bangor,
returning, before her family expected, that she might spend with
Manny the last days he should be ashore. Not only poor little Ora,
but Almira Green, was stricken by the blow, and they mourned
together. "She is all alone," said Ora, "and she loved him. I think I
ought to stay with her now, Aunt Phosie, for she has no one else."
Therefore to Almira went the girl with the intention of passing her life
under the roof which had sheltered the boyhood of her young
husband.
The sorrowful news affected everyone, and it was a depressed and
subdued girl who greeted Kenneth when he appeared at Wits' End
that morning. The tears were very near Gwen's eyes, and she could
scarce speak at first, for the thought constantly recurred: suppose it
had been you. Kenneth, too, looked grave, and the joyousness of
their past evening seemed to have gone from them.
"I feel so sorry for Ora," said Gwen. "We grew to be friends after a
fashion, for we were companions in misery, that day of the storm, the
very storm, I am afraid, in which Manny lost his life. We went down
to the shore together. I was anxious about Ethel, and—" she
hesitated, then made bravely frank in the remembrance of a grief
which might have come to her—"I was anxious about you, for I had
seen you go out."
Kenneth caught her hand and held it tightly for a moment, then laid it
gently back on her lap. It was hard to have self-command at such a
moment, and he would fain have taken her in his arms then and
there. "If I had known you were anxious about me it would have
made a difference," he said in a low voice.
She laid her hand lightly on his sleeve for just a second, and they sat
looking at one another, their eyes full of the love their lips might not
speak. Gwen was the first to break the silence. "You have brought
the picture. It was so good of you to come early. May I see it?"
He set the picture on a chair and she knelt in front of it. "How lovely it
is," she said presently with a sigh. "I think I like it better than the
other. I can't believe that it is really mine. What shall I say to thank
you?"
"You have already given me more thanks than are due me, and such
as I value most, for you truly like it."
"I love it, and to think it is going to stay with me always! I don't agree
with you in thinking no more thanks are due you."
"There is only one thing you could give," he answered unsteadily.
"Perhaps I ought not to ask it, but if anything were to happen to
either of us—we are soon to be separated—it would mean much to
me if I could carry away the remembrance of one kiss."
Gwen stood in front of him with drooping head. Suppose anything
were to happen to either of them! She lifted her face and he kissed
her gently, holding her close to him for one moment, and then letting
her go. "It shall not be a long time," he said passionately. "I must
have the right soon. I shall work as never man worked before."
"Don't work too hard," said Gwen, with the solicitude of the woman
who loves. "I can wait—I will wait, Kenneth, no matter how long, and
what does it matter how long when—we love each other?"
The last words were spoken so low that he must bend his head to
hear them, and for the moment his self-control was flung to the
winds. "My darling!" he said, "we love each other. Bless you for
saying what I dared not say." He drew her close again, and kissed
her lips, her eyes, her hair, then put her from him. "It will not do," he
sighed. "I cannot be a selfish beast. I will not demand anything from
you. I want you to be as free as ever, but I shall never forget this
blessed hour. No matter what happens, I shall have had this."
"'Now who can take from us what has been ours?'" quoted Gwen
softly. "Yes, Kenneth, dear, it is best for us to be only friends, though
in our hearts we feel that we are otherwise. I won't, won't, won't
stand in the way of your career."
"And I won't, won't, won't stand in the way of your future if it chances
that you should become tired of waiting."
"I'll not tire, but all the same we are to be friends, just good friends
and comrades."
Just then a step interrupted them, and Gwen turned to greet Cap'n
Ben, who had come to say that Ora wanted to see Miss Whitridge.
"I will go, of course I will," Gwen responded. She turned to Kenneth.
"You will come back later?"
"This afternoon, if I may, and I will bring some of my sketches for you
to see."
Gwen gave him her hand. "Please," she said. She could not bear the
thought of being parted from him for long, when there was Ora whom
death had parted from her lover.
"She's at Almiry's," said Cap'n Ben, as he strode by the girl's side. "I
cal'late we'll have to give her up to Almiry now, and I guess it's right
she should go. Almiry's had a pretty hard time of it, working for the
boy, and now her and Ora can help each other. Almiry'd pine away
left to herself. It's a good thing her boarders have most all gone. She
won't have much sperrit to look after 'em. Last one'll leave to-
morrow. I guess she won't bother with 'em next year."
There was a feeling of fall in the air. The White Mountains stood out
blue and distinct, the sea was almost indigo-hued, save where a
golden path of sunlight spread across it, and where white-rimmed
breakers chased each other shoreward. Everything was clean-cut
and intense in color. The houses showed sharply against their
background of sea, the tops of the sombre firs were outlined against
the unclouded sky, the rocks showed purply-gray. The apples on
Cap'n Ben's stunted little trees were slowly reddening. Only a few
flowers flaunted themselves still in the gardens, dahlias, asters and
sweet peas held their own, while against the gray shingles of some
deserted cottages a tangle of nasturtiums displayed glowing blooms
of flame-color and orange.
But bright though the day, there was a subdued air about the island.
Those Gwen and Cap'n Ben met nodded gravely. There was a
troubled look upon the women's faces, as though they feared a
remorseless answer to the often recurring question, Who next?
In the sitting-room of Almira Green's low white cottage they found
Ora at Almira's feet, her head resting in the lap of the elder woman.
She did not rise as Gwen came in, and the girl, throbbing with her
own new joy, knelt down by the other, put her arms around her and
laid her cheek against Ora's, wet with her womanhood's first tears.
There were no words to say. Comfort was too distant a thing to be
looked for now; the phantom of a lost happiness hovered mockingly
near, a happiness that found the sorrowing girl but a little maid, and
left her a weeping wife. Almira sat, dry-eyed, her toil-worn hand
fingering Ora's fair hair. "She's most worn out with crying," she said
to Gwen. "It's come sooner to her than to most."
The tears sprang to Gwen's eyes. She hated the sea for the
moment, that sea in which she had gloried every day during these
holiday weeks. She did not wonder that fisher people did not love it,
that it seemed to them a cruel thing upon which they were glad to
turn their backs. "I wish there were something I could do or say," she
murmured as she rose to her feet and stood looking down at Almira.
Presently Ora lifted her heavy head. "If we only had a picture of him,
but we haven't. He meant to have some taken, but we spent the
money that time in Portland, and he promised as soon as he came
back he'd go right to the photographer's. We were going together."
She dropped her head again and burst into a fresh paroxysm of
weeping.
Some one knocked at the door, and Gwen turned. "Shall I go, Mrs.
Green?" she asked.
Almira nodded, and Gwen went through the silent house and opened
the front door. Kenneth stood there. "Oh," said Gwen, "did you come
for me?"
He stepped inside. "I have brought a little study of Manny that I
made one day down at the cove. It is only a quick sketch, but I think
it looks rather like him, and maybe they would like to have it."
"Oh, Kenneth!" Gwen held out her hand eagerly for the small
canvas. "Ora was just grieving because they have no photograph of
him. You dear boy to think of coming with it."
"I worked it up a little," said Kenneth, "so it is still wet, but I thought
I'd try to make it less of a sketch. Do you think it is like him?" He held
off the picture at arm's length.
Gwen looked at it earnestly. "It is very like," she told him. "You have
caught his happy, careless expression. He was a good-looking lad,
poor boy. May I take it in? Will you go, too?"
"I'll wait outside for you."
She carried the picture carefully to the sitting-room, and set it on a
chair where the light could strike it. Then she touched the forlorn
figure whose face was still hidden in Almira's lap. "Ora," she said,
"look here, dear. You see there does sometimes come some small
comfort in our darkest hours. Mr. Hilary has brought you a little
picture he made of Manny. Will you look at it? Mrs. Green, you, too,
please. It is still wet and must not be touched for a day or two."
Ora sprang to her feet, and gazed with sobbing breath at the picture
of Manny leaning against the railing of the boat-landing, his hat
pushed back from his smiling face, his hands in his pockets, the
whole attitude one of careless ease. So had his friends seen him
often. "It is Manny," whispered Ora, "Manny. Aunt Almira, do see."
"Aunt Almira," murmured Mrs. Green. "Some one still calls me that."
She raised her eyes, leaned forward and looked long and earnestly
at the picture, then the blessed relief of tears came to her. She
dropped her head on Ora's shoulder and shook with sobs. The act of
dependence aroused Ora to a sense of responsibility. "There, there,"
she whispered, "don't take on, Aunt Almira. We've got each other,
and we loved him."
Mrs. Green wiped her eyes. "Please thank the gentleman," she said.
"It was very kind of him."
"There ain't a thing we'd sooner have, please tell him," said Ora. "It's
wonderful." It was hard for these people to say even so much.
Thanks were not easily expressed, obligations were rarely admitted.
Gracious acceptance did not come naturally, but Gwen felt that they
were sincerely gratified.
"I'll tell Mr. Hilary," she said, "and I know he will be glad you like the
picture. He would not come in."
"Perhaps you'll bring him another time," said Almira. "I'd like to tell
him we appreciate his present."
Ora followed Gwen to the door. "I know now why you understood,"
she said in a low voice. "I hope you'll be very, very happy."
"Oh, Ora, we must wait a long while, and no one knows yet, not even
my aunt, so please—"
"I won't mention it, but I know, and I'm glad he did that picture. I'm
glad he's the one, for he must be good and kind to think of bringing
it. I can't tell you what it means to have it."
This was saying a great deal, and Gwen knew it meant more than
extravagant thanks from some others. She kissed the girl's pale
cheek and went out into the bright sunlight.
"Shall we go home by the rocks?" asked Kenneth, coming forward.
"No, I don't want to look at the sea to-day," Gwen told him. Then she
gave him the messages from the two women she had just left, and
they talked softly of the picture as they walked along.
Further on they met Ethel Fuller. "We're going to-morrow," she said.
"Aunt Harriet wanted to go long ago, and she's sorry now we didn't
leave yesterday. It is dreadful to be in a house where there is such
trouble, and we can't do a thing. I'm quite ready myself to go now.
We shall stop in Boston for a few days."
Gwen smiled. "And Mr. Mitchell?"
"He is going to-morrow, too. He gave up his trip to Bar Harbor, after
all." Ethel looked exultant.
"Then you'll have his escort to Boston. That's good. I hope he'll make
it pleasant for you while you're there."
"He's sure to do that. I am coming over to see you this afternoon,
Gwen, to say good-by. I left Aunt Harriet making her rounds, but I
have my packing to do. Auntie is so forehanded; her trunks are all
ready. I'm really dying to be off. It will be good to get into the stir and
bustle of a city again, and I love the Boston shops. I suppose you'll
be going soon, Mr. Hilary."
"My sister is beginning her preparations, I believe, though I shall stay
while the weather is pleasant."
Ethel gave Gwen a laughing glance as she walked on. "See you this
afternoon," she said.
"Then we shall not have our walk to the woods," remarked Kenneth
when Ethel was out of hearing.
Gwen shook her head. "Afraid not, but to-morrow we shall have the
island to ourselves or nearly so. The Gray sisters go next week.
Most of the boarders have gone, and I noticed more than one
cottage closed for the winter as I came along. I shall love it when the
transients stop traipsing over the pasture, and cease to crowd the
rocks like a flock of pelicans. Already the place seems more our
own."
"There will be a moon, though rather late to-night. May I come to
Wits' End and watch it rise?"
"Most certainly, and what about the sketches?"
"I left a load of them with Miss Elliott. You can look at them at your
leisure."
"Without the showman?"
"Do you want him?"
"I want him to tell me the merits of each, so you'd better come along
now. You can stay to dinner. There will be quantities of excellent
chowder, warmed over baked beans, with whatever vegetables we
can scrape together. I think there is pie for dessert. Can you stand
the combination?"
"It sounds appetizing, especially the chowder. I see Ira's wagon
going our way; I'll send word to my sister not to expect me." He ran
after the wagon, which was turning into the cove road, and gave his
message.
"Do you like cranberries?" asked Gwen. "I think we shall have some
of them, too. I adore them. If you gather them when they are just
turning pink, not red, they make much better sauce than when they
are fully ripe. If you will not tell anyone I'll show you where they
grow." She led the way across the pasture to a marshy spot a short
distance from the beaten path. Lifting the graceful tendrils of the
pretty vines, she showed, buried in soft gray-green moss, the tiny
globes of waxy pink. "This is my own special find," she said. "I have
already gathered two quarts, and to-morrow I can get more. I am
glad there is a to-morrow," she added. "Now come and show me the
sketches. I hope there are some moonlit waves. Isn't it wonderful to
see the golden gates open and that glittering pathway unroll upon
the sea? One feels as if it led up—up to some enchanted palace. I
can almost persuade myself into starting across the shiny road to
fairy land. Then those little dancing flecks, 'patines of bright gold,' are
like water-fairies luring one on to where the glittering path leads. I
can scarce resist them."
"Don't follow them, please."
"I won't, I promise you. Are there any moonlights among your
sketches?"
"Several. I have tried to express the effect very often, but I am afraid
I have made many failures."
"Perhaps I can tell whether you have or not."
The sketches occupied the time till the dinner hour, after which meal
Kenneth took his leave, but not before Miss Fuller arrived. The door
had hardly closed after the young man when Ethel grasped Gwen's
hand. "Congratulate me," she cried, "I'm engaged."
"Really?" Gwen looked pleased. "Of course it is Mr. Mitchell, and that
accounts for his giving up Bar Harbor."
"Yes, and I have to thank you for making us known to each other. It
might not have happened if we had not gone to Jagged Island that
day, for I am candid enough to admit that you occupied first place up
to then. However our being in common danger, as it were, put us on
a different footing. Ever since then I have noticed a difference in his
manner toward me. It was Jagged Island that settled it, I am sure. Do
give me the satisfaction of hearing that you really do not mind,
Gwen. Now that I have actually won the race I feel a little guilty."
"My dear, you needn't in the very least. I am perfectly delighted. It
isn't every day that one's friends marry millionaires. I congratulate
you with all my heart, and have not the smallest pang."
"It only happened yesterday," Ethel went on, "but I had to tell you
before I left. It will be announced when we get home. Aunt Harriet is
so pleased."
Gwen's smile might be called a veritable grin. "Of course she is. Very
few aunts would not be."
"Would yours?"
"I am not sure. She is so darlingly unworldly that she might ask all
sorts of probing questions that one couldn't answer to her
satisfaction. Shall you be married soon, Ethel?"
"In the spring, I think. Who could ever dream that in this little
unfashionable isolated place I should meet a man like Cephas? As
Aunt Harriet says, I might have gone up and down the coast for
years and never have found his like. I was so disgusted, too, when
we first arrived at what seemed to me a perfectly impossible place. It
has been the loveliest summer I ever spent, and it is all due to you,
Gwen." In her great content Ethel was at her best.
"I am so very, very glad," murmured Gwen.
"I do wish the Hardy girls were still here, and Flossy Fay." Ethel
would have enjoyed the triumph of announcing her engagement to
them.
"All the other butterflies have flown," said Gwen. "We are the only
ones left."
"I have my doubts about your being a butterfly at all," returned Ethel.
"I think you tried to be and failed."
"Why do you think that?"
Ethel smiled. "You'll not like it if I tell you why."
"I promise not to turn and rend you."
"Then I think you would rather help a poor man build up his fortunes
by—we will say—stirring up pancakes in a studio—than to be
mistress of an establishment on Commonwealth Avenue."
"Do give me credit for more common sense than to consent to spoil
a man's career would indicate," replied Gwen lightly. "No, it just
happens that I shouldn't care to live in Boston, having been brought
up south of Mason and Dixon's line."
Ethel laughed. "Tell that to the marines! I'll yet see in some exhibition
a 'portrait of the artist's wife' in which I shall recognize my friend
Gwendolin Hilary, née Whitridge."
"All right. Have it your own way," said Gwen, trying not to look
conscious. "At all events I am honestly glad for you, Ethel, as I want
you to believe."
"Oh, I believe; I'm only too ready to. Good-by, dear. I count on you to
be one of my bridesmaids."
"No rash promises," declared Gwen. "I shall then be teaching finger-
plays and kindergarten songs to such an extent that there'll be no
time to devote to wedding fixings."
"I shall count on you, nevertheless. Good-by and thank you for being
the dear generous girl that you are."
Gwen watched the red jersey disappear over the brow of the hill.
"'Tis an ill wind that blows nobody good," she said to herself. "I
suppose the Lord sent a millionaire my way just to see what I'd do,
and to teach me not to make vain boasts. I feel very meek when I
think of Commonwealth Avenue."
CHAPTER XVII
THE END OF THE SEASON
Within a week most of the summer cottages were boarded up and
closed for the winter. Only a few lights still twinkled out at night along
shore. The crickets sang in the dry grass or under some still warm
hearthstone. The waxy cranberries had turned a rosier pink and
down in the marsh hardhack and roseberries disputed the sway of
golden rod and asters. Outside Ira Baldwin's barn was a row of
newly hewn decoy ducks, freshly painted and ready for use. The
report of the hunters' rifles was already heard in the early morning as
the "honk! honk!" of wild geese betokened a flight southward.
Strange weirdly-moving fingers of light played across the northern
skies at night, rosy pulsings and quivering gleams travelled from left
to right and back again, growing and fading and growing again
mysteriously.
Still Miss Elliott and Gwen stayed on, and though from the cottage by
the cove the tenants had all gone, Kenneth remained, having
persuaded Cap'n Ben to take him in for the little time he should be
on the island. He had seen his sister, with her children and the maid,
safely on the steamer which should bear them to New York, and then
he had returned with a feeling of possessing the beauty of Fielding's
Island in a new sense, since now, in all its length and breadth were
no summer visitors remaining except himself and the dwellers at
Wits' End. Sheldon woods seemed a vast silence, the barrier of
rocks along the ocean front a fortress with but a solitary sentinel left
to watch. Jagged Island, afar off, appeared unapproachable. The
Domhegan's single trip a day served to give one the feeling of not
being cut off entirely from the outside world, though there was an
ever present sense of indifference to what might be going on in other
places. The wizard's most triumphant hour was near when his fetters
would bind so tightly that no one could set foot outside his realm.
Miss Phosie coddled her new boarder unremittingly, and, because of
their nearer association, Luther Williams and the young man became
closer friends than ever, and spent much time together. Frequently
Gwen made a third in long walks in the crisp air, and sometimes
Kenneth would go on a cruise to a near island with Luther Williams
as skipper, and it was seldom that they returned without a cargo of
sketches.
To Daddy Lu Gwen had opened her heart and he had received her
confidences, as she knew he would, sympathetically and with grave
interest. "Of course we are not engaged," Gwen told him. "That
wouldn't do, but I suppose it is what people call an understanding,
and we are very happy. It will be years before we can think of
marrying, perhaps we shall never be able to, but it doesn't matter so
long as we love each other. So, dear Daddy Lu, you will probably
see us mooning about the island for many summers to come. So
long as we shall not be living in the same city we shall have to be
separated in winter, but we hope our summers can be spent here. I
shall go on teaching while he is working, and it will not seem hard to
either of us."
"Do you like teaching?" asked Mr. Williams.
"I don't mind it. I love the dear babies, and I get interested when I am
fairly started. Now, with the beautiful summers up here to look
forward to, I shall mind less than ever. I should hate to think I must
do it always till I became a worn-out decrepit old hack. I often
wonder how I should feel to be going on without Aunt Cam, and the
three or four rooms we call home. Sometimes I think that day may
come, for now I don't believe I could ever go to China if occasion
offered."
Mr. Williams looked startled. "Do you think it will ever come? Does
she speak of going back?"
"She hints at it sometimes. Perhaps I ought not to tell even you,
though I know you are not a gossip." She smiled, for anything further
from a gossip than Luther Williams could not be imagined. "There is
some one in China," she went on, "some one Aunt Cam met when
she went over there, a man who has been, and still is, devoting his
life to the people in a far-off district. He has been the one man to
Aunt Cam, a hero above all others. She would willingly have joined
him in his work, but he felt that it would be insupportable for a
woman in the place where he believed himself to be the most
needed, and so they parted, although each cared more for the other
than for anyone else in the world. If he should need her at any time,
if his health should fail, and he should go to a more comfortable
place, leaving his work to a younger man, I think she would not
hesitate to devote the rest of her life to him. She put the case before
me once, and asked me if I would be willing to go with her. She feels
very responsible for me, dear Aunt Cam, and I know it is mainly on
my account that she stays here and does not go back."
"There are few women who love like that," said Mr. Williams, after a
pause.
"There are a good many, I think," returned Gwen. "I used to believe I
could be easily persuaded to go with her, but now I know I could not
go, for there is some one as dear to me here as there is dear to me
there. It would tear out Aunt Cam's heart to leave me behind unless
it were in a home of my own, but so would it distress her to stay if
she were needed there."
"Perhaps the question will never arise," said Mr. Williams, "but it
ought to be provided for if it does." He spoke half to himself.
"Perhaps I could find some nice quiet people to board with," Gwen
went on. "At all events I can take care of myself. I don't know why all
this has come up to-day, unless it is because there was a letter from
China in yesterday's mail and Aunt Cam has had a far-off look ever
since. She is splendid, that dear aunt of mine, and I should feel
pretty forlorn and desolate without her. I should pity myself for being
an orphan if it were not for her. As it is, I suppose my lack of relatives
has been a bond of sympathy between Ethel Fuller and myself, for
she has no parents, either, though I don't think her aunt is half so
dear as mine."
"If you could marry, you and the boy," said Mr. Williams after a
silence, "it would settle it all, wouldn't it? You could have the home
and the protection without the necessary parents. It would have to
come some day. You would leave your parents, if you had them, for
the boy." He always spoke thus of Kenneth.
"Oh yes, no doubt, for it is what girls do every day."
"That is what I mean. Well, my dear, when the time comes it is
probable there will be a way provided."
"If it hadn't been for you," said Gwen softly, "I might never have come
to my own. I think you scared me, dear Daddy Lu, into giving up any
thought of marrying for money."
"I'm glad of that, very glad," he answered smiling. "I've done
something then to be thankful for."
"I'm the one to be thankful. To think of my losing the 'boy' through
any such hallucination as the idea that I could be happy with anyone
else. I realize that more and more every day in proportion as I know
him better and he grows dearer to me. You've saved me, Daddy Lu.
You've saved my life."
He laid his hand gently on hers. "That's a big thing to say, but I think
maybe you're right. What shall it profit a man if he gain the whole
world and lose—"
"His own soul," Gwen finished the text. "It amounts to that when one
forfeits his best self to a craving for luxury and ease. Aunt Cam says
our best development always comes through sacrifice of some kind."
"She's right."
"So you have helped me to my best development, by showing me
how the life can be more than meat and the body than raiment. I was
thinking more of the meat and the raiment, I am afraid. Dear me,
what a serious talk we are having, full of texts and such things. I feel
as if I were actually preparing for the missionary field. However I am
glad to have had the talk, and shall think of it many times when I am
far away."
"That's a time I don't like to think about."
"Then you'd better come, too."
He shook his head. "I'm like a barnacle, glued to the rock by my own
inner forces. I couldn't leave now."
He went to Portland the next day. Kenneth met him as he was
coming home from the boat. "We missed you, old man," said
Kenneth. "Gwen and I thought maybe you'd like a trip to Birch Island
or somewhere. It's pretty sharp, but we shouldn't mind that. We were
both saying that it would be harder to leave you than anybody or
anything else." He put his hand affectionately on the older man's
shoulder. "I am thinking of spending part of my winters in
Washington where Gwen will be. Life is too short for us to waste it
apart, if it can be avoided. Say, old man, why don't you come too? It
would do you good to get into the world again. Why not come down
and see the White House?"
Mr. Williams shook his head. "I've been here too long in my shell. I
shouldn't know how to stand a city, now. You would be ashamed of
your old fisherman."
"Not a bit of it. You'd soon fall into the old ways, for I know well
enough you've been a city man."
"Yes," answered Mr. Williams slowly, "I've been a city man." Then,
after a pause, "Do you expect to settle in Washington eventually?
Perhaps, if you do, you'd be willing some time to take in an old fellow
who'd be ready to bear up his end of the householder's burden. It
might make that studio apartment come a little sooner."
"New York is the only place where I could make my bread and butter,
I'm afraid," returned Kenneth. "My mother will be living there, and I
shall put my pride in my pocket—who wouldn't for such a girl as
Gwen?—and shall hope for a mad rush for my pictures from the
moneyed friends of my new papa. Wouldn't New York suit you as
well?"
"Never New York, never—" said Mr. Williams with intensity.
"Too bustling and noisy after this beautiful silence, isn't it? Still it is
about the best place for an artist. What city would you suggest, if we
didn't take New York into consideration?"
"Paris maybe, or somewhere abroad would suit me."
"Paris sounds seductive. We'll have to talk this scheme over, we
three. It's good of you to think of it, dear old man. I know what you
have in mind, and that is only the happiness of us two. You're the
best friend I ever had. By the way, you told me once you had been
married, that your wife died years ago. Were there any children?"
"There was a boy—a little fellow. He lived only a week. I think of him
sometimes when I am talking to you. He would have been about
your age. I can't tell you what I felt at losing him. The parental feeling
is pretty strong in me, and I grieved terribly for that little week old
baby. I grieve yet. Things might have been different if he had lived.
He would have been an anchor I could not have cut loose from. As it
was—well, it's a long time ago. One cannot alter the past."
"He can make his future, though," said Kenneth with the hope of
youth strong within him.
"He can in a great measure, if there's much future left him, though it
does appear sometimes as if there must be such a thing as
inexorable fate."
"It was a happy fate that sent us your way," said Kenneth
affectionately. "I think I must adopt you, too, as Gwen has done. You
stand for a good deal more than the pork-packer who has recently
become my step-father."
They went into the house together. Miss Phosie was watching for
them, and had a table spread. The odor of fish and coffee, fresh
gingerbread and baked apples filled the air. The room was piping
hot. Under the stove lay Tinker snoring comfortably. Cap'n Ben was
poring over his paper—now-a-days the mail was soon distributed.
Miss Phenie in the most comfortable chair was knitting a pink
"sweaterette" while she exchanged gossip with Zerviah Hackett.
Ground was soon to be broken for two new cottages which would be
ready for the next year, this was one item of news. Miss Elliott's well
was to be started in a few days. Effie Jackson was going to teach
school over on the Neck, and was keeping company with a young
man of that neighborhood who was no one less than Ora's former
lover, Al Daly,—and so it went.
Miss Phenie had lately arisen to the glory of a pompadour, thus
emulating Mrs. Dow. "Who's ten years older than I am, if she's a
day," said Miss Phenie to Zerviah. The pompadour, very heavy, very
black, overhung Miss Phenie's forehead like a beetling crag. She
was very conscious of it and bore it stiffly, as if she expected it
momentarily to topple over and crush her. Cap'n Ben never tired of
poking fun at it. He looked up now and said, "Why don't you take off
your hat, Phenie, and stay with us awhile?"
Miss Phenie ignored the question and went on with her talk. "As I
was saying, Zerviah, Ora's duty was just as much to me as to Almira,
and her going leaves me pretty much cramped for time."
"She comes over every day and helps a lot," put in Miss Phosie, who
more than Miss Phenie, missed her helper.
"I cal'late you wouldn't be so cramped for time, if you wasn't so
everlastingly particular about that new hair contrivance of yours,"
spoke up Cap'n Ben. "Phenie cal'lates she'll prepare for cold weather
in season," he said with a grin and a nod, as he turned to Miss
Zerviah. "I guess I'll get myself one o' them warm pillows for the top
o' my head," he went on. "Hair's getting kinder thin." He passed his
hand over his bald pate and chuckled. "Keeps the sun out of your
eyes pretty good, too, don't it, Phenie? I never thought your eyes
was weak, but maybe it'll prevent you from having to get glasses. I
had to put 'em on before I was your age."
Miss Phenie arose majestically, gathering up her knitting and saying,
"Suppose we go to the settin'-room, Zerviah."
"I saw Obadiah Foster yist'day," shouted out Cap'n Ben, after her.
"He'd just shot a coot. Wanted to know if you wouldn't like a wing to
stick in that new cap he saw you was wearing." Obadiah Foster was
a widower of some months standing. He had already buried three
wives, and it was reported that he was looking out for the fourth, and
therefore Cap'n Ben's witticism was not without point. Every
available spinster or widow on the island had been mentioned by
Miss Zerviah as "settin' her cap" for Obadiah, as Cap'n Ben well
knew. He followed the departing pair to the door and continued his
pleasantries by calling, "I say, Zerviah, why don't you git one of them
caps like Phenie's? Obadiah might shoot another coot." This was too
much, as the slamming of the sitting-room door proclaimed, and
Cap'n Ben having had his joke, returned chuckling, to his paper.
"Now, father, you hadn't ought to be such a tease," said Miss Phosie,
pouring out a cup of coffee for Mr. Williams.
"Phenie hadn't ought to be such an everlasting fool, then," answered
her father. "You'd think she hadn't a namable thing to do, but dress
up her head like a Guinea nigger's. She behaves like a year old colt,
instead of a settled down old mare. Makes me sick." Cap'n Ben gave
a mighty yawn, readjusted his spectacles, and betook himself again
to his paper.
Miss Phosie, having finished serving her boarders, began to clear
the table. Her eyes followed the two men wistfully as they left the
room together. She did not wish Kenneth to go, but she would be
pleased when, for lack of other company, Luther Williams would tarry
longer in the kitchen, to talk to her while her father was absorbed in
his paper. She wondered what had been the errand to town, for it
was rarely that Mr. Williams went. Perhaps he thought he needed
winter flannels; she could tell him that those he had, well mended,
would last quite a while yet. She soon finished washing the few
dishes, and sat down to her knitting. She was making wristlets for
her father, and for Luther Williams. She kept both pairs going, and
when Zerviah was present she always worked on Cap'n Ben's, which
were red. Just now she preferred to work on the others, which were
gray. Cap'n Ben liked lively colors, Luther Williams always chose
quiet ones.
Presently the door opened and Ora came in. The pretty color was
coming back to her cheeks, but she looked older, and her blue eyes
had an expression in them which only a woman who has suffered,
may know. "Just a little too late, ain't I, Aunt Phosie?" she said. "I see
you have everything done up. I heard Mr. Williams went to town this
morning, and I knew you'd be later'n usual getting through. You had
two dinners to get, didn't you?"
"Oh, it wasn't a mite of trouble just to set his things on the table,"
returned Miss Phosie.
"Nothing is a trouble to you," said Ora. She had grown much gentler,
and liked to be with her younger aunt more than formerly. "There
doesn't seem to be much to do at our house," she went on. "We
clear up and there's nobody to put things out of order. It's harder
work having men-folks around, but I'd rather have 'em." She sighed a
little.
"It must be dull for a young thing like her to spend her days with just
one quiet woman," thought Miss Phosie. "Zerviah and Phenie are in
the other room," she remarked to Ora. "Go in and hear the news.
Zerviah's fetched quite a budget to-day."
Ora shook her head. "I don't want to, Aunt Phosie. She speaks so
loud and says such things about—our needing a man about the
house, and about its being wrong to hug our sorrow and waste our
lives in useless repining, and all that—as if—as if I could ever forget
Manny."
"She means well," responded Miss Phosie, "but she's so fond of
managing other folks she can't see beyond her own ideas for 'em.
Don't you mind her, Ora. You ain't wasting your life, not a mite.
You've had what a good many would be thankful for, and that's the
love of the man you cared for. There wasn't ever any clouds between
you, and you was free to love each other all you wanted. It's a good
thing to be free to do that; some never are. They have to hide their
feelings from all eyes, and if the time comes that's come to you they
wouldn't be free even to mourn, except in secret."
"That's true, Aunt Phosie," replied Ora. "And now that the worst has
come I'm glad we did really belong to each other, and were husband
and wife; that's a great comfort to me.
"I'm sure it must be," returned her aunt. "I'm glad, too, Ora."
"Aunt Phenie isn't. She talks about my throwing myself away, and all
that—even now she does."
"Never you mind what folks say. You ain't wasting your life, and it
ain't likely you ever will. I guess as time goes on your duties will be
marked out pretty plain for you, and nobody'll gainsay that they're not
duties. How's Almira?"
"She's pretty smart. She eats better. That reminds me. I thought I'd
get you to let me have some of grandpap's nice good apples, if you
have any to spare. She's real fond of apples."
"Of course you shall have some," Miss Phosie responded cordially.
"We gathered some to-day from the trees down by the potato patch;
they're proper good, too." She went through to the pantry, and saw,
passing the window, Luther Williams and Kenneth pacing slowly. She
gave a quick sigh. "Yes," she murmured, "it's a great thing to have
the right to speak out your feelings. Ora hasn't lived very long, but
she's had more than I've had." Then because it seemed too bold a
thought, she thrust it from her, and diving down into the bag of
apples, selected the finest for Almira who, too, had loved and lost,
but had mourned openly.
CHAPTER XVIII
ON HASKINS' ISLAND
"It is getting too lonely for three women to be down here on this point
by themselves," remarked Miss Elliott one morning after a three
days' storm during which they had scarcely set foot out of doors.
"Lizzie is becoming discontented and yearns for city streets.
Moreover, the supplies are not what they were, and she thinks our
daily bill of fare unworthy of her powers. To be sure we are perfectly
safe, for Mr. Williams comes prowling around before daybreak to see
that we haven't been blown off the rocks over night, and Kenneth
spends most of his time here, keeping his eye on us, as it were, or
on you I should say," for it had been evident long before this how
matters stood between the young people, and Gwen had confessed
that there was an understanding between them. Once satisfied that
Kenneth's character was all that she could approve, Miss Elliott
offered no objections. "I hate to take you back to the city," she went
on. "You look like a different girl, but I should like you to have a still
longer holiday."
"I am a different girl," returned Gwen. "I am a very happy one. What
a wonderful summer it has been. To be sure it will be a little hard to
get into the traces again, but I feel quite equal to it, and the waiting
for Kenneth doesn't seem hard when I am to see him before spring."
"I hope you will not have to wait all your life, dear child," said her
aunt wistfully. "I should like to see you in a home of your own before I
am called away."
Gwen felt that the last remark did not refer to a summons to another
world. Had not Aunt Cam waited long and faithfully and might she
not any day set sail for the land of her youthful labors?
"I wish," Miss Elliott went on, "that one of you had a little fortune of
your own so you could marry while you are young."
"We don't need a big fortune, that is true," said Gwen. "We only
require just enough to keep the pot boiling. When Kenneth is sure of
that I shall be ready to share the 'olla podrida' with him, whatever olla
podrida may be. I must ask Daddy Lu. By the way, Aunt Cam, he
seems to be quite familiar with Spanish. I imagine he has been either
to Spain or to some Spanish speaking country."
"Very possibly. He is an enigma, Gwen. Once or twice I have fancied
I could solve the mystery of his early life, but now I realize that it is
only one of those strong resemblances which are evident sometimes
in persons distantly connected. At first I was very much upset by it,
but I have gradually come to believe that he simply looks like some
one else."
"I've felt, myself, as if his were a familiar face," returned Gwen. "Well,
no matter whom he looks like, he always appears like a gentleman.
Even in his old fisherman's clothes he is never anything but neat and
tidy. He is a dear, and I shall hate to part from him. We have been
trying to persuade him, Kenneth and I, to come away with us, but he
will not do it. He says as we shall be in different cities, he couldn't be
with us both, though he confesses he is trying to work out a plan
which will bring us all together. I hope he will. I have become so used
to seeing his dear old face around that I shall miss it. I hate to think
of leaving him here. I know he will be lonely."
"After all these years? Surely he has become accustomed to the
place and the people."
"Oh, but consider; this summer is the first time that he has made
advances to anyone who came from the outside world. He has lived
with his books. I fancy they will seem somewhat unresponsive now."
The day was bright and clear, though the wind still whistled through
the pines and made a doleful clamor around the corners of the
house. The open fire was now a necessity instead of merely a luxury,
and the kitchen stove sent out a comforting heat all day. The nights
were cold indeed, and more than once the dwellers at Wits' End had
resorted to hot bricks in order to remove the chill from the beds when
they crept between the sheets.
"Yes, it is time we were going," said Gwen as she and Kenneth
started for a last walk to Sheldon woods. "We cannot stay till the
snow flies, although I'd like to see the islands all a beautiful white like
frosted cakes sitting on the blue platter of the ocean. Aunt Cam is
fairly frozen out, and says it is getting to be next door to impossible
to find anything we like to eat. I suppose we could order stores from
Portland, but we really ought to be back, so next week finger-plays
and cardboard patterns for me, while for you?"
"A plunge into study, life classes, models, talks with my fellow artists,
and a hunt for a cheap studio."
"It makes life seem very complicated after this lovely simplicity,
doesn't it? We are so free here, and it is so delightful to be able to
wear your old clothes all the time. Now I shall have to wrestle with
the problem of a winter outfit, and of how to make the best
appearance on the least outlay. I can manage very well, though," she
added quickly. "I'm not wild about clothes, and yet I don't believe I
ever look really dowdy. Did I look dowdy that first time you saw me,
so long, so long ago?"
"You never looked anything but adorably lovely," returned Kenneth
with enthusiasm.
She lifted a protesting hand. "None of that."
"I thought you the most graceful girl I ever saw," Kenneth went on. "I
remember thinking I'd like to make a study of you as you sat there."
"Where? That first time, was it?"
"Yes, at Madge McAllister's tea, where I had gone with my sister. You
were sitting on a divan in one of your unconsciously picturesque
poses. You wore a big black hat and some sort of pale yellow thing
around your neck. Your dress was a pastel green, I remember. It was
a charming study in color, and I would like to have painted you then
and there."
"You never said so."
"I didn't dare then. I hoped to see you again and I had a sense of
being defrauded when you suddenly disappeared and I couldn't find
you, though I went through all the rooms. I remember that day when
I met you on the train going to Annapolis; I thought it such a streak of
good luck and meant to follow it up, but when I got back to the city
you had left."
"And if you hadn't come up here, perhaps our ways would have
parted."
"No, they would not. I should have hunted you out this winter when I
went to Washington."
"And we should not yet have been more than mere acquaintances."
"Are you glad it is otherwise, sweet Gwen?"
"Please don't."
"I can't help it. The parting hour is so near. It makes me wild to think
of it. How can I keep back what I so long to say? I love you, love you,
love you, Gwen. Let me tell you here in these woods where we have
had so many happy times. You needn't say anything in return, my
darling girl, though I am a selfish beast, and long to have you." He
caught her hand and kissed the blue-veined wrist where it showed
white between her glove and the dark of her jacket.
HE CAUGHT HER HAND AND KISSED THE BLUE-VEINED
WRIST.
"Oh, Kenneth!" expostulated Gwen. "You mustn't, you know you

mustn't."
"I'll behave," he said, pulling himself up, "but it's awfully hard, when
you're all the world to me, and I am going to lose you so soon."
"You're not going to lose me—ever."
"Darling!" he murmured. "There, I'll not say it again, and I'll not touch
even your little finger, if you say I mustn't. See that boat off there. It
looks like Daddy Lu's."
"Where?" Gwen looked off toward the nearest island to their right.
The ocean lay to their left, but from the blue waters of the bay more
than one island rose to view. "I am sure it is Daddy Lu's boat,"
declared Gwen after a few minutes' steady outlook. "I wonder what
he has been doing at Haskins' Island."
"He told me he was going there to-day to take something to the old
fellow who lives on the island as sort of caretaker. You know there
are only two or three summer cottages, and when their owners
leave, this old man is about the only person remaining. Daddy Lu
told me he goes over once in a while to see that all is well with John
Bender, I believe they call him."
"The one who is in the boat is not Daddy Lu," said Gwen. "See, he is
rowing as fast as he can pull. He is making straight for this island."
"Probably he is using the boat to make the trip in, and has left Daddy
Lu behind till he gets back."
"Why should he do that? I don't understand it," said Gwen. "Let us
go back and see."
"My dear Gwen, you look as if you thought something was wrong."
"I am afraid there is."
"But why? It seems to me a very natural thing that Bender should
use the boat to come over in."
"He never does come over. He always goes to the Neck for his
supplies. Cap'n Ben told me so. Come, please come."
She was so evidently anxious that Kenneth said not another word of
dissent, but led the shortest way back and before long they had
arrived at Cap'n Ben's door. Two or three men were standing outside
talking excitedly. Gwen went up to one of them. "What is the matter,
Ned?" she asked, for it was Ned Symington whom she questioned.
"Bad news, Miss Gwen," he replied, shaking his head. "Mr. Williams
—"
"Not dead"—cried Gwen, clutching his arm, "Please don't say he is
dead."
"No, but badly hurt."
Cap'n Ben at this moment came dashing by in his buggy, urging his
old horse to its utmost speed. He was on his way to the end of the
island, from which point he would be quickly rowed across to the
next, and would bring back the physician who lived there, for
Fielding's did not boast of a doctor among its winter residents.
"Cap'n Ben's going for the doctor," said Kenneth, who had been
speaking to one of the other men. "We can't do anything yet."
"Tell me about it." Gwen turned again to Ned.
"He went over to take some tobaccy to John Bender. They was on
the rawks together, John says, looking at some ducks off shore.
John took a crack at 'em, and the rawk he was standing on gave
way. Soon as Mr. Williams saw him go, he reached out and tried to
haul him back, but more rawks had got loose, and he went down,
too, with the rawks on top of him. Fortunate for John he'd kind of slid,
and wasn't hurt any to speak of, but Mr. Williams got the worst of it."
"Where is he now?"
"There still. John couldn't lug him by himself. Two or three of the
boys have gone back with John, but they'll wait till the doctor gets
there before they attempt to move him; it mightn't be safe to do it at
once."
Gwen turned to Kenneth, her eyes full of tears. "Isn't it dreadful,
dreadful?" she said. "Can't we do something?"
"I'm going right over with Ned and the rest," he told her. "I will come
back and tell you what the doctor says. He may not be so badly hurt
as it seems. A broken arm or leg may mean he must be laid up for
awhile, but I hope there is nothing worse to fear."
Gwen scanned his face earnestly. "You believe there is nothing
worse to fear?"
"We can't tell yet. Very likely there is not."
"You will come and tell me soon?"
"As soon as I possibly can."

Ebook First Aid For The Usmle Step 1 2020 30Th Anniversary Edition PDF Full Chapter PDF

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Ebook First Aid For The Usmle Step 1 2020 30Th Anniversary Edition PDF Full Chapter PDF

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First Aid for the USMLE Step 1 2020,

30th Anniversary Edition - eBook PDF

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)