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FIRST AID FOR
THE®
USMLE
STEP 1
2023
TAO LE, MD, MHS VIKAS BHUSHAN, MD
Founder, ScholarRx Founder, First Aid for the USMLE Step 1
Associate Clinical Professor, Department of Medicine Boracay, Philippines
University of Louisville School of Medicine
CONNIE QIU, MD, PhD ANUP CHALISE, MBBS, MS, MRCSEd

Resident, Department of Dermatology Kathmandu, Nepal
Johns Hopkins Hospital
PANAGIOTIS KAPARALIOTIS, MD CAROLINE COLEMAN, MD

University of Athens Medical School, Greece Resident, Department of Medicine
Emory University School of Medicine
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_2023_00_Frontmatter.indd 1 11/18/22 5:38 PM

First Aid for the® USMLE Step 1 2023: A Student-to-Student Guide
Copyright © 2023 by Tao Le and Vikas Bhushan. All rights reserved. Printed in the United States of America. Except as
permitted under the United States Copyright Act of 1976, no part of this publication may be reproduced or distrib-
uted in any form or by any means, or stored in a data base or retrieval system, without the prior written permission of
the publisher.
Previous editions copyright © 1991 through 2022 by Tao Le and Vikas Bhushan. First edition copyright © 1990, 1989
by Vikas Bhushan, Jeffrey Hansen, and Edward Hon.
Photo and line art credits for this book begin on page 757 and are considered an extension of this copyright page.
Portions of this book identified with the symbol are copyright © USMLE-Rx.com (MedIQ Learning, LLC).
Portions of this book identified with the symbol are copyright © Dr. Richard Usatine.
Portions of this book identified with the symbol are under license from other third parties. Please refer to page 757
for a complete list of those image source attribution notices.
First Aid for the® is a registered trademark of McGraw Hill.
1 2 3 4 5 6 7 8 9 LMN 27 26 25 24 23 22
ISBN 978-1-264-94662-4
MHID 1-264-94662-7
Notice
Medicine is an ever-changing science. As new research and clinical experience broaden our knowledge,
changes in treatment and drug therapy are required. The authors and the publisher of this work have checked
with sources believed to be reliable in their efforts to provide information that is complete and generally in
accord with the standards accepted at the time of publication. However, in view of the possibility of human
error or changes in medical sciences, neither the authors nor the publisher nor any other party who has been
involved in the preparation or publication of this work warrants that the information contained herein is in
every respect accurate or complete, and they disclaim all responsibility for any errors or omissions or for the
results obtained from use of the information contained in this work. Readers are encouraged to conﬁrm the
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that the information contained in this work is accurate and that changes have not been made in the recom-
mended dose or in the contraindications for administration. This recommendation is of particular importance
in connection with new or infrequently used drugs.
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The editors were Bob Boehringer and Christina M. Thomas.
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Dedication
To medical students and physicians worldwide, whose adaptability

to the ever-changing landscape of medical education and practice
enables them to provide the best care when it is needed most.

Contents
Contributing Authors vii General Acknowledgments xiii

Associate Authors viii How to Contribute xv
Faculty Advisors ix How to Use This Book xvii
Preface xi Selected USMLE Laboratory Values xviii
Special Acknowledgments xii First Aid Checklist for the USMLE Step 1 xx
` 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 19

USMLE Step 1—The Basics 2 Clinical Vignette Strategies 21
Learning Strategies 11 If You Think You Failed 22
Timeline for Study 14 Testing Agencies 22
Study Materials 18 References 23
` SECTION I SUPPLEMENT S P E C I A L S I T UAT I O N S 25
` SECTION II HIGH-YIELD GENERAL PRINCIPLES 27
How to Use the Database 28 Pathology 201

Biochemistry 31 Pharmacology 227
Immunology 93 Public Health Sciences 255
Microbiology 121

` SECTION III H I G H - Y I E L D O R G A N S YS T E M S 279
Approaching the Organ Systems 280 Neurology and Special Senses 499
Cardiovascular 283 Psychiatry 571
Endocrine 329 Renal 597
Gastrointestinal 363 Reproductive 631
Hematology and Oncology 409 Respiratory 679
Musculoskeletal, Skin, and Connective Tissue 449 Rapid Review 709
` SECTION IV TO P - R AT E D R E V I E W R E S O U R C E S 741
How to Use the Database 742 Biochemistry 746

Question Banks 744 Cell Biology and Histology 746
Web and Mobile Apps 744 Microbiology and Immunology 746
Comprehensive 745 Pathology 747
Anatomy, Embryology, and Neuroscience 745 Pharmacology 747
Behavioral Science 746 Physiology 748
`
Abbreviations and Symbols 749 Index 775
Image Acknowledgments 757 About the Editors 828
vi

Contributing Authors
CHRISTIAN FAABORG-ANDERSEN, MD ELENI BOUZIANI

Resident, Department of Medicine University of Athens Medical School, Greece
Massachusetts General Hospital
ANNA LIGOCKI, MD, MS JULIANA MAYA CASTRO, MD

Medical University of Warsaw, Poland Research Fellow, Department of Obstetrics and Gynecology
Fundación Valle de Lili, Universidad Icesi, Colombia
FAATEH AHMAD RAUF, MBBS CAROLINA CABAN RIVERA

CMH Lahore Medical College and Institute of Dentistry, Pakistan Lewis Katz School of Medicine at Temple University
Class of 2025
JAIMIE LYNN ROGNER, MD, MPH COLLIN ANDREW WEINTRAUB, MD

Resident, Departments of Medicine and Pediatrics Resident, Department of General Surgery
University of Rochester Medical Center State University of New York, Upstate
PHILLIP YANG, MD, MSE

Resident, Department of Anesthesiology
Washington University–St. Louis
Image and Illustration Team
YOOREE GRACE CHUNG NIKITHA CRASTA, MBBS

Emory University School of Medicine Mangalore, India
MD/PhD Candidate
SEAN EVANS, MD ANA GOGOLASHVILI, MD

Resident, Department of Internal Medicine Tbilisi State Medical University, Georgia
ANGEL XIAO, MD
Resident, Department of Orthopedic Surgery
University of California, San Francisco
vii

Associate Authors
ATHANASIOS ANGISTRIOTIS, MD ANTHONY G. CHESEBRO

Resident, Department of General Surgery MD/PhD candidate
Stony Brook University Hospital, NY Renaissance School of Medicine, Stony Brook University
MARGARET GINOZA, MD, MPH TALEAH KHAN, MBBS

Resident, Internal Medicine–Pediatrics CMH Lahore Medical College and Institute of Dentistry, Pakistan
Baylor College of Medicine
VASILEIOS PARASCHOU, MD, MSc DANUSHA SANCHEZ, MD

Resident, Department of Medicine Poznań University of Medical Sciences, Poland
424 General Military Hospital, Greece
GEORGIOS MARIOS STERGIOPOULOS, MD ARVIND SURESH

University of Patras Medical School, Greece Geisel School of Medicine at Dartmouth
Class of 2023
ZURABI ZAALISHVILI, MD
Tbilisi State Medical University, Georgia
Image and Illustration Team
YAMNA JADOON, MD
Resident, Department of Medicine
UMass Chan Medical School, Baystate
viii

Faculty Advisors
MARK A.W. ANDREWS, PhD RAYUDU GOPALAKRISHNA, PhD

Professor and Director of Physiology Associate Professor, Department of Integrative Anatomical Sciences
Lake Erie College of Osteopathic Medicine at Seton Hill Keck School of Medicine of University of Southern California
MARIA ANTONELLI, MD MEREDITH K. GREER, MD

Assistant Professor, Division of Rheumatology Assistant Professor, Department of Medicine
Case Western Reserve University at MetroHealth Medical Center, Cleveland Emory University School of Medicine
HERMAN SINGH BAGGA, MD AMBER J. HECK, PhD

Clinical Professor Associate Professor, Department of Microbiology, Immunology, and
Lake Erie College of Osteopathic Medicine and Chatham University Genetics
University of North Texas Health Science Center, Fort Worth
JOE B. BLUMER, PhD
Associate Professor, Department of Pharmacology JENNIFER O. HOWELL, MD
Medical University of South Carolina College of Medicine Associate Professor, Obstetrics and Gynecology
Duke Women’s Health Associates
CHRISTOPHER M. BURNS, PhD
Professor of Basic Medical Sciences VASUDEVA G. KAMATH, MSc, PhD
University of Arizona College of Medicine, Phoenix Assistant Professor of Biochemistry and Medical Genetics
Touro College of Osteopathic Medicine
BROOKS D. CASH, MD
Chief, Gastroenterology, Hepatology, and Nutrition CLARK KEBODEAUX, PharmD
University of Texas Health Science Center at Houston Clinical Associate Professor, Pharmacy Practice and Science
University of Kentucky College of Pharmacy
DIMITRI CASSIMATIS, MD
Associate Professor, Department of Medicine MATTHEW KRAYBILL, PhD
Emory University School of Medicine Clinical Neuropsychologist
Cottage Health, Santa Barbara, California
CATHERINE CHILES, MD
Associate Clinical Professor of Psychiatry GERALD LEE, MD
Yale School of Medicine Associate Professor, Departments of Pediatrics and Medicine
BRADLEY COLE, MD
Assistant Professor of Neurology KACHIU C. LEE, MD, MPH
Loma Linda University School of Medicine Assistant Professor (Adjunct), Department of Dermatology
Lewis Katz School of Medicine at Temple University
MARTHA FANER, PhD
Associate Professor of Biochemistry and Molecular Biology JAMES LYONS, MD
Michigan State University College of Osteopathic Medicine Associate Dean, Professor of Pathology and Family Medicine
Alabama College of Osteopathic Medicine
CONRAD FISCHER, MD
Associate Professor, Medicine, Physiology, and Pharmacology NILADRI KUMAR MAHATO, MBBS, PhD
Touro College of Medicine Ohio University, Athens
AYAKO WENDY FUJITA, MD CARL MARFURT, PhD

Fellow, Division of Infectious Diseases Professor Emeritus, Department of Anatomy, Cell Biology and Physiology
Emory University School of Medicine Indiana University School of Medicine–Northwest, Gary
ix

PETER MARKS, MD, PhD NATHAN WM. SKELLEY, MD
Center for Biologics Evaluation and Research Associate Professor, Medical Director of Orthopaedic Surgery
US Food and Drug Administration Sanford Health–University of South Dakota School of Medicine
DOUGLAS A. MATA, MD, MPH TONY SLIEMAN, PhD, MSc

Senior Pathologist and Associate Medical Director Associate Professor, Department of Basic Sciences
Foundation Medicine, Cambridge, Massachusetts New York Institute of Technology College of Osteopathic Medicine at
Arkansas State University
KRISTEN L. PAGEL, MD, MPH
Assistant Professor, Department of Psychiatry MATTHEW SOCHAT, MD
University of Utah School of Medicine Physician, Hematology/Oncology
Southeastern Medical Oncology Center
SAMAN BENTOTA, MD
Physician and Microbiologist HOWARD M. STEINMAN, PhD
Sri Lanka Assistant Dean, Biomedical Science Education
Albert Einstein College of Medicine
SOROUSH RAIS-BAHRAMI, MD
Associate Professor of Urology and Radiology LORREL TOFT, MD
University of Alabama at Birmingham School of Medicine Associate Professor of Cardiology, Department of Medicine
University of Nevada, Reno School of Medicine
RICHARD P. RAMONELL, MD
Clinical Instructor, Department of Medicine RICHARD P. USATINE, MD
University of Pittsburgh School of Medicine Professor, Dermatology and Cutaneous Surgery
University of Texas Health Science Center San Antonio
KEISHA RAY, PhD
Assistant Professor, McGovern Center for Humanities and Ethics SYLVIA WASSERTHEIL-SMOLLER, PhD
University of Texas Health Science Center at Houston Professor Emerita, Department of Epidemiology and Population Health
Albert Einstein College of Medicine
JOHN ROSE, DO, MSc
Assistant Professor of Anesthesiology ADAM WEINSTEIN, MD
Mount Sinai Morningside–West Associate Professor of Medical Sciences and Pediatrics
Frank H. Netter MD School of Medicine at Quinnipiac University
SASAN SAKIANI, MD
Assistant Professor of Medicine, Department of Medicine ABHISHEK YADAV, MBBS, MSc
University of Maryland School of Medicine Associate Professor of Anatomy
Geisinger Commonwealth School of Medicine
SARAH SCHIMANSKY, MB BCh BAO
Resident, Department of Ophthalmology KRISTAL YOUNG, MD
Bristol Eye Hospital Clinical Instructor, Department of Cardiology
Huntington Hospital, Pasadena, California
SHIREEN MADANI SIMS, MD
Professor, Obstetrics and Gynecology DONG ZHANG, PhD
University of Florida College of Medicine Associate Professor and Director of Center for Cancer Research
New York Institute of Technology College of Osteopathic Medicine

Preface
With the 33rd 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 this exam. This edition represents an outstanding revision in
many ways, including:
73 entirely new or heavily revised high-yield topics reflecting evolving trends in the USMLE Step 1.
Extensive text revisions, new mnemonics, clarifications, and corrections curated by a team of 19 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 148 new and revised diagrams and illustrations as part of our ongoing collaboration with
USMLE-Rx and ScholarRx (MedIQ Learning, LLC).
Updated with 159 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 exam preparation advice for the current pass/fail scoring system of the USMLE Step 1, and Step 1
blueprint changes.
Updated photos of patients and pathologies to include a variety of skin colors to better depict real-world
presentations.
Revised pharmacology sections to include only those drugs currently approved for the US market.
Improved organization and integration of text, illustrations, clinical images, and tables throughout for focused
review of high-yield topics.
Updated Rapid Review section to better reflect exam contents by removing the ‘Classic/Relevant Treatments’
section and adding in a ‘Pathophysiology of Important Diseases’ section.
Revised ratings of current, high-yield review resources, with clear explanations of their relevance to USMLE
review. Replaced outdated resources with new ones recommended by Step takers.
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. xv.)
Louisville Tao Le
Boracay Vikas Bhushan
Baltimore Connie Qiu
Kathmandu Anup Chalise
Athens Panagiotis Kaparaliotis
Atlanta Caroline Coleman
San Francisco Kimberly Kallianos
xi

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.
We provide special acknowledgment and thanks to the following individuals who made exemplary contributions
to this edition through our voting, proofreading, and crowdsourcing platform: Amalia D. Ardeljan, Heather Beyea,
Avneet Kaur, Yekaterina Khamzina, Alexandra Jan Mrani, and Ajay Ajit Pal Singh.
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, Christina Thomas, Kristian
Sanford, and Don Goyette.
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 Megan Chandler. Special thanks to our indexer, Dr.
Anne Fifer. We are also grateful to our art manager, Susan Mazik, and illustrators, Stephanie Jones and Rachael
Joy, for their creative work on the new and updated illustrations. Lastly, tremendous thanks to our compositor,
GW Inc., especially Anne Banning, Gary Clark, Cindy Geiss, Denise Smith, and Gabby Sullivan.
Louisville Tao Le
Boracay Vikas Bhushan
Baltimore Connie Qiu
Kathmandu Anup Chalise
Athens Panagiotis Kaparaliotis
Atlanta Caroline Coleman
San Francisco Kimberly Kallianos
xii

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 Ra’ed Ababneh, Hadi Abbas, Mohamed Fouad
Abdrabo, Ehsen Abdul-Kabir, Catreen Abouelsaad, Maria Acosta, Ataa Ahmed, Ibrahim Al-Zoubi, Isaiah Alexander,
Majed Alghamdi, Hasan Alhelo, Ans Ali, Lubna Allawi, Yazmin Alejandra Heredia Allegretti, Sulaiman Alshakhs,
Einer Arevalo-Rios, Rohan Arora, Stephanie Asdell, Raja Faizan Aurangzeb, Amir Bagheri, Wardah Bajwa, David
Bandy, Adhish Beri, Moussa Berro, Hershey Bhagat, Karun Bhattarai, Pratik Bhattarai, Lokesh Dahal Bikram, Arwa
Bohra, Niloofar Bondariyan, Scout Bownman-Gibson, Steven Braun, Lauren Burney, Jorge Cajias, Jack Carey,
Kevin Cheng, Grigory Davidov, Sara Moghareh Dehkordy, Ainel Loy Diaz, Jeevan Divakaran, Manasa Dutta, Awab
Elnaeem, Zarifa Eshova, Lukas Franke, Jordan Frausto, Louna Ftouni, Allie Funderburk, Asmita Gera, Luciana
Gizzo, Megan Gosling, Camila M. Luis Gronau, Florian Guillot, Yassine Hamdaoui, Jack Healy, Christophe
Hornung, Kayla Howard, Ibrahim Ibikunle, David Ibrahim, Abdelrhman Muqafaq Janem, Tareq Yara Jazzar,
Dhruv Jivan, Bhavya Johani, Alec Kacew, Reema Khatri, Troy Kleber, Mariia Kukushkina, Daniel Lamanna, Dafnia
Leyva, Alwyn Louis, Carra Lyons, Abdelrahman Mahmoud, Sajjad Nazar Majeed, Haruki Majima, Freda Quimba
Malanyaon, Hamdan Mallick, Kshitij Manchanda, Jamal Masri, Michael Heustess McLatchey, Jose Antonio Meade,
Akhil Meti, David Momtaz, Alejandra Moncayo, Dyese Moody, Andrew Moya, Waneeza Mughees, Geraldine
Nabeta, Sofia Nadav, Shamsun Nahar, Nelly Navarro, Kamil Nazer, Hyder Nizamani, Maria Felix Torres Nolasco,
Hisashi Nomura, Rafy Souheil Farah Odeh, Gerald Olayan, Ider Oujamaa, Abhishek Pandey, Arun Paniker, Nidhit
Patel, Kevin Aldwych Zayas Pena, Zainab Pervaiz, Samantha Pfiffner, Vivek Podder, Prabhat Poudel, Kevin Pruitt,
Yochitha Pulipati, Punnatorn Punkitnirundorn, Erik Rabin, Kirstin Reed, Asmaa Rjoob, Gessel Romero, Aon
Ryalat, Richard Ryngel, Neha Sehgal, Kristina Sevcik, Tarif Shaaban, Muhammad Shahriar, Tina Sharma, Emily
Sherry, Kinan Al Shunaigat, Alondra Sierra, Joshua St. Louis, Michael Steadman, Ashley Su, Anastasiia Sumenkova,
Lana Adel George Tannous, Nicholas Ting, Joshua Tobin, Jason Tung, Songphol Tungjitviboonkun, Mehrbod
Vakhshoori, Sai akhil Veeramachaneni, Amanjot Virk, Christos Vrysis, Dayanara Wert, Jonathan Wikcock, Whitney
Wood, Hafsa Yaseen, and Peleg Zohar.
xiii

How to Contribute
This edition 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
Pathology and radiology images (high resolution) relevant to the facts in the book
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 or our diversity initiative as discussed
in the Foreword.
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, 2023, receive priority consideration for the 2024 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.
xv

` 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/ScholarRx team is pleased to offer paid editorial and coaching positions. We are looking for passionate,
experienced, and dedicated medical students and recent graduates. Participants will have an opportunity to work
on a wide variety of projects, including the popular First Aid series and the growing line of USMLE-Rx/ScholarRx
products, including Rx Bricks. Please use our webform at https://www.usmle-rx.com/join-the-first-aid-team/ to apply,
and include a CV and writing examples.
For 2023, we are actively seeking passionate medical students and graduates with a specific interest in improving our
medical illustrations, expanding our database of photographs (including clinical images depicting diverse skin types),
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.
xvi

How to Use This Book
CONGRATULATIONS: You now possess the book that has guided nearly two million students to USMLE success
for over 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.
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 this book with material from other resources,
such as class notes or comprehensive textbooks. 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, red for Rx Bricks).
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, USMLE-Rx Step 1 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, ScholarRx Bricks and USMLE-Rx Step 1 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.
xvii

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) 10–40 U/L 10–40 U/L

*Alkaline phosphatase 25–100 U/L 25–100 U/L
Amylase, serum 25–125 U/L 25–125 U/L
*Aspartate aminotransferase (AST, GOT at 30°C) 12–38 U/L 12–38 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 2.1–2.6 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+) 136–146 mEq/L 136–146 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: 70–100 mg/dL 3.8–6.1 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 mOsmol/kg H2O 275–295 mOsmol/kg H2O
*Phosphorus (inorganic), serum 3.0–4.5 mg/dL 1.0–1.5 mmol/L
Prolactin, serum (hPRL) Male: < 17 ng/mL < 17 µg/L
Female: < 25 ng/mL < 25 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 0.4–4.0 µU/mL 0.4–4.0 mIU/L
*Urea nitrogen, serum (BUN) 7–18 mg/dL 25–64 nmol/L
*Uric acid, serum 3.0–8.2 mg/dL 0.18–0.48 mmol/L
(continues)
xviii

Cerebrospinal Fluid Reference Range SI Reference Intervals
Cell count 0–5/mm3 0–5 × 106/L

Glucose 40–70 mg/dL 2.2–3.9 mmol/L
Proteins, total < 40 mg/dL < 0.40 g/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/hr 0–15 mm/hr
Female: 0–20 mm/hr 0–20 mm/hr
Hematocrit Male: 41–53% 0.41–0.53
Female: 36–46% 0.36–0.46
Hemoglobin, blood Male: 13.5–17.5 g/dL 135–175 g/L
Female: 12.0–16.0 g/dL 120–160 g/L
Hemoglobin, plasma < 4 mg/dL < 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 25–35 pg/cell 0.39–0.54 fmol/cell
Mean corpuscular hemoglobin concentration 31%–36% Hb/cell 4.8–5.6 mmol Hb/L
Mean corpuscular volume 80–100 μm 3
80–100 fL
Partial thromboplastin time (activated) 25–40 sec 25–40 sec
Platelet count 150,000–400,000/mm3 150–400 × 109/L
Prothrombin time 11–15 sec 11–15 sec
Reticulocyte count 0.5–1.5% of RBCs 0.005–0.015
Urine
Creatinine clearance Male: 97–137 mL/min 97–137 mL/min

Female: 88–128 mL/min 88–128 mL/min
Osmolality 50–1200 mOsmol/kg H2O 50–1200 mOsmol/kg H2O
Proteins, total < 150 mg/24 hr < 0.15 g/24 hr
Other
Body mass index Adult: 19–25 kg/m2 19–25 kg/m2
xix

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.
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 from early on.
Weeks Prior Do test simulations in question banks.

Assess how close you are to your goal.
Pinpoint remaining weaknesses. Stay healthy (eg, exercise, sleep).
Verify information on admission ticket (eg, location, date).
One Week Prior Remember comfort measures (eg, loose clothing, earplugs).
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
or at firstaid@scholarrx.com.
xx

SECTION I
Guide to Efficient
Exam Preparation
“One important key to success is self-confidence. An important key to self- ` Introduction2

confidence is preparation.”
—Arthur Ashe ` USMLE Step 1—The
Basics2
“Wisdom is not a product of schooling but of the lifelong attempt to
acquire it.” ` Learning Strategies 11
—Albert Einstein
` Timeline for Study 14
“Finally, from so little sleeping and so much reading, his brain dried up
and he went completely out of his mind.” ` Study Materials 18
—Miguel de Cervantes Saavedra, Don Quixote
` Test-Taking
“Sometimes the questions are complicated and the answers are simple.” Strategies19
—Dr. Seuss
` Clinical Vignette
“He who knows all the answers has not been asked all the questions.” Strategies21
—Confucius
` If You Think You
“The expert in anything was once a beginner.”
Failed22
—Helen Hayes
“It always seems impossible until it’s done.” ` Testing Agencies 22

—Nelson Mandela
` References23
FAS1_2023_00_Section_I.indd 1 11/18/22 7:31 AM

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 result means
Not using review books along with your classes
Not analyzing and improving your test-taking strategies
Getting bogged down by reviewing difficult topics excessively
Studying material that is rarely tested on the USMLE Step 1
Failing to master certain high-yield subjects owing to overconfidence
Using First Aid as your sole study resource
Trying to prepare for it all alone
In this section, we offer advice to help you avoid these pitfalls and be more
productive in your studies.
` USMLE STEP 1—THE BASICS
` The test at a glance: The USMLE Step 1 is the first of three examinations that you would
8-hour exam normally pass in order to become a licensed physician in the United
Up to a total of 280 multiple choice items States. The USMLE is a joint endeavor of the National Board of Medical
7 test blocks (60 min/block) Examiners (NBME) and the Federation of State Medical Boards (FSMB).
Up to 40 test items per block The USMLE serves as the single examination system domestically and
45 minutes of break time, plus another 15 internationally for those seeking medical licensure in the United States.
if you skip the tutorial 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). In late
2020, the USMLE increased the number of items assessing communication
skills. While pharmacology is still tested, they are focusing on drug mecha-
nisms rather than on pharmacotherapy. You will not be required to identify
the specific medications indicated for a specific condition. Instead, you will
be asked more about drug mechanisms and side effects.

Guide to Efficient Exam Preparation SECTION I 3
T A B L E 1 . Frequency of Various Constructs Tested on the USMLE Step 1.1,*
Competency Range, % System Range, %
Medical knowledge: applying foundational 60–70 General principles 12–16
science concepts
Patient care: diagnosis 20–25 Behavioral health & nervous systems/special senses 9–13
Communication and interpersonal skills 6–9 Respiratory & renal/urinary systems 9–13
Practice-based learning & improvement 4–6 Reproductive & endocrine systems 9–13
Discipline Range, % Blood & lymphoreticular/immune systems 7–11
Pathology 44–52 Multisystem processes & disorders 6–10
Physiology 25–35 Musculoskeletal, skin & subcutaneous tissue 6–10
Pharmacology 15–22 Cardiovascular system 5–9
Biochemistry & nutrition 14–24 Gastrointestinal system 5–9
Microbiology 10–15 Biostatistics & epidemiology/population health 4–6
Immunology 6–11 Social sciences: communication skills/ethics 6–9
Gross anatomy & embryology 11–15
Histology & cell biology 8–13
Behavioral sciences 8–13
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 the same as
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 for free (https://www.usmle.
org/prepare-your-exam) 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, cell phones, tablets, and calculators. Examinees are also
prohibited from carrying in their books, notes, pens/pencils, and scratch
paper (laminated note boards and fine-tip dry erase pens will be provided
for use within the testing area). 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 or more
A, B, etc—letter choices
possible answer options. There is a countdown timer on the lower left corner
Esc—exit pop-up Calculator and Notes
of the screen as well. There is also a button that allows the examinee to mark
windows
a question for review. If a given question happens to be longer than the
screen, a scroll bar will appear on the right, allowing the examinee to see the
rest of the question. Regardless of whether the examinee clicks on an answer
choice or leaves it blank, he or she must click the “Next” button to advance
to the next question.
The USMLE features a small number of media clips in the form of audio
` 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, Hb, WBC, Ca2+, Na+,
In order to do so, he or she must click the “Lab” icon on the top part of
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
background). Being familiar with these features can save time and may help
you better view and organize the information you need to answer a question.

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 ` You can take a shortened CBT practice test at
on the USMLE website are used at these sessions. No new items will be a Prometric center.
presented. The practice session is available at a cost of $75 ($155 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 first ` The Prometric website will display a calendar
two weeks in January and major holidays. Check with the test center you with open test dates.
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.

` Be familiar with Prometric’s policies for Once you receive your scheduling permit, you may access the Prometric
cancellation and rescheduling due to website or call Prometric’s toll-free number to arrange a time to take the
COVID-19. exam. You may contact Prometric two weeks before the test date if you
want to confirm identification requirements. Be aware that your exam may
be canceled because of circumstances related to the COVID-19 pandemic
or other unforeseen events. If that were to happen, you should receive an
email from Prometric containing notice of the cancellation and instructions
on rescheduling. Visit www.prometric.com for updates regarding their
COVID-19 cancellation and rescheduling policies.
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 US medical students
` Test scheduling is done on a “first-come,
attending a school which uses the two-year preclerkship curriculum choose
first-served” basis. It’s important to schedule
the April–June or June–August period. Most US medical students attending
an exam date as soon as you receive your
a school which uses the 18-month preclerkship curriculum choose the
scheduling permit.
December–February or January–March period.
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 correlates with the end of the preclerkship
curriculum, which is around June for schools on a two-year preclerkship
schedule, and around January for schools on an 18-month schedule. Thus
US medical students should plan to register before January in anticipation of
a June test date, or before August in anticipation of a January 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 Result?
The USMLE reports results in three to four weeks, unless there are delays
in processing. Examinees will be notified via email when their results are
available. By following the online instructions, examinees will be able
to view, download, and print their exam report online for ~120 days after
notification, after which results can only be obtained through requesting an
official USMLE transcript. Additional information about results reporting
timetables and accessibility is available on the official USMLE website.
Between 2020 and 2021, Step 1 pass rates dropped from 97% to 95% across
US/Canadian schools and from 83% to 77% across non-US/Canadian
schools (see Table 2).
What About Time?

` Gain extra break time by skipping the
Time is of special interest on the CBT exam. Here’s a breakdown of the tutorial, or utilize the tutorial time to add
exam schedule: personal notes to your scratch paper.
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 exam 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 Exam?
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
result will be reported if you do not complete the exam. If you leave at any
time after starting the test, or do not open every block of your test, your test
will not be scored and will be reported as incomplete. Incomplete results
count toward the maximum of four attempts for each Step exam. Although
a pass or fail result is not posted for incomplete tests, examinees may still be
offered 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 four or more options. You are required to select the single best
T A B L E 2 . Passing Rates for the 2020-2021 USMLE Step 1.2

2020 2021
No. Tested % Passing No. Tested % Passing
Allopathic 1st takers 19,772 98% 22,280 96%
Repeaters 571 67% 798 66%
Allopathic total 20,343 95% 23,078 95%
Osteopathic 1st takers 5,235 96% 5,309 94%
Repeaters 39 74% 56 75%
Osteopathic total 5,274 95% 5,365 94%
Total US/Canadian 25,617 97% 28,443 95%
IMG 1st takers 11,742 87% 16,952 82%
Repeaters 1,375 50% 2,258 45%
IMG total 13,117 83% 19,210 77%
Total Step 1 examinees 38,734 92% 47,653 87%

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 exam result.
How Is the Test Scored?
The USMLE transitioned to a pass/fail scoring system for Step 1 on January 26,
2022. Examinees now receive an electronic report that will display the outcome
of either “Pass” or “Fail.” Failing reports include a graphic depiction of the
distance between the examinee’s score and the minimum passing standard
as well as content area feedback. Feedback for the content area shows the
examinee’s performance relative to examinees with a low pass (lower, same, or
higher) and should be used to guide future study plans. Passing exam reports
only displays the outcome of “Pass,” along with a breakdown of topics covered
on that individual examination (which will closely mirror the frequencies listed
in Table 1). Note that a number of questions are experimental and are not
counted toward or against the examinee’s performance.
Examinees who took the test before the transition to pass/fail reporting received
an electronic report that includes the examinee’s pass/fail status, a three-
digit test score, a bar chart comparing the examinee’s performance in each
content area with their overall Step 1 performance, and a graphic depiction
of the examinee’s performance by physician task, discipline, and organ system.
Changes will not be made to transcripts containing three-digit test scores.
The USMLE does not report the minimum number of correct responses
needed to pass, but estimates that it is approximately 60%. The USMLE ` Depending on the resource used, practice
may update exam result reporting in the future, so please check the USMLE questions may be easier than the actual
website or www.firstaidteam.com for updates. exam.
Official NBME/USMLE Resources
The NBME offers a Comprehensive Basic Science Examination (CBSE) for

practice that is a shorter version of the Step 1. The CBSE contains four blocks
of 50 questions each and covers material that is typically learned during the
basic science years. CBSE scores represent the percent of content mastered and
show an estimated probability of passing Step 1. Many schools use this test to
gauge whether a student is expected to pass Step 1. If this test is offered by your
school, it is usually conducted at the end of regular didactic time before any
dedicated Step 1 preparation. If you do not encounter the CBSE before your
dedicated study time, you need not worry about taking it. Use the information
to help set realistic goals and timetables for your success.

The NBME also offers six forms of Comprehensive Basic Science Self-
Assessment (CBSSA). Students who prepared for the exam using this web-
based tool reported that they found the format and content highly indicative
of questions tested on the actual exam. In addition, the CBSSA is a fair
predictor of historical USMLE performance. The test interface, however,
does not match the actual USMLE test interface, so practicing with these
forms alone is not advised.
The CBSSA exists in two formats: standard-paced and self-paced, both of

which consist of four sections of 50 questions each (for a total of 200 multiple
choice items). The standard-paced format allows the user up to 75 minutes
to complete each section, reflecting time limits similar to the actual exam.
By contrast, the self-paced format places a 5-hour time limit on answering all
multiple choice questions. Every few years, new forms are released and older
ones are 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. In addition to the performance profile, examinees will be informed
of the number of questions answered incorrectly. You will have the ability
to review the text of all questions with detailed explanations. The NBME
charges $60 for each assessment, payable by credit card or money order. For
more information regarding the CBSE and the CBSSA, visit the NBME’s
website at www.nbme.org.
The NBME scoring system is weighted for each assessment exam. While
some exams seem more difficult than others, the equated percent correct
reported takes into account these inter-test differences. Also, while
many students report seeing Step 1 questions “word-for-word” out of the
assessments, the NBME makes special note that no live USMLE questions
are shown on any NBME assessment.
Lastly, the International Foundations of Medicine (IFOM) offers a Basic

Science Examination (BSE) practice exam at participating Prometric test
centers for $200. Students may also take the self-assessment test online for
$35 through the NBME’s website. The IFOM BSE is intended to determine
an examinee’s relative areas of strength and weakness in general areas of
basic science—not to predict performance on the USMLE Step 1 exam—
and the content covered by the two examinations is somewhat different.
However, because there is substantial overlap in content coverage and many
IFOM items were previously used on the USMLE Step 1, it is possible to
roughly project IFOM performance onto the historical USMLE Step 1
score scale. More information is available at http://www.nbme.org/ifom/.

` LEARNING STRATEGIES
Many students feel overwhelmed during the preclinical years and struggle to
find an effective learning strategy. Table 3 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.
T A B L E 3 . Effective Learning Strategies.

Efficacy Strategy Example Resources
High efficacy Practice testing UWorld Qbank
(retrieval practice) NBME Self-Assessments
USMLE-Rx QMax
Amboss 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

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
` Research has shown a positive correlation more effortful the recall, the better the long-term retention. This advantage
between the number of boards-style practice has been shown to result in higher test scores and GPAs.6 In fact, research
questions completed and Step 1 performance has shown a positive correlation between the number of boards-style practice
among medical students. questions completed and Step 1 performance among medical students.7
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-
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
` Studies have linked spaced repetition cards to improved long-term knowledge retention and higher exam scores.6,8,10
learning with flash cards to improved long- Apps with automated spaced-repetition software (SRS) for flash cards exist for
term knowledge retention and higher exam smartphones and tablets, so the cards are accessible anywhere. Proceed with
scores. caution: there is an art to making and reviewing cards. The ease of quickly
downloading or creating digital cards can lead to flash card overload (it is
unsustainable to make 50 flash cards per lecture!). Even at a modest pace,
the thousands upon thousands of cards are too overwhelming for Step 1
preparation. Unless you have specific high-yield cards (and have checked
the content with high-yield resources), stick to pre-made cards by reputable
sources that curate the vast amount of knowledge for you.
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.
` Customize your schedule. Tackle your weakest Make a Schedule

section first.
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. 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 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 confidence in comfortably achieving a passing 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.

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 ` Buy review resources early (first year) and use
even during your undergraduate years should provide the groundwork on while studying for courses.
which to base your test preparation. Student scores on NBME subject tests
(commonly known as “shelf exams”) have been shown to be highly correlated
with subsequent Step 1 performance.16 Moreover, undergraduate science
GPAs as well as MCAT scores are strong predictors of performance on the
Step 1 exam.17
We also recommend that you buy highly rated review books early in your first
year of medical school and use them as you study throughout the two years.
When Step 1 comes along, these books will be familiar and personalized to the
way in which you learn. It is risky and intimidating to use unfamiliar review
books in the final two or three weeks preceding the exam. Some students find
it helpful to personalize and annotate First Aid throughout the curriculum.
Months Prior
Review test dates and the application procedure. Testing for the USMLE
Step 1 is done on a year-round basis. If you have disabilities or special
circumstances, contact the NBME as early as possible to discuss test
accommodations (see the Section I Supplement at www.firstaidteam.com/
bonus).

` Simulate the USMLE Step 1 under “real” 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
` One week before the test: Make sure you have your CIN (found on your scheduling permit) as
Sleep according to the same schedule you’ll well as other items necessary for the day of the examination, including
use on test day a current driver’s license or another form of photo ID with your signature
Review the CBT tutorial one last time (make sure the name on your ID exactly matches that on your scheduling
Call Prometric to confirm test date and time permit). Confirm the Prometric testing center location and test time. Work
out how you will get to the testing center and what parking, traffic, and
public transportation problems you might encounter. Exchange cell phone
numbers with other students taking the test on the same day in case of
emergencies. Check www.prometric.com/closures for test site closures due
to unforeseen events. Determine what you will do for lunch. Make sure you
have everything you need to ensure that you will be comfortable and alert at
the test site. It may be beneficial to adjust your schedule to start waking up
at the same time that you will on your test day. And of course, make sure to
maintain a healthy lifestyle and get enough sleep.
One 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
(and need not!) 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
screens at night). Do not change your daily routine prior to the exam. Exam
day is not the day for a caffeine-withdrawal headache.
Morning of the Exam
On the morning of the Step 1 exam, wake up at your regular time and ` No notes, books, calculators, pagers, cell
eat a normal breakfast. If you think it will help you, have a close friend phones, recording devices, or watches of any
or family member check to make sure you get out of bed. Make sure you kind are allowed in the testing area, but they
have your scheduling permit admission ticket, test-taking materials, and are allowed in lockers and may be accessed
comfort measures as discussed earlier. Wear loose, comfortable clothing. during authorized breaks.
Limiting the number of pockets in your outfit may save time during security
screening. Plan for a variable temperature in the testing center. Arrive at
the test site 30 minutes before the time designated on the admission ticket; ` Arrive at the testing center 30 minutes before
however, do not come too early, as doing so may intensify your anxiety. your scheduled exam time. If you arrive
When you arrive at the test site, the proctor should give you a USMLE more than half an hour late, you will not be
information sheet that will explain critical factors such as the proper use of allowed to take the test.
break time. Seating may be assigned, but ask to be reseated if necessary; you
need to be seated in an area that will allow you to remain comfortable and
to concentrate. Get to know your testing station, especially if you have never
been in a Prometric testing center before. Listen to your proctors regarding
any changes in instructions or testing procedures that may apply to your test
site.
If you are experiencing symptoms of illness on the day of your exam, we

strongly recommend you reschedule. If you become ill or show signs of
illness (eg, persistent cough) during the exam, the test center may prohibit
you from completing the exam due to health and safety risks for test center
staff and other examinees.
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.
` 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.
Review Books
` If a given review book is not working for you, In selecting review books, be sure to weigh different opinions against each
stop using it no matter how highly rated it other, read the reviews and ratings in Section IV of this guide, examine the
may be or how much it costs. 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.
` Charts and diagrams may be the best There are two types of review books: those that are stand-alone titles and
approach for physiology and biochemistry, those that are part of a series. Books in a series generally have the same style,
whereas tables and outlines may be and you must decide if that style works for you. However, a given style is not
preferable for microbiology. optimal for every subject.
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

` Most practice exams are shorter and less
and weaknesses in your fund of knowledge and test-taking skills. Some
clinical than the real thing.
students use practice examinations simply as a means of breaking up the
monotony of studying and adding variety to their study schedule, whereas
other students rely almost solely on practice. You should also subscribe to
one or more high-quality question banks.
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
Your test performance will be influenced by both your knowledge and your ` Practice! Develop your test-taking skills and
test-taking skills. You can strengthen your performance by considering each strategies well before the test date.
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.
Guessing
There is no penalty for wrong answers. Thus no test block should be left
with unanswered questions. If you don’t know the answer, first eliminate
incorrect choices, then guess among the remaining options. Note that
dozens of questions are unscored experimental questions meant to obtain
statistics for future exams. Therefore, some questions may seem unusual
or unreasonably difficult simply because they are part of the development
process for future exams.
Changing Your Answer
The conventional wisdom is not to second-guess your initial answers.

However, studies have consistently shown that test takers are more likely
to change from a wrong answer to the correct answer than the other way
around. Many question banks tell you how many questions you changed
from right to wrong, wrong to wrong, and wrong to right. Use this feedback

to judge how good a second-guesser you are. If you have extra time, reread ` Go with your first hunch, unless you are
the question stem and make sure you didn’t misinterpret the question. certain that you are a good second-guesser.
` CLINICAL VIGNETTE STRATEGIES
In recent years, the USMLE Step 1 has become increasingly clinically ` Be prepared to read fast and think on your
oriented. This change mirrors the trend in medical education toward feet!
introducing students to clinical problem solving during the basic science
years. The increasing clinical emphasis on Step 1 may be challenging to
those students who attend schools with a more traditional curriculum.
What Is a Clinical Vignette?
A clinical vignette is a short (usually paragraph-long) description of a patient,

including demographics, presenting symptoms, signs, and other information
concerning the patient. Sometimes this paragraph is followed by a brief
listing of important physical findings and/or laboratory results. The task of
assimilating all this information and answering the associated question in the ` Practice questions that include case histories
span of one minute can be intimidating. So be prepared to read quickly and or descriptive vignettes are critical for Step 1
think on your feet. Remember that the question is often indirectly asking preparation.
something you already know.
A pseudovignette is a question that includes a description of a case similar to

that of a clinical vignette, but it ends with a declarative recall question; thus
the material presented in the pseudovignette is not necessary to answer the
question. Question writers strive to avoid pseudovignettes on the USMLE
Step 1. Be prepared to tackle each vignette as if the information presented is
important to answer the associated question correctly.
Strategy
Remember that Step 1 vignettes usually describe diseases or disorders in

their most classic presentation. So look for cardinal signs (eg, malar rash for
lupus or nuchal rigidity for meningitis) in the narrative history. Be aware that
the question will contain classic signs and symptoms instead of buzzwords. ` Step 1 vignettes usually describe diseases or
Sometimes the data from labs and the physical exam will help you confirm disorders in their most classic presentation.
or reject possible diagnoses, thereby helping you rule answer choices in or
out. In some cases, they will be a dead giveaway for the diagnosis.
Making a diagnosis from the history and data is often not the final answer. Not
infrequently, the diagnosis is divulged at the end of the vignette, after you have
just struggled through the narrative to come up with a diagnosis of your own.
The question might then ask about a related aspect of the diagnosed disease.
Consider skimming the answer choices and lead-in before diving into a long
stem. However, be careful with skimming the answer choices; going too fast
may warp your perception of what the vignette is asking.

` IF YOU THINK YOU FAILED
After taking the test, it is normal for many examinees to feel unsure about
their performance, despite the majority of them achieving a passing score.
Historical pass data is in Table 2. If you remain quite concerned, it may
be wise to prepare a course of action should you need to retest. There are
several sensible steps you can take to plan for the future in the event that
you do not achieve a passing score. First, save and organize all your study
materials, including review books, practice tests, and notes. Familiarize
yourself with the reapplication procedures for Step 1, including application
deadlines and upcoming test dates.
Make sure you know both your school’s and the NBME’s policies regarding
retakes. The total number of attempts an examinee may take per Step
` If you pass Step 1, you are not allowed to examination is four.18 You make take Step 1 no more than three times within
retake the exam. a 12-month period. Your fourth attempt must be at least 12 months after
your first attempt at that exam, and at least 6 months after your most recent
attempt at that exam.
If you failed, the performance profiles on the back of the USMLE Step 1
score report provide valuable feedback concerning your relative strengths
and weaknesses. Study these profiles closely. Set up a study timeline to
strengthen gaps in your knowledge as well as to maintain and improve what
you already know. Do not neglect high-yield subjects. It is normal to feel
somewhat anxious about retaking the test, but if anxiety becomes a problem,
seek appropriate counseling.
` TESTING AGENCIES
National Board of Medical Examiners (NBME) / USMLE Secretariat

Department of Licensing Examination Services
3750 Market Street
Philadelphia, PA 19104-3102
(215) 590-9500 (operator) or
(215) 590-9700 (automated information line)
Email: webmail@nbme.org
www.nbme.org
Educational Commission for Foreign Medical Graduates (ECFMG)

3624 Market Street
Philadelphia, PA 19104-2685
(215) 386-5900
Email: info@ecfmg.org
www.ecfmg.org

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Rev Educ Res. 1981;51(2):247–275.
12. Dyer J-O, Hudon A, Montpetit-Tourangeau K, et al. Example-based
learning: comparing the effects of additionally providing three different
integrative learning activities on physiotherapy intervention knowledge.
BMC Med Educ. 2015;15:37.
13. Chamberland M, Mamede S, St-Onge C, et al. Self-explanation in learning
clinical reasoning: the added value of examples and prompts. Med Educ.
2015;49(2):193–202.
14. Nesbit JC, Adesope OO. Learning with concept and knowledge maps: a
meta-analysis. Rev Educ Res. 2006;76(3):413–448.
15. Pohl CA, Robeson MR, Hojat M, et al. Sooner or later? USMLE Step 1
performance and test administration date at the end of the second year. Acad
Med. 2002;77(10):S17–S19.
16. Holtman MC, Swanson DB, Ripkey DR, et al. Using basic science
subject tests to identify students at risk for failing Step 1. Acad Med.
2001;76(10):S48–S51.
17. Basco WT, Way DP, Gilbert GE, et al. Undergraduate institutional
MCAT scores as predictors of USMLE Step 1 performance. Acad Med.
2002;77(10):S13–S16.
18. United States Medical Licensing Examination. What are the rules regarding
retakes? Available from: https://www.usmle.org/common-questions/general.
Accessed October 2022.

24 SECTION I GUIDE TO EFFICIENT EXAM PREPARATION
` NOTES

Another random document with
no related content on Scribd:
Text Page of Didot’s Racine, Paris, 1801 256
Firmin Didot. From Engraving by Pierre Gustave Eugène Staal
(1817–1882) 256
William Morris. From Portrait by G. F. Watts, R. A., in the National
Portrait Gallery, London. Painted in 1880 258
Sir Edward Burne-Jones, Bart. From a Photograph at the British
Museum 260
Text Page of Kelmscott Chaucer, 1896 262
Title Page of Doves Bible, London, 1905 265
Text Page of Doves Bible, London, 1905 267
The Sala Michelangiolo, in the Laurenziana Library, Florence 276
Dott. Comm. Guido Biagi, in 1924 278
Vestibule of the Laurenziana Library, Florence 280
Miniature Page from the Biblia Amiatina, R. Lau. Bibl. Cod. Amiatinus
I 288
Antonio Magliabecchi 293
Library Slips used by George Eliot while working on Romola in
Magliabecchian Library, Florence 296
CHAPTER I
In Quest of the Perfect Book

I
IN QUEST OF THE PERFECT BOOK
“Here is a fine volume,” a friend remarked, handing me a copy of The Ideal

Book, written and printed by Cobden-Sanderson at the Doves Press.
“It is,” I assented readily, turning the leaves, and enjoying the composite
beauty of the careful typography, and the perfect impression upon the soft,
handmade paper with the satisfaction one always feels when face to face with a
work of art. “Have you read it?”
“Why—no,” he answered. “I picked it up in London, and they told me it
was a rare volume. You don’t necessarily read rare books, do you?”
My friend is a cultivated man, and his attitude toward his latest acquisition
irritated me; yet after thirty years of similar disappointments I should not have
been surprised. How few, even among those interested in books, recognize the
fine, artistic touches that constitute the difference between the commonplace
and the distinguished! The volume under discussion was written by an
authority foremost in the art of bookmaking; its producer was one of the few
great master-printers and binders in the history of the world; yet the only
significance it possessed to its owner was the fact that some one in whom he
had confidence had told him it was rare! Being rare, he coveted the treasure,
and acquired it with no greater understanding than if it had been a piece of
Chinese jade.
“What makes you think this is a fine book?” I inquired, deliberately
changing the approach.
He laughed consciously. “It cost me nine guineas—and I like the looks of
it.”
Restraint was required not to say something that might have affected our
friendship unpleasantly, and friendship is a precious thing.
“Do something for me,” I asked quietly. “That is a short book. Read it
through, even though it is rare, and then let us continue this conversation we
have just begun.”
A few days later he invited me to dine with him at his club. “I asked you
here,” he said, “because I don’t want any one, even my family, to hear what I
am going to admit to you. I have read that book, and I’d rather not know what
you thought of my consummate ignorance of what really enters into the
building of a well-made volume—the choice of type, the use of decoration, the
arrangement of margins. Why, bookmaking is an art! Perhaps I should have
known that, but I never stopped to think about it.”
One does have to stop and think about a well-made book in order to
comprehend the difference between printing that is merely printing and that
which is based upon art in its broadest sense and upon centuries of precedent.
It does require more than a gleam of intelligence to grasp the idea that the
basis of every volume ought to be the thought expressed by the writer; that the
type, the illustrations, the decorations, the paper, the binding, simply combine
to form the vehicle to convey that expression to the reader. When, however,
this fact is once absorbed, one cannot fail to understand that if these various
parts, which compositely comprise the whole, fail to harmonize with the
subject and with each other, then the vehicle does not perform its full and
proper function.
I wondered afterward if I had not been a bit too superior in my attitude
toward my friend. As a matter of fact, printing as an art has returned to its
own only within the last quarter-century. Looking back to 1891, when I began
to serve my apprenticeship under John Wilson at the old University Press in
Cambridge, Massachusetts, the broadness of the profession that I was
adopting as my life’s work had not as yet unfolded its unlimited possibilities.
At that time the three great American printers were John Wilson, Theodore L.
De Vinne, and Henry O. Houghton. The volumes produced under their
supervision were perfect examples of the best bookmaking of the period, yet
no one of these three men looked upon printing as an art. It was William
Morris who in modern times first joined these two words together by the
publication of his magnificent Kelmscott volumes. Such type, such
decorations, such presswork, such sheer, composite beauty!
This was in 1895. Morris, in one leap, became the most famous printer in
the world. Every one tried to produce similar volumes, and the resulting
productions, made without appreciating the significance of decoration
combined with type, were about as bad as they could be. I doubt if, at the
present moment, there exists a single one of these sham Kelmscotts made in
America that the printer or the publisher cares to have recalled to him.
When the first flair of Morris’ popularity passed away, and his volumes
were judged on the basis of real bookmaking, they were classified as
marvelously beautiful objets d’art rather than books—composites of Burne-
Jones, the designer, and William Morris, the decorator-printer, co-workers in
sister arts; but from the very beginning Morris’ innovations showed the world
that printing still belonged among the fine arts. The Kelmscott books awoke in
me an overwhelming desire to put myself into the volumes I produced. I
realized that no man can give of himself beyond what he possesses, and that to
make my ambition worth accomplishing I must absorb and make a part of
myself the beauty of the ancient manuscripts and the early printed books. This
led me to take up an exhaustive study of the history of printing.
JOHN GUTENBERG, c. 1400–1468
From Engraving by Alphonse Descaves
Bibliothèque Nationale, Paris
Until then Gutenberg’s name, in my mind, had been preëminent. As I

proceeded, however, I came to know that he was not really the “inventor” of
printing, as I had always thought him to be; that he was the one who first
foresaw the wonderful power of movable types as a material expression of the
thought of man, rather than the creator of anything previously unknown. I
discovered that the Greeks and the Romans had printed from stamps centuries
earlier, and that the Chinese and the Koreans had cut individual characters in
metal.
I well remember the thrill I experienced when I first realized—and at the
time thought my discovery was original!—that, had the Chinese or the
Saracens possessed Gutenberg’s wit to join these letters together into words,
the art of printing must have found its way to Constantinople, which would
have thus become the center of culture and learning in the fifteenth century.
From this point on, my quest seemed a part of an Arabian Nights’ tale.
Cautiously opening a door, I would find myself in a room containing treasures
of absorbing interest. From this room there were doors leading in different
directions into other rooms even more richly filled; and thus onward, with
seemingly no end, to the fascinating rewards that came through effort and
perseverance.
Germany, although it had produced Gutenberg, was not sufficiently
developed as a nation to make his work complete. The open door led me away
from Germany into Italy, where literary zeal was at its height. The life and
customs of the Italian people of the fifteenth century were spread out before
me. In my imagination I could see the velvet-gowned agents of the wealthy
patrons of the arts searching out old manuscripts and giving commissions to
the scribes to prepare hand-lettered copies for their masters’ libraries. I could
mingle with the masses and discover how eager they were to learn the truth in
the matter of religion, and the cause and the remedies of moral and material
evils by which they felt themselves oppressed. I could share with them their
expectant enthusiasm and confidence that the advent of the printing press
would afford opportunity to study description and argument where previously
they had merely gazed at pictorial design. I could sense the desire of the
people for books, not to place in cabinets, but to read in order to know; and I
could understand why workmen who had served apprenticeships in Germany
so quickly sought out Italy, the country where princes would naturally become
patrons of the new art, where manuscripts were ready for copy, and where a
public existed eager to purchase their products.
While striving to sense the significance of the conflicting elements I felt
around me, I found much of interest in watching the scribes fulfilling their
commissions to prepare copies of original manuscripts, becoming familiar for
the first time with the primitive methods of book manufacture and
distribution. A monastery possessed an original manuscript of value. In its
scriptorium (the writing office) one might find perhaps twenty or thirty monks
seated at desks, each with a sheet of parchment spread out before him, upon
which he inscribed the words that came to him in the droning, singsong voice
of the reader selected for the duty because of his familiarity with the subject
matter of the volume. The number of desks the scriptorium could accommodate
determined the size of this early “edition.”
When these copies were completed, exchanges were made with other
monasteries that possessed other original manuscripts, of which copies had
been made in a similar manner. I was even more interested in the work of the
secular scribes, usually executed at their homes, for it was to these men that
the commissions were given for the beautiful humanistic volumes. As they had
taken up the art of hand lettering from choice or natural aptitude instead of as
a part of monastic routine, they were greater artists and produced volumes of
surpassing beauty. A still greater interest in studying this art of hand lettering
lay in the knowledge that it soon must become a lost art, for no one could
doubt that the printing press had come to stay.
Then, turning to the office of Aldus, I pause for a moment to read the
legend placed conspicuously over the door:
Whoever thou art, thou art earnestly requested by Aldus to state thy business briefly
and to take thy departure promptly. In this way thou mayest be of service even as was
Hercules to the weary Atlas, for this is a place of work for all who may enter
ALDUS MANUTIUS, 1450–1515
From Engraving at the British Museum
But inside the printing office I find Aldus and his associates talking of
other things than the books in process of manufacture. They are discussing the
sudden change of attitude on the part of the wealthy patrons of the arts who,
after welcoming the invention of printing, soon became alarmed by the
enthusiasm of the people, and promptly reversed their position. No wonder
that Aldus should be concerned as to the outcome! The patrons of the arts
represented the culture and wealth and political power of Italy, and they now
discovered in the new invention an actual menace. To them the magnificent
illuminated volumes of the fifteenth century were not merely examples of
decoration, but they represented the tribute that this cultured class paid to the
thought conveyed, through the medium of the written page, from the author
to the world. This jewel of thought they considered more valuable than any
costly gem. They perpetuated it by having it written out on parchment by the
most accomplished scribes; they enriched it by illuminated embellishments
executed by the most famous artists; they protected it with bindings in which
they actually inlaid gold and silver and jewels. To have this thought cheapened
by reproduction through the commonplace medium of mechanical printing
wounded their æsthetic sense. It was an expression of real love of the book
that prompted Bisticci, the agent of so powerful a patron as the Duke of
Urbino, to write of the Duke’s splendid collection in the latter part of the
fifteenth century:
In that library the books are all beautiful in a superlative degree, and all written
by the pen. There is not a single one of them printed, for it would have been a shame to
have one of that sort.
Aldus is not alarmed by the solicitude of the patrons for the beauty of the
book. He has always known that in order to exist at all the printed book must
compete with the written volume; and he has demonstrated that, by supplying
to the accomplished illuminators sheets carefully printed on parchment, he can
produce volumes of exquisite beauty, of which no collector need be ashamed.
Aldus knows that there are other reasons behind the change of front on the
part of the patrons. Libraries made up of priceless manuscript volumes are
symbols of wealth, and through wealth comes power. With the multiplication
of printed books this prestige will be lessened, as the masses will be enabled to
possess the same gems of thought in less extravagant and expensive form. If,
moreover, the people are enabled to read, criticism, the sole property of the
scholars, will come into their hands, and when they once learn self-reliance
from their new intellectual development they are certain to attack dogma and
political oppression, even at the risk of martyrdom. The princes and patrons
of Italy are intelligent enough to know that their self-centered political power
is doomed if the new art of printing secures a firm foothold.
What a relief to such a man as Aldus when it became fully demonstrated
that the desire on the part of the people to secure books in order to learn was
too great to be overcome by official mandate or insidious propaganda! With
what silent satisfaction did he settle back to continue his splendid work! The
patrons, in order to show what a poor thing the printed book really was, gave
orders to the scribes and the illuminators to prepare volumes for them in such
quantities that the art of hand lettering received a powerful impetus, as a result
of which the hand letters themselves attained their highest point of perfection.
This final struggle on the part of the wealthy overlords resulted only in
redoubling the efforts of the artist master-printers to match the beauty of the
written volumes with the products from their presses.
These Arabian Nights’ experiences occupied me from 1895, when Morris
demonstrated the unlimited possibilities of printing as an art, until 1901, when
I first visited Italy and gave myself an opportunity to become personally
acquainted with the historical landmarks of printing, which previously I had
known only from study. In Florence it was my great good fortune to become
intimately acquainted with the late Doctor Guido Biagi, at that time librarian
of the Laurenziana and the Riccardi libraries, and the custodian of the Medici,
the Michelangelo, and the da Vinci archives. I like to think of him as I first saw
him then, sitting on a bench in front of one of the carved plutei designed by
Michelangelo, in the wonderful Sala di Michelangiolo in the Laurenziana Library,
studying a beautifully illuminated volume resting before him, which was
fastened to the desk by one of the famous old chains. He greeted me with an
old-school courtesy. When he discovered my genuine interest in the books he
loved, and realized that I came as a student eager to listen to the master’s word,
his face lighted up and we were at once friends.
Dott. Comm. GUIDO BIAGI
Seated at one of the plutei in the
Laurenziana Library, Florence (1906)
In the quarter of a century which passed from this meeting until his death
we were fellow-students, and during that period I never succeeded in
exhausting the vast store of knowledge he possessed, even though he gave of
it with the freest generosity. From him I learned for the first time of the far-
reaching influence of the humanistic movement upon everything that had to
do with the litteræ humaniores, and this new knowledge enabled me to crystallize
much that previously had been fugitive. “The humanist,” Doctor Biagi
explained to me, “whether ancient or modern, is one who holds himself open
to receive Truth, unprejudiced as to its source, and—what is more important
—after having received Truth realizes his obligation to the world to give it out
again, made richer by his personal interpretation.”
This humanistic movement was the forerunner and the essence of the
Renaissance, being in reality a revolt against the barrenness of mediævalism.
Until then ignorance, superstition, and tradition had confined intellectual life
on all sides, but the little band of humanists, headed by Petrarch, put forth a
claim for the mental freedom of man and for the full development of his
being. As a part of this claim they demanded the recognition of the rich
humanities of Greece and Rome, which were proscribed by the Church. If this
claim had been postponed another fifty years, the actual manuscripts of many
of the present standard classics would have been lost to the world.
The significance of the humanistic movement in its bearing upon the
Quest of the Perfect Book is that the invention of printing fitted exactly into
the Petrarchian scheme by making it possible for the people to secure volumes
that previously, in their manuscript form, could be owned only by the wealthy
patrons. This was the point at which Doctor Biagi’s revelation and my previous
study met. The Laurenziana Library contains more copies of the so-called
humanistic manuscripts, produced in response to the final efforts on the part
of patrons to thwart the increasing popularity of the new art of printing, than
any other single library. Doctor Biagi proudly showed me some of these
treasures, notably Antonio Sinibaldi’s Virgil. The contrast between the hand
lettering in these volumes and the best I had ever seen before was startling.
Here was a hand letter, developed under the most romantic and dramatic
conditions, which represented the apotheosis of the art. The thought flashed
through my mind that all the types in existence up to this point had been
based upon previous hand lettering less beautiful and not so perfect in
execution.
“Why is it,” I demanded excitedly, “that no type has ever been designed
based upon this hand lettering at its highest point of perfection?”
HAND-WRITTEN HUMANISTIC CHARACTERS
From Sinibaldi’s Virgil, 1485
Laurenziana Library, Florence (12 × 8 inches)
Doctor Biagi looked at me and shrugged his shoulders. “This, my friend,”

he answered, smiling, “is your opportunity.”
At this point began one of the most fascinating and absorbing adventures
in which any one interested in books could possibly engage. At some time, I
suppose, in the life of every typographer comes the ambition to design a
special type, so it was natural that the idea contained in Doctor Biagi’s remark
should suggest possibilities which filled me with enthusiasm. I was familiar
with the history of the best special faces, and had learned how difficult each
ambitious designer had found the task of translating drawings into so rigid a
medium as metal; so I reverted soberly and with deep respect to the subject of
type design from the beginning.
In studying the early fonts of type, I found them exact counterfeits of the
best existing forms of hand lettering at that time employed by the scribes. The
first Italic font cut by Aldus, for instance, is said to be based upon the thin,
inclined handwriting of Petrarch. The contrast between these slavish copies of
hand-lettered models and the mechanical precision of characters turned out by
modern type founders made a deep impression. Of the two I preferred the
freedom of the earliest types, but appreciated how ill adapted these models
were to the requirements of typography. A hand-lettered page, even with the
inevitable irregularities, is pleasing because the scribe makes a slight variation
in forming the various characters. When, however, an imperfect letter is cut in
metal, and repeated many times upon the same page, the irregularity forces
itself unpleasantly upon the eye. Nicolas Jenson was the first to realize this,
and in his famous Roman type he made an exact interpretation of what the
scribe intended to accomplish in each of the letters, instead of copying any
single hand letter, or making a composite of many hand designs of the same
character. For this reason the Jenson type has not only served as the basis of
the best standard Roman fonts down to the present time, but has also proved
the inspiration for later designs of distinctive type faces, such as William
Morris’ Golden type, and Emery Walker’s Doves type.
Specimen Page of proposed Edition of Dante. To be
printed by Bertieri, of Milan, in Humanistic Type (8¼ × 6)
William Morris’ experience is an excellent illustration of the difficulties a

designer experiences. He has left a record of how he studied the Jenson type
with great care, enlarging it by photography, and redrawing it over and over
again before he began designing his own letter. When he actually produced his
Golden type the design was far too much inclined to the Gothic to resemble
the model he selected. His Troy and Chaucer types that followed showed the
strong effect of the German influence that the types of Schoeffer, Mentelin,
and Gunther Zainer made upon him. The Doves type is based flatly upon the
Jenson model; yet it is an absolutely original face, retaining all the charm of the
model, to which is added the artistic genius of the designer. Each receives its
personality from the understanding and interpretation of the creator (pages 22,
23).
Jenson’s Roman Type.

From Cicero: Rhetorica, Venice, 1470 (Exact size)
Emery Walker’s Doves Type.
From Paradise Regained, London, 1905 (Exact size)
From this I came to realize that it is no more necessary for a type designer
to express his individuality by adding or subtracting from his model than for a
portrait painter to change the features of his subject because some other artist
has previously painted it. Wordsworth once said that the true portrait of a man
shows him, not as he looks at any one moment of his life, but as he really
looks all the time. This is equally true of a hand letter, and explains the vast
differences in the cut of the same type face by various foundries and for the
typesetting machines. All this convinced me that, if I were to make the
humanistic letters the model for my new type, I must follow the example of
Emery Walker rather than that of William Morris.
During the days spent in the small, cell-like alcove which had been turned
over for my use in the Laurenziana Library, I came so wholly under the
influence of the peculiar atmosphere of antiquity that I felt myself under an
obsession of which I have not been conscious before or since. My enthusiasm
was abnormal, my efforts tireless. The world outside seemed very far away, the
past seemed very near, and I was indifferent to everything except the task
before me. This curious experience was perhaps an explanation of how the
monks had been able to apply themselves so unceasingly to their prodigious
labors, which seem beyond the bounds of human endurance.
My work at first was confined to a study of the humanistic volumes in the
Laurenziana Library, and the selection of the best examples to be taken as final
models for the various letters. From photographed reproductions of selected
manuscript pages, I took out fifty examples of each letter. Of these fifty,
perhaps a half-dozen would be almost identical, and from these I learned the
exact design the scribe endeavored to repeat. I also decided to introduce the
innovation of having several characters for certain letters that repeated most
frequently, in order to preserve the individuality of the hand lettering, and still
keep my design within the rigid limitations of type. Of the letter e, for instance,
eight different designs were finally selected; there were five a’s, two m’s, and so
on (see illustration at page 32).
After becoming familiar with the individual letters as shown in the
Laurenziana humanistic volumes, I went on to Milan and the Ambrosiana
Library, with a letter from Doctor Biagi addressed to the librarian, Monsignor
Ceriani, explaining the work upon which I was engaged, and seeking his co-
operation. It would be impossible to estimate Ceriani’s age at that time, but he
was very old. He was above middle height, his frame was slight, his eyes
penetrating and burning with a fire that showed at a glance how affected he
was by the influence to which I have already referred. His skin resembled in
color and texture the very parchment of the volumes he handled with such
affection, and in his religious habit he seemed the embodiment of ancient
learning.
After expressing his deep interest in my undertaking, he turned to a
publication upon which he himself was engaged, the reproduction in facsimile
of the earliest known manuscript of Homer’s Iliad. The actual work on this, he
explained, was being carried on by his assistant, a younger priest whom he

First Aid For The Usmle Step 1 2023 33Rd Edition Vikas Bhushan Full Chapter

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First Aid for the USMLE Step 1 2023,

33rd Edition Vikas Bhushan

CONNIE QIU, MD, PhD ANUP CHALISE, MBBS, MS, MRCSEd

PANAGIOTIS KAPARALIOTIS, MD CAROLINE COLEMAN, MD

FAS1_2023_00_Frontmatter.indd 1 11/18/22 5:38 PM

First Aid for the® is a registered trademark of McGraw Hill.

This book was set in Electra LT Std by GW Inc.

This book is printed on acid-free paper.

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To medical students and physicians worldwide, whose adaptability

FAS1_2023_00_Frontmatter.indd 3 11/18/22 5:38 PM

Contributing Authors vii General Acknowledgments xiii

Introduction 2 Test-Taking Strategies 19

` SECTION I SUPPLEMENT S P E C I A L S I T UAT I O N S 25

` SECTION II HIGH-YIELD GENERAL PRINCIPLES 27

How to Use the Database 28 Pathology 201

FAS1_2023_00_Frontmatter.indd 5 11/18/22 5:38 PM

How to Use the Database 742 Biochemistry 746

FAS1_2023_00_Frontmatter.indd 6 11/18/22 5:38 PM

CHRISTIAN FAABORG-ANDERSEN, MD ELENI BOUZIANI

ANNA LIGOCKI, MD, MS JULIANA MAYA CASTRO, MD

FAATEH AHMAD RAUF, MBBS CAROLINA CABAN RIVERA

JAIMIE LYNN ROGNER, MD, MPH COLLIN ANDREW WEINTRAUB, MD

PHILLIP YANG, MD, MSE

Image and Illustration Team

YOOREE GRACE CHUNG NIKITHA CRASTA, MBBS

SEAN EVANS, MD ANA GOGOLASHVILI, MD

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ATHANASIOS ANGISTRIOTIS, MD ANTHONY G. CHESEBRO

MARGARET GINOZA, MD, MPH TALEAH KHAN, MBBS

VASILEIOS PARASCHOU, MD, MSc DANUSHA SANCHEZ, MD

GEORGIOS MARIOS STERGIOPOULOS, MD ARVIND SURESH

Image and Illustration Team

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MARK A.W. ANDREWS, PhD RAYUDU GOPALAKRISHNA, PhD

MARIA ANTONELLI, MD MEREDITH K. GREER, MD

HERMAN SINGH BAGGA, MD AMBER J. HECK, PhD

AYAKO WENDY FUJITA, MD CARL MARFURT, PhD

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DOUGLAS A. MATA, MD, MPH TONY SLIEMAN, PhD, MSc

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FAS1_2023_00_Frontmatter.indd 13 11/18/22 5:38 PM

 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

Alternatively, you can email us at: firstaid@scholarrx.com.

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` JOIN THE FIRST AID TEAM

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* = Included in the Biochemical Profile (SMA-12)

Blood, Plasma, Serum Reference Range SI Reference Intervals

*Alanine aminotransferase (ALT, GPT at 30°C) 10–40 U/L 10–40 U/L

Bicarbonate (HCO3–) 22–28 mEq/L 22–28 mmol/L

FAS1_2023_00_Frontmatter.indd 18 11/18/22 5:38 PM

Cell count 0–5/mm3 0–5 × 106/L

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

Creatinine clearance Male: 97–137 mL/min 97–137 mL/min

Body mass index Adult: 19–25 kg/m2 19–25 kg/m2

FAS1_2023_00_Frontmatter.indd 19 11/18/22 5:38 PM

Months Prior Review computer test format and registration information.

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

“One important key to success is self-confidence. An important key to self- ` Introduction2

“It always seems impossible until it’s done.” ` Testing Agencies 22

Starting to study (including First Aid) too late

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