USMLE STEP 1

SYLLABUS
OUTLINE
General Principles
Biochemistry and Molecular Biology

Gene expression: DNA structure, replication, and exchange

DNA structure: single- and double-stranded DNA, stabilizing forces,
supercoiling
Analysis of DNA: sequencing, restriction analysis, PCR amplification,
hybridization
DNA replication, mutation, repair, degradation, and inactivation
Gene structure and organization; chromosomes; centromere, telomere
Recombination, insertion sequences, transposons
Mechanisms of genetic exchange, including transformation, transduction,
conjugation, crossover, recombination, linkage plasmids and
bacteriophages
Gene expression: transcription, including defects
Transcription of DNA into RNA, enzymatic reactions, RNA, RNA degradation
Regulation: cis-regulatory elements, transcription factors, enhancers,
promoters, silencers, represents, splicing
Gene expression: translation, including defects
The genetic code
Structure and function of tRNA
Structure and function of ribosomes
Protein synthesis
Regulation of translation
Post-translation modifications, including phosphorylation,
addition of CHO units
Protein degradation
Structure and function of proteins
Principles of protein structure and folding
Enzymes: kinetics, reaction mechanisms
Structural and regulatory proteins: ligand binding, self-assembly
Regulatory properties
Energy metabolism, including metabolic sequences and
regulation, and disorders
Generation of energy from carbohydrates, fatty acids, and essential amino
acids; glycolysis, pentose phosphate pathway, tricarboxylic acid cycle,
ketogenesis, electron transport and oxidative phosphorylation,
glycogenolysis
Storage of energy: gluconeogenesis, glycogenesis, fatty acid and
triglyceride synthesis
Thermodynamics: free energy, chemical equilibria and group transfer
potential, energetics of ATP and other high-energy compounds
Metabolic pathways of small molecules and associated diseases
Biosynthesis and degradation of amino acids (e.g., homocystinuria, maple
syrup urine disease)
Biosynthesis and degradation of purine and pyrimidine nucleotides (e.g.,
gout, Lesch-Nyhan syndrome)
Biosynthesis and degradation of lipids (e.g., dyslipidemias, carnitine
deficiency, adrenogenital syndromes)
 Biosynthesis and degradation of porphyrins
Biosynthesis and degradation of other macromolecules and associated
abnormalities, complex carbohydrates (e.g., lysosomal storage disease),
glycoproteins, and proteoglycans (e.g., type II glycogen storage disease)
Biology of cells

Structure and function of cell components (eg, nucleus, cytoskeleton,

endoplasmic reticulum, plasma membrane)
Signal transduction (including basic principles, receptors and channels,
second messengers, signal trasnduction pathways)
Cell adhesion and cell motility
Intracellular sorting (eg, trafficking, endocytosis)
Cellular homeostasis (eg, turnover, pH maintenance, proteasome, ions,
soluble proteins)
Cell cycle (eg, mitosis, meiosis, structure of spindle apparatus, cell cycle
regulation)
Structure and function of basic tissue components (including epithelial
cells, connective tissue cells, muscle cells, nerve cells, and extracellular
matrix)
Adaptive cell response to injury
Intracellular accumulations (eg, pigments, fats, proteins, carbohydrates,
minerals, inclusions, vacuoles)
Mechanisms of injury and necrosis
Apoptosis

Human development and genetics

Embryogenesis: programmed gene expression, tissue differentiation and

morphogenesis, homeotic genes, and developmental regulation of gene
expression
Congenital abnormalities: principles, patterns of anomalies,
dysmorphogenesis
Principles of pedigree analysis, including inheritance patterns, occurrence
and recurrence risk determination
Population genetics: Hardy-Weinberg law, founder effects, mutation-
selection equilibrium
Genetic mechanisms: chromosomal abnormalities, mendelian inheritance,
multifactorial diseases
Clinical genetics, including genetic testing, prenatal diagnosis, newborn
screening, genetic counseling/ethics, gene therapy
Biology of tissue response to disease

Inflammation, including cells and mediators

Acute inflammation and mediator systems
Vascular response to injury, including mediators
Inflammatory cell recruitment, including adherence and cell migration, and
phagocytosis
Bactericidal mechanisms and tissue injury
Clinical manifestations (eg, pain, fever, leukocytosis, leukemoid reaction,
and chills)
 Chronic inflammation
Reparative processes
Wound healing, hemostasis, and repair: thrombosis, granulation tissue,
angiogenesis, fibrosis, scar/keloid formation
Regenerative processes
Neoplasia
Classification, histologic diagnosis
Grading and staging of neoplasms
Cell biology, biochemistry, and molecular biology of neoplastic cells:
transformation, oncogenes, altered cell differentiation, and proliferation
Hereditary neoplastic disorders
Invasion and metastasis
Tumor immunology
Paraneoplastic manifestations of cancer
Cancer epidemiology and prevention

Multisystem processes

Nutrition
Generation, expenditure, and storage of energy at the whole-body level
Assessment of nutritional status across the life span, including calories,
protein, essential nutrients, hypoalimentation
Functions of nutrients, including essential, trans-fatty acids, cholesterol
Protein-calorie malnutrition
Vitamin deficiencies and/or toxicities
Mineral deficiencies and toxicities
Eating disorders (eg, obesity, anorexia, bulimia)
Adaptation to environmental extremes, including occupational
exposures
Physical and associated disorders (eg, temperature, radiation, burns,
decreased atmospheric pressure, high-altitude sickness, increased water
pressure)
Chemical (eg, gases, vapors, smoke inhalation, agricultural hazards,
volatile organic solvents, heavy metals, principles of poisoning and
therapy)
Temperature regulation
Fluid, electrolyte, and acid-base balance and disorders (eg,
dehydration, acidosis, alkalosis)
Pharmacodynamic and pharmacokinetic processes

Pharmacokinetics: absorption, distribution, metabolism, excretion, dosage

intervals
Mechanisms of drug action, structure-activity relationships
Concentration- and dose-effect relationships (eg, efficacy, potency), types
of agonists and antagonists and their actions
Individual factors altering pharmacokinetics and pharmacodynamics (eg,
age, gender, disease, tolerance, compliance, body weight, metabolic
proficiency, pharmacogenetics)
Drug side effects, overdosage, toxicology
Drug interactions
 Regulatory issues (eg, drug development, approval, scheduling)
General properties of autacoids, including peptides and analogs, biogenic
amines, prostanoids and their inhibitors, and smooth muscle/endothelial
autacoids
General principles of autonomic pharmacology
General properties of antimicrobials, including mechanisms of action and
resistance
General properties of antineoplastic agents and immunosuppressants,
including drug effects on rapidly dividing mammalian cells
Microbial biology and infection

Microbial classification and its basis

Bacteria and bacterial diseases
Structure and composition
Metabolism, physiology, and regulation
Genetics
Nature and mechanisms of action of virulence factors
Pathophysiology of infection
Epidemiology and ecology
Principles of cultivation, assay, and laboratory diagnosis
Viruses and viral diseases
Physical and chemical properties
Replication
Genetics
principles of cultivation, assay, and laboratory diagnosis
Molecular basis of pathogenesis
pathophysiology of infection
Latent and persistent infections
Epidemiology
Oncogenic viruses
Fungi and fungal infections
Structure, physiology, cultivation, and laboratory diagnosis
Pathogenesis and epidemiology
Parasites and parasitic diseases
Structure, physiology, and laboratory diagnosis
Pathogenesis and epidemiology
Principles of sterilization and pure culture technique

Immune responses

Production and function of granulocytes, natural killer cells, and

macrophages
Production and function of T lymphocytes, T-lymphocyte receptors
Production and function of B lymphocytes and plasma cells;
immunoglobulin and antibodies: structure and biologic properties
ntigenicity and immunogenicity; antigen presentation; cell activation and
regulation; tolerance and clonal deletion
Immunologic mediators: chemistry, function, molecular biology, classic
and alternative complement pathways, cytokines, chemokines
 Immunogenetics; MHC structure and function, class I, II molecules;
erythrocyte antigens; transplantation Immunizations: vaccines, protective
immunity
Immunologic principles underlying diagnostic laboratory tests (eg, ELISA,
complement fixation, RIA, agglutination)
Innate immunity
Alterations in immunologic function
T- or B-lymphocyte deficiencies (eg, DiGeorge Syndrome)
Deficiencies of phagocytic cells
Combined immunodeficiency disease
HIV infection/AIDS and other acquired disorders of immune responsiveness
Drug-induced alterations in immune responses, immunopharmacology
Immunologically mediated disorders
Hypersensitivity (types I-IV)
Transplant rejection
Autoimmune disorders
Risks of transplantation, transfusion (eg, graft-versus-host disease)
Isoimmunization, hemolytic disease of the newborn Immunopathogenesis

Quantitative methods

Fundamental concepts of measurement

scales of measurement
Distribution, central tendency, variability, probability
Disease prevalence and incidence
Disease outcomes (eg, fatality rates)
Associations (eg, correlation and covariance)
Health impact (eg, risk differences and ratios)
Sensitivity, specificity, predictive values
Fundamental concepts of study design
Types of experimental studies (eg, clinical trials, community intervention
trials)
Types of observational studies (eg, cohort, case-control, cross-sectional,
case series, community surveys)
Sampling and sample size
Subject selection and exposure allocation (eg, randomization,
stratification, self-selection, systematic assignment)
Outcome assessment
Internal and external validity
Fundamental concepts of hypothesis testing and statistical
inference
Confidence intervals
Statistical significance and Type I error
Statistical power and Type II error
Hematopoietic and Lymphoreticular Systems
Normal processes

Embryonic development, fetal maturation, and perinatal changes

Organ structure and function
Repair, regeneration, and changes associated with stage of life
Cell/tissue structure and function
production and function of erythrocytes, hemoglobin, O2 and CO2
transport, transport proteins
production and function of leukocytes and the lymphoreticular system
production and function of platelets
production and function of coagulation and fibrinolytic factors

Abnormal processes

Infectious, Inflammatory, and Immunologic disorders

Infections of the blood, Reticuloendothelial system, and lymphatics
Allergic and anaphylactic reactions and other immunopathologic
mechanisms
Acquired disorders of immune deficiency
Autoimmunity and autoimmune diseases (eg, Coombs positive hemolytic
anemia, pernicious anemia, cryoglobulinemias, ITP)
Anemia of chronic disease
Transfusion complications, transplant rejection
Traumatic and mechanical injury (eg, mechanical injury to
erythrocytes, splenic rupture)
Neoplastic disorders (eg, lymphoma, leukemia, multiple myeloma)
Metabolic and regulatory disorders, including acquired and congenital
Anemias and cytopenias (eg, iron deficiency anemia, hemoglobinopathies,
hereditary spherocytosis)
Cythemia
Hemorrhagic and hemostatic disorders (eg, coagulopathies, DIC)
Bleeding secondary to platelet disorders (eg, von Willebrand)
Vascular and endothelial disorders (eg, effects and complications of
splenectomy, hypersplenism, TTP, hemolytic-uremic syndrome)
Systemic disorders affecting the hematopoietic and lymphoreticular
system (eg, nutritional deficiencies, systemic lupus erythematosus)
Idiopathic disorders

Principles of Therapeutics

Mechanisms of action, use, and adverse effects of drugs for

treatment of disorders of the hematopoietic system
Blood and blood products
Treatment of anemia, drugs stimulating erythrocyte production (eg,
erythropoietin)
Drugs stimulating leukocyte production (eg, G-CSF, GM-CSF)
Anticoagulants, thrombolytic drugs
Antiplatelet drugs
Antimicrobials (eg, antimalarials, anti-HIV)
 Antineoplastic and immunosuppressive drugs
Drugs used to treat acquired disorders of immune responsiveness
Other therapeutic modalities (eg, splenectomy, chelating agents,
radiation therapy for lymphomas, plasmapheresis)
Gender, ethnic, and behavioral considerations affecting disease treatment and
prevention, including psychosocial, cultural, occupational, and environmental

Emotional and behavioral factors (eg, diet, depression and immune

responses, "blood doping" among athletes)
Influence on person, family, and society (eg, childhood leukemia)
Occupational and other environmental risk factors (eg, heavy metals,
hydrocarbons, lead)
Gender and ethnic factors (eg, herbal treatments with bone marrow
depression)
Progression through the life cycle, including birth through
senescence
Cognitive, language, motor skills, and social and interpersonal
development
Sexual development (eg, puberty, menopause)
Influence of developmental stage on physician-patient interview
Psychologic and social factors influencing patient behavior
Personality traits or coping style, including coping mechanisms
Psychodynamic and behavioral factors, related past experience
Family and cultural factors, including socioeconomic status, ethnicity, and
gender
Adaptive and maladaptive behavioral responses to stress and illness (eg,
drug-seeking behavior, sleep deprivation)
Interactions between the patient and the physician or the health care
system (eg, transference)
Patient adherence, including general and adolescent
Patient interviewing, consultation, and interactions with the
family
Establishing and maintaining rapport
Data gathering
Approaches to patient education
Enticing patients to make lifestyle changes
Communicating bad news
"Difficult" interviews (eg, anxious or angry patients)
Multicultural ethnic characteristics
Medical ethics, jurisprudence, and professional behavior
Consent and informed consent to treatment
Physician-patient relationships (eg, ethical conduct, confidentiality)
Death and dying
Birth-related issues
Issues related to patient participation in research
Interactions with other health professionals (eg, referral)
Sexuality and the profession; other "boundary" issues
Ethics of managed care
Organization and cost of health care delivery
Central and Peripheral Nervous Systems
Normal processes

Embryonic development, fetal maturation, and perinatal changes,

including neural tube derivatives, cerebral ventricles, neural crest
derivatives
Repair, regeneration, and changes associated with stage of life
Organ structure and function
Spinal cord, including gross anatomy, blood supply, and spinal reflexes
Brain stem, including cranial nerves and nuclei, reticular formation, gross
anatomy, and blood supply
Brain, including gross anatomy and blood supply; cognition, language,
memory; hypothalamic function; limbic system and emotional behavior;
circadian rhythms and sleep; control of eye movement
Sensory systems, including proprioception, pain, vision, hearing, balance,
taste, and olfaction
Motor systems, including brain and spinal cord, basal ganglia and
cerebellum
Autonomic nervous system
Peripheral nerve
Cell/tissue structure and function
Axonal transport
Excitable properties of neurons, axons and dendrites, including channels
Synthesis, storage, release, reuptake, and degradation of
neurotransmitters and neuromodulators
Pre- and postsynaptic receptor interactions, trophic and growth factors
Brain metabolism
Glia, myelin
Brain homeostasis: blood-brain barrier; cerebrospinal fluid formation and
flow; choroid plexus
Abnormal processes

Infectious, inflammatory, and immunologic disorders (eg, meningitis,

multiple sclerosis, myasthenia gravis)
Traumatic and mechanical disorders (eg, subdural and epidural
hematomas, cord compression, peripheral nerve injury)
Neoplastic disorders, including primary and metastatic
Acquired metabolic and regulatory disorders (eg, delirium, Reye
syndrome)
Vascular disorders (eg, cerebrovascular occlusion, venous sinus
thrombosis, arterial aneurysms, hemorrhage)
Systemic disorders affecting the nervous system (eg, lupus, diabetic
neuropathy)
Idiopathic disorders affecting the nervous system
Congenital disorders, including metabolic (eg, neural tube defects,
cerebral palsy, mental retardation, Down syndrome)
Degenerative disorders (eg, peripheral neuropathy, Alzheimer dementia,
Parkinson disease, Huntington disease, amyotrophic lateral sclerosis)
 Paroxysmal disorders (eg, epilepsy, headache, pain syndromes, and sleep
disorders including narcolepsy, restless legs syndrome/periodic limb
movement, circadian rhythm disorders, parasomnias)
Disorders of special senses (eg, blindness, deafness)
Psychopathologic disorders, processes and their evaluation
Early-onset disorders (eg, learning disorders)
Disorders related to substance use
Schizophrenia and other psychotic disorders
Mood disorders
Anxiety disorders
Somatoform disorders
Personality disorders
Physical and sexual abuse of children, adults, and elders
Other disorders (eg, dissociative, impulse control, post-traumatic stress
disorder)
Principles of therapeutics

Mechanisms of action, use, and adverse effects of drugs for

treatment of disorders of the nervous system
Anesthetics
Hypnotics
Psychopharmacologic agents (eg, anxiolytics, antidepressants,
antipsychotic agents, mood-stabilizing agents)
Anticonvulsants
Analgesics
Stimulants, amphetamines
Antiparkinsonian drugs
Skeletal muscle relaxants, botulinum toxin
Neuromuscular junction blocking agents (postsynaptic)
Antiglaucoma drugs
Drugs used to decrease intracranial pressure (eg, mannitol, high-dose
glucocorticoids)
Antimigraine agents
Drugs affecting autonomic nervous system (eg, anticholinesterases)
Other therapeutic modalities (eg, radiation, CFS shunting,
surgery)
Gender, ethnic, and behavioral considerations affecting disease treatment and
prevention, including psychosocial, cultural, occupational, and environmental

Emotional and behavioral factors (eg, drug abuse, dementia, sleep

deprivation, accident prevention, pets)
Influence on person, family, and society (eg, developmental disabilities,
dementia, generation reversal, nutrition, seizures, sleep disorders)
Occupational and other environmental risk factors (eg, boxing, carbon
monoxide exposure)
Gender and ethnic factors
Skin and Related Connective Tissue
Normal processes

Embryonic development, fetal maturation, and perinatal changes

Organ structure and function
Cell/tissue structure and function, including barrier functions, thermal
regulation, eccrine function
Repair, regeneration, and changes associated with stage of life or ethnicity
(eg, senile purpura, male pattern baldness, postmenopausal hair changes)
Skin defense mechanisms and normal flora

Abnormal processes

Infectious, inflammatory, and immunologic disorders

Bacterial infections, (eg, acne, cellulitis, carbuncle, abscess, necrotizing
fasciitis, gangrene)
Viral infections (eg, herpes infections, chickenpox, rubella, measles,
roseola, verrucae)
Fungal infections, including mycoses, dermatophytosis (eg, tinea)
Parasitic infections (eg, scabies, lice)
Immune and autoimmune disorders (eg, discoid lupus erythematosus,
scleroderma, dermatomyositis, alopecia, psoriasis, urticaria, allergic
dermatosis)
Traumatic and mechanical disorders (eg, thermal injury, decubitus
ulcers, effects of ultraviolet light and radiation)
Neoplastic disorders
Keratinocytes (eg, seborrheic keratosis, actinic keratosis, basal cell
carcinoma, squamous cell carcinoma, and ichthyosis)
Melanocytes (eg, nevi, melanoma)
Vascular neoplasms (eg, hemangiomas, Kaposi sarcoma)
Other (eg, T-cell lymphoma, skin appendage tumors)
Metabolic, regulatory, and structural disorders (eg, vitamin
deficiencies, hypervitaminosis, hyperhidrosis)
Vascular disorders (eg, vasculitis, Raynaud disease)
Systemic disorders affecting the skin (eg, Ehlers-Danlos
syndrome, Marfan syndrome)
Principles of therapeutics

Mechanisms of action, use, and adverse effects of drugs for treatment of

disorders of the skin and connective tissue, including anti-inflammatory
agents (eg, corticosteroids, antihistamines), emollients, sunscreen,
retinoids, antimicrobial agents, cytotoxic and immunologic therapy (eg,
methotrexate, PUVA, keratinolytics)
Other therapeutic modalities (eg, laser, tattoo removal, cryotherapy)

Gender, ethnic, and behavioral considerations affecting disease treatment and

prevention, including psychosocial, cultural, occupational, and environmental

Emotional and behavioral factors (eg, sun exposure, acne)

Influence on person, family, and society (eg, psoriasis)
 Occupational and other environmental risk factors
Gender and ethnic factors (eg, keloid)
Musculoskeletal System
Normal processes

Embryonic development, fetal maturation, and perinatal changes

Organ structure and function
Cell/tissue structure and function
Biology of bones, joints, tendons, skeletal muscle
Exercise and physical conditioning
Repair, regeneration, and changes associated with stage of life

Abnormal processes

Traumatic and mechanical disorders (eg, fractures, sprains,

strains, dislocations, repetitive motion injuries)
Neoplastic disorders (eg, osteosarcoma, metastatic disease)
Metabolic, regulatory, and structural disorders (eg, dwarfism,
osteogenesis imperfecta, osteomalacia, osteoporosis,
osteodystrophy, gout)
Vascular disorders (eg, polyarteritis nodosa, bone infarcts)
Systemic disorders affecting the musculoskeletal system (eg,
diabetes mellitus)
Idiopathic disorders (eg, Dupuytren contracture, scoliosis, Paget
disease)
Degenerative disorders (eg, disc disease, osteoarthritis)
Infectious, inflammatory, and immunologic disorders
Infectious disorders (eg, septic arthritis, Lyme disease, osteomyelitis)
Inflammatory disorders (eg, fibrositis, synovitis, tenosynovitis)
Immunologic disorders (eg, rheumatoid arthritis, ankylosing spondylitis,
polymyositis, systemic lupus erythematosus, dermatomyositis,
polymyalgia rheumatica)
Principles of therapeutics

Mechanisms of action, use, and adverse effects of drugs for treatment of

disorders of the musculoskeletal system
Nonsteroidal anti-inflammatory drugs and analgesics
Muscle relaxants
Antigout therapy (eg, allopurinol, colchicine, uricosuric drugs)
Immunosuppressive drugs (eg, glucocorticoids, gold, cytotoxic agents)
Drugs affecting bone mineralization (eg, diphosphonates, calcitonin,
estrogen analogs)
Other therapeutic modalities (eg, radiation, surgery, casts, rehabilitation)

Gender, ethnic, and behavioral considerations affecting disease treatment and

prevention, including psychosocial, cultural, occupational, and environmental

Emotional and behavioral factors (eg, diet, exercise, seat belts, bicycle
helmets)
Influence on person, family, and society (eg, osteoporosis, fractures in
elderly, alcohol abuse, and fractures)
 Occupational and other environmental risk factors (eg, athletes,
musicians)
Gender and ethnic factors (eg, bone mass)
Respiratory System
Normal processes

Embryonic development, fetal maturation, and perinatal changes

Cell/tissue structure and function, including surfactant formation,
alveolar structure
Repair, regeneration, and changes associated with stage of life
Pulmonary defense mechanisms and normal flora
Organ structure and function
Airways, including mechanics and regulation of breathing
Lung parenchyma, including ventilation, perfusion, gas exchange
Pleura
Nasopharyx and sinuses

Abnormal processes

Infectious, inflammatory, and immunologic disorders

Infectious diseases
Infectious diseases of the upper respiratory tract (eg, sinusitis,
pharyngitis)
Acute infectious diseases of the lower respiratory tract and pleura and
their complications (eg, pneumonia, bronchiectasis, abscess, empyema)
Chronic infectious diseases of the lower respiratory tract (eg,
Mycobacterium, endemic fungal infections, Nocardia/Actinomyces)
Immunologic disorders
Allergic and hypersensitivity disorders (eg, asthma)
Autoimmune disorders (eg, Wegener granulomatosis, Goodpasture
syndrome)
Inflammatory disorders
Pneumoconioses
Acute and chronic alveolar injury (eg, acute respiratory distress syndrome,
chlorine gas/smoke inhalation)
Obstructive pulmonary disease
Restrictive pulmonary disease (eg, sarcoidosis, idiopathic fibrosis)
Traumatic and mechanical disorders (eg, foreign body aspiration,
pneumothorax, atelectasis, sleep apnea)
Neoplastic disorders (eg, polyps, bronchogenic carcinoma,
mesothelioma, metastatic tumors)
Metabolic, regulatory, and structural disorders (eg,
hypoventilation, disorders of gas exchange, ventilation-perfusion
imbalance, neonatal respiratory distress syndrome)
Vascular and circulatory disorders (eg, thromboembolic disease,
pulmonary hypertension, pulmonary edema, pleural effusion)
Systemic disorders affecting the respiratory system

Principles of therapeutics

Mechanisms of action, use, and adverse effects of drugs for treatment of

disorders of the respiratory system (eg, decongestants, cough
suppressants, expectorants, mucolytics; bronchodilator drugs; anti-
 inflammatory and cytotoxic drugs; antimicrobial agents; antineoplastic
agents)
Other therapeutic modalities (eg, oxygen therapy, nasal CPAP, mechanical
ventilation, physical therapy, surgical procedures, including
transplantation)
Gender, ethnic, and behavioral considerations affecting disease treatment and
prevention, including psychosocial, cultural, occupational, and environmental

Emotional and behavioral factors (eg, smoking, substance abuse, pets,

and allergies)
Influence on person, family, and society (eg, tuberculosis, asthma, chronic
obstructive pulmonary disease, school issues, protective parents, family
smoking)
Occupational and other environmental risk factors
Gender and ethnic factors (eg, sarcoidosis, lung cancer)
Cardiovascular System
Normal processes

Embryonic development, fetal maturation, and perinatal changes

Organ structure and function
Chambers, valves
Cardiac cycle, mechanics, heart sounds, cardiac conduction
Hemodynamics, including systemic, pulmonary, coronary, and blood
volume
Circulation in specific vascular beds
Cell/tissue structure and function
Heart muscle, metabolism, oxygen consumption, biochemistry, and
secretory function (eg, atrial natriuretic peptide)
Endothelium and secretory function, vascular smooth muscle,
microcirculation, and lymph flow
Mechanisms of atherosclerosis
Neural and hormonal regulation of the heart, blood vessels, and blood
volume, including responses to change in posture, exercise, and tissue
metabolism
Repair, regeneration, and changes associated with stage of life

Abnormal processes

Traumatic and mechanical disorders (eg, tamponade, valvular

disease, obstructive cardiomyopathy)
Neoplastic disorders
Metabolic and regulatory disorders (eg, dysrhythmias, systolic
and diastolic dysfunction, low- and high-output heart failure, cor
pulmonale, systemic hypertension, ischemic heart disease,
myocardial infarction, systemic hypotension, and shock)
Vascular disorders (eg, aneurysms, occlusions, varicosities,
atherosclerosis)
Systemic diseases affecting the cardiovascular system (eg,
amyloidosis, aortic dissection with Marfan syndrome, and
scleroderma)
Congenital disorders of the heart and central vessels
Infectious, inflammatory, and immunologic disorders
Infectious disorders (eg, endocarditis, myocarditis, pericarditis)
Inflammatory and immunologic disorders (eg, acute rheumatic fever,
systemic lupus erythematosus, transplant rejection, vasculitis, temporal
arteritis)
Principles of therapeutics

Mechanisms of action, use, and adverse effects of drugs for

treatment of disorders of the cardiovascular system
Coronary and peripheral vasodilators
Antiarrhythmic drugs
Antihypertensive drugs
Measures used to combat hypotension and shock
Drugs affecting cholesterol and lipid metabolism
 Drugs affecting blood coagulation, thrombolytic agents
Inotropic agents and treatment of heart failure
Immunosuppressive and antimicrobial drugs
Drugs to treat peripheral arterial disease
Other therapeutic modalities (eg, pacemakers, angioplasty,
valves, grafts, other surgical procedures)
Gender, ethnic, and behavioral considerations affecting disease treatment and
prevention, including psychosocial, cultural, occupational, and environmental

Emotional and behavioral factors (eg, smoking, alcohol, ischemic heart

disease, obesity, exercise, diet)
Influence on person, family, and society (eg, altered lifestyle)
Occupational and other environmental risk factors (eg, stress)
Gender and ethnic factors (eg, hypertension)
Gastrointestinal System
Normal processes

Embryonic development, fetal maturation, and perinatal changes

Organ structure and function, including alimentary canal, liver
and biliary system, salivary glands and exocrine pancreas,
motility, and digestion and absorption
Cell/tissue structure and function
Endocrine and neural regulatory functions, including GI hormones
Salivary, gastrointestinal, pancreatic, hepatic secretory products, including
Enzymes, proteins, bile salts, and processes
Synthetic and metabolic functions of hepatocytes
Repair, regeneration, and changes associated with stage of life
Gastrointestinal defense mechanisms and normal flora

Abnormal processes

Infectious, inflammatory, and immunologic disorders

Infectious disorders (eg, peritonitis, hepatitis, gingivostomatitis, peptic
ulcer, gastritis, esophagitis, traveler's diarrhea, food poisoning)
Inflammatory disorders (eg, cholecystitis, pancreatitis)
Immunologic disorders (eg, Crohn disease, ulcerative colitis)
Traumatic and mechanical disorders
Malocclusion
Hiatus hernia
Obstruction (eg, volvulus, intussusception, esophageal atresia, annular
pancreas, postsurgical obstruction)
Perforation of hollow viscus and blunt trauma
Inguinal, femoral, and abdominal wall hernias
Esophageal and colonic diverticula (eg, Meckel diverticulum)
Neoplastic disorders, including benign and malignant metabolic
and regulatory disorders (eg, motility disorders, malabsorption,
hepatic failure, cholelithiasis)
Vascular disorders (eg, portal hypertension, hemorrhoids,
ischemia, angiodysplasia)
Systemic disorders affecting the gastrointestinal system

Principles of therapeutics

Mechanisms of action, use, and adverse effects of drugs for

treatment of disorders of the gastrointestinal system
Treatment and prophylaxis of peptic ulcer disease and gastroesophageal
reflux (eg, antacids, antisecretory drugs, motility drugs, mucosal
protective agents, antibiotics)
Drugs to alter gastrointestinal motility (eg, cathartics, antidiarrheal drugs,
antiemetic drugs, prokinetic drugs)
Fluid replacement (eg, oral rehydration)
Pancreatic replacement therapy and treatment of pancreatitis
Drugs for treatment of hepatic failure (eg, lactulose) and biliary disease
(eg, drugs to dissolve gallstones)
 Anti-inflammatory, immunosuppressive, antineoplastic, and antimicrobial
drugs
Other therapeutic modalities (eg, surgical procedures, stents,
feeding tubes)
Gender, ethnic, and behavioral considerations affecting disease treatment and
prevention, including psychosocial, cultural, occupational, and environmental

Emotional and behavioral factors (eg, compliance in diabetes mellitus,

factitious use of insulin, psychogenic polydipsia)
Influence on person, family, and society
Occupational and other environmental risk factors (eg, radiation exposure,
iodine deficiency)
Gender and ethnic factors

Renal/Urinary System
Normal processes

Embryonic development, fetal maturation, and perinatal changes

Organ structure and function
Kidneys, ureters, bladder, urethra
Glomerular filtration and hemodynamics
Tubular reabsorption and secretion, including transport processes and
proteins
Urinary concentration and dilution
Renal mechanisms in acid-base balance
Renal mechanisms in body fluid homeostasis
Micturition
Cell/tissue structure and function, including renal metabolism and
oxygen consumption, hormones produced by or acting on the
kidney
Repair, regeneration, and changes associated with stage of life

Abnormal processes

Infectious, inflammatory, and immunologic disorders

Infectious disorders
Upper urinary tract (eg, pyelonephritis, papillary necrosis)
Lower urinary tract (eg, cystitis, urethritis)
Inflammatory and immunologic disorders
Glomerular disorders (eg, glomerulonephritis, nephrotic syndrome, and IgA
nephropathy)
Tubular interstitial disease (eg, interstitial nephritis, transplant rejection)
Metabolic and regulatory disorders
Renal failure, acute and chronic (eg, acute tubular necrosis)
Tubular and collecting duct disorders (eg, Fanconi syndrome, renal tubular
acidosis, nephrogenic diabetes insipidus, polycystic kidney disease)
Renal calculi
Traumatic and mechanical disorders (eg, obstructive uropathy)
Neoplastic disorders, primary (eg, renal, urinary bladder and
collecting system) and metastases
Vascular disorders (eg, renal artery stenosis)
Systemic diseases affecting the renal system (eg, diabetes
mellitus, hepatitis, amyloidosis, systemic lupus erythematosus,
Wegener granulomatosis)
Principles of therapeutics

Mechanisms of action, use, and adverse effects of drugs for

treatment of disorders of the renal and urinary system
Diuretics, antidiuretic drugs
Drugs and fluids used to treat volume, electrolyte, and acid-base disorders
Drugs used to enhance renal perfusion (eg, dopamine)
Anti-inflammatory, antimicrobial, immunosuppressive, and antineoplastic
drugs
 Drugs used to treat lower urinary tract system (eg, incontinence, bladder
function, benign prostatic hyperplasia)
Other therapeutic modalities (eg, dialysis, renal transplantation)

Gender, ethnic, and behavioral considerations affecting disease treatment and

prevention, including psychosocial, cultural, occupational, and environmental

Emotional and behavioral factors (eg, drug-induced interstitial nephritis,

diet)
Influence on person, family, and society (eg, hemodialysis, living related
kidney donation, transplants)
Occupational and other environmental risk factors (eg, heavy metals)
Gender and ethnic factors (eg, disease progression, urinary tract
infections)
Reproductive System
Normal processes

Embryonic development, fetal maturation, and perinatal changes

Organ structure and function
Female structure, including breast
Female function (eg, menstrual cycle, puberty, menopause)
Male structure
Male function (eg, spermatogenesis, puberty)
Intercourse, orgasm
Pregnancy, including labor and delivery, the puerperium, lactation,
gestational uterus, placenta
Cell/tissue structure and function, including hypothalamic-
pituitary-gonadal axis, sex steroids, and gestational hormones
Reproductive system defense mechanisms and normal flora

Abnormal processes

Infectious, inflammatory, and immunologic disorders (eg, toxic

shock syndrome, breast abscess, orchitis, sexually transmitted
diseases, autoimmune hypogonadism, cystic mastitis)
Traumatic and mechanical disorders (eg, female incontinence,
torsion of testis, varicocele)
Neoplastic disorders (eg, female reproductive, male reproductive,
breast [including fibrocystic changes], trophoblastic disease)
Metabolic and regulatory processes
Female (eg, anovulation, infertility, polycystic ovaries, endometriosis,
orgasmic dysfunction, delayed and premature puberty)
menopausal syndrome
Male (eg, infertility, impotence, gynecomastia, delayed and premature
puberty)
Benign prostatic hyperplasia
Systemic disorders affecting reproductive function (eg, obesity,
myotonic dystrophy, cirrhosis, renal failure)
Disorders relating to pregnancy, the puerperium, and the
postpartum period
Obstetric problems (eg, ectopic pregnancy, third-trimester bleeding)
Complications affecting other organ systems (eg, eclampsia, gestational
diabetes, thyroid disorders)
Disorders associated with the puerperium (eg, postpartum hemorrhage,
sepsis, depression)
Antepartum, intrapartum, postpartum disorders of the fetus (eg,
prematurity, postmaturity, cord compression, macrosomia)
Principles of therapeutics

Mechanisms of action, use, and adverse effects of drugs for

treatment of disorders of the reproductive system and
management of normal reproductive function
Female reproductive tract
Fertility drugs
 Oral contraception, other methods of contraception (eg, condoms)
Estrogen, progestogen replacement, treatment of menopause
Stimulants and inhibitors of labor
Estrogen and progesterone antagonists
Stimulators and inhibitors of lactation
Male reproductive tract
Fertility drugs
Androgen replacement and antagonists
Gonadotropin-releasing hormone and gonadotropin replacement
Abortifacients
Antimicrobials
Antineoplastics
Restoration of potency
Other therapeutic modalities affecting the reproductive system
(eg, tampons, anabolic steroids)
Gender, ethnic, and behavioral considerations affecting disease treatment and
prevention, including psychosocial, cultural, occupational, and environmental

Emotional and behavioral factors (eg, sexually transmitted diseases)

Influence on person, family, and society (eg, infertility)
Occupational and other environmental risk factors (eg, radiation)
Family planning and pregnancy (eg, unwanted)
Gender identity, sexual orientation, sexuality, libido
Effects of traumatic stress syndrome, violence, rape, child abuse
Endocrine System
Normal processes

Embryonic development, fetal maturation, and perinatal changes

Organ structure and function
Hypothalamus, posterior and anterior pituitary gland
Thyroid gland
Parathyroid glands
Adrenal cortex, adrenal medulla
Pancreatic islets
Ovary and testis
Adipose tissue
Cell/tissue structure and function, including hormone synthesis,
secretion, action, and metabolism
peptide hormones
Steroid hormones, including vitamin D
Thyroid hormones
Catecholamine hormones
Renin-angiotensin system
repair, regeneration, and changes associated with stage of life

Abnormal processes

Infectious, inflammatory, and immunologic disorders (eg, subacute

thyroiditis, Graves disease, sarcoidosis)
Traumatic and mechanical disorders
Neoplastic disorders (eg, pituitary, thyroid, parathyroid, adrenal cortex,
pancreatic islets, neural crest, pheochromocytoma)
Metabolic and regulatory processes (eg, diabetes mellitus, pituitary,
hypothalamus, thyroid, parathyroid, pancreatic islet disorders, adrenal
disorders)
Vascular disorders (eg, pituitary apoplexy)
Systemic disorders affecting the endocrine system
Idiopathic disorders (eg, hirsutism)

Principles of therapeutics

Mechanisms of action, use, and adverse effects of drugs for

treatment of disorders of the endocrine system
Hormones and hormone analogs
Stimulators of hormone production (eg, sulfonylureas)
Inhibitors of hormone production (eg, thiouracils)
Hormone antagonists
Potentiators of hormone action (eg, thiazolidinediones)
Antiobesity agents
Other therapeutic modalities (eg, surgery, radiation)

Gender, ethnic, and behavioral considerations affecting disease treatment and

prevention, including psychosocial, cultural, occupational, and environmental
 Emotional and behavioral factors (eg, compliance in diabetes mellitus,
factitious use of insulin, psychogenic polydipsia)
Influence on person, family, and society
Occupational and other environmental risk factors (eg, radiation exposure,
iodine deficiency)
Gender and ethnic factors
OTHER BOOKS

First Aid is a favourite amongst American medical students. I only went

through it twice but I found it to be quite helpful. You may like to study it
once early in your coursework and once later before the exam. You can
even go one step further and make it your primary book. In that case you
may have to annotate it and make up for the deficiencies in this book. In my
opinion, it still has enough information to guarantee a 99 on Step1 provided
you study it comprehensively and carefully.
Kaplan medessentials is a similar book to First Aid. It has essentially all
of the Kaplan series condensed into a single book. Some Americans call it
medsuperfluous. Its unnecessarily detailed at some places and
understated in others. Still it has the benefit of complementing your Kaplan
textbook study. You may use it if you like a very quick glance at a lot of
information, typically arranged system-wise e.g. Cardiovascular system.
This helps you to save time flipping through different books in case you like
to apply a systems approach at some point during your coursework.

Step1 secrets is another rather useful book I encountered. I didnt study it

all so I cannot comment but based on others opinions, it has everything
arranged neatly in a question-and-answer format and written in simple
language. Oversimplification is evident at a lot of places and requires
rigorous supplementation by more detailed textbooks. If a high 99 is not
your aim or if you realize that studying simple textbooks may ensure
something like a 90-99 score rather than pursuit of a high 99 having to
utilize detailed textbooks and running the risk of losing score, thats the
book for you. It has little of everything that should benefit you in the actual
exam. If nothing else works or you have run into anxiety, throw every other
book away even First Aid. Pick this book and just study it. It is written in a
beautiful manner utilizing a very student friendly approach and doesn't run
aggressively amok anywhere. Studying this book alone carefully can give
you a 90+ score.

QUESTION RESOURCES:
You have the following question banks. They are discussed separately.

USMLE World:

It can be found at usmleworld.com. This question resource has consistently

high ratings amongst students and Americans love using it to supplement
their study of First Aid. You can buy it for 100$ for one month. Subscriptions
greater than a month have substantial discounts. You can get their books
but theyre all pirated and illegal material. I would highly recommend buying
this for a single month at least. Typically this should be used to maximum
effect about 1-2 months before your actual exam. Others recommend using
it as soon as possible but I have a different opinion. The explanations given
in this resource are the best amongst all others and some Americans
actually solely rely upon the explanations for their revision. If you start it
late in coursework, you ensure adequate revision and security of keeping it
in memory. Questions typically use 2-3 step thinking processes and require
good integration of concepts, so its a tough question resource. My advice
is to solve all questions and read their explanation regardless of whether
you get any question correct or incorrect.

KAPLAN Qbank:
This can be accessed at kaplanmedical.com. It is very expensive: 130$ per
month and additional months purchased have substantial discounts. You
can get their books but again, thats pirated and illegal. They dont release
any textbooks. Americans dont prefer using this resource. Kaplan Qbank
relies quite extensively on knowledge given in their textbooks and at times,
it feels they are exclusively focused on specific knowledge pointers in their
questions, rather than good integration of concepts as done by usmleworld.
Furthermore it has a habit of testing knowledge that is both Step1 irrelevant
and not given in recommended textbooks (not even in their own
textbooks!). Overall I would recommend this Qbank. It has the advantage of
using Qtutorials (refer to their website), good media, good explanations and
a huge question resource. You dont have to attempt all of the questions
given. Its preferable to use this resource early in your coursework.

USMLErx:

This can be accessed at usmlerx.com. This is the least expensive of all

qbanks with a single month subscription at 70$. Instead of Kaplan you may
want to utilize this resource early in your coursework. This is the work of
contributors of First Aid. So it heavily relies on info resource of First Aid.
This can be an advantage if you are using First Aid as well. Repetition of
facts in first aid ensures adequate retention in memory. However some
questions may not correctly reflect the standard and format of current
USMLE exams and rely somewhat on typical case scenario facts and
explanations. In addition, a lot more questions directly test knowledge
rather than careful integration of facts. Best utilized early in coursework.
 First Aid Q & A book:
Similar to usmlerx. In fact they state questions are taken from usmlerx
resource. It has 1000 questions, 650 organized systems wise and 350
organized into a full length exam with 7 blocks (remember current USMLE
has only 322 questions in 7 blocks). I used this book late in my study but I
recommend using it early. It may be a less expensive substitute to usmlerx
questions resource as well. Explanations are good and have cross
referencing to First Aid text which may help your revision. Remember this is
an official First Aid release.

Mededia Qbank:
Surprised? Stay tuned for more updates in near future! I assure you this
would be a very high quality Qbank with MCQs according to the new format
of more clinical scenarios and quality better than all mentioned qbanks. I
am working with Dr. Umar Tariq on it; it would be available online in a few
months times and would be entirely free of cost so you may start using this
questions resource early or late in your coursework depending upon your
choice.

If you are interested in authoring MCQs for this Qbank, kindly contact me at
dr.ayazmk@yahoo.com or Dr. Umar Tariq and we would be happy to
include you as a co-author/ contributor on submission of some high-quality
MCQs and would mention your name on the main book cover. I am sure it
would prove to be a big boost to your CV and provide help to your
colleagues; the same reason I am doing it for.

The reason for its inception is to reflect the current trends in the USMLE
Step 1 exam. Step1 is an ever-evolving exam; the examiners are very well
aware of what guide-books and short-cuts students love using. As an
example heart sounds that appeared in previous Step1 exams could
typically be resolved by simply contemplating the question stem and not
even listening to the sounds, as stated by some examinees! Now you must
have a sound knowledge of heart sounds. If you are as unlucky as I was,
you may get those varieties sometimes only cardiologists can decipher with
a degree of confidence. Apart from that, the examiners know that many
students rely heavily on First Aid. By no means you can't get a 99 by
studying First Aid alone, but this is to tell you that the style keeps evolving
in order to maintain a very high standard of this exam. Therefore we
decided to make a brand new collection of questions resource that would
adequately aid your Step 1 preparation.
 Wikitestprep.org:
This is a spin-off of Wikipedia with about 800+ questions free of cost,
contributed by various authors. Because there is little quality check and
control over the type of questions, a lot more questions do not reflect the
USMLE style than questions that do. Integration of concepts is rarely
tested. Since its free, you may like to use it early in coursework but
remember that some questions are factually incorrect, others are vague
and their explanations may not reflect high yield material.

NBME exams:
These exams can be purchased at NBME website for about 45$ each and
has 200 questions each arranged in 4 blocks. You may buy about 2 or 3
such exams, from a total of 7. It is very important to use atleast one exam
early in coursework and another late in coursework to gauge your
performance levels, strengths and weaknesses. In addition a projected 3
digit score is given to you at the end of your exam that is highly predictive
of your actual USMLE Step 1 score. NBMEs are also not reflective of
current USMLE style. Most questions are very easy making the marking
very stringent and strict. But you have to use these exams to quantitate
your performance levels. I recommend buying 3. Use one early, another in
the middle and the last one late in your coursework to ensure adequate
progression in your study.

USMLE World Self-Assessment forms:

They can be accessed at usmleworld.com and have a cost of 30$ each.
They are two in number. When purchased together, they cost 50$ in total.
They have the added advantage of allowing you to study questions you got
incorrect or correct and read all explanations, over NBME which allows
neither. Best used late in your coursework and you should attempt to study
all the explanations. There are 192 questions in each exam.

Kaplan Qbook:
This is an official release of Kaplan Medical. I did go through it randomly at
first. It has various blocks of 50 questions each organized in a subject-wise
manner (not systems wise). Unfortunately various questions are again not
reflective of current exam and are typically "easy". The most poorly
composed section is, as expected, Behavioural sciences. Two blocks of 50
questions each of absolute madness. It follows the same philosophy of
Kaplan's Qbank somewhat hinting more at retrieval of an examinee's
memory rather than integration of concepts.

GETTING STARTED WITH IT ALL:

You have the choice to study either during your medical studies or after
your graduation. As I already explained earlier, studying during your
medical school is substantially better than after your graduation. However
USMLE is a difficult exam that needs honesty and time commitment. You
cannot study this exam for the fun or sake of it because that may seriously
backfire with a very low score. Only sit this exam once you are sure of your
preparation. Using NBMEs is one way of assessing your preparedness.

In case you wished to appear in Step 1 during your medical studies but
became very anxious or your NBME score is not so good, your time wasnt
lost! You can carry that knowledge over to studying for Step2 CK as well
during your final year. In that case you may begin to feel confident enough
to give Step2 Ck before your Step1 because you had already had some
feel of how Step1 looks like.

The best way is to begin as early as possible in your medical studies.

Study only good American textbooks. I recommend you to study the
following textbooks during your medical education:

Snells Anatomy
Snells Neuroanatomy
Ganongs Physiology
Lippincott Biochemistry and Molecular Biology
Katzungs Pharmacology (Board Review Series)
Levinsons Microbiology and Immunology
Medium Robbins supplemented by Goljan, or even Goljan alone
For behavioural science, you may have to rely on textbooks already stated
above.

The textbooks above ensure you get a sound grasp on the subject in
question. Using these resources ensure youre automatically geared
towards Step1 prep. Strictly avoid using textbooks authored in the
subcontinent as not one single such textbook lives up to the standard of the
books above.
Heres a tour through a Step1 preparation.

First few months; getting started:

A lot of us subcontinent people use Kaplan. Americans get about 2 months

off at end of their 2nd year, and study Goljan, First Aid and Usmleworld.

You may need to use the videos. You dont necessarily have to listen to all
these videos. You may form good concepts but as soon as that happens,
youd immediately forget later on. Using videos for referencing again and
again is time consuming and frustrating. A good detailed textbook is a very
good substitute. If grasping DNA synthesis from Kaplans biochemistry
textbook is difficult, jump straight to Lippincott. Unfortunately this cross
referencing is something youd have to do extensively throughout your
Step1 study. So keep all the major textbooks readied.

First just go through the Kaplan. Understand, learn or not, is not a matter.
Try to get a feel of what Step1 syllabus content is like. Next you may want
to use video lectures to aid you in understanding difficult concepts and also
for the sake of simply touring through the Step1. In these first few months,
use your major textbooks extensively. Dont be afraid to open Snells
neuroanatomy or Ganongs Physiology to clarify difficult concepts. Once
done, write them for your records somewhere. You can maintain a
notebook to serve that purpose. Alternatively you may annotate the Kaplan
books. Choice is yours.

Doing all of that would take quite a lot of time. Be patient. Dont rush
through your study schedule or try jumping ahead. Do justice to all your
subjects. Remember subjects like Pharmacology and Microbiology require
constant attention. This means that as soon as youre done with your first
pass, try to immediately jump back to these subjects and revise them. Dont
limit these subjects to a mere 3 or 4 reads. Its indefinitely high yield to do
as many quick reads of these subjects as is possible. This ensures
adequate retention of facts in your memory. You dont have to use question
resources at this moment.

So the initial stage of your study is simply quick pass through the syllabus
content + careful pass through selected and difficult topics with extensive
cross referencing from major textbooks and maintenance of important
pointers in a notebook. Dont try to be a copycat and emulate others
timetables. Find the right solution to studying yourself.

Intermediate stage:
This stage introduces the question resources. As already stated, you can
rely on Usmlerx or Kaplan Qbank. Although you can find illegally printed
textbooks to these question resources, they dont give you the advantage
of mixing your questions, making random timed or self-paced blocks and
maintain a record of used and unused questions. As soon as MedEdia
releases its questions resources free of cost, you may like to check it out as
well.

My recommendation would be to use either question resource, and try

attempting questions systems wise. If you just finished a revision of
Biochemistry, hit the questions. Read the explanations to all questions, pick
up a notebook and write the important facts in that. Go through those facts
at regular stages. This would especially help you, in Biochemistrys case,
learn all the rate limiting enzymes and hormonal and allosteric controls.
Allosteric controls form an important testing component and is especially
tricky to understand, especially in the whole context of all metabolic
pathways.

Use this approach and apply to all subjects. You dont have to attempt the
whole question resource, but make sure you do attempt atleast a sufficient
number of questions. At this stage you may use either timed or self-paced
mode.

At the end, try and attempt an NBME exam. This should give you an idea
where you land and how far are you from your goal. Depending upon your
goal and the difference from your goal, you can modify that final stage of
your preparation in whatever manner you like.

Final stage:

Once again, quickly hit Pharmacology, Microbiology and especially

Behavioural science and revise these subjects. At least go through
remaining subjects once but the aforementioned ones should be given
special attention to because of the ease with which they are forgotten.
Remember now your momentum is very important. If you remain consistent
in this stage, you would drastically improve your final score. If you take
breaks or delay your exam, you would only end up wasting time.
Now is the time to start usmleworld.coms question resource. Americans at
this stage do 2 blocks of 48 questions (46 in real exam) everyday and
spend time reading all explanations. They supplement those explanations
into First Aid. You can try doing that too, to good effect. Mix in another
NBME and/or Usmle world Self Assessment forms which have already
been referenced to above.

Heres an important point: IF your NBME score is far off from your goal,
NOW you may contemplate delaying your exam. Always aim for the very
high, but you have to have a realistic appraisal of your own intellect and
ability. You must have both a very high goal, and a very realistic goal. Its
only you who can tell you what your abilities are. NBMEs usually are a very
accurate gauge of your performance. What they state is approximately
what your abilities are.

Keep using First Aid also, especially towards the week leading up to your
eventual exam. Make sure you have been following CTs, MRIs,
photomicrographs, gross specimens and X-Rays all along because these
are heavily tested. Keep focused on learning heart sounds as well. Last but
definitely not least, all those notes you made into your notebook, using your
own familiar handwriting towards the end of your preparation would most
likely keep your anxiety levels in check. Do not even think about opening a
new book at this stage.

When youre done with your Kaplan, throw those books away and
concentrate only on First Aid and your own notes from Kaplan and question
resource explanations in last two weeks.

In your final day, you may take a day off after a stressful spell that spanned
several months. Make a list of things you need to take. Check your permit,
Prometric appointment, passport and National ID card.

Some tips about what to do during your last day and exam day:

I had the biggest misfortune of totally screwing up my sleep the very last
day. It wasnt anxiety. It happens sometimes to me that I cant go to sleep
even after 4-5 hours and by chance, it happened the very last night too.
Eventually I took a pill of Bromazepam, slept for 4 hours, and went to the
exam. The whole day was a battle with drowsiness. Energy drinks did
some trick but really, my first and second blocks were almost sacrificed
which must have led to reduction in my eventual score.
I would advise you to take a sleeping pill the last night and ensure a good
nights sleep. This is critically important before your exam that drowsiness
doesnt take over. You can use energy drinks during the day of your exam
but make sure you have used them before to be sure they dont end up
causing diarrhoea instead during the exam.

My experience with Step 1 preparation:

I started at the beginning of my fourth year. I was confident because I had

the fortune of having studied good textbooks in preference to local ones. I
started as usual: Buy Kaplan textbooks and the Video lectures. But I didn't
use all the video lectures because quarter-way through I realized that
although they are helping me solidify my concepts, they are of little value in
revision. I listened to Dr. Lionel Raymon's biochemistry lectures, Dr.
Anthony Trevor's Pharmacology lectures, and Dr. James'
Neuroanatomy lectures. I may have listened to others too somewhat, but
I don't clearly remember. All these mentioned lectures were the works of
genius people indeed and by all means, you should listen to what they
have to say about their subjects. You may elect to skip the other lectures.

As I have stated in the ideal preparation above, cross-referencing to good

textbooks is important and I felt the need always to do that. From February
through June, I managed to cover some subjects atleast once
(Pharmacology, Biochemistry, Anatomy), others twice (Microbiology),
still others only less than half (Immunology, Pathology) and remaining
none (Physiology, Behavioural sciences). You can try this same
methodology with the exception of including Behavioural sciences in the
"twice" category with Microbiology. So much for a "first read" I guess?

In July I managed to cover some major portions of usmleworld questions

resource especially microbiology and pharmacology. This helped
strengthen my knowledge of these subjects. Later I finished my first pass
through Physiology and Behavioural science (I told you I developed a
deja vu right after studying this!).

I would cover Pathology text with my medical studies in fourth year.

For example, when they had a class test, I'd study Goljan and Medium
Robbins.

Time passed and I started wasting time too. Perhaps I realized that
attempting the Step1 at end of my fourth year was overly ambitious. It
would have been very realistic if I started in 3rd year, which is why if you
are a student in 3rd year, by all means start your exam preparation! Till
November I had managed another pass at least once through most
subjects, with the exception of Physiology and Behavioural sciences (yet
again). In November I picked up First Aid and went through it in 2 weeks. I
registered for NBME form 3. I attempted it on November.....27th I think
(right after that was Eid-ul-Azha day). My score was projected 244. I
realized that this was very decent, given that I had yet to seriously cover
behavioural sciences and Physiology also.

After that, time for my professional exams at end of fourth year arrived.
ENT, Eye, Community Medicine and Special Pathology were the subjects
and I somehow managed a third position and distinction in Pathology. The
latter was significant because it motivated me once again for Step 1. But
this exam had seriously upset my rhythm and because my first ward in final
year was a maternity duty (day and night for 2 weeks = no time for Step 1
prep), I lost my way. This was why I stated how important is your study
momentum when taking into the final date. I somehow managed to pick
myself up, had to spend substantial time applying for electives and finally
started seriously in April. I finalized my date for June 10th, and immediately
started covering Physiology and Behavioural sciences which I had
neglected (and I'd advise you to not do as I did).

In that time I also went through Katzung board review pharmacology and
some part of Levinson, especially Parasitology. I also immediately revised
all of Pathology which I hadn't touched ever since I gave my fourth year
exam. All of a sudden it turned into a hi-octane study mode. Cursing myself
for wasting time, I gradually navigated my way through immediate
revisions, and then picked up First Aid Q and A book. I attempted all 1000
questions and wrote a majority of explanations in my notebook. Afterwards
I went through that once, especially revising the behavioural science
explanations. This really helped me immensely. Now it was already May
12th. I picked up first aid and finished it in next 8 days. I had attempted
Usmle world self-assessment form 1 on May 18th and my projected score
was 256. Needless to say, I felt more relieved than happy that the break in
my tempo didn't destroy my hopes. Then I picked up usmleworld once
again and navigated my way through it studying the majority of
explanations, and combining with the very final quick revision of kaplan
series. This continued on into June.

On June 5th, I attempted the second usmle world self assessment form
online. My projected score was 265+. Usmleworld doesn't give a score
beyond 265 so it states it as 265+ instead. I was happy. In the final few
days I went through explanations to the exam questions I just gave and my
own notebook. I'd occasionally open a few books but I would advise you
against it, to guard against unnecessary anxiety induction. Then the final
day came, I arranged my things together: Passport, permit, ID etc, went
and bought snacks, a sandwich, and energy drinks. At 9:30 PM I went to
bed. I thought I fell asleep at 10PM only to wake up moments later.
Sleeplessness continued till late night at 3AM when I finally took
Bromazepam and went to sleep for good. But the damage was done, and
damage continued into the first block of my exam. Second block suffered
as well but after that, through sheer willpower I fought with my drowsiness
and the exam and eventually finished it.

Moral of the story? A good night's sleep before your exam!

The exam really was very much like what usmle.org described it as. 46
questions per block, framed into clinical vignettes more so than not so. At
some stages I felt that questions were unnecessarily stretched with clinical
information. Exam has increased in difficulty overall, and timing did become
an issue for me especially in the first block where I had to resort to
guesswork towards the end but this was more attributable to my sleep
problems rather than the exam itself. The new Mededia Qbank is designed
to, therefore, reflect this trend and style. I will not write what topics were
tested or what was the distribution of subjects and I strictly advise you not
to do that either. The repercussions include ban from taking USMLE exam
for a limited number of years! So don't disseminate exam information
anywhere, even under the veil of anonymity internet provides you!