First Aid for the USMLE Step 1 2024: A Student-to-Student Guide (2024)

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FIRSTAIDUSMLESTEP2024FORTHE®®ASTUDENT-TO-STUDENTGUIDETHEmostrecommendedcontentresourceforUSMLEprepOver1,300must-knowconceptswithmanynewhigh-yieldfactsEnhancedtablesandmnemonicsforrapidlearningandhighretentionExceptionalillustrationsandimageshelpyouvisualizekeyconceptsTaoLeVikasBhushanConnieQiuAnupChalisePanagiotisKaparaliotisBoards&BeyondISNOWPARTOFTHEMcGRAWHILLFAMILYL E A R NM O R EMcGrawHill

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FORTHE®New York / Chicago / San Francisco / Athens / London / Madrid / Mexico CityMilan / New Delhi / Singapore / Sydney / TorontoUSMLESTEP 12024FIRSTAIDTAO LE, MD, MHSFounder, ScholarRxAssociate Clinical Professor, Department of MedicineUniversity of Louisville School of MedicineVIKAS BHUSHAN, MDFounder,First Aid for the USMLE Step 1Boracay, PhilippinesCONNIE QIU, MD, PhDResident, Department of DermatologyJohns Hopkins HospitalPANAGIOTIS KAPARALIOTIS, MDUniversity of Athens Medical School, GreeceKIMBERLY KALLIANOS, MDAssistant Professor, Department of Radiology and Biomedical ImagingUniversity of California, San Francisco School of MedicineANUP CHALISE, MBBS, MS, MRCSEdRegistrar, General and Colorectal SurgeryNorth Middlesex University Hospital, LondonCAROLINE COLEMAN, MDAssistant Professor, Department of MedicineEmory University School of MedicineSEAN EVANS, MDResident, Department of MedicineEmory University School of Medicine

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First Aid for the® USMLE Step 1 2024: A Student-to-Student GuideCopyright © 2024 by Tao Le and Vikas Bhushan. All rights reserved. Printed in the United States of America. Except aspermitted 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 ofthe publisher.Previous editions copyright © 1991 through 2023 by Tao Le and Vikas Bhushan. First edition copyright © 1990, 1989by Vikas Bhushan, Jeffrey Hansen, and Edward Hon.Photo and line art credits for this book begin on page 755 and are considered an extension of this copyright page.Portions of this book identified with the symbolare copyright © USMLE-Rx.com (MedIQ Learning, LLC).Portions of this book identified with the symbolare copyright © Dr. Richard Usatine.Portions of this book identified with the symbolare under license from other third parties. Please refer to page 755for 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 9LMN27 26 25 24 23 22ISBN 978-1-266-07720-3MHID 1-266-07720-0NoticeMedicine 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 checkedwith sources believed to be reliable in their efforts to provide information that is complete and generally inaccord with the standards accepted at the time of publication. However, in view of the possibility of humanerror or changes in medical sciences, neither the authors nor the publisher nor any other party who has beeninvolved in the preparation or publication of this work warrants that the information contained herein is inevery respect accurate or complete, and they disclaim all responsibility for any errors or omissions or for theresults obtained from use of the information contained in this work. Readers are encouraged to confirm theinformation contained herein with other sources. For example and in particular, readers are advised to checkthe product information sheet included in the package of each drug they plan to administer to be certainthat 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 importancein connection with new or infrequently used drugs.This book was set in Electra LT Std by GW Inc.The editors were Bob Boehringer and Christina M. Thomas.Project management was provided by GW Inc.The production supervisor was Jeffrey Herzich.LSC Communications was printer and binder.This book is printed on acid-free paper.Copyright © 2024. Exclusive rights by McGraw Hill for manufacture and export. This book cannot be reexported fromthe country to which it is consigned by McGraw Hill. The International Edition is not available in North America.McGraw Hill books are available at special quantity discounts to use as premiums and sales promotions,or for use in corporate training programs. To contact a representative please visit the Contact Us pages atwww.mhprofessional.com.

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DedicationTo medical students and physicians worldwide forcollaborating to improve medical education and practice.

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vContentsContributing AuthorsviiAssociate AuthorsviiiFaculty AdvisorsixPrefacexiSpecial AcknowledgmentsxiiGeneral AcknowledgmentsxiiiHow to ContributexvHow to Use This BookxviiSelected USMLE Laboratory ValuesxviiiFirst Aid Checklist for the USMLE Step 1xx`S E C T I O N IG 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 N1Introduction2USMLE Step 1—The Basics2Learning Strategies10Timeline for Study14Study Materials17Test-Taking Strategies20Clinical Vignette Strategies21If You Think You Failed22Testing Agencies23References23`S E C T I O N I S U P P L E M E N TS P E C I A L S I T UAT I O N S25`S E C T I O N I IH I G H - Y I E L D G E N E R A L P R I N C I P L E S27How to Use the Database28Biochemistry31Immunology93Microbiology121Pathology201Pharmacology227Public Health Sciences255

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vi`S E C T I O N I I IH I G H - Y I E L D O R G A N S YS T E M S279Approaching the Organ Systems280Cardiovascular283Endocrine329Gastrointestinal363Hematology and Oncology409Musculoskeletal, Skin, and Connective Tissue449Neurology and Special Senses499Psychiatry569Renal595Reproductive629Respiratory677Rapid Review707`S E C T I O N I VTO P - R AT E D R E V I E W R E S O U R C E S739How to Use the Database740Question Banks742Web and Mobile Apps742Comprehensive743Anatomy, Embryology, and Neuroscience743Behavioral Science744Biochemistry744Cell Biology and Histology744Microbiology and Immunology744Pathology745Pharmacology745Physiology746`Abbreviations and Symbols747Image Acknowledgments755Index773About the Editors828

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viiContributing AuthorsCHRISTIAN FAABORG-ANDERSEN, MDResident, Department of MedicineMassachusetts General HospitalMORGAN BUCHANAN, MPHEmory University School of MedicineClass of 2025ANTHONY G. CHESEBRORenaissance School of Medicine, Stony Brook UniversityMD/PhD candidateEMILY HANDSt. George’s University School of Medicine, GrenadaClass of 2024KATHERINE LEBLANC, MScUniversity of Washington School of MedicineMD/PhD CandidateANNA LIGOCKI, MD, MSResident, Department of MedicineAscension Saint Agnes HospitalFAATEH AHMAD RAUF, MBBSResident, Department of MedicineISMMS NYC Health+Hospitals/QueensCAROLINA CABAN RIVERALewis Katz School of Medicine at Temple UniversityClass of 2025JAIMIE LYNN ROGNER, MD, MPHResident, Departments of Medicine and PediatricsUniversity of Rochester Medical CenterGEORGIOS M. STERGIOPOULOS, MDResearch Fellow, Department of Molecular MedicineMayo Clinic, MinnesotaImageandIllustratIonteamYOOREE GRACE CHUNGEmory University School of MedicineMD/PhD CandidateTANYA KONDOLAY, MPHAureus University School of MedicineMD CandidateNOAH NEWMAN, MDResident, Department of Internal MedicineEmory University School of Medicine

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viiiAssociate AuthorsMAKENNA ASHEmory University School of MedicineClass of 2025MARGARET GINOZA, MD, MPHResident, Internal Medicine–PediatricsBaylor College of MedicineTALEAH KHAN, MBBSCMH Lahore Medical College and Institute of Dentistry, PakistanPRABHAT POUDEL, MBBSNepal Medical College Teaching Hospital, NepalDANUSHA SANCHEZ, MDResident, Department of Emergency MedicinePoznań University of Medical Sciences, PolandADITYA SINGH, MBBSAll India Institute of Medical Sciences, Raipur, IndiaANNABEL LUEmory University School of MedicineClass of 2024ImageandIllustratIonteamAUBREY REEDEmory University School of MedicineMD/PhD Candidate

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ixFaculty AdvisorsRITU AMATYAFHI 360, NepalMARK A.W. ANDREWS, PhDProfessor and Founding Chairman, Department of PhysiologyDuquesne University College of Osteopathic MedicineMARIA ANTONELLI, MDAssistant Professor, Division of RheumatologyCase Western Reserve University at MetroHealth Medical Center, ClevelandSAMAN BENTOTA, MDPhysician and MicrobiologistSri LankaJOE B. BLUMER, PhDAssociate Professor, Department of PharmacologyMedical University of South Carolina College of MedicineBRADLEY J. BRUGGEMAN, MDAssistant Professor, Obstetrics and GynecologyUniversity of Florida College of MedicineCHRISTOPHER M. BURNS, PhDProfessor of Basic Medical SciencesUniversity of Arizona College of Medicine, PhoenixBROOKS D. CASH, MDChief, Gastroenterology, Hepatology, and NutritionUniversity of Texas Health Science Center at HoustonDIMITRI CASSIMATIS, MDAssociate Professor, Department of MedicineEmory University School of MedicineCATHERINE CHILES, MDAssociate Clinical Professor of PsychiatryYale School of MedicineBRADLEY COLE, MDAssistant Professor of NeurologyLoma Linda University School of MedicineCAROLINE COLEMAN, MDAssistant Professor, Department of MedicineEmory University School of MedicineMARTHA FANER, PhDAssociate Professor of Biochemistry and Molecular BiologyMichigan State University College of Osteopathic MedicineCONRAD FISCHER, MDAssociate Professor, Medicine, Physiology, and PharmacologyTouro College of MedicineAYAKO WENDY FUJITA, MDFellow, Division of Infectious DiseasesEmory University School of MedicineRAYUDU GOPALAKRISHNA, PhDProfessor, Department of Integrative Anatomical SciencesKeck School of Medicine of University of Southern CaliforniaMEREDITH K. GREER, MDAssistant Professor, Division of Pulmonary, Allergy, Critical Care, and SleepMedicineEmory University School of MedicineAMBER J. HECK, PhDAssociate Professor, Department of Microbiology, Immunology, andGeneticsUniversity of North Texas Health Science Center, Fort WorthVASUDEVA G. KAMATH, MSc, PhDAssistant Professor of BiochemistryThe University of Arizona College of Medicine, PhoenixCLARK KEBODEAUX, PharmDClinical Associate Professor, Pharmacy Practice and ScienceUniversity of Kentucky College of PharmacyMATTHEW KRAYBILL, PhDClinical NeuropsychologistCottage Health, Santa Barbara, CaliforniaGERALD LEE, MDAssociate Professor, Departments of Pediatrics and MedicineEmory University School of MedicineKACHIU C. LEE, MD, MPHAssistant Professor (Adjunct), Department of DermatologyLewis Katz School of Medicine at Temple University

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xJAMES LYONS, MDAssociate Dean, Professor of Pathology and Family MedicineAlabama College of Osteopathic MedicineNILADRI KUMAR MAHATO, MBBS, MS, PhDAssistant Professor of AnatomyMarian University College of Osteopathic Medicine, IndianapolisCARL MARFURT, PhDProfessor Emeritus, Department of Anatomy, Cell Biology and PhysiologyIndiana University School of Medicine–Northwest, GaryPETER MARKS, MD, PhDCenter for Biologics Evaluation and ResearchUS Food and Drug AdministrationDOUGLAS A. MATA, MD, MPHDirector of Molecular PathologyFoundation Medicine, Cambridge, MassachusettsSOROUSH RAIS-BAHRAMI, MD, MBAProfessor of Urology and RadiologyUniversity of Alabama at Birmingham Heersink School of MedicineRICHARD P. RAMONELL, MDAssistant Professor of Medicine, Division of Pulmonary, Allergy, CriticalCare, and Sleep MedicineUniversity of Pittsburgh School of MedicineKEISHA RAY, PhDAssociate Professor, McGovern Center for Humanities and EthicsUniversity of Texas Health Science Center at HoustonSASAN SAKIANI, MDAssistant Professor of Medicine, Department of MedicineUniversity of Maryland School of MedicineSARAH SCHIMANSKY, MB BCh BAOResident, Department of OphthalmologyBristol Eye HospitalNATHAN WM. SKELLEY, MDAssociate Professor, Medical Director of Orthopaedic SurgerySanford Health–University of South Dakota School of MedicineTONY SLIEMAN, PhD, MScAssociate Professor, Department of Basic SciencesNew York Institute of Technology College of Osteopathic Medicine atArkansas State UniversityMATTHEW SOCHAT, MDPhysician, Hematology/OncologySoutheastern Medical Oncology CenterHOWARD M. STEINMAN, PhDAssistant Dean, Biomedical Science EducationAlbert Einstein College of MedicineJACQUELINE TRUONG, DPM, MPHAssociate Professor, College of Podiatric MedicineWestern University of Health SciencesRICHARD P. USATINE, MDProfessor, Dermatology and Cutaneous SurgeryUniversity of Texas Health Science Center San AntonioSYLVIA WASSERTHEIL-SMOLLER, PhDProfessor Emerita, Department of Epidemiology and Population HealthAlbert Einstein College of MedicineADAM WEINSTEIN, MDAssociate Professor of Medical Sciences and PediatricsFrank H. Netter MD School of Medicine at Quinnipiac UniversityABHISHEK YADAV, MBBS, MScAssociate Professor, Department of MedicineRutgers New Jersey Medical SchoolKRISTAL YOUNG, MDClinical Instructor, Department of CardiologyHuntington Hospital, Pasadena, California

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xiPrefaceWith the 34th edition ofFirst Aid for the USMLE Step 1we continue our commitment to providing students withthe most useful and up-to-date preparation guide for this exam. This edition represents an outstanding revision inmany ways, including:22 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 16 medical studentand resident physician authors who excelled on their Step 1 examinations, and verified by a team of expertfaculty advisors and nationally recognized USMLE instructors.Updated with 81 new and revised diagrams and illustrations as part of our ongoing collaboration withUSMLE-Rx and ScholarRx (MedIQ Learning, LLC).Updated with 21 new and revised photos to help visualize various disorders, descriptive findings, and basicscience concepts. Additionally, revised imaging photos have been labeled and optimized to show both normalanatomy and pathologic findings.Updated exam preparation advice, tailored for the current pass/fail scoring system and Step 1 blueprint changes.New advice on how to utilize emerging AI tools to increase studying efficiency.Updated photos of patients and pathologies to include a variety of skin colors to better depict real-worldpresentations.Improved organization and integration of text, illustrations, clinical images, and tables throughout for focusedreview of high-yield topics.Revised ratings of current, high-yield review resources, with clear explanations of their relevance to USMLEreview. 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 improveFirst Aid for theUSMLE Step 1through our blog and collaborative editorial platform. (See How to Contribute, p. xv.)LouisvilleTao LeBoracayVikas BhushanBaltimoreConnie QiuLondonAnup ChaliseAthensPanagiotis KaparaliotisAtlantaCaroline ColemanAtlantaSean EvansSan FranciscoKimberly Kallianos

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xiiSpecial AcknowledgmentsThis has been a collaborative project from the start. We gratefully acknowledge the thousands of thoughtfulcomments, corrections, and advice of the many medical students, international medical graduates, and faculty whohave supported the authors in our continuing development ofFirst Aid for the USMLE Step 1.We provide special acknowledgment and thanks to the following individuals who made exemplary contributions tothis edition through our voting, proofreading, and crowdsourcing platform: Yazmin Allegretti, Athanasios Angistriotis,and Nikitha Crasta.For support and encouragement throughout the process, we are grateful to Thao Pham, Jinky Flang, and JonathanKirsch, Esq. Thanks to Louise Petersen for organizing and supporting the project. Thanks to our publisher, McGrawHill, for the valuable assistance of its staff, including Bob Boehringer, Jeffrey Herzich, Christina Thomas, KristianSanford, and Don Goyette.We are also very grateful to Dr. Fred Howell and Dr. Robert Cannon of Textensor Ltd for providing us extensivecustomization and support for their powerful Annotate.co collaborative editing platform (www.annotate.co), whichallows us to efficiently manage thousands of contributions. Thanks to Dr. Richard Usatine and Dr. Kristine Kraftsfor their outstanding image contributions. Thanks also to Jean-Christophe Fournet (www.humpath.com), Dr. EdUthman, and Dr. Frank Gaillard (www.radiopaedia.org) for generously allowing us to access some of their strikingphotographs.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 RachaelJoy, 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, Debra Clark, and Gabby Sullivan.LouisvilleTao LeBoracayVikas BhushanBaltimoreConnie QiuLondonAnup ChaliseAthensPanagiotis KaparaliotisAtlantaCaroline ColemanAtlantaSean EvansSan FranciscoKimberly Kallianos

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xiiiEach year we are fortunate to receive the input of thousands of medical students and graduates who provide newmaterial, 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, andminimizing 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 recognizethat 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 Ehsen Abdul-Kabir, Suleiman Jamal Abou Ramadan,Ghaith Abu-Hassan, Raghed Abu Jabeh, Ruby Abu Nassar, Suhaib Abusara, Rochana Acharya, Biplov Adhikari,Sumera Afzal-Tohid, Marium Aisha, Wahid Aloweiwi, Sajjad Altmimi, Mohammad Arabi, Laila Ashkar, Nabil Askar,Emily Babcock, Abdulrahman Bani-Yassin, Angelina Bania, Gabriella Barr, Shreya Bavishi, Heather Beyea, KarunBhattarai, Pratik Bhattarai, Suzit Bhusal, Iuliia Bochinina, Stephanie Brown, Nicholas Buehler, Jack Carey, PaolaDel Cueto, Amy Cunningham, Suyash Dawadi, Molly Dexter, Jeevan Divakaran, Manasa Dutta, Prabin Duwadee,Gian Ferrando, Talia Fradkin, Louna Ftouni, Aaron Goldman-Henley, Priyanka Goswami, Jackson Green, IshanGupta, Fariah Asha Haque Haque, Mariam Hassan, Shelly Colleen Heredia, Hung Ho, Rachel Holmes, KaitlynHoyt, Samkit Jain, Subhah Jalil, Abdelrhman Muwafaq Janem, Julia Katcher, Avneet Kaur, Nadim Khutaba,Sourabh Kumar, Nery y Mara Lamothe, Guilherme Leite, Anna Marmalidou, Tanya Mateo, Juliana Maya, NathanMcDermott, Jose Antonio Meade, Shivani Mehta, Muhammed Mikaeel, Dylan Mittauer, Andrew Mohama,Gamble Morrison, Andrew Moya, Alexandra Jan Mrani, Waneeza Mughees, Ziad Nabil, Ezra Nadler, ShamsunNahar, Sajjad Nazar Majeed, Antony Nemr, Hyder Nizamani, Sophie O’Hare, Charis Osiadi, Fahreddin Palaz,Sharon Pan, Archana Pandey, Abigail Poe, Emily Pompeo, Zoe Pujadas, Yochitha Pulipati, Nicholas Purvis, DeniseQyqja, Parul Rai, Yoshita Rao, Liran Raz, Eva Rest, Carol Sánchez Jiménez, Ridha Saad, Luke Schroeder, SirousSeifirad, Muhammad Shahzaib, Amir Hossein Shams, Naimatullah Sharifi, Ajay Ajit Pal Singh, Ramzi Skaik, SwatiSrivastava, Zargham Abbas Syed, Miranda Teixeira, Grayson Tishko, Hirak Trivedi, Ana Tsiklauri, Luis Vilatuna,Amanjot Virk, Stefani Wren, Richard Wu, and Hsinyu Yin.General Acknowledgments

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xvThis edition ofFirst Aid for the USMLE Step 1incorporates thousands of contributions and improvements suggestedby 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 1New facts, mnemonics, diagrams, and clinical imagesHigh-yield topics that may appear on future Step 1 examsPersonal ratings and comments on review books, question banks, apps, videos, and coursesPathology and radiology images (high resolution) relevant to the facts in the bookFor each new entry incorporated into the next edition, you will receiveup to a $20 Amazon.com gift cardas well aspersonal acknowledgment in the next edition. Significant contributions will be compensated at the discretion of theauthors. 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 Webresource such as UpToDate, AccessMedicine, and ClinicalKey.We welcome potential errata on grammar and style if the change improves readability. Please note thatFirst Aidstyleis somewhat unique; for example, we have fully adopted theAMA Manual of Stylerecommendations on eponyms(“We recommend that the possessive form be omitted in eponymous terms”) and on abbreviations (no periods witheg, ie, etc). We also avoid periods in tables unless required for full sentences. Kindly refrain from submitting “styleerrata” unless you find specific inconsistencies with theAMA Manual of Style.Thepreferredwaytosubmitnewentries,clarifications,mnemonics,orpotentialcorrectionswithavalid,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 platformto contribute suggestions, mnemonics, diagrams, clinical images, and potential errata.Alternatively, you can email us at:firstaid@scholarrx.com.Contributions submitted byMay 15, 2024, receive priority consideration for the 2025 edition ofFirst Aid for theUSMLE Step 1. We thank you for taking the time to share your experience and apologize in advance that we cannotindividually respond to all contributors as we receive thousands of contributions each year.How to Contribute

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xvi`NOTE TO CONTRIBUTORSAll contributions become property of the authors and are subject to editing and reviewing. Please verify all data andspellings 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 TEAMTheFirst 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 workon a wide variety of projects, including the popularFirst Aidseries and the growing line of USMLE-Rx/ScholarRxproducts, 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 2024, we are actively seeking passionate medical students and graduates with a specific interest in improving ourmedical 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 experienceand talent in these areas. Relevant skills include clinical imaging, digital photography, digital asset management,information design, medical illustration, graphic design, tutoring, and software development.

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