How to Study for Step 1 — 2024 USMLE Step 1 Exam Guide

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USMLE Step 1 was previously regarded as the most important test that future doctors take. Although USMLE Step 1 is now pass/fail, it is still an incredibly challenging exam that you shouldn’t take lightly. It is critical that you pass this test, and the testing skills you build during this time are what will serve you when it comes time for Step 2 and Step 3.

Our Step 1 guide will dig into what the pass/fail change means for students, the best resources to use, how to create a study plan, success strategies, and FAQs.

Scroll below for the following topics:

  • What is USMLE Step 1?
  • When Do Students Take Step 1?
    • Eligibility and Scheduling
  • Step 1 Pass/Fail Transition
  • Ideal Step 1 Study Books and Resources
  • USMLE Step 1 Study Schedule: Pre-Dedicated and Dedicated
  • Step 1 Prep Tips and Advice
  • What to Know About Test Day
  • USMLE Step 1 FAQs

 

What Is USMLE Step 1?

The United States Medical Licensing Exam (USMLE) is a 3-part test designed to evaluate a student’s medical knowledge as well as their ability to apply that knowledge to patient care. Step 1 organizes basic science material along two dimensions: systems and processes. Special emphasis is placed on the principles and mechanisms that underlie health, disease, and modes of therapy.

USMLE Step 1 is a one-day exam that’s divided into seven 60 minute blocks. It is administered in one 8-hour testing session, which includes an optional 15-minute tutorial and 45 minutes of break time. While the number of questions per block may vary, they will not exceed 40. The total number of questions in Step 1 will not be more than 280. The current minimum USMLE Step 1 score to pass Step 1 is 196, and the maximum possible score is 300.

 

When Do Medical Students Take Step 1?

Students typically take USMLE Step 1 at the end of second year (MS2), USMLE Step 2 CK is typically taken at the end of third year (MS3) or during fourth year (MS4), and Step 3 is typically taken during the first year of residency.

Eligibility and Scheduling

Your eligibility comes from being enrolled at an accredited school. Technically, you can take the exam whenever you want, but your specific scheduling usually depends on your medical school’s policies.

Once you start down the path of preparing for Step 1, register for it at least six months in advance of your test date. This is because the test dates at the Prometric test centers open up six months in advance. As such, you want to get enough of a head start to ensure you get the date and location you want.

When registering, you will input all of your demographic information, including your medical school. They will then send your information to your med school to ensure you’re qualified. Once this is confirmed, you’ll receive a token to schedule your exam. Timing on this process will vary, with some schools taking multiple weeks to review your information and release your token, which is why it’s so important to get started early and be proactive.

Once you have your token, you can return to the original site where you registered and choose the eligibility window you want to complete it in. Your eligibility window is a three month period in which you can schedule your Step 1 exam anywhere in the country, as long as there are available dates.

The good thing about being early is you can move your test date within your three month eligibility period up to 45 days in advance of the test date without a fee. If you try to move it within those 45 days, you will be charged.

Your eligibility period cannot change. You can technically request a one-time eligibility period extension that falls directly after your current eligibility period, but you cannot re-pick your eligibility period outside of that window. These exams are $600 each, and you will not be refunded if you try to schedule an exam outside of your three months.

 

USMLE Step 1 Pass/Fail Transition

sign with arrows left and right - usmle step 1 pass fail

USMLE Step 1 officially became pass/fail on January 26, 2022. This change was conceived to decrease medical school burnout and improve the mental health and wellbeing of students, as Step 1 was widely regarded as the most important test a future doctor would ever take.

Step 1 was originally designed to help state authorities grant medical licenses, but over time, Step 1 scores became more and more important, especially when it came to applying to residency.

Scores started to be weighted so heavily that a low score meant you had no hope of pursuing a competitive specialty. For example, if you wanted to be a dermatologist but had a low Step 1 score, you would need to completely rethink the trajectory of your career and choose a less competitive specialty.

In the past, the first two years of medical school were spent studying for (and stressing out about) this monumental exam. Students would need to study so much that they would skip more and more classes the closer it came to exam time.

The stress was so notably destructive to the mental health of students that Step 1 was made pass/fail, as a pass/fail medical school curriculum has been shown to improve group cohesion and reduce stress. When you’re not focused on surpassing the accomplishments of your classmates, it’s easier to play nice and work together.

Step 1’s extremely narrow score standard deviation also did not accurately reflect two students’ differences in medical knowledge, which made a residency’s score filtering threshold largely arbitrary. Plus, studies have shown that Step 1 propagates racial disparities, as Black and Latinx students have, historically, received lower test scores than Caucasian students, which meant many Black and Latinx students were denied interviews for competitive specialties.

However, it must be noted that making Step 1 pass/fail does not reduce the competitiveness of the most competitive specialties. Students weren’t necessarily stressed out by Step 1 specifically; they were worried they wouldn’t be able to get into their most desired specialty. Making Step 1 pass/fail doesn’t alleviate this concern.

By making the exam pass/fail, there is also less incentive for students to do as well as they possibly can. When you lower the bar, people often aren’t willing to jump as high. This is problematic, as even just passing Step 1 is still challenging. There is a ton of content covered on the exam, and you still need to put in substantial effort just to pass.

Plus, in the past, if you didn’t do well on Step 1, you still had Step 2 CK to help improve your application. Changing Step 1 to pass/fail means much more pressure is now placed on Step 2 CK. If things don’t go well for you on Step 2 CK, you don’t have another exam to help bolster your qualifications. Only time will tell if this change helps or hinders students.

If you want to learn more about this important change, watch our video or read our guide: How USMLE Step 1 Pass/Fail is Changing Medical School.

 

USMLE Step 1 Books and Resources

Infographic UFAPS study resources

The gold standard resources for USMLE prep are often referred to using the acronym UFAPS. This consists of UWorld, First Aid, Anki, Pathoma, and Sketchy.

UWorld

First, there’s UWorld. This comprehensive question bank is often regarded as one of the highest-yield resources for all of the Step and shelf exams. The consensus among medical students is that the questions are very similar to the actual exam—both in content and difficulty.

Many students also find the explanations, diagrams, and tables that come with each question to be incredibly helpful when reviewing information for the exam.

First Aid

Next, there’s First Aid. First Aid is a review book that covers everything you need to know for Step 1, including helpful mnemonics to memorize key information. Students often refer to it as the “Bible” for Step 1, as it is incredibly high-yield and contains all of the topics you need to know for the exam.

That being said, it lacks contextualization of key disease processes and doesn’t always go to the level of depth that you need to know for each topic, so you will need to supplement it with other resources.

Anki

Next is Anki. We’ve talked about spaced repetition time and time again on Med School Insiders, as well as the Med School Insiders YouTube channel, for good reason: it works. Given the breadth and depth of knowledge that you need to know for Step 1, there’s a delicate balance between retaining and forgetting information.

Anki is the go-to for spaced repetition in medical school. By reviewing information at increasing intervals, you can maximize retention while minimizing forgetting. There are a variety of different premade decks out there; however, the Anking deck is regarded by many students as the best for Step 1 prep. Unlike other premade decks, this one is constantly being updated, added to, and organized to work with the most common USMLE materials.

There are other premade decks out there students swear by, including Brosencephalon and Lightyear, which also integrate well with common USMLE prep materials. You can also make your own deck, which has the benefit of being more personalized to you and your weak areas; however, the biggest drawback of doing this is the inordinate amount of time needed to create hundreds or even thousands of cards.

Read our 13 Best Practices to Create Effective Anki Flashcards.

Pathoma

Next, we have Pathoma. Pathology is the foundation of medicine; a strong understanding of it is necessary to do well on Step 1.

According to many students, the gold standard for learning pathology for Step 1 is Pathoma.

This video lecture series breaks down everything you need to know about pathology and includes PDF notes to help you review the material.

Sketchy Medical

Lastly, there’s Sketchy Medical. Using Sketchy for micro can be incredibly helpful. They have offerings in other areas too, but most agree that micro and pharm are where Sketchy excels.

These topics are incredibly memorization-heavy, so things like flashcards are helpful; however, many students report that Sketchy micro and Sketchy pharm help make memorization even easier.

They use pictures and storytelling to teach you high-yield topics in a memorable way. Additionally, the videos are entertaining and easy to go through during breaks or downtime when you aren’t highly focused but still want to make the most of your time.

Practice Exams

Although they are not part of the UFAPS acronym, practice exams are another key component to your Step 1 prep. There are generally two resources recommended for your practice exams: the UWorld Self-Assessments and the NBME practice tests.

NBME Practice Tests:

The NBME is the same body that administers the Step 1 exam, and their practice tests are made up of old USMLE Step 1 test questions. As such, it is highly recommended to go through at least a few of these late into your prep as you prepare to take the real thing.

The NBME offers 7 self-assessment tests, including the Free 120 as well as 6 Step 1 self-assessment tests.

UWorld Self-Assessments (UWSA):

In addition to the NBME Practice Tests, there are the UWorld Self-Assessments.

Much like the UWorld question banks, these self-assessments are similar to what you can expect to see on the exam and can give you a good idea of how you’ll perform on the real thing.

Although these resources (UFAPS and practice exams) should make up the bulk of your Step 1 prep, other supplemental resources can be incredibly useful, both during your preclinical years and in the weeks leading up to Step 1.

Boards and Beyond

Boards and Beyond is a comprehensive resource that corresponds to the material covered in First Aid. It consists of video lectures and USMLE-style questions to help you learn the material that will be tested on Step 1.

Amboss

Amboss is similar to UWorld in that it is a question bank with USMLE-style questions. It also has a clinical library that many students find helpful, especially during the clinical years of medical school.

Anecdotally, many students have said that the questions are more challenging than what you’ll experience with UWorld and less representative of the types of questions on the real exam.

The consensus also seems to be that the explanations of the answers are not as helpful as the ones you find on UWorld. Many students recommend Amboss as a supplementary resource to be used either before UWorld during the pre-dedicated period or after having gone through UWorld to help dial in areas of weakness.

That said, we’ve also heard from students who have had great success from using Amboss over UWorld, especially in recent years, as Amboss allows you to gather additional information directly on the platform.

Goljan Audio

Goljan audio lectures are ideal for learning and reviewing pathology during medical school, as the lectures are very easy to listen to during what would otherwise be downtime. You can listen to them while driving, walking, getting groceries, etc.

That being said, it does depend on how you value your time. If you find listening to the lecture is taking away from your limited recharge time, adjust when you listen to them. For example, Med School Insiders founder Kevin Jubbal says he tried listening to them at the gym for some time but stopped because it took any enjoyment out of the activity.

 

How to Study for Step 1: Pre-Dedicated & Dedicated Study Schedule

There are two phases to your Step 1 preparation. There’s the pre-dedicated period and the dedicated period. The pre-dedicated period consists of the months leading up to your exam. The dedicated period consists of the 4-8 weeks before your exam.

Pre-Dedicated Period

The goal of the pre-dedicated period is to build a foundation. We recommend taking a pass through First Aid and Pathoma at least once before your dedicated period. Resources such as Anki, Boards and Beyond, etc., can also help dial in the information from these two resources.

Some students have found success going through video lectures while reading along in First Aid and taking notes, then adding the Anki cards to their rotation to review. Maximize your time by watching Sketchy medical videos while you’re eating instead of watching TV. Consider these a form of low-stress studying you can do while taking a break from practice questions or video lectures.

Next, try to finish your first pass of the UWorld Question bank (or Amboss, but not both). Set a daily question quota so you can complete the entire question bank before dedicated starts.

Lastly, make sure you’re still maintaining your performance in medical school. Although preparing for boards is important, you still have to pass your exams and fulfill your other commitments.

Spend about one quarter to one third of your day keeping on top of coursework and lectures for medical school. Spend the remainder of your day going through UFAPS. Switch to nearly 100% focus on coursework in the days leading up to your school’s block exams so that you can make sure you do well.

If you can maintain this rhythm throughout your preclinical years, you will have a solid foundation of knowledge going into your Step 1 dedicated period.

Dedicated Period

Your dedicated study period often varies between 4-8 weeks, depending on your school schedule and policies.

Before jumping in headfirst, carefully choose your resources. The UFAPS protocol should be your core. You may also want to consider Goljan’s Audio Lectures for pathology. You can augment UWorld with Amboss, or if you prefer, you could use Amboss as your main resource instead of UWorld.

Try not to have too many resources during your dedicated study period. You will quickly become overwhelmed, as you won’t be able to get through all of them. Once you have your resources, creating a plan of attack is key.

Here’s an example of how you might break up your days.

Divide each day into three 4-hour studying blocks of morning, afternoon, and evening, with 5-10 minute breaks once per hour during each of these sessions. You can follow this structure 5-6 days of the week, such as Sunday-Friday, depending on your own study preferences and what else you have going on outside of medical school.

Intentionally schedule downtime, as you will need this as well. For example, every Friday evening could be blocked off for fun and relaxation, meaning you will not do any work Friday evenings. On your scheduled time off (Ex. Saturday morning), set aside time for groceries, laundry, and other errands.

Once you have your daily schedule determined, go back and prioritize your study materials to organize your weekly studying. If you’ve already built a solid foundation during your pre-dedicated period, go through First Aid and UWorld at least once during your dedicated period. Figure out how many pages of First Aid and questions of UWorld you need to get through each day to reach this goal. Again, depending on your preferences, you might choose to use Amboss instead of UWorld.

Sketchy micro and pharm videos are entertaining, so you can integrate these when you have a spare moment or during your downtime.

Choose any form of spaced repetition (i.e., Anki, physical flashcards) to help you remember weak topics/missed concepts. Create your own flashcards/Anki cards of the questions you miss in UWorld and continuously review these weak topics by keeping up with your Anki cards. If you stay mindful of the number of cards you create and don’t overdo it, you will have an efficient and effective way of reviewing the topics you truly need to focus on.

Lastly, for practice tests, we recommend taking one towards the beginning of your dedicated period for self-assessment purposes and the rest of them towards the end. These practice tests will help you get used to the USMLE question style, hone your endurance, and master your pacing. As you take the practice test, try to pick out the most important details that were needed to answer the question and consider what information was only put there to trip you up.

Avoid taking a practice test within the preceding 48-72 hours of your test, as you want to be fresh for the real deal. You should absolutely review your practice tests thoroughly and see why you got questions wrong.

We highly recommend taking the NBME Free 120 before your test. The reason for this is the material covered on this practice test is often very high-yield and sometimes questions can be repeated on the actual test. For students who battle with testing anxiety, the NBME offers this practice test in person at various Prometric testing facilities, which can really help reduce any nerves you may have.

For more details, read our guides: Leading up to the Dedicated Period and Dedicated Study Period Schedule.

 

USMLE Step 1 Prep Strategies

1 | Don’t Neglect Step 1 Because It’s Pass/Fail

Yes, Step 1 is pass/fail now, but it’s still an incredibly difficult test that requires a passing score. Don’t make the mistake of neglecting this test, thinking only getting a pass will be easy.

Being relaxed about your studying not only risks you failing the test, but also makes it all the harder on yourself when facing the inevitable pressure of studying for Step 2 CK. Studying is a skill that you need to hone throughout your entire time in medical school. Understand that you won’t need to put the same amount of pressure on yourself as you might have before the pass/fail change, but understand passing Step 1 at all is no mean feat.

2 | Don’t Over Resource

UFAPS (UWorld, First Aid, Anki, Pathoma, and Sketchy) are tried-and-true Step 1 resources, with an option to focus on Amboss instead of UWorld, depending on your preference.

Do not start by doing Boards and Beyond, Osmosis, and First Aid all at once (or again for that matter). These resources are redundant together. Pick your core study resources and stick to those. Ensure that what you’re getting out of each isn’t a repeat of the other.

Students often make the mistake of thinking the more resources they can get through, the better. This is an impractical use of your time because you will end up going over the same material you’ve already learned multiple times. Plus, for each new resource you choose to use, there will be a new learning curve as you familiarize yourself.

At this point in your medical education, your time is extremely limited, so you must be efficient in how you study. Zero in on your weak areas early on, and continue to review the content you get wrong.

3 | Maintain Your Performance in Med School Courses

While Step 1 is extremely important, do not neglect your regular med school courses. Your academic performance is still of the utmost importance to your future medical career.

Create a study plan that accounts for your regular courses, and stick to it. This will be a continuing theme throughout your final years of medical school. You must build systems that help you balance exams, clinical hours, extracurriculars, your own wellness, and your regular studies in order to find success.

4 | Schedule a Simulated Step 1

Schedule a simulated Step 1. NBME Free 120 is the closest in terms of the kind of questions you’ll be asked as well as simulating the testing environment. The material covered on this test is extremely high-yield; there’s also a chance some of the questions asked could appear on your real test.

If you struggle with anxiety or simply want to be as prepared as possible, NBME offers this in-person practice test at various testing facilities. This will give you an authentic feel for what the exam will really be like. Ensure you schedule it close to exam day, at least a week or two before, so that you get into test mode. However, don’t schedule your practice test in the 48-72 hours before your real test, as you want to be as fresh as possible on the big day.

Do any and all practice exams as well, and make the experience as alike to the real test day as possible. Leave your home. Go to the library. Drive to the testing center and back. Mimic the realities of test day as much as you can so that when test day rolls around, you know you can do it because you’ve already done it before. It’s just like any sport; make it like game day so that the process feels automatic when you’re faced with the real thing.

5 | Prioritize Wellness

Now that Step 1 is pass/fail, you’ll be able to find more balance, but it’s still important to push yourself and learn the material to the best of your ability. While you will be studying quite a lot, remember that this is your time. Take ownership of it. What do you need to do to adequately prepare yourself?

Build time for wellness into your study schedule. Be intentional. Without time for rest and relaxation, you will burn yourself out and could end up failing Step 1. Finding time for rest is more important than cramming until the very last minute.

Develop and hone a personalized and solid morning routine and night routine to ensure you get quality sleep every night. Getting a good sleep helps your brain further process and retain information, so don’t sacrifice it.

 

What to Know About Test Day

When you schedule your test date, you will be emailed a confirmation number that you will need to present on the day of your test.

Ensure you show up early, as there will be a line to check in. When you check in, you will be fingerprinted, they will confirm you’re registered for the test, and you will get to store any snacks or valuables. Lockers are much smaller than your average high school locker, so be careful not to bring too many large snacks or drinks.

Another good reason to show up early is that most of the testing centers are also located in industrial areas or office buildings, which can be confusing as many of them look the same. You will likely be stressed enough without getting lost the morning of your test.

If you’re one of the first in the door, you’re one of the first to start, and one of the first to leave. This is important because it means you won’t be standing there with your anxiety.

You will be allowed 45 minutes of break time (which can be increased to an hour if you skip the tutorial), and it’s important to think about how you want to schedule those breaks. This is a personal decision, as everyone takes tests differently. Be aware that your fingerprints will be taken each time you step outside of the testing space and before you enter it, which will eat into your breaktime. Anything you bring into the testing space will be checked. You can bring your own earplugs, but the center will also provide these for you.

It’s going to feel like a testing cubicle. You will be assigned a seat with a blinder on either side of you. You will be given passcodes to get in and out of the space, and you are required to raise your hand before leaving your seat. You will be given some scratch paper or a dry erase board to make notes with.

If you finish a section early, keep in mind you don’t have to launch into the next section right away. You could take that time to collect your thoughts, take some deep breaths, and refresh yourself.

 

USMLE Step 1 Frequently Asked Questions

When Can You View Step 1 Results?

You’ll receive an email saying your results are ready. Step 1 results are released every Wednesday. Depending on the time of year, results can be released in as little as two weeks to as much as eight weeks, but you’re most likely to receive your results within two to four weeks.

How Long is the Step 1 Exam?

Student holding a pen with paper notes - USMLE Step 1 Length

Step 1 is a one-day exam that’s divided into seven 60-minute blocks and administered in one 8-hour testing session.

This includes an optional 15-minute tutorial and 45 minutes of break time. So, if you were to skip the tutorial and the breaks, which we do not recommend, the test would take you 7 hours.

Learn more: How Long is USMLE Step 1?

How Does Pass/Fail Work for Step 1?

As of January 26, 2022, Step 1 became pass/fail. You will not be given your specific test scores, and neither will residency programs. The current minimum score to pass Step 1 is 196, so if you pass, you at least scored 196 or higher.

Step 1 becoming pass/fail means that Step 2 will now be given more weight, as it will still be scored. Plus, other metrics like clerkship grades, Dean’s lists, class rankings, and letters of recommendation will also be given more weight. This means medical students will need to dedicate the time they save studying for Step 1 on Step 2 CK prep as well as maximizing their research experience and other extracurricular activities.

That said, while Step 1 becoming pass/fail changes some of the details, the overall picture is still the same: if you want to join a competitive specialty, you will need to outshine your peers.

Can You Retake Step 1?

You are able to retake Step 1 four times; however, you can only take Step 1 three times within a 12-month period. Your fourth attempt must be at least 12 months after your first attempt and at least six months after your most recent attempt.

Are There Consequences for Retaking Step 1?

One failure does not necessarily hinder your chances of being accepted to residency, but residency programs can see how many times you’ve taken the test. Residency admissions committees see each student they accept as an investment. If you’ve failed a Step exam before, it makes you a much riskier investment.

Additionally, timing is an issue for students who fail Step 1. It takes a lot of time and effort to prepare for this test to begin with, and now you’ll have to do much of that process over again. Your time in medical school is already extremely limited—adding on test retakes will pull from time you could be spending on your studies, extracurriculars, or wellness.

Gaining an ideal match into residency takes much more than good test scores. You’ll need quality letters of recommendation and an impressive list of extracurricular experience on top of rock solid grades. Any time spent retaking tests puts you at a notable disadvantage compared to other residency candidates.

Read our complete Residency Application Guide, which includes an ideal preparation timeline, success strategies, an application checklist, and mistakes to avoid.

Just like failing a clerkship, failing any Step exam is bad news. You can still recover from it, and you can still do well, but to state the obvious: do whatever you can to avoid failing Step 1 or any Step exam.

What Happens If You Fail Step 1?

I failed USMLE Step 1- sad student looking at computer

If you fail Step 1, take a deep breath. It’s not the end of the world. You can retake the test.

If you fail, contact your school and your academic advisor right away. If you don’t know who to reach out to, ask peers a year ahead of you. The person they consulted about Step 1 should be the same person you will need to reach out to.

Failing Step 1 looks bad on the school too, so they want to help you succeed however they can. They may have additional resources, such as tutors, or they may help you rearrange your schedule so that you have more flexibility to study for your next test. Of course, this depends on the specific medical school and the resources they have available.

Learn more about USMLE Step 1 Tutoring options.

You have the option to retake it two more times within 12 months of your first attempt. If you need to, you can take Step 1 a fourth and final time at least 12 months after your first attempt and at least six months after your more recent attempt. However, do note that admissions committees can see how many times you’ve taken the test.

Failing Step 1 should be a notable wake-up call—what you are currently doing isn’t working and will not work throughout your remaining time at medical school. Take time to assess why you might have failed and determine what you must do to course correct. You do not want to risk failing a second time—just one failure makes you a less attractive residency candidate.

Read our guide: What Happens If You Fail Step 1 (and What to Do Next).

What Are the Other USMLE Exams?

The other USMLE exams are Step 2 CK and Step 3. Step 2 CK is generally taken at the end of third year, and Step 3 is generally taken during the first or second year of residency.

How Much Does USMLE Step 1 Cost?

For students and graduates of medical schools located in the United States and Canada and accredited by the LCME or AOA, Step 1 costs $660. For information about regional surcharges and taking Step 1 at international centers, email [email protected] or call 215-590-9700.

 

Optimize Your Prep With a USMLE Step 1 Tutor

Take your Step 1 prep to the next level and ensure yourself a passing score. Med School Insiders offers customizable USMLE Step 1 Tutoring to give you peace of mind. Each of our tutors aced the USMLE Step 1 exam by utilizing the Med School Insiders methodology, which means you will be able to learn from the best.

At Med School Insiders, we believe no two students are the same, which is why we emphasize one-on-one mentorship and relationship building with your tutor, a diagnostic process to evaluate where you can make the greatest improvements, as well as a custom approach designed specifically to suit your strengths, weaknesses, and personal habits.

Getting into residency is about a lot more than your Step 1 score. Med School Insiders can help you prepare a stand out residency application that will ensure a match at one of your top programs. We offer a number of Residency Admissions Consulting Services tailored to your needs, including personal statement editing, interview prep and mock interviews, and overall application editing.

We’re here to answer all of your questions and help you choose the path that best aligns with your interests and desired outcomes. It’s our goal to help you create a future that aligns with your vision.

For more advice straight from students who have been where you are before, read:

What I Wish I Knew Before Taking USMLE Step 1 and Don’t Make the Top 4 Mistakes I Made Studying for Step 1.

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