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How to Master Pharmacology for the USMLE Step 1 Over a Glass of Wine

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USMLE Step 1 Pharmacology

Along with biochemistry, pharmacology has the power to induce terror in the majority of medical students preparing for their USMLE Step 1 exam.  This is a shame, since so much of pharmacology is simply learning a large volume of basic information – once you know enough basic information, you can get the majority of questions correct.  In other words, pharmacology = free points on your USMLE Step 1!  Here, I outline 6 simple steps to set up highly efficient cards, to learn the basic information necessary for each drug.  Note: this specifically deals with learning the drugs for Step 1, Step 2, and Step 3; the basic principles of pharmacology (e.g. competitive inhibitors, kinetics curves, etc.) can be learned using the basic principles of Anki card-making detailed here.

USMLE Step 1 Pharmacology

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1. Use electronic resources to facilitate “copy + paste” of basic information

First, get a copy of First Aid for the USMLE Step 1 (note: I HIGHLY recommend getting an electronic copy like the Kindle copy linked to here, as the “copy + paste” functionality will save you LOTS of time).  For the vast majority of drugs, knowing the information in First Aid is sufficient for getting the questions correct.

Second, decide which drugs you will cover.  This may sound simple, but given that it can be such an overwhelming topic, simply having a jumping off point is a huge step.

If you are still in the classroom-portion of medical school (i.e. not yet in serious Step 1 mode):  the drugs you choose should be part of the organ system/block you are currently in, and identify the “pharmacology” section for the block in First Aid, typically the last section per organ block.  For example, if I was studying cardiology, I would turn to the back of the cardiology section:

First Aid Cardiovascular Pharmacology

2. Use simple cards to save time and improve retention

Next, and this is critical, make separate forward AND reverse cards for “mechanism,” “clinical use,” and “toxicity.”  This means that you will likely have at least 6 cards per drug.

For question/answer design, I prefer simple cards.  For example, “(Drug) – mechanism,” “(Drug) – use,” and “(Drug) – toxicity,” with appropriate reverse cards.  Then, on the reverse side, I will use my electronic copy of FA to copy/paste the information into my card.



In Anki, this would look like:

Anki for USMLE Step 1 Pharm

What the $β↑α% happened to my symbols?

When copying symbols from electronic copies of books, it often will not recognize it, and so instead of having nice symbols like ↑ or →, I end up with things like atomic death.  By using  the super-useful text expander aText program, I can replace all of the symbols quickly to their original form.

USMLE Step 1 Pharmacology Add Reverse

3. Check the “add reverse” box to save time on making cards

Note that I put a “y” in the “Add Reverse” text box, signifying that I want to make a reverse card.  A “Forward” card means that the front box (i.e. “Hydralazine – mechanism”) is the question, and the back box (“↑ cGMP → smooth muscle relaxation…”) is the answer.  A “Reverse” card is the opposite, where the back box is now the question, and I have to identify that the drug is from the mechanism itself.

This is important, because most USMLE Step 1 pharmacology questions will deal with your basic knowledge regarding these drugs.  Some will ask you the name of the drug after identifying the mechanism, while others will ask the toxicity while giving you the name.  In other words, they may ask you the equivalent of either a “forward” or a “reverse” Anki question.  Make your Anki cards accordingly, to deal with any such scenario.

So far, we’ve made 2 cards (a mechanism card, in both “forward” and “reverse” directions).  We repeat the process until we have “forward” and “reverse” cards for “clinical use” and “toxicity,” for a total of at least 6 cards per drug.

Applying the same “Copy and Paste” to this, the two “drug uses” cards would look something like this:

USMLE Step 1 Pharmacology Pre-Edit

Note that despite bolding what I felt was the important information to recall, that this is still a fair amount of information (this breaks the rule that basic cards should have no more than 2-3 unrelated facts).  Additionally, the forward question (e.g. where the “front” is the question, and the “back” is the answer; i.e. the question is “Hydralazine – use?”) is significantly more difficult than the reverse question (e.g. uses of hydralazine).  In other words, to answer the forward question, I would have to recall that hydralazine is used for hypertension, CHF, hypertension in pregnancy, and that it can be co-administered with β blockers to prevent reflex tachycardia (4 facts).  However, in the reverse direction, I would just have to recall one of those facts to recall that the drug is hydralazine (1 fact).

How can I make these cards easier to recall, while simultaneously improving my retention?

4. Balance the difficulty of the “forward” and “reverse” directions by rating the difficulty from 1-10

The simplest thing I can do is recognize that it is often much more difficult in the forward than in the reverse direction, and to try and balance those difficulties.  I like to rate cards from a 1-10 (1 being so simple I could remember it even without Anki; 10 being so difficult it’d be like memorizing the opening to Canterbury Tales).  In this case, I would rate the “forward” question “Hydralazine – uses” as roughly a 7, since I would find it hard to remember all of these uses together, while I would rate the “reverse” question of “(uses) – drug?” as a 2.  I prefer to have forward and reverse cards that are approximately equal difficulty, which will reduce the overall number of times I will have to repeat that information for it to stick.  In this case, I would re-write the card to the following:

USMLE Step 1 Pharmacology

5. + 6. Additionally, for lists, give reminders for number of facts to recall, and explain “why” when possible

Notice that now, the forward question is easier, as there are only 3 things to remember.  Additionally, I made it easier by reminding myself that there will be 3 things (3) to recall in the future, as often I can recall most of the things easily, but will forget how many things I am supposed to recall.  Finally, I added a brief explanation for why it would make sense to coadminister with β blockers, since in the months/years I will review this card, I am likely to forget why this is, and remembering “why” will significantly increase recollection.

Applying the same principles to drug toxicities

Now, let’s try the same thing with drug toxicities.  The basic “Copy + Paste” approach yields us this:

USMLE Step 1 Pharmacology Toxicities

Here, we have the same problems as before.  After first trying to make sense of as many symptoms as possible, I then try and balance out the difficulties of the cards in either direction.  This would lead to a card like the following:

USMLE Step 1 Pharmacology Toxicities Edit

Here, I have grouped together the adverse effects I can make sense of.  An afterload reducer will lead to reflex sympathetic effects (I am not blocking sympathetic receptors like I am w/ β blockers), so when my baroreceptors sense decreased BP, I will feel the full sympathetic reflex effects, which include tachycardia (leading to increased cardiac demand/potentially angina) and RAAS activity → fluid retention.  Making sense of these toxicities will improve retention.  This cannot be emphasized enough:

Investing the time to make sense of as many things as possible will vastly improve recall, save time, and supercharge your USMLE Step 1 score

I was relatively confident that I could identify tachycardia and fluid retention, but I was less sure I could recall that it might cause angina.  For that reason, I asked specifically for what it was contraindicated in (angina/CAD), to help me remember this fact.  Finally, you can see that I moved the “Lupus-like syndrome” to the opposite side, since I couldn’t relate it to any of the CV facts.

Additionally, note that I intentionally didn’t bold “nausea” since I felt that it was a nonspecific, and signaled to myself that it was less important to recall.  Why?  Because so many drugs are associated with nausea that it is unlikely that it would be the defining feature of this particular drug.

HIGH YIELD STEP 1 TIP: Remember that on any USMLE exam, the question-writers MUST give you enough information that a group of experts could agree on the specific answer  without knowing the answer choices.

In other words, ask yourself, “if they gave me a patient with this side-effect, could I unambiguously identify the drug without needing to look at the answer choices?”  For “nausea”, there is no way.  Imagine the question stem, “47 year old man comes in with hypertension diagnosed 3 months ago.  He complains of nausea for the past several weeks.  What drug was he given?”  No dice.  If instead, they gave you the same clinical scenario, but told you he had been having a photosensitive rash in the malar distribution, you could definitely identify the particular drug.

Study accordingly.

If there is other information that appears relevant that does not fit neatly in one of the three aforementioned categories, consider making separate cards for these (in addition to the 6).  A major category would be drug names in a given category (e.g. “Azithromycin, clarithromycin, erythromycin” instead of their class – macrolides).  Remember that you will be tested much more frequently on your ability to recognize/recall specific drugs names, both for Step 1, as well as for clerkships, and so it is a worthwhile investment in time to learn the specific drug names now, along with the specific pronunciation.

Too much information in cards = retention ↓, needless repetitions ↑

Most people ask, “why don’t you put more information on your pharm cards?  Aren’t you making lots of extra cards?  What if you made fewer cards with more information on each?”  This approach isn’t wrong, per se, but I would argue that you will review lots of material unnecessarily, which will add unnecessary hours to your studying.  Let me give you an example to illustrate.

Let’s say I wanted to learn antibiotics, and I started with the macrolides class.  If I were to write a question that included the mechanism, use, and toxicity, it would look something like this.

Anki for USMLE Step 1 Pharm

This is clearly way too much information, and it illustrates  why having cards with too much information can quickly make your cards worthless, and can consume inordinate amounts of time.  Let’s say I were to review this card, and remembered everything except the mechanism of resistance.  I would have to review the entire card again, despite not knowing one of the 4 facts associated with the card.  But I would be reviewing 90% of the information that I already knew well!  And what if the next time I remembered everything but the mechanism?  The more unrelated information you have in a card, the more likely it is you will forget any one piece of it.

Additionally, when I try and recall the information on the card, I likely try to run through the card in a specific order (i.e. I will recite the mechanism first, then the use, then the toxicity, etc.).  In other words, when I’m taking my Step 1 exam, if I get a question on the toxicity of macrolides, I will have to run through the mechanism and use first, which will extend the amount of time it takes to answer the question unnecessarily.

The most common mistake for both me and the students I work with is to make cards that are too long, which makes reviewing cards much longer than it needs to be, and much less effective.

Finally, you’ve probably noticed that making these cards, unlike many other cards that require you to be doggedly on the lookout for  explanations, these are largely “mindless” activities.  When I was studying pharm for my USMLE Step 1, I liked to save making cards for the evening when I needed a break.  Once I got the hang of the general layout of how I wanted my cards to look, I would sit on the couch, watching TV with my family, while having a glass of wine, copying and pasting the information from First Aid into my flashcards.  It was a nice way to relax while also still feeling like I was moving forward.

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What should you do next?

  1. If you haven’t already, get an electronic copy of First Aid.
  2. Consider using a text expander program like aText to make your cards visually easier to follow.
  3. Remember the 6 simple steps for making pharm cards:
    1. Use electronic resources to facilitate “copy + paste” of basic information
    2. Use simple cards to save time and improve retention (~6 cards / drug)
    3. Check the “add reverse” box to save time on making cards
    4. Balance the difficulty of the “forward” and “reverse” directions by rating the difficulty from 1-10
    5. For lists, give reminders for number of facts to recall
    6. Explain “why” when possible
  4. Grab your favorite beverage and get started!

What do you think?  Please share your experiences with the rest of the YOUSMLE community by leaving a comment below.

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Photo by Bernaldo Leal

Want FREE Cardiology Flashcards?

Cardiology is key for impressive USMLE scores. Master cardiology from a Harvard-trained anesthesiologist who scored 270 on the USMLE Step 1 with these 130+ high-yield flash cards. You’ll be begging for cardio questions - even if vitals make you queasy.