How to Master Step 1 Pharmacology Over a Glass of Wine

by Alec Palmerton, MD in Experienced

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USMLE pharmacology is typically worth 40+ points on Step 1. With pathology, physiology, and immuno/micro, it is one of the most important subjects. Thus, how you approach mastering pharmacology will go a long way to determining your final score.

As we’ve discussed elsewhere, so much of the USMLEs focus on the application of knowledge. Unlike many med school exams, it’s not enough to know a particular fact on the USMLEs. Test-writers write questions that can’t be easily crammed. You have to be able to apply the concept.

However, USMLE pharmacology is different. Much of USMLE pharmacology revolves around knowing the basic information. There are many application-type questions for USMLE drugs. However, many items require basic information like mechanisms and side effects. In other words, the more you know, the higher your score will be.

How to Master Pharmacology in the Least Amount of Time Possible

In this article, you will learn:

• Why it’s critical to start pharmacology as soon as possible. (And why most people procrastinate).
• The six steps to create an awesome pharmacology deck or cards in the shortest time possible
• Specific examples of how to create pharmacology flashcards
• When the best time to make (and review) your high-yield pharm flashcards
• Much more

Note: this deals explicitly with learning the drugs for Step 1, Step 2, and Step 3. For pharmacology principles, you can use the basic principles of flashcard making here. USMLE pharmacology principles would involve things like competitive inhibitors, kinetics curves, etc.

Are you stressed with how little time you have to learn pharmacology? To master USMLE pharmacology in even less time, you can see the Yousmle Pharmacology deck here.

USMLE Pharmacology: 3 Things to Know

Before we start, here are 3 things to know to master pharmacology in the least time possible.

1. USMLE Pharmacology = Free Points

USMLE pharmacology can be boiled down to two main points:

1. Pharmacology is worth a lot of Step 1 points
2. You can get many of those points by knowing a large volume of knowledge

So how do you learn a large volume of knowledge? By using spaced repetition. I’d recommend using Anki to make flashcards, which is simple and – if you use the desktop app – free.

Making cards is so simple you can do so while drinking a glass of wine.

2. You Have to Start Early

Many students’ biggest regret is not starting pharmacology early on. There are plenty of good excuses not to start.

• “I’m too busy.”
• “There’s so much to learn; I don’t know where to start.”
• “I’ll forget everything anyway, so why bother?”

It’s natural to avoid hard things. However, the more you delay learning pharm, the more painful it will be when you start.

They say the best time to plant a tree was ten years ago. The second best time? Right now.

3. A Little Bit Over a Long Time >> Cramming

How do you eat an elephant? You do it bit by bit.

Learning USMLE pharmacology is the same thing. Instead of trying to eat the entire elephant at once, you need to do a little every day.

Anki makes continuous learning easy. Either make your own Anki cards or use the Yousmle Pharmacology Deck. Then, do a small number of flashcards every day.

The Yousmle Pharmacology Deck has ~1800 cards in it. Thus, if you had 90 days, if you did only 20 new cards/day, you could get through the entire deck.

5 Steps to Make USMLE-Crushing Pharmacology Flashcards

Here are the steps to making your own high-yield USMLE pharmacology cards.

1. “Copy + Paste” From an Electronic Resource

Knowing First Aid pharmacology is sufficient for getting the most questions correct. Of course, First Aid isn’t the only source for USMLE pharmacology. (You can find the information presented in a more straightforward form in the Yousmle Pharmacology Deck). However, if you want to make your own Anki flashcards, First Aid is a great place to start.

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. The “copy + paste” functionality will save you LOTS of time.

Second, decide which drugs you will cover. Choosing what drugs you want to start with may sound simple. However, given pharmacology can be so overwhelming, having a jumping-off point is a huge step.

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

2. Make Simple USMLE Pharmacology Cards to Save Time and Improve Retention

Next, make separate forward AND reverse cards for “mechanism,” “clinical use,” and “toxicity.” Making forward/reverse cards means that you will likely have at least six cards per drug.

You should have more but simpler cards. For example, “(Drug) – mechanism,” “(Drug) – use,” and “(Drug) – toxicity,” with appropriate reverse cards. Then, on the opposite side, I will use my electronic copy of FA to copy/paste the information into my card.

What the $β↑α% Happened to My Symbols?

In Anki, this would look like:

Anki struggles to recognize symbols from electronic resources, particularly pdfs. Instead of having nice symbols like ↑ or →, I end up with things like atomic death. If this happens, you can use text expander programs like aText. I can replace all the symbols quickly to their original form. Using these symbols gives you more legible cards that will speed your reviews.

3. Check the “Add Reverse” Box for Better Cards in Less Time

Note that I put a “y” in the “Add Reverse” text box. The “Add Reverse” box lets you make a reverse card.

A “Forward” card means that the front box (i.e. “Hydralazine – mechanism”) is the question. The back box (“↑ cGMP → smooth muscle relaxation…”) is the answer.

A “Reverse” card is the opposite. The back box is now the question, and the front is now the answer. In this case, I’d have to identify the drug from the mechanism itself.

Your Exam Will Test Information in Both “Directions.” Your Cards Should Prepare You For This.

Why is it important to make reverse cards? Because most Step 1 pharmacology questions test your basic knowledge about these drugs. Some will ask you the name of the drug after identifying the mechanism. 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.” This gives us 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:

Reverse Cards Prevent USMLE Pharmacology Information Overload

A basic tenet of making Anki cards is not to overload your cards with too much information. My rule is to have no more than 2-3 unrelated facts tested at one time.

Despite bolding the important information, many pharm cards have too much information. One place this shows up is the level of difficulty between the forward and reverse questions. The forward question is significantly more difficult than the reverse question.

To answer the forward question, I need to recall hydralazine is used for hypertension and CHF. I’d need to remember it’s used for hypertension in pregnancy. And don’t forget that β blockers can prevent reflex tachycardia (4 facts).

While the forward direction is very challenging, the reverse direction is much easier. 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? By balancing the difficulty of facts to recall.

4. Balance the Difficulty of the “Forward” and “Reverse” Directions

The forward card is usually harder than the reverse card. To improve recall of USMLE pharmacology, try and balance those difficulties.

I like to rate cards from a 1-10. “1” means the card is so simple I could remember it even without Anki. A “10” would be so complicated it’d be like memorizing the opening to Canterbury Tales.

Let’s look at the above case to see how this works in practice. I would rate the “forward” question “Hydralazine – uses” as roughly a 7. It’s hard to remember all these uses together.

I would rate the “reverse” question of “(uses) – drug?” as a 2. I prefer the forward and reverse cards have equal difficulty. Remember, every time we forget an Anki card, our studying will take longer. Balancing difficulties reduces the number of unnecessary repetitions.

In this case, I would re-write the card to the following:

Remind Yourself the Number of Facts to Recall

Notice that now, the forward question is easier, as there are only three things to remember. Additionally, I made it easier by reminding myself that there will be three things (3) to recall in the future.

If you’ve used Anki before, this will be a familiar problem. Of a list of three things, you’ll recall two of them but will forget the last one. It’s not that you forgot that fact, to begin with. Had you known there were three items to remember, you’d know all three. However, by not knowing how many things you need to know, you’ll forget the last one.

So what do you do? Remind yourself of how many items you need to remember.

5. Explain “Why” When Possible

Finally, whenever possible, explain “why” something is. I added a brief explanation for why it would make sense to coadminister with β blockers. (Hydralazine will lead to hypotension, which will lead to increased sympathetic tone. To block the reflex tachycardia, you can use β blockers).

Why add explanations? First, remember, the goal of USMLE question-writers is to assess understanding, NOT memorization. Many questions will test your ability to apply knowledge, not simple recall. Additionally, knowing “why” helps with simple recall, as well.

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:

Here, we have the same problems as before: too much information and unbalanced cards. The solutions are the same.

First, we make sense of as many symptoms as possible. Then we try and balance out the difficulties of the cards in either direction.

Balancing the Difficulties of the Forward/Reverse Directions

Balancing the forward and reverse directions’ difficulties would give us cards like this:

Here, I have grouped the adverse effects I can connect. An afterload reducer will lead to reflex sympathetic effects. (I am not blocking sympathetic receptors like I am w/ β blockers). When my baroreceptors sense decreased BP, sympathetic tone increases. Reflex sympathetic activation leads to:

• Tachycardia (leading to increased cardiac demand/potentially angina)
• RAAS activity → fluid retention

Making sense of these toxicities will improve retention.

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

Balancing the Difficulties of Each Card Helps Retention

I was confident that I could identify tachycardia and fluid retention. However, I was less sure I could recall that it might cause angina. To help me remember this fact, I asked for its contraindications (angina/CAD). Finally, 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.” Nausea is nonspecific, and is less critical to recall. Why? Because so many drugs cause nausea. As such, it is unlikely that nausea would be the defining feature of any particular drug.

Specific – Not Nonspecific – Symptoms Are Key to Answering USMLE Questions

USMLE MUST give enough information that a group of experts could agree on the answer from only the stem. They call this the “cover the responses” rule.

(To read How Are USMLE Questions Written? 9 Open Secrets for Impressive Boards Scores, click here).

In other words, with any side effect, could you identify the drug without the answer choices? For “nausea,” there is no way.

Imagine the question stem, “47-year-old man comes in with hypertension diagnosed three months ago. He complains of nausea for the past several weeks. What drug was he given?” No dice. If instead, they told you he had had a photosensitive rash in the malar distribution? You could identify the particular drug.

Learn the most specific adverse effects/uses of each drug. Worry less about the nonspecific signs.

Make Cards for Other Important Information

What about other information that’s not a mechanism, use, or adverse effect? Consider making separate cards for these in addition to the six base cards for each drug.

A significant category would be drug names in a given group. For example, I’d try to learn the macrolides’ names (azithromycin, clarithromycin, erythromycin) instead of their class.

Why should you know individual drug names? Because rarely will they give you the drug class. Instead, you will need to recognize the drug names and infer the category. Knowing drug names is vital for both for Step 1 as well as for clerkships. Thus, it is a worthwhile investment in time to learn the specific drug names now.

While you’re at it, you can also learn the drug pronunciations. While not tested on Step 1, you’ll be a rockstar on wards if you can say the drugs properly.

Information Overload → Retention ↓, Wasted Time ↑

Most people ask why I’d recommend making more, but shorter USMLE pharmacology cards:

• “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?”

Remember, for every incorrect Anki card increases the number of times you’ll have to review it. If I made only one Anki card per drug, I’d have 1/6 the total number of cards. But I’d argue that by making so few cards, you’ll end up wasting more time on your reviews. 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 made one card, instead of six, it would look like this:

This card contains way too much information. It illustrates why overloading your cards with information wastes times.

The More Facts Per Card, the More Times You’ll Get Something Wrong

Let’s say I were to review this card. If I’m lucky, I’ll remember most of the facts. But what if I remembered everything except the mechanism of resistance. I could:

• Review the entire card again to get that one unknown fact, or
• Skip the critical fact

Most people won’t feel comfortable skipping a fact that might be on their test. So what would you do if you missed one of four points on a bloated card? You’d have to review the entire card again, to get the one fact you missed. But I would be redoing ~80% of the information that I already knew well! Re-reviewing things you already know is a massive waste of time.

And what if during my next review, 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, the more information on each card, the more jumbled it will become. Why? When I review a long card, I likely try to run through the card in a specific order in a controlled way. (i.e., I will recite the mechanism first, then the use, then the toxicity, etc.). But what happens when the information is out of order? On Step 1, recalling the last item from a long memorized list will leave you confused and anxious.

Students’ most common mistake is to make cards that are too long. Reviewing marathon cards takes longer and is much less effective.

Making USMLE Pharmacology Cards is Simpler

The USMLEs ask you to make connections between different concepts. However, USMLE pharmacology is more straightforward. Unlike the Yousmle Step 1 cards, making pharmacology cards is simpler. Some might even call these cards “mindless.”

Regardless, making USMLE pharmacology cards requires less brainpower. As a result, I’d recommend doing it later in the day, since to make the cards you don’t have to be at your peak. (In contrast, I would recommend doing your reviews earlier in the day. Reviewing USMLE pharmacology flashcards is challenging).

When I was studying pharm for my USMLE Step 1, I liked to save making cards for the evening when I needed a break. After a while, I got the hang of the general layout of how I wanted my cards to look. Then I would sit on the couch, watching TV with my family, while having a glass of wine.

I’d copy and paste information from First Aid into my flashcards. It was an excellent way to relax while also still feeling like I was moving forward.

You’ll eventually get the hang of making USMLE Pharmacology cards. When you do so, you can even enjoy a tasty beverage while you make your cards.

Want to save hours of time and get a huge jumpstart to learning pharmacology – for FREE??

Concluding Thoughts

Along with microbiology, pharmacology is the most procrastinated USMLE topic. Why? Because it’s hard! There are so many details to learn. Perfectionism kicks in, and we keep pushing back our start time.

But the best thing you can do is to get started. Will you be perfect and make lots of connections? Probably not. However, your cards will improve over time. Most importantly, by starting the process of making/reviewing pharmacology flashcards, you’ll start eating that elephant.

Are you overwhelmed with the idea of making flashcards for every USMLE drug? Does the idea of making connections between drug mechanisms and uses scare you? If so, you should consider the Yousmle Pharmacology Deck. It has all of the most-tested USMLE drugs so you can learn this all-important topic in less time.

See the Yousmle Pharmacology Deck here.

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.

Photo by Anthony DELANOIX.