PreTest® Self-Assessment and Review Pharmacology, Thirteenth Edition, 2010

From the Introduction “Even though your profs may tell you otherwise, pharmacology is pure memorization ... the ultimate challenge in medical memorization ... [and] some remedy to dull the pain of the subject is needed.” That was the admonition to students in a popular exam study aid written, of course, by students. “Baloney,” I say. My Perspectives on and Approaches to Learning “Pharm” Before you get on with your studying, I’d like to give you a little insight into who another otherwise faceless author might be, because it might explain where I’m “coming from” when I prepared this book. Having taught many areas of pharm over the last 25 years, to more University of Michigan Medical School and other health professions students than I can count, I know that things pertaining to pharmacology and therapeutics are overwhelming in terms of breadth, detail, number, and consequences. A generation or so ago the pharmacologic armamentarium (and what you ostensibly needed to know) was a small fraction of what it is now. Now the number of drugs is in the thousands, and new drugs are coming at a mind-boggling frequency. Do you need to know about them all? Can you possibly be taught about, or be expected to learn, everything? In my opinion, no. There’s simply too much information, and too much presented to you in the preclinical years. Even though a host of drugs “exist” there’s little point in knowing about them all explicitly. Trying to do so would be a futile and needless task, and truth be told many of the new drugs are not so creative spin offs of what I refer to as the “oldies but goodies.” No matter how well you think you know your information (pharmacology or otherwise), no matter how completely or comprehensively you’ve been taught, all the content tends to become jumbled and incomprehensible when you’re faced with the task of “knowing it all” all at once. You lose sight of the proverbial forest. Knowing too much about trees and too little about the forest they’re in may not be sufficient once you get into a clinical situation. You can’t put yourself in the position of knowing so much about the details that you can’t think in broader terms. Borrowing from literature, you are expected to be like the cheerful Major General in Gilbert and Sullivan’s Pirates of Penzance. You seemingly need to know “all the facts” and be able to spit them back almost without having to strain to think. Sure, it’s rewarding and often important to answer an ostensibly complicated or detailed question correctly (you possess the main positive

attributes of Gilbert and Sullivan’s Major General). But you don’t want to find yourself so bogged down in knowing the details that you miss seeing the more important big picture, or how the facts apply or relateto one another (the Major General’s main flaw). The simplest or most basic concepts can be overlooked with teaching or learning that is too detailed in terms of fact and focus. (I’ll also go out on a limb and state that you’ve also been taught, and expected to learn, a ton of information that is trivial or, at best, not necessary for your understanding and ultimate application of basic pharmacology to clinical reality.) And So, a Disclaimer of Sorts Your experiences from the courses and exams you’ve taken may be quite different from those of students in other medical schools, the medical students I’ve taught, or the very same students here or elsewhere taught by different profs. Therefore, the focus of questions you’ll see here, and the way they’re stated, may be different from those you’ve encountered on your exams. The explanations may differ too. There’s no one “standard” pharmacology curriculum for all medical schools. Some have separate preclinical courses for the basic sciences (anatomy, physiology, pharm, and so on). Others, such as ours, have a curriculum in which, for example, the basic sciences applicable to cardiovascular diseases are all in one section (we call them “sequences”). And when we think about individual faculty it’s obvious that points emphasized by a particular instructor may differ (sometimes markedly) in scope and orientation from those made by others. Some faculty place considerable emphasis on detailed or complex mechanisms of drug action; detailed pathways of drug metabolism; chemical structures and perhaps structure-activity relationships; mathematical approaches to pharmacokinetics; and so on. Students leave lecture wondering what the clinical implications are. Conversely, other faculty address the clinical “relevance” of certain drugs, but do little more than say “Your 50-year-old male patient has recently been diagnosed with Type 2 diabetes mellitus. Prescribe metformin.” (As Homer Simpson might say, “duh-oh, ok.” But why? Always start with metformin?) ...I try to balance the basic science and the clinical relevance in teaching and testing. My focus usually is on the “whys” of things probably more than the “whats,” and I try to reduce the number of what you’d call rat facts to a minimum. I don’t spend time teaching about all the angiotensin converting enzyme inhibitors when I can teach the essentials by focusing on captopril. I prune the teaching of β-blockers by focusing on propranolol as the prototype (most representative drug), then spend some time talking about the so-called cardioselective β-blockers (atenolol, metoprolol), those that have vasodilator activity (whether by virtue of

α-blockade or nitric oxide generation), trying to show how or why those drugs are different and important clinically. No discussion or testing on the two dozen or so other β-blockers. Since there is no universally adopted or “official” medical pharmacology course or course content (and even though the National Board of Medical Examiners ...has relatively focused learning and testing objectives), I choose material I think is important, exclude what I deem unnecessary, simplify that which can be unnecessarily complicated, try to bridge learning of basic facts and concepts and apply them clinically, and largely ignore content I think is irrelevant. For lack of a better phrase, I skip things that are just something else to learn. That’s what I do in class and on exams, and that’s my main approach to writing questions and explaining the answers in this book. Suggestions on How to Use This Book Prepare yourself to answer the questions in each chapter by studying first the corresponding material from your lecture notes and favorite (or, at least, assigned) text. This book that you hold in your hands is, after all, a review and self-assessment tool, not an original source of learning information. Before you work on the questions and your studying overall, try to do the following: “Be able to identify main drug classes, recognizing that sometimes we use more than one classification scheme (eg, chemical; by main mechanism(s) or site(s) of action; by clinical use); and be able to cite a prototype drug for each. Conversely, given a named prototype or otherwise representative drug, be able to work backward and know the rest of the most relevant information, including the class(es) to which it belongs...” “Be able to identify the class to which a drug belongs by looking at its generic name or other name...” “Be able to state the main expected effects or side effects of major drugs or drug classes. This should give you a good idea of what the relevant precautions or contraindications are, even if you haven’t been taught about the latter, even if your learning focus hasn’t been too clinical...” “Be able to state the most important (eg, serious or life-threatening) unwanted side effects, adverse responses, and clinically relevant drug interactions for the main drugs or drug classes...” Each question is written to elicit the one “best” or “most likely” correct response. Mark your answer by each question, or download, print, and use the answer sheets I’ve posted on my personal teaching web site. (The URL is www.

umich.edu/~mshlafer/pharm.html. When you get there, click the PreTestΤΜ button at the top of the page.) Don’t rush. There are no penalties for going through this review and answering incorrectly, and no rewards for speed. After you finish all the questions in a chapter, spend as much time as you need verifying your answers and carefully reading all the explanations. This is particularly important if you chose a wrong answer, didn’t have a clue about what the right answer might be, or just made a lucky guess, perhaps because of your test-savvy skills. I wrote most of the explanations to reinforce and supplement the information sought by the questions, and sometimes to gently encourage you to look at (usually earlier) parts of this review book. Do revisit your class notes for further clarification too... And so now, as you turn the pages for your review and self-assessment, do as one of my favorite comics would encourage you to do: “Git er done!” Good luck. Marshal Shlafer, PhD Department of Pharmacology University of Michigan Medical School Ann Arbor, MI 48109 mshlafer@umich.edu Pharmacology: PreTestTM Self Assessment and Review, Thirteenth Edition Copyright © 2010 by The McGraw-Hill Companies, Inc. All rights reserved. Reproduced here with permission.