Anki Guide for Medical Students

Hi all,

So many of you know that I found an incredible learning tool called Anki last fall.

I've continued using it for the entire year, and I'm still using it on the wards. It has helped me so
much that I want to share my experience and advice with my fellow med student colleagues. For
that reason, I wrote a guide a week ago for the incoming 1st years at Duke.

I figure there are other people out there who would benefit from it too, so I'm posting it here. If you
have any questions or comments, leave them below and I'll address them as soon as I can.

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Youre going to forget most of what you learn in first year anyway, so dont worry
too much. This is what I was told at the beginning of my first year in med school
by a lot of people. I remember recoiling when I first heard this. What a depressing
thought. To spend so much time and energy (and a lot of money too) just to
quickly forget most of what I was to learn!


I wondered, "Did it really have to be like this?" Need I invest so much just for
most of my efforts to fade away? And if that really is the case, does it even
matter?


The truth is, it does matter, or at least I think it does. The pre-clinical years are
the time to build a strong foundation of basic science knowledge that will support
the life-time of learning well do as physicians.


So, I decided that it was in my best interest to try to retain as much of what the
pre-clinical year would throw my way. With my goal determined, I then sought the
tools.I knew that I was going to have to find something more advanced and more
organized than the study tools I used as an undergraduate.


After some hours of searching the web and talking with friends I learned about
Anki. Anki is a spaced repetition flash card program. Let me explain.


Anki takes advantage of a learning principle called the spacing effect. The idea is
that in order to commit something to memory, one needs to review a fact multiple
times. This is common sense. Whats not so apparent is knowing when we need
to do those reviews. The spacing effect asserts that in order to remember
something, we need to see it multiple times at increasingly longer intervals. Each
time you review, the time until you forget becomes longer and longer.


It follows that the most efficient way to study would be to review a fact just before
the moment youre about to forget. In the lead up to that moment, it would be a
waste to spend your time reviewing because you werent going to forget anyway.


So lets recap. In order to remember we need to review multiple times at
increasingly long intervals and in order to be most efficient, we need to review at
exactly the right moment. But how do we know when that moment is? Surely,
some things are easier to remember than others, and so different facts are going
to have different intervals. How could we possibly know when the best time to
study is?


Thankfully, forgetting follows a pattern. The brain forgets exponentially. Programs
that use spaced repetition take this into account and have sophisticated
algorithms that project with high accuracy when you need to see a fact for
review. Only with the aid such programs is it possible to take advantage of the
spacing effect in the most efficient and effective way possible. It is for this reason
that I am so excited about Anki. Its the best in the class of these programs.
Others such as Supermemo, Mnemosyne and Mental case exist, but Anki is the
best because it is free, simple to use, has a dynamic online community and most
importantly, its effective.

People use Anki for lots of things. Foreign language learners love it. But I love
Anki for med school. There is no way around it. You need to commit lots of
information to memory. Brute force is not enough. Studying smarter, not harder is
the goal, and in my opinion, Anki is the way to achieve that.


The other benefits of Anki are many. For one, all studying is digital, which means
that your cards are searchable, editable, categorized, and take up no space. At
the moment, I have over 10,000 cards. How could I possibly manage that many
cards with actual physical flashcards? Moreover, without spaced repetition, how
could I ever study those in a way that wouldnt take me an eternity?


Digital flashcards can also incorporate media such as images, video and sound.
Studying things like histology or pathology become much more effective when
youve got images associated with textual information, as can be done with Anki.


Another major benefit is portability. In medical school, time is your most precious
asset, and you want to make the best use of every moment you have. If you
thought about your day, I bet you could identify several places where you could
be studying but you dont because its not convenient. Walking from parking
garage is the time period that comes to my mind. Its about 15 minutes each way.
Thats 30 minutes a day. I could do a lot of studying in 30 minutes, but I cant
take out a book or my notes binder while walking. I can, however, whip out my
iPhone and crush 40+ cards on the walk to my car. The mobile app for Anki is
excellent, and it was one of the most valuable apps Ive ever bought. I picked up
at least an hour in my day for studying just with my iPhone alone. Thats huge!


Another thing is that you can study while youre moving. I found that I hate to sit
for hours on end at my desk. So when its warm out, Id take my iPhone out and
do my studying while enjoying the outdoors. I can walk for miles and do my
studying at the same time. Thats high yield. : )


At this point you may be wondering. Whats the catch? Whats not good about
this method of study?


The first thing that comes to mind is that it takes time. Making cards will take
some time. I cant deny this. But you know what takes a lot more time? Forgetting
and then having to relearn what you forgot. Plus, card-making is instructive in
itself. As you read or look at lecture notes, the act of extracting information
makes your eye much keener. You read more critically, rather than just passing
your eyes over text with the confidence that its just going into your head.


Reviewing also takes time. To use Anki the right way, you need to review your
cards when theyre due. You cant decide when you want to study. You need to
study when Anki say to. If you miss some days, cards can pile up in your inbox,
and its easy to become discouraged and overwhelmed and just quit. Ive been in
this situation from time to time when life takes precedence over studying, so I
understand the feeling of seeing 500 cards piled up. But if you stay disciplined
and do your cards daily, you wont be in this spot.


Another criticism is that Anki is promoting just rote memorization and not
conceptual understanding. That too is true. Anki is for remembering discrete
facts. But understanding is made up of facts. When we make connections
between facts and integrate them into a mental framework, that is understanding.
So Anki is not one stop shopping. You still need to ruminate on the facts youve
memorized and make connections, but memorization is a pre-requisite to that
concept building.


Some people dont like Anki because it doesnt suit their learning style. This
complaint usually comes from the auditory or kinesthetic learners. Thats a valid
criticism and if they have methods for remembering that are as effective as
spaced repetition, thats wonderful. Im just not one of those people and I need
the structure of Anki to really help me keep things in my head.


Finally, Anki can sometimes be buggy. The user interface isnt the flashiest ever
and sometimes there can be annoying bugs or glitches. But the program is free
and the developer plans to keep it that way. So, these points are forgivable and
minor in my opinion.


Putting Anki to Practice in Med School
OK. So I hope Ive convinced you that Anki is an incredibly useful study tool that
could help you make the most of medical school. Now what?


The first step is to download Anki from http://ankisrs.net/. It works on multiple
platforms and syncs across all of them, so what kind of device youre using is not
a problem.


After you download the program, you should then spend a few minutes watching
the tutorial videos on the Anki website. Theyre clear and simple and theyll help
you get a feel for the interface.
Youve got the tools. Now you need to make some cards and study them.


Best Practices for Making Anki Cards
Your studying will only be as good as your cards. Just like a computer, if you put
garbage in, youll get garbage out. When people think of flashcards, they usually
think of them as mobile, easy containers for lots of information. Flashcards to
most people consist of index cards with a ton of information on them.
That kind of card is not good for Anki. Rather, the best kind of card consists of a
discrete question and answer.


For an excellent primer on card-making, read the 20 Rules of Formulating
knowledge (http://www.supermemo.com/articles/20rules.htm).
Why is the discrete card the best kind? First, we remember small chunks of
information better than large, multi-part pieces of info. Second, and most
importantly I would say, is that discrete, unitary facts can be graded
unambiguously, which allows you to accurately and reproducibly score yourself
using Anki. But with large, multi-part answers, how would you score yourself?


Consider the following example.
Q: What are the characteristics of the Dead Sea?
A: Salt lake located on the border between Israel and Jordan. Its shoreline is the
lowest point on the Earth's surface, averaging 396 m below sea level. It is 74 km
long. It is seven times as salty (30% by volume) as the ocean. Its density keeps
swimmers afloat. Only simple organisms can live in its saline waters
Lets say you remember that the Dead Sea is a salt lake, is 396 m below sea
level and seven times as salty as the ocean. Thats only part of the answer.
These components you dont need to see for a while because you remembered
them. But the remainder of the answer was forgotten and you should see those
components sooner in your reviews than the parts you remembered. However, if
all these things are part of one card, you cant separate them. You have to see
them all together. How would you score this? The answer is, you cant score it
accurately. The right way to handle this kind of information is to write several
cards with one fact each.


If you dont want to read the 20 Rules, Ill give you the short version that I use to
guide my card-making.
(1) Keep it simple to the best of your ability, make cards discrete (one fact per
question/answer set).
(2) Make questions unambiguous with only one right answer.
(3) Avoid lists as much as possible.
a. Notice I didnt say NEVER use lists. Sometimes theyre unavoidable and at times
useful. The key is to keep them short (less than 5 components) and whenever
you can, use a mnemonic to help your remember. First Aid for Step 1 is a great
source of mnemonics. You should refer to it whenever youre studying.
(4)Use media liberally to enhance your cards.
(5)Write your questions in complete sentences.
a. Some people use short hand. Thats fine. But if you ever want to share cards with
other people, they dont know your language.

So What Should I Study?
This is a very important question without a right answer. It depends on what your
personal goals and preferences are. Some people really want to destroy class
exams and want to follow the curriculum closely. Others would rather just get by
in class and spend more time studying for Step 1 or pursuing their personal
clinical or scientific interests. The nice thing about P/F is that youre no longer
penalized for not being the first kind of student. You can study what you want or
you can study what your school wants you to study. Or you could do a mix of
both. Regardless, Anki will help you achieve your goals.


One firm suggestion Ill make though is that you should get yourself a copy of
First Aid for the Step 1 (or a PDF from your big sib/classmates) and make that
the minimum baseline for the entire year. The information in this book is non-
negotiable. As you go through course material, make sure you cover the
corresponding section in First Aid and make cards. By years end, youll have
covered the whole book. In the past, people would say that reading First Aid
during your first year was a waste because youd forget so much and would
eventually need to go back and review anyway. Without a review mechanism like
Anki, this criticism would be correct. But no longer is it true. Youll be well
rewarded by putting the effort in now to make a deck that you can review
throughout the year and during your second year leading up to Step 1. Plus,
youll be learning relevant stuff for class too, so your time will never be spent
poorly if you do this.


On Using Other Peoples Cards
You might be wondering whether you could use other peoples decks instead of
making your own. The answer is yes. You can use other peoples decks. But my
experience has been that its not nearly as useful as making your own for some
of the reasons cited above. As I mentioned, making cards is an instructive part of
the learning process. It sharpens your eye during reading. Also, people have
different ways of making cards, and unless everyone is on board with a strict
standard, it can be difficult to use other peoples decks.


With that said, if you can manage to find a group of people to share the work load
with, doing a collaborative card-building project can be extremely useful. Its like
notesgroup for Anki. I suggest you find a group of dedicated classmates who
want to make a deck for a particular book. Someone should set up standards as
to the format of the cards and decide what information should make it onto the
cards. After everyone does their part, the individual files can be compiled and
distributed for everyones use. Some friends and I did that with First Aid
pharmacology last year and it worked out very well. We made about 1500 cards
over a week. It would have taken me forever to do that alone. So collaborative
decks have a time and place, but I still recommend doing your own work.


Summary
Well, thats all Ive got. I hope Ive convinced that Anki and spaced repetition is a
worthwhile endeavor. If you read the supplementary articles linked above, youll
see that there is quite a bit of evidence to support the principles behind Anki if
you need more convincing. Ill admit. Its not always fun to be quizzing yourself
with cards, but the sweet reward at the end of having so much useful medical
knowledge safely stored in your memory is well worth the labor. Dont forget.
Youre learning for your future, for your patients. Anki is not a quick fix. It is for
building long-term knowledge.


If you have any questions about implementing Anki, dont ever hesitate to contact
me. I can check out your cards or share some of mine. If time permits, I hope to
put some video tutorials and tips online to help you guys get going.
Happy Studying!