Sunday, August 21, 2011

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.

********************

You’re going to forget most of what you learn in first year anyway, so don’t 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 we’ll 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. What’s 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 you’re about to forget. In the lead up to that moment, it would be a waste to spend your time reviewing because you weren’t going to forget anyway.

So let’s 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. It’s 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, it’s 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 wouldn’t 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 you’ve 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 don’t because it’s not convenient. Walking from parking garage is the time period that comes to my mind. It’s about 15 minutes each way. That’s 30 minutes a day. I could do a lot of studying in 30 minutes, but I can’t 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 I’ve ever bought. I picked up at least an hour in my day for studying just with my iPhone alone. That’s huge!

Another thing is that you can study while you’re moving. I found that I hate to sit for hours on end at my desk. So when it’s warm out, I’d 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. That’s high yield. : )

At this point you may be wondering. What’s the catch? What’s 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 can’t 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 it’s just going into your head.

Reviewing also takes time. To use Anki the right way, you need to review your cards when they’re due. You can’t 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 it’s easy to become discouraged and overwhelmed and just quit. I’ve 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 won’t 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 you’ve memorized and make connections, but memorization is a pre-requisite to that concept building.

Some people don’t like Anki because it doesn’t suit their learning style. This complaint usually comes from the auditory or kinesthetic learners. That’s a valid criticism and if they have methods for remembering that are as effective as spaced repetition, that’s wonderful. I’m 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 isn’t 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 I’ve 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 you’re 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. They’re clear and simple and they’ll help you get a feel for the interface.
You’ve 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, you’ll 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
Let’s 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. That’s only part of the answer. These components you don’t 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 can’t separate them. You have to see them all together. How would you score this? The answer is, you can’t score it accurately. The right way to handle this kind of information is to write several cards with one fact each.

If you don’t want to read the 20 Rules, I’ll 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 didn’t say NEVER use lists. Sometimes they’re 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 you’re studying.
(4)Use media liberally to enhance your cards.
(5)Write your questions in complete sentences.
a. Some people use short hand. That’s fine. But if you ever want to share cards with other people, they don’t 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 you’re 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 I’ll 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 year’s end, you’ll have covered the whole book. In the past, people would say that reading First Aid during your first year was a waste because you’d 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. You’ll 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, you’ll be learning relevant stuff for class too, so your time will never be spent poorly if you do this.

On Using Other People’s Cards
You might be wondering whether you could use other people’s decks instead of making your own. The answer is yes. You can use other people’s decks. But my experience has been that it’s 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 people’s 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. It’s 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 everyone’s 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, that’s all I’ve got. I hope I’ve convinced that Anki and spaced repetition is a worthwhile endeavor. If you read the supplementary articles linked above, you’ll see that there is quite a bit of evidence to support the principles behind Anki if you need more convincing. I’ll admit. It’s 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. Don’t forget. You’re 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, don’t 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!

25 comments:

  1. Thank you for the information. I am four months into my first year in med school, and have been only very lightly starting to compile cards for Anki. What should I do? I'm so lost as what would be the right way to incorporate Anki at this point. Should I fervently make cards for the four months worth of material that has passed (only covered 10% of it in Anki)? Or should I just stick to the summary of each lecture and then quizing myself of the questions I made for me for each lecture? I made Anki from these summary/quiz sets so I have them for the past four months.

    It's just my current plan of summarizing each lectures, then making quizzes out of them, and THEN putting the quizzes into Anki takes so much time for each lecture that I don't even have time for actual post-lecture reading of the books, which I find is crucial to understand concepts.

    Any input would be helpful.

    Thanks!
    Seungjin

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  2. Seungjin,

    I'm glad you found my article helpful. So you can usse Anki any way you want. It depends on your goals. Think of it this way - if you want to remember something, make a card. It's as easy as that. In medical school, we're expected to remember lots of fine detail. That means lots of cards. There is no way around it.

    For your situation, I'd say forget about the past. Start fresh going forward.

    How do you primarily learn? Lecture slides? Videos? Text books? A mixture?

    If you like to read, make cards for anything important that you read. If you use mostly lecture slides, make cards as you go over your slides. No need to be redundant and do double duty. Make cards as you're studying your preferred source. Capture as much detail as is necessary for your goals. If you want to destroy class exams, that means you need to remember most everything. That means a lot of cards.

    After you're done with your study session, study your cards IMMEDIATELY! This is something I should have mentioned in the guide. I heard from a lot of people that they were making hundreds of cards and then waiting until right before their tests to start using them. That is not the best way to use Anki. Slow and steady wins the race. Studies have shown that in order to get stuff into your long term memory, you need to review within 24 hours. So do your reviews right after you make your cards. You'll be amazed at how much you will have already forgotten! That's what Anki is good for. It shows you what you don't know and it helps get it in there.

    Also, by doing a small number of cards each day (no more than 100 new cards/day is my rule), you make your successive review loads much more manageable. If you try to crush 300 cards in 1 day, you'll see 300 cards again the next day for review IN ADDITION to your new cards.

    Does that make sense? Overall, just remember. Making cards and reading is great, but the most important thing you can do is to review your cards. That's more important than anything. Actually using the cards over and over is the aim.

    I hope that helps.

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  3. Thank you for the information. I'll try to use make the cards as I read/review. Yeah using the cards steadily is the hard thing. But I'll forgo the past and stick to the 5 weeks remaining for my Anki deck buildup! Thanks again!

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  4. Hey,

    I would love to use Anki for studying medicine but I can't figure out how to format my cards. All the guides say to avoid lists as much as possible but almost everything I want to memorize is in some way a list. Take for example symptoms of anemia or the treatment of a severely burnt patient. Can you offer any advice on how I should be studying etiologic factors, symptoms, treatments, complications, drug contraindications etc. with Anki?

    Thanks in advance,
    Toni
    Finland

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  5. Just wanted to throw in my experience with Anki. In our class, some people really like studying with Anki, and some are use it less extensively and only for certain courses.
    In my studying, I gradually veered away from using Anki extensively and into summarizing each lectures by writing. But a long-term memorization Anki would be awesome, but in my case I had many cramming to do and the time to spend to make Anki was not cost-effective for me. However, since the semester is over, I plan to use Anki to refresh myself of the previous courses, in preparation for USMLE or what other big exams in front of me. (I am M1). Thanks!

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  6. @ Toni

    It's true, you should avoid lists as much as possible, but that doesn't mean no lists. You're absolutely right that in medicine, lists are everywhere, and sometimes there is no other way to organize information. Lists are just not great for memorization, so you need to do things to make it easier to recall a list.

    Things I do:
    (1) Use mnemonics whenever possible. There are free sources online for medical mnemonics. First Aid for the USMLE has a lot of good ones. Or you can make your own.
    (2) Don't make lists more than 5 items if you can avoid it. If you have to go more than 5 items, use a mnemonic definitely.
    (3) Use images to help remember lists. For example, for microbiology, there is a great book called Clinical Microbiology Made Ridiculously Simple. It has great illustrations. There is one illustration for the diseases caused by S. aureus. Wrapped up in this one illustration of a wizard are six different diseases. I can look at the image in my head and go through the list in that way.
    (4) Break lists down. For example, for something like Cystic Fibrosis, instead of saying, "what is the clinical presentation" I'll break it down by system. So I'll ask one question. "What are the pulmonary manifestations of CF?" And then "What are the GI symptoms of CF?" In this way, I can make much smaller lists with 1 or 2 items rather than 10.

    This things help you handle lists, but still, there a ton of questions in medicine that you can write where there is just a single answer. Most of my cards are like that. If you go to the shared deck in Anki, look for "Pathology". I've uploaded my deck for others to use, so you can see how I make questions.

    I hope that helps. Anki is most definitely applicable in medicine, and while you might have to make some lists, that shouldn't deter you.

    Best of luck,
    Alex

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  7. @ Lovebes,

    As I often tell people, do what works for you. If summarizing works, great. For me, I thought that anything but making cards was a waste of my time, because I wasn't going to use those note sheets or outlines again, and because they don't help me recall the information as well as Anki.

    You can cram with Anki if you want using the cram function.

    Best of luck.
    -Alex

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  8. Thanks Alex. Hm.. from what you said I'm thinking of giving Anki another shot this semester. Perhaps I'll just make cards for First Aid as I do Patho, Physio, Epi, Microbio(virus/fung/paras) this semester.

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  9. Thanks for the tips. I checked out your pathlogy cards, very nice work. Just out of curiosity, how many cards do you do per day (reviews vs new) and how much time does it take you.

    - Toni

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  10. @ Toni. I'm glad you liked the cards.

    My daily load depends on how quickly I've added new cards to the queue and whether or not I had any lapses. If you don't keep adding new cards, eventually the daily reviews keep getting less and less. But of course, in medical school, you're always adding new stuff and still trying not to forget the old.

    When I was in the classroom last year, at some points I was doing 400-600+ cards a day. That's overwhelming. This year, I've been adding much fewer, and my card load of reviews are down to about 100-200/day. That's very manageable. I have nearly 10K cards in circulation right now, and I'm trying to keep that all in my head. It takes a lot of work, but I make it a priority. I use my iPad and iPhone so that I can crush cards everywhere, whenever I have a free moment. I love the Anki mobile app, even though it wasn't cheap.

    If you have the time, the right way to do this is to add new cards slowly, no more than 100 a day. I think about 50 is optimal. This way, your future reviews are not massive. Also, your brain can only add so much new information/day. You don't want to overwhelm.

    So optimal conditions would be max 100 new cards/day.

    How intense of an Anki user you are depends on your goals. I make a lot of cards because there is a lot to remember. But based on your goals and your abilities, you might choose to do far less cards and just use Anki for the really hard or important stuff. There is no perfect way. It depends on your goals, but the guidelines I've provided should be useful to everyone.

    Best,
    Alex

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  11. Thanks for the comments. So far I love Anki for studying swedish. I've noticed that doing cards is actually pretty fun as long as the individual cards are fast to do. With vocabulary cards it only takes like 10 mins to speed through 50+ cards. Will be interesting to see how I fare with the medical cards.

    - Toni

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  12. Did you make the 5000+ card "Pathology" deck? If so, when I downloaded it, almost all 800 pictures associated with it did not download. Any way you can update that?

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  13. Yes I did. :) Did you download from Anki's shared database? Media aren't included. Did you see my latest post? I just linked to all my Anki decks plus media on a public dropbox link. I also have more than 6K cards.

    Check it out.
    http://drwillbe.blogspot.com/2012/02/studying-pathology.html#comment-form

    Enjoy!

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  14. Thanks, I did a little more digging on your site and found the new set before I returned here. They're incredible!

    Also, it seems like a good portion of your micro images aren't working (even just looking at them from dropbox). Are they different format that my CPU doesn't support or is there a problem?

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  15. See my comments @ http://drwillbe.blogspot.com/2012/02/studying-pathology.html

    Sorry about the media. Enjoy the cards though.

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  16. Hey, nice guide.

    I too had the problem with the sets. Ofc you can try to break them down into pieces, but oftentimes you will have to make a set. What I did was to write a model where I could enter a question and up to ten items.
    The model then creates one card for each item and one that goes reverse by showing you the items and asking for the question.

    The single cards then look like this:

    Symptoms of pulmonary embolism are:

    ... , thoracic pain , [...] , ...

    [...] represents the asked item.

    I made it this way following the rules from SuperMEMO, where they say you should break down enumerations and always do them in the same order, to make them easier to remember.

    Though I'm quite happy with that solution, learning it is still more difficult than simple questions, but it goes much quicker than previously.

    I'd highly recommend to activate that knowledge by doing some old exams. When you only repeat your cards all the time you may have difficulties recalling the information in daily routine.

    Currently I add 100 cards per day on 5 days a week and on one day I do old exams. Things I don't know there may get added to my cards as well. I'm getting along quite well with that.

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  17. Wow, really glad that I found this post a few months before I start medical school. Looks extremely useful.

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  18. Hey Dr. Willbe,

    I really like the concept of this, and my only concern is that I feel like the intervals are too long and I won't get adequate exposure to the material. I have blocks ever 3-4 weeks and with 3 day intervals for some levels of confidence I feel like just going over normal flash cards every day would be a better option.

    I'm worried about wasting precious time putting together cards only to find out the system won't work. I'm mainly doing this for my path and med micro classes (especially med micro). Do you have a way to contact you for specific questions regarding configuring the software? Thanks for your help.

    -Mike

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  19. I'd be interested in people talking more about dealing with sets. For example, Marfan: tall with long extremities, pectus excavatum, hyperextensive joints, and long, tapering fingers and toes (arachnodactyly); cystic medial necrosis of aorta --> aortic incompetence and dissecting aorticaneurysms; floppy mitral valve. Subluxation of lenses.

    How are sets like this formatted better. I thought about it, and breaking it up could work but it still seems challenging to recall this in the same order each time.

    ReplyDelete
    Replies
    1. Hey,
      Good question. Sets are inevitable. In a perfect world, every question would have a single answer, but sometimes, there is no way around producing a set of items as an answer. But, still, the general principle should be to (1) keep the sets as small as possible, (2) use mnemonics whenever possible, (3) break down sets into more specific questions if possible.

      So for your Marfan question above. Your set of info is actually at least 3 or 4 different questions in my mind. Making a card with Marfan on the front and then all the info related to Marfan on the back is not the way to make a good Anki card. That's how people traditionally use flashcards, but that method is not conducive to retention or accurate self-grading.

      So here is how I would break it down.

      First, clinical presentation

      Q: Clinical presentation: Marfan Syndrome (5)
      A: tall with long extremities, pectus excavatum, hyperextensive joints, and long, tapering fingers and toes (arachnodactyly), ectopia lentis

      If you wanted to make this card into even more cards, you could easily do it, and I sometimes do.

      So...

      Q: What is the effect of Marfan Syndrome on the eyes?
      A: Ectopia lentis

      Q: What is the effect of Marfan syndrome on the chest?
      A: Pectus excavatum

      Q: Provide a mechanism for the cardiac effects of Marfan syndrome
      A: cystic medial necrosis of aorta --> aortic incompetence and dissecting aorticaneurysms; floppy mitral valve.

      Does that make sense?

      In general, the more specific the card, the better. That often means making more cards. That's fine. You'll actually have a chance of remembering and reproducing the information if you do it like that.

      In general, for each disease, I make the following cards

      Definition:
      Clinical presentation:
      Etiologies:
      Pathogenesis:
      Histopathology:
      Treatment:

      And anything that you feel needs to be a specific question, just make a card for that.

      Hope that helps. See my decks for examples.

      Delete
  20. Thank you for sharing. Your cards are just awesome!!!

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  21. I've been aware of anki for a while and had thought to use it as a flashcard system, but your idea of having *almost* solely anki as a review tool is phenomenal. I'm a med student in Ireland and have just started me degree 2-3 months ago.

    I have some questions about the frequency of the review though. When I answer something was "easy", the next review is 4 days away!! However when I answer something was good it's asking me again 10 minutes later, until it becomes easy, and then I'm waiting 4 days until I see it again.

    What do you recommend? Would it make sense to change the "good" review to the next day, and then have easy as 4 days after AND then have anki take over with the SR learning??
    To be honest I just started making flashcards tomorrow, but I'm really excited by the idea, and hope it'll work for me :)

    Thanks is advance,
    Pidge

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  22. I am not sure where you're getting your info, but good topic. I needs to spend some time learning more or understanding more.
    I would to share this: www.inventhistory.com

    Medical Mirror
    inventhistory
    Medical Stethoscopes and Sphygmomanometers
    Electronic Cigarette
    Stark Hand


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  23. Wow!!! Wonderful blogs for many times I need the good guide that is really helpful for my study and I love the concept that is given in this blog and I also want to say that this type of guides is really helpful in my medical practice..
    source:Starting a Medical Practice

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  24. Just starting to use Anki for medical school. Out of curiosity did you find it most practical to leave all the settings as is in the "default" mode? If not, what tweaks did you make or find most advantageous for going through the cards?

    ReplyDelete