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.
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.
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.