It's here! Learning Medicine: An Evidence-Based Guide
Dear Readers,
I'm glad you're still here. I've been quiet here on the DrWillBe blog because I've been hard at work on a major project. For over two years, I've been writing an a book on learning in medical school with my friend and colleague, Dr. Peter Wei.
Since the inception of this blog, I've written enthusiastically about the power of spaced repetition (SR) using the program Anki. No doubt, SR and Anki are extremely potent, but they are not the only components of highly effective learning. There are many ingredients in that recipe, and so I wanted to flesh out a comprehensive methodology for learning medicine well.
Learning Medicine is the
result of several years worth of research and experimentation on our
part to discover the most effective methods for learning in medical
school. We've distilled the insights from those efforts so as to create a
guide that is very practical, allowing you to apply these high-yield
study hacks immediately.
Here are some highlights from the book:
Take a brief tour through the science of learning and memory
Learn about the power of spaced repetition for building long-term knowledge
Practically apply spaced repetition using the popular app Anki. We give you very specific instructions on how to make this program work for you.
Go step by step through our comprehensive Learning Method, which embodies all the study hacks we discovered in our research.
This is the "instruction manual" so many of you have asked for. It will help you get started using SR decks, like my Pathology Anki deck, and will give you many more tools to continue learning effectively on your own.
I hope you you find much value in this book. Let us know what you think by leaving comments on the book site, or here on the DrWillBe blog. Happy Studying! -DrWillBe (Alex)
I'm going to make this quick. Honestly, for the next few days at least, I want to have nothing to do with medicine. I've dedicated enough time, and I think I need to get back the world that doesn't revolve around crushing qbanks all day. I don't want to think about Step 1 either until I find out how I did. Doing otherwise is a sure-fire way to induce some needless anxiety.
So here's my impression: I feel fairly good about the test. What I've studied and what I know, I got those questions right. Most were very straightforward, bread and butter stuff. There were a couple of "what the heck" questions with terms or facts I had never seen before. I didn't expect that. Not many, but maybe 4-5 q's. I reasoned them out and think I got them right, but it was still surprising.
- Many questions looked just like UWorld. It's unreal actually how good UWorld is at identifying topics that Step likes to ask about.
- Questions stems are a bit longer than my practice qbank questions
I'm going to refrain from being too specific until after I find out how I did.
I was physically and mentally drained by the exam, I have to admit. I'm not used to sitting for 8 hours. I use a standing desk at home, so I can move around. Sitting for that many hours was definitely painful. Made my neck tight too.
When I walked out of the test center, I felt strange. I had just finished a marathon that had loomed for so long, and now it's all over. I had expended quite a bit of energy on it, and now it was done. Time to figure out what to do with my time now :)
And so, that is what I will begin to do today. I'm not starting lab rotations until the first week of November. I'm taking this week and the next for some R&R. I have a lot of projects and books I want to read, and I'll do that in the next week. Then will take a road trip to a wedding the following week.
Over the next few months, I'm going to transition this blog to talk more about science and grad school than med school.
For the next few days, here's a list of stuff I'm going to do:
(1) sleep
(2) clean the house
(3) spend time with my wife, whom I've neglected for too long because of my studies
(4) learn some computer science and programming
(5) work on AgoraMed, the med education startup I'm doing with my buddy Peter
(6) start reading books for grad school - I'm going to take a general study of scientific method, experimental design, practical programming for bio-ish stuff, biostats, etc. Stuff that I could use no matter what I'm doing in the lab.
(7) Develop my productivity workflow. I've been tinkering with some programs like Omnifocus, Papers, Devonthink, Anki and Scrivener, and I want to develop a clean workflow that helps me integrate these tools and make them work for me. I'm going to write more about this as I do it.
(8) Do some fall stuff - pick pumpkins, apples, etc. I'm really liking fall these days and want to enjoy it while it's here
That's it for now. Thanks for following me in my Step 1 journey. Hopefully my reflections have been useful to you all. That is my main reason for keeping this blog in fact. I enjoy getting stuff off my chest, but I like even more when my words help others.
So the time has come to finally take Step 1. It's been nearly 7 weeks of on-off but dedicated prep, and just about 2 years of learning med school stuff. I think enough of my energies have been expended on this test, and tomorrow will be the end.
I'm feeling pretty good right now. I did a quick cram this morning of stuff I care to forget - embryology, some behavioral science stuff, helminths, etc. By midday I called it quits and did other stuff. Mowed the lawn, spent time with my wife. In about 30 mins, the computers and devices are going off and I'm going to chill out for the night. Dinner, some meditation and some Bible reading with the Mrs. Get to bed, then hopefully fall fast asleep so I can get to tomorrow morning sooner.
Taking this test marks the end of one of phase of my training and the beginning of another. I'm looking forward to devoting my time and energy to new pursuits, and without the burden of studying for Step, I'll be free to do all those things. More on that after tomorrow.
To those who have been following this series, I thank you. After I get my results, I'll do a post-mortem and see how my somewhat unconventional methodology fared.
Just an update. Nothing crazy going on over here. On Friday I finished the last of my content review days. My plan from here on out is to just do qbank questions all day, every day. As I come across things that I don't know, I make an Anki card. That's pretty much it. Qbank, Anki, review, repeat.
I'll try to make some more resources or videocasts in the next few days.
Just an update. Last week was kind of a wash for me. I had a lot of family and school obligations, and thus, my study schedule fell by the wayside. I got some anatomy and embryology done at least. I might need to do a little more anatomy studying, but otherwise, I feel comfortable with those topics. With anatomy, biochemistry, behavioral science and embryology behind me, there is no more "new" learning to be done. I can really enter into study mode now and just do a lot of questions from UWorld and USMLERx.
The plan for the next few days is do some reading in selected topics:
Cardiac physiology - Boron and Boulpaep
Respiratory Physiology - Boron and Boulpaep
Pharmacology - autonomic, antiarrhythmics, pharmacodynamics/kinetics - Principles of Pharmacology by Golan
I'll be doing questions as I go along. I'm doing the above reading not so much because I feel deficient for the purposes of Step 1, but because these are topics that I want to really know well for the future and I see now as a fine time to delve in and fill holes. B&B is an awesome and detailed physiology book and I want to zoom in to that level so I can really know the heart and lungs well. I'll update my Anki decks with any nuggets I pull out.
Found this site while cruising on google for something. This is pretty sweet. It's a really comprehensive library of free modular videos on medical topics. I haven't dug too much, but I think this worth a look. Actually, it's a lot of like what I want to do with my startup Agora, but without the market mechanism and multiple authors. It shows, at the very least, that there are talented people out there who are willing and wanting to teach, and not even be compensated (monetarily, that is). Fascinating.
So yesterday was Day 1 of my Step 1 study time. I got off to a slow start, waking up a little later than I would have liked, and then goofed off a bit on the next. But by around 10 am I got rolling.
I decided to wade into the whole study process and watch some Pathoma.
What I Did Today
1. Chapter 1 of Pathoma: Growth Adaptations, Cellular Injury and Cell Death
Activity: Watched all the videos in this chapter at 1.7x speed. Took some notes.
2. Chapter 2 of Pathoma: Inflammation, Inflammatory Disorders and Wound Healing
Activity:Watched all the videos in this chapter at 1.7x speed. Took some notes.
Reflection:
I really like Dr. Sattar's videos. They are incredibly clear and filled with relevant, high-yield material. I look to them as exemplars of excellent teaching. As I was sitting with my buddy watching these videos, I thought about what we were doing. It's the middle of the day and we're in my office watching teaching videos. We stop when we want to. We pause and discuss. We go back and re-watch stuff that was unclear. We take notes at our own pace. We move quickly through things that we already know. This is the future of learning. One day we'll all be doing it like this, all the time.
The traditional lecture setting, where one lecturer gives one type of presentation to multiple individuals, all of whom have different needs and backgrounds, is really outmoded. There is no need for that anymore. All of us can have individualized, custom learning, and it can be fun, relaxed and highly effective. What we did yesterday with Pathoma was an example of that.
Anyway, I liked watching the vids, but I found that I already knew most of the stuff, and so I don't think I'm going to keep plowing through the videos as I had intended. Maybe I'll return here and there for specific topics, but I'm finding that right now, for where I'm at in my studies, doing questions is really the highest-yield use of my time.
I also fell off schedule yesterday. Day 1, I'm already off to a bad start with sticking to schedule.
Tomorrow's Agenda and Strategy
I need to review biostats and the behavior science section of First Aid. That is what I'm going to do tomorrow. Hopefully I can knock it all out.
Resources: First Aid for Step 1 (2012) Behavior Science Section, High-Yield Biostatistics (2nd edition), USMLERx, USMLEWorld Method: Just going to read right through. No Anki card making for this one. I downloaded a behavioral science deck for FA from quizlet. I made this into an Anki deck. I'll cram them after I read. Then I'll do qbank questions from USMLERx and UWorld (time permitting)
I've decided to compile a Wiki of high-yield facts that I pick up from my studies. My intention is to build a review sheet for me to use right before Step, and also for other people to peruse when they want to learn some useful knowledge. I'd ideally be making more Anki cards from everything I study, but I don't think I want to be doing too many new cards right now, and the cards are not generally usable the way a Wiki is.
Cards: My Anki deck. I built this one with my classmates. It's all of First Aid Pharmacology + some Katzung + USMLE world. This covers the bases and helps you drill what you've read.
There are other resources out there, but this is what I used to good effect. Any comments and thoughts are welcome!
Hi all,
On the drive into work today, I was thinking about how every day, I'm learning new things and being exposed to new ideas. No use in keeping all that to myself.
So I'm going to make a habit of just posting whatever it is I'm reading, researching, thinking about or learning on here for others to see. I might not always defend or explain, but I'm just going to put it out there for other people to check out. Getting a discussion going would be awesome too.
So here we go....
1. Omnifocus: This is a piece of software that is based on the Getting Things Done methodology (GTD). The web is full of adherents to this productivity method, and I've come across it enough times that I decided to check it out and take the plunge. I started when I came to med school a year and a half ago. I've tried it on and off and it really hasn't done much to enhance my productivity yet. But that's mostly because I've given it a half-hearted effort. Yesterday I decided to get back on the wagon. I took the plunge and got a book called Creating Flow in Omnifocus that I hope will help me understand and implement this complex piece of software. At this point, I've spent more time trying to learn this piece of productivity software than I have been doing productive things. But I hope it's worth the effort. I want a system. I told my wife this morning, the ideal system would be one in which you just look at the app and there is no question about what you should be doing at any given time. That is where the stress and floundering we all suffer comes from. When I have a block of time to do something, I spend a good portion of that deciding what I should do. And sometimes, by the time I've decided, my time is up!
I'm hoping that if I use Omnifocus the right way, I'll get to the point where I'll have all my possible tasks outlined and prioritized such that at any given moment, I can just plug in and see what I should be doing. I think that would be incredibly helpful.
2. Food Logging
I'm really getting into self-tracking. My friend Peter has turned me onto the Quantified Self site. We've got the tools now to track so much of our lives. Why we would want to do that? Because when you catalog events and personal data, you can see patterns over time. With that information, one stands a better chance of making positive behavior changes. I'm very satisfied with how I eat, but that mean I shouldn't tweak it. I've been a long time low-carber/paleo adherent. The major virtue of this way of eating is that I don't have to count very much at all. My food decisions are qualitative. I eat meat, veggies, some fruits and nuts. I know the foods that are carb-rich, and I avoid them. I don't bother counting anything.
But I think there is value in logging my food over time. I'm going get my bloodwork done this week and I'll see where I stand. I'll do this periodically over the next year and I'll compare my blood work to my food log. In this way, I can see how my eating is changing, and what effect, if any, it has on parameters such as cholesterol, fasting glucose, minerals and vitamins, etc. I've even toyed with the idea of tracking my blood glucose, to see if there are any foods that are unexpectedly spiking my sugar (and thus also my insulin). Ii've always assumed that the way I eat is keeping my sugar stable and relatively low, but maybe that's not true? I don't know for certain. I'm not a diabetic, so tracking my blood sugar is a bit unnecessary, I know. But I think it might be interesting for a little while at least. Why Not? is what I ask myself. Now with the automatic USB glucose monitors that track and log your sugars for you, it's so easy.
Re: food logs. Does anyone have any suggestions for good online logs? I could just use a spreadsheet. But I'd like to have something that knows the nutrient values for the foods I'm eating. FitDay looks pretty sweet, but there may be better ones out there. Any thoughts?
Update 2015-05-28: I've co-written a comprehensive guide to learning in medical school that incorporates Anki with a host of other evidence-backed study hacks. This book is an essential companion to the ideas in this post. Disclaimer: The recommendations below are for how to best learn key subjects in med school. In fact, any study advice I give on this blog or elsewhere is always with the aim of learning for the long term. For that should be the primary goal in my mind. However, I just want to be clear: my recommendations are not geared toward destroying class exams. If that is your goal, you need to really pay attention to lecture slides and class material and old exams and such. I also want to be clear about my intentions and own abilities. I'm a regular med student who just likes to share ideas. I'm know there a lot smarter people in med school then me. In fact, I'm sure of it. But I think I've found things that work well and I want to share that information with anyone who will listen. Always be critical and always evaluate whether what I'm saying will suit your needs and abilities. Thanks for checking out Dr. WillBe.
I've been meaning to write this post for a while. With the first years at my school starting pathology last week, I thought now would be the right time.
Pathology is perhaps the most important preclinical subject. Pretty much, this is medicine. You've learned about how the body functions normally. Now it's time to see what happens when things go awry. Spending the time to learn pathology right will pay great dividends in your future clinical career. Having solid knowledge of the diseases that afflict people and their underlying mechanisms is a requisite to being an excellent physician, in my opinion. It's what separates doctors from technicians. We understand the why as much as the what. And with that understanding, physicians can push the boundaries of medicine rather than merely practicing it.
OK. Enough of my soapbox speech. Clearly I think Pathology has intrinsic value, but more practically, Pathology is the most heavily represented subject on the USMLE Step 1 exam. If you want to do well on Step 1, you need to know Path. And know it cold. There is no way around that. That's reason enough for most med students to take Path seriously.
How does one do that? Well, that's what I'm going to talk about today. As in my other posts, I'll discuss what I actually did and do in my own studying, and then I'll suggest what I would have done if I could do it again.
Methods
First, let's talk about methodology. I'm beginning to sound like a broken record, but I can't help singing the praises of Anki, a spaced-repetition flashcard program. I've benefitted so much from this tool that I want to tell everyone I know about it. You can read about the how and why of SR and Anki here and here. Needless to say, I think Anki is awesome for pathology and it has been the core method for my study of the subject. Actually, of all the subjects in med school, I think Anki is most important for Path because of the vast number of facts and ideas that one has to commit to memory.
For Path - and pretty much every other subject I study using Anki - the process goes like this.
Read - Make cards - Immediately review cards after reading - Repeat
It's that simple. What makes Anki challenging for many students, however, is the fact that you need to continue to review old cards even while you plow through copious amounts of new stuff. It's a struggle, I'll admit, but it's the only way to keep all the hard wrought information you learned already in your head. It get's better over time, and when you stop adding new material, the number of old cards you have to review gets smaller and smaller.
Before I go on, I want to clear up a misconception that people have about Anki. Flashcards ARE NOT A PRIMARY LEARNING TOOL! (sorry for the caps, but I feel like I need to scream this). I don't learn from looking at a bunch of disjointed flashcards. Nobody does. And if they do, they're probably doing a pretty poor job of learning. My primary learning tool is a book. I want a story. I need to see facts in context. We all do. That's not what Anki is for. Anki is for retention of information, not first-pass learning. You use it AFTER you've learned and understood something. This is one of the cardinal rules of SR best practices. Don't make a card for something until you understand it.
Many people will crush a 50 page chapter in Robbin's Pathology or something similar and then close the book, deluding themselves into thinking that just because they scanned their eyes over that much text, they actually are going to remember most of it. Then they go to take a test or something, and they find out that they only remember about 10-20% of what they read, if that.
Maybe there are 1 or 2 beasts in medical school who read massive texts without any other consolidation strategy, but for the rest of us, there needs to be some way to retain and maintain the knowledge we gleaned from our primary studies. Lots of cognitive research - and just good common sense- confirms that repetition and review is essential to long term retention. Moreover, the spacing of reviews over time with increasingly longer intervals is key. And that is what Anki gives us in a way that we could never do before. My personal path deck (see below) has over 6000 cards in it. Those facts are all pulled from the sources that all medical students use to learn path. If the number is daunting, that's because it is. There are just that many factoids to remember. Without a digital SR program like Anki, however, I could never make and manage that many physical flashcards. It's awesome to be a student in 2012 :)
So, bottom line. All my recommendations for studying path, and pretty much any other subject in medical school, depend on Anki. I don't believe in binge and purge. Slow and steady wins the race. Come time for Step 1, if you've used Anki diligently and continuously throughout medical school, there will be no need to have to go back and relearn most of 1st and 2nd year in the 4-6 weeks allotted to you for Step 1 study. Rather, all that knowledge you gained will be burned permanently in your mind, ready to access when needed. Then, instead of focusing on content review, you can spend your time mastering the information by doing tons of questions and problems. This is what I'm doing for my own Step 1 strategy. So that's the point of all this. To not forget. To master the material. To build a rock-solid foundation for rest of your clinical career. And to destroy Step 1.
Resources
This is the part that you've probably been waiting for. You're saying to yourself, "OK WillBe, I know you're an Anki zealot. I get it. I'll use it. But what should I make those cards from? What should I study?"
I'm glad you asked.
Because Pathology is such an important topic, there are a lot of resources to choose some. Some are better and more appropriate than others.
Let me first give a list of all the ones I know about and then we'll talk about which ones you should be using.
General First Aid for the USMLE Step 1 - the gold standard for Step 1 review. Getting through FA should be the minimum goal you achieve in your studies. Everything in this book is high yield. This book might just seem like a litany of bulleted factoids (and it is), but it's surprisingly helpful. There are things in here that don't show up in any other source.
Textbooks Robbins and Cotran Pathologic Basis of Disease, 8th ed ("Big Robbins") - the Bible of Pathology. This is the book that Pathologists learn from. Med students for decades have used Robbins as their go-to source for path. Most people use it now as a reference, but some students use it as their primary source. Depending on how much time you have and your willpower, you could slog through all of Robbins in your pathology course.
Robbin Basic Pathology 8th ed (9th coming out in April) ("Middle Robbins") - A pared down down version of Big Robbins. This book is more approachable, and more appropriate for medical students learning pathology. The core concepts are the same as in Big Robbins, but there is less information about the histopathology and sometimes less detail in the discussions of pathogenesis. Still, at 946 pages, Basic Pathology is no push over.
Review Books Rapid Review Pathology 3ed ("Goljan") - In the last few years, this 'review' book (and I put review in quotes because this book is 600+ pages) has emerged as the favorite of medical students. The author, Edward Goljan, is sort of a legend amongst med students because of this text and the accompanying bootleg audio lectures. This book has everything one needs to crush the pathology on Step 1. It's written in bulleted format with high yield factoids in the margins. Many students bypass the above textbooks and learn directly from Rapid Review. This book has proven it's effectiveness over the years, and that's why it continues to be the favorite every year. I'm not so sure though that it's the best anymore (see below). Pathoma may have knocked the king off the hill.
Fundamentals of Pathology by Dr. Sattar (Pathoma) - Pathoma is a new resource that just came out in April 2011. It is a series of video lectures and a review book made by Dr. Hussain Sattar from the University of Chicago. In less than a year, Pathoma has become the hottest Pathology resource around. I learned about it after I was already done with Pathology, but I've been using it to fill in the blanks since then. There is 35 hours of extremely high-yield, high-quality videos and an accompanying textbook that is equally impressive. And all this comes at $100, which is an amazing deal when you think about it. Many have dubbed Pathoma 'the New Goljan'. I think this is correct. The book is more concise. The videos give more explanation. Dr. Sattar is just a gifted teacher. The difference between Pathoma and Goljan is that the latter has proven itself over the years as a tool for success. Students have used it for Step 1 and have done very well. Pathoma, on the other hand, has not had that kind of track record yet. Many med students rave about it on Student Doctor Network and some have used it for Step 1, but not as many as have used Goljan. So that's the downside. Using Pathoma is using an unproven tool. But that shouldn't deter you.
I've used all the canonical resources. I've read Robbins. I've read First Aid. I've read Goljan. And I've been reading Pathoma and using the videos. So I know them all. Pathoma has everything that First Aid has and more. So right there, Pathoma is already as good as First Aid, which people trust without a doubt. There is significantly less material in Pathoma than Goljan. But it is questionable whether that means much. I'd say everything in Pathoma is high yield. Goljan, despite being a review book, has lots of miscellaneous info that may or may not be useful on Step 1. In fact, I've heard it said that Goljan not merely for Step 1 (although that's how it's used) but also for Steps 2 and 3. So that explains some of the difference.
So while Pathoma hasn't stood the test of time yet, I think in a few years it will completely replace Rapid Review. Because Pathoma is higher yield, better written and more approachable than Goljan, I think one would be better served to use it. One stands a better chance of actually getting through all of Pathoma than Goljan too, which is significant. Better to have a complete view with good detail rather than an incomplete one with lots of detail in some areas but none in other. If one knew everything in Pathoma inside and out, I think he'd know more than enough pathology to excel in class and on the boards.
Plus the videos are excellent. Until now, everyone has used the bootleg audio from Goljan. I never did like these very much. The quality is poor. There are a lot of jokes and tangents. Plus, there is no visual component. And did I mention it's bootleg? Pathoma, on the other hand, is a whole library of video clips that one can watch as well as listen to. The visual component is key. And with the book, you can read along.
I am really enthusiastic about this new resource, in case you couldn't tell. I wish it was around when I was learning path the first time.
* Full disclosure. I have no ties to Pathoma. I've spoken to Dr. Sattar once just to tell him I loved his work and to keep it up. That's it. I want to support a good thing when I see it and so that's why I'm promoting it here.
Here is a sample video. Check it out and see if this style of teaching appeals to you.
BRS Pathology - This used to be the go-to source for Pathology review a couple of years ago, but it's since been replaced by Goljan. I really didn't use it, so I can't say much about it. Some people like it. The BRS format is familiar and effective. It's less dense than Goljan, bigger than Pathoma and First Aid. I think with Pathoma on the scene, BRS will become less popular even, but I don't think it's a bad book. If you like BRS books, check it out.
Question Banks Robbins Review of Pathology - This is a companion book to Robbins. It's all questions testing your knowledge of path. My classmates used this book to study for our exams and we were well served. It's quite detailed, much more so than Step 1 level pathology. The nice thing about it is that every question references a section in the Robbins family of books so you can go read when you get a question wrong. I think this book is worth having.
USMLE World Step 1 - Does this even need an explanation? USMLE World is recognized as the best source for Step 1 prep questions. There is debate about whether or not you should use these questions while still learning material. Some people think you should save UWorld for when you're doing dedicated study for Step 1. I think this is a sound idea. There are plusses and minuses to both. The idea is that if you do UWorld too early, you'll forget what you learned and waste questions. That may be true if you do the binge-and-purge thing. But if you're using Anki, you could use UWorld and make cards for the explanations and thus remember everything. UWorld is as much a learning tool as a testing tool. There is stuff in here that might only show up in Big Robbins or maybe not even. So using UWorld and Anki together makes sense. This is what I do in fact. I've been going through the q's and making cards for things I didn't know so that they're in my review deck.
Kaplan Step 1 Qbank - Another USMLE q bank. I haven't used it. I might though. Word is that the questions can be esoteric at times. Not as high quality as UWorld but people use Kaplan while they're learning so that they don't waste the good stuff (UWorld) before they're Step 1 review time. This isn't a bad idea.
USMLERx - Questions made by the First Aid authors. It's like being pimped on First Aid. I don't think it's bad. I haven't used it much.
Putting It All Together - An Optimal Sequence
So we've covered the methods and the sources. Now how do we put it together? What is the optimal way to learn pathology?
As I've said before, I think learning complex subjects like Pathology is best done in layers. What I mean is, first you want to get an aerial view and become familiar with the landscape. Then fly a little lower in see some detail. Then, zoom in even further and examine the nitty gritty. Studying this way makes the learning more meaningful and effective. If you zoom in to the little stuff right from the get-go, you tend to lose the forest for the trees. That's not good. The detailed stuff makes much more sense and sticks better once you've mastered the big ideas.
I'm recommending here my preferred sources. This is basically what I did. As I said before, when I was first learning, I didn't have the benefit of Pathoma. So my experience has been to back track. Everything that I'm suggesting I've done myself. I just didn't do it in that order. The order I'm giving is the ideal one that I would have followed if I had known better.
Step 1 - The Aerial View
- Watch the relevant Pathoma video(s) at 1x speed
- Follow along in Fundamentals of Pathology
- At the end of the video, make Anki cards for every nugget in Fundamentals
- Cross-reference with the corresponding section of First Aid and make a card for anything not covered in Pathoma
- After making cards, immediately review them
Step 2 - Zooming In
- Read the same material in Robbins Basic Pathology
- Capture any high-yield/relevant factoids that you didn't get from Pathoma. Use your judgment here. You need to decide what's worth remembering and what's not. This is an art that is learned from experience.
- After making cards, immediately review them.
Step 3 - The Microscope
This part is optional. If you're the sort of person who really likes fine detail (or perhaps your class exams require this), you can go a step further.
- Read corresponding section in Big Robbins
- Capture factoids that you didn't get from any other source
- After making cards, immediately review them
Step 4 - Refining
- After having completed an entire topic or chapter (say Cardiac Pathology), use USMLE World or Kaplan or USMLE Rx. Use the questions to help you integrate all the information you've learned.
- Make cards for the ones you get wrong and/or the factoids that you don't already have in your set
You might be wondering when you should be doing all this. My advice is to spread this out as much as you can. So for example, I would do Step 1 on Monday. This should take you the whole day. If it's a particularly large chapter, spread out Step 1 over two days.
On Day 3 do Step 2. Then on Day 4 do Step 3. Take a break on day 5 or catch up on any part of the prior steps that you didn't get to. Remember that you're going to have all of your prior Anki reviews from other subjects coming due too. So make time in your day for that.
Then on the weekend, you can do Step 4 and do some integration questions from UWorld or elsewhere.
How you carry out this sequence will depend a lot on your class requirements, your own learning pace and style and your time commitments. If you notice, I say nothing about studying from lecture slides. That's because I don't think class material is particularly good. If you go to a P/F school, you can follow my suggestions closely. If you don't do P/F, you'll need to figure out how to satisfy your class requirements. You might have required attendance or something like that. I want to be clear. PASSING YOUR CLASSES IS THE MOST IMPORTANT THING. This is just the reality of medical school. Although we'd all probably love for med school to get out of our way so we can learn medicine, the fact remains that passing your med school classes is necessary. So don't jeopardize that by completely disregarding class if you don't have that luxury. With that said, I'm certain that every medical school is in some way, shape or form covering the same material. Robbins is what your professors use to make their lectures. So if you do as I suggest, you're not going to miss anything. But what is emphasized by your class and what is emphasized by Step 1 are often not one and the same. Just keep that in mind.
Goal Setting
In all of this, you need to decide what you can handle and what you want out of your education. School is tough, and sometimes for all the wrong reasons. Mandatory classes, clinical skills classes(i.e. "tell me about your feelings"), busy work, and sundry other obstacles get in our way when trying to learn. That's just the way it is. So be realistic about what you can achieve.
I think a necessary, feasible and totally effective goal would be to cover First Aid and make cards for all of First Aid. That is the minimum goal. First Aid is not everything you need to know for Step 1, but it's a very large chunk of it. At the end of your preclinical courses, wouldn't it be great to have at least 50-60% of what you need to know down cold? If you aim for knowing 100% of everything, you'll get discouraged and likely quit this whole project and remember even less. Maybe like 20%. Be willing to compromise and be flexible.
My Pathology Deck and More
Disclaimer: I am sharing this deck because I want help other medical students learn pathology. I think making one's own cards is a valuable exercise and is superior to using someone else's, but I recognize that for a lot of people, this task is too much to handle. It's enough to turn people away from using Anki all together. So, I'm offering my cards as a compromise. If using my cards helps people learn Pathology and it encourages use of a system I really believe in (Anki), then I'm a happy man. I put hundreds of hours into building this deck but I see no reason why I should be the only one to benefit. I would have had to make these cards regardless, so why horde them all for myself? All I ask is that you give credit where it is due; if you share these cards with your classmates or anyone else, just let them know where they came from.
Also, I am almost certain that there will be some errors in these cards. There are over 6000 of them. I've done my best to ensure the accuracy and quality of my deck, but some errata have certainly slipped through the cracks. This is true of every learning resource, from First Aid, to Robbins. Please double check the material and I welcome you to post in the comments section any errata so I can fix my own deck. I'll periodically update the files with those improvements and any additions that I make.
A word on the content... This deck is nearly complete. It's covered all the pathology of First Aid. There are tidbits from Pathoma for things not covered by First Aid. There is a lot of Goljan. There is also material related to Big Robbins and from USMLE World. The only subject that needs a little more work is Female Pathology. That's about it.
Feel free to add your own cards to this deck once you take it down from Dropbox. If you feel so inclined, share those updates here by posting links so other people can benefit.
Happy Studying!
Update (04.24.13)
The Pathology deck has been revamped and updated, and is now for sale here on the site. You can find it here: DrWillBe Pathology Anki Deck
All other decks are still available for free. You can find them here
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. 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.
So What Should I Study?
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.
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.
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.
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.
