Step 1 Prep: Days 7-14: Lagging

Hey everyone,

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.

I'll try to make some resources as I go along.

Anki Guide for Medical Students

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. 


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.

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.

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!

Study Skills

What I used to do
When I went to college, I realized that the one thing I never really learned was how to learn.

You'd think with 13 years of school behind me, in that time, someone would have shown me how to properly amass knowledge. That was a lesson I never got. Rather, like most everyone else, I just concocted my own habits, largely by copying everybody else.

So, for many years I went to class and took notes, but never did anything with those notes after the class was over. I rarely even kept the notes. I was operating under the idea that writing notes in class is a good way to learn because just the process of writing things out will implant the knowledge firmly in mind and trap it there. Wrong!

My main mechanism of obtaining information was reading books. I did truly like to read, especially later in high school. That was how I absorbed information, and at least for the level of high school coursework, reading a textbook once over was sufficient to allow me to perform reasonably well. I remember cracking open my AP World History book for the first time a few hours before my AP World History test and just cruising through it. I remember almost nothing of that futile exercise except that I got the highest grade possible on that AP test. So, lesson is, cramming works, but the information you 'learn' - if it can even be learning - is so fleeting. Its in one ear and out the other. Does this sound familiar to anyone?

As a freshman in college, I realized that I would need to amend my methods, but what could I do? I went to class diligently, took notes, reviewed them sometimes. I read the textbook before class and again after. Before big exams, I'd re-read whole chapters and do more problems. I had abandoned the days of cramming, and I was much more attentive to the time frame in which I needed to operate. I was studying as well as anyone could, I convinced myself. My grades were quite good, so I figured this was the best I could do.

The summer after freshman year, I was taking a general chemistry lab course at Columbia and I was struggling to recall much the stuff I learned just a few months earlier in Gen Chem course. Did I really spend all that time and money just to forget most of what I learned? Sure, I remembered the broad concepts and could apply them, but what about the finer details? One might argue that for the fine details, you can go to a book. But that's inefficient, especially the way I was accustomed to doing it, re-reading whole chapters in a futile attempt to get that information to stay put.

There had to be a better way. I needed to learn how to learn.

Learning How to Learn - Cornell Notes

In the summer of 2006, a few weeks before sophomore year was about to begin, I was in the local library scanning the stacks for books on study skills. I had never thought to read about studying before, but I wanted to see what kind of methods others had devised. My goal was to learn for the long-term. How depressing it was to think about the time, money, and effort I would put into the rest of my college career only to lose most of that to forgetting.

I remember the day vividly. I looked on the book shelf and there was a title calling me.

How to Study in College by Walter Pauk (HTSIC)


I immediately went to the nearest Starbucks and devoured the 200-something pages of that book in one sitting. Yes, I'm a huge nerd.

So what was inside that was so wonderful?

A couple of things. Several chapters were dedicated to time management. I had never managed time. Not methodically at least. I would plan in my head for the next few days ahead, but I never ever followed any kind of set schedule. That was the first thing HTSIC told me I needed to do. And so I did. I found the useful program iCal on my computer and began arranging my life.

6 AM: Wake up
6:15 AM: Breakfast
7:00 AM: Study Organic Chemistry
9:00 AM: Go to class
....
6 PM: Free time (yes, I scheduled free time)
7 PM: Gym
8 PM: Dinner
9 PM: Study class notes
11 PM: Sleep

I found this process of planning my day just as liberating as the book said it would be. I didn't need to waste time thinking about what I'd do next, and I didn't need to worry about not having enough time because I could plan well enough in advance to prevent crises.

Did I stay exactly on schedule? Well, I tried. In life one has to be flexible. I often fudged my schedule and maneuvered blocks of time to conform to what I was actually doing. Study sessions would go longer, dinners longer, sleep shorter, gym completely tossed. But on the whole, I was able to stick to the broad schedule +/- an hour or two. So this was really helpful.

But the best and most important thing from that book was not time management. It was Cornell Notes and the Q method.

The author of HTSIC, Walter Pauk, was a study skills instructor at Cornell. Based on evidence from educational psychology in the early post-war era, Pauk came up with the Cornell Notes method.

Here's a summary of what the method consists of.

(1) Take a plain piece of paper and make it look like the one above. That's Cornell Note paper. I generated mine on MS Word and then kept that template for the rest of college. Pretty simple.

(2) In class, take notes in the note taking area. Keep them concise and clear.

(3) Immediately after class (or at your earliest convenience, but no later than 24 hours after the class) take the most important bits from the body of notes and write 2-3 sentences in the summary box.

(4) Questions in the margin. You write questions pertaining to the details in the note box. Check out the example below.

The questions should be as direct and clear as possible. In essence, you're making mini-tests on each page of your notes.

(5) RECITATION. This is the most important part and what makes the Cornell Notes so effective. Cover up the details with a blank piece of paper but leave the question exposed. Proceed to recite aloud the answer to each question. If you get it right, move to the next. If you get it wrong, do it again.

Does this mean you have to talk to yourself? You betcha! It's weird, yah, but the benefits of doing this far outweigh any embarrassment or uneasiness you might get from talking to yourself. Pretend you're teaching your imaginary friend.

(6) Review. After you're done reciting, skim over the notes again, eying the summaries.

(7) Reflect. When you're done reciting and reviewing, you should think about what you've just learned, connecting it with you already know, integrating the information into the conceptual framework you've already built up on related material.

I began using Cornell Notes sophomore year. I used it in class, when reading textbooks (modified method), when reading everything. And it worked so well. I was able to recall myriad details from my notes with ease, and not just in the first few days after learning them. Weeks, months later, the information was there still firmly implanted.

So why is Cornell Notes so effective?

A couple reasons I think. The most important part of all this is the recitation. That is what sets Cornell Notes apart. Devising and answering specific questions immediately after learning new material gives you instant feedback. You know if you know it and you know if you don't. If there isn't some testing mechanism to assess how much we've retained, we can very happyily read our notes or read a book chapter and feel that we've got it all in our minds. But then, when we are pressed to recall specific information, such as on an exam, you realize that you really didn't have the nitty gritty in there. The recitation and questions gets around this problem by pinpointing precisely what you know and what you don't.

The recitation also makes the learning an active rather than a passive process. You're not just receiving knowledge. You're repeating it, as if you were teaching. People often say that the surest way to learn something is to teach it to someone else. When I was doing my recitations, I felt as if I were teaching an imaginary audience.

I also think there is something about reciting aloud that really makes the stuff stick. You add another sense - hearing - to the learning process that solidifies the imprint that new information makes on your mind.

The anticipation of knowing that I'd have to answer questions after reading my notes or a book chapter made me more attentive to the details. I didn't just gaze over text on a page. I read with a purpose, and I think that primed my mind for maximum uptake.

Another major benefit of Cornell Notes is that now you have a systemic way of studying in the future for an exam or whatever. No more re-reading whole book chapters. Or going over all of your notes. With the questions and summaries, you've got all you need. The weekend before an exam, I'd go straight to the questions without looking at the details. In this way, I avoided having to read over all my notes again. Questions I got right I didn't need to review. I only looked at the details to questions I didn't get right. Rinse, wash, repeat.

I aced my exams, was able to recall most all of what I learned, and all this made me enthusiastic to learn more.

That's a lot of work

An objection that people have to studying this way is that it seems like a lot of work. Compared to what? It's a lot of work to read over all your notes a bunch of times because they just won't stick. It's a real time killer to go back an re-read textbook chapters before an exam. And it's even more time consuming to have to go back an relearn 75% of your course material a year or two down the road when you take a more advanced course that presumes you remember what you learned at the lower level.

You've go to put you're time in. Learning isn't easy. Cornell Notes is front loaded. You put the effort in at the beginning, but after you've made your notes, it's easy sailing. You just recite, review, recite, review. And best of all, it sticks for good.

I know I sound like a zealot about this, but I'm just so grateful to have learned how to learn early in college. I have a system that works, that helps me learn for a lifetime. So naturally I want to share it with others.

In Medical School

Given the effort needed to study like this, I was a bit concerned that I couldn't make it work in medical school. But, thankfully, I can report that it has worked remarkably well, just as it did in college. I've tweaked the process a bit to accommodate the fact that all our learning is now digital. I don't use the Cornell Note paper. Instead, I've been annotating PDFs from class directly and then covering the details and reciting. It works like a charm.

However, I have not been able to review as much as I should. In the past, for me the magic number was three times. That was how many times I needed to recite the information before it was firmly embedded in my memory. And, the greater the span of time over which those reviews were spread, the better the retention. That's something I realized from the very beginning. Three reviews in rapid succession (say, in three days), is not as good for long term retention as three reviews spread across say 3 weeks. Which brings me to my next point.

Spaced Repetition

Spaced Repetition is revolutionary study methodology based on a common sense insight: to remember information for the long-term, you need to review that information several times and those reviews need to be spread out at appropriate intervals. If you review several times in a short period (say, 5x in 1 week) you may remember that information for the short term, but not for the long term.

We all know that the key to memorization of facts and information is frequent review. But how frequently? And at what intervals? Are there optimum times to review such that you'll be most efficient with your time and most effective in embedding the material deeply in your long-term memory?

People have thought about this question for quite some time. Educational psychologists, beginning with Hermann Ebbinghaus in the late 1800's, have tried to understand why we forget and how to combat it. An excellent article in Wired Magazine about spaced repetition discusses Ebbinghaus' early experiments and the line of inquiry that has followed since that time.

[H]uman forgetting follows a pattern. We forget exponentially. A graph of our likelihood of getting the correct answer on a quiz sweeps quickly downward over time and then levels off. This pattern has long been known to cognitive psychology, but it has been difficult to put to practical use. It's too complex for us to employ with our naked brains.

So basically, we forget things exponentially. The time to forgetting after each review increases, and if we knew when forgetting was about to happen, we could review right before that time. If you review too early, you don't maximize the the time you get until the next time you need to review. The graph above summarizes the effect of appropriate spacing.

But how do I know when I should review?

That's where Supermemo and a string of spin-off computer programs come in.

SuperMemo is based on the insight that there is an ideal moment to practice what you've learned. Practice too soon and you waste your time. Practice too late and you've forgotten the material and have to relearn it. The right time to practice is just at the moment you're about to forget. Unfortunately, this moment is different for every person and each bit of information. Imagine a pile of thousands of flash cards. Somewhere in this pile are the ones you should be practicing right now. Which are they?

Supermemo was created by a remarkable computer scientist and learning afficionado named Pietr Wozniak. He, like so many of us, was totally distraught by the fact that he studied hard in college and as a graduate student, and he'd learn, but the stuff he learned would rapidly fade from memory after a period of time. He harnessed his frustration to try to find a way to not forget. To that end, he came up with a program that makes an algorithm that predicts when you need to review certain information. Basically, it's a flash card program, but with a twist. When you answer a flashcard, you rate how difficult it was for you to recall the answer. Based on your ratings, the Supermemo algorithm will schedule your next review of the card.

Supermemo has quite a following on the net and with some learning enthusiasts, but it hasn't caught on the way you think it might. This is such a game-changer, you'd think everyone would be all over it. Here is a way to learn things for good. The legions of people that have used Supermemo to learn just about everything - commonly languages, but a slew of other topics - swear by it. I didn't know about Supermemo or spaced repetition until this year when I learned about one of its spin-off programs, Anki.

The beauty of these programs and the spaced repetition method is that you are being maximally efficient. When we make notes or review cards, the reason most of stop looking at them is because we just don't have the time to completely review old stuff while new stuff just keeps coming. So we don't review the old stuff, even though that is what is necessary in order to not forget. Programs like Anki and Supermemo use their algorithms to only present to you cards that need to be reviewed, not every single card in the deck.

For example, let's say I have 100 cards in my deck that I've generated from class notes. Then I add more and more cards as I learn new stuff. So what happens to the 100 old cards? I need to review them, but how can I review 100 cards while adding more and more every day? The key is that you don't review them all on each day. Those 100 cards will be spread out in the future based on how you rated them the first time you used them. The key is daily review so that the cards don't pile up. So a year from now, when Duke 1st year is long over, I might have thousands of cards. I need to still review them, but I won't have time to review 100's of cards a day. Thankfully, I don't need to. Maybe 20 cards will be in my review deck every day, based on how I rated them. I'll easily be able to handle those many cards on a daily basis. If not for the algorithm that informs the spaced repetition, there'd be no way to review all those cards in a timely way and in a way that commits the info to memory.

So what about the Cornell Notes method?

The question-recitation component of Cornell Notes is still very effective. I'm not throwing the baby out with the bath water. I'm convinced that review and recitation is critical for learning. But in the past, I had no methodical way schedule for review. I'd review my notes and do the recitation arbitrarily - maybe 3 times before a test, at no particular interval. Anki and the spaced repetition algorithm will just help me know when to do my review and recitation. This is an enhancement to an already excellent system.

I'm very excited to experience the results of this new and improved study strategy. My goal is to build a permanent foundation of knowledge. I absolutely hate the idea of spending all the time and effort this year learning all this medical knowledge just to forget 75% of it by next year. And then, while doing clerkships, I'll need to constantly backtrack to re-learn everything. If I could just do it right the first time, that wouldn't be necessary.

Also, since I'm going to have at least four years during my PhD when I'll be away from the clinic, I need to have a way to continually review the material I will have learned by the end of second year. With Anki and the spaced repetition algorithm, I will be able to do that easily. How much work is it to study 10-20 cards a day, every day? 10 minutes max. Slow and steady wins the race I say, and that's how I like to study.

Making those cards takes a lot of time, you might be saying. And you're right. Making the cards does take time, but in my mind, it's totally worth it. The workload is front end, but then I can use the cards for years to come. And I can modify them if need be, and I can search them easily with the programs available.

If you don't want to make the cards but you want to reap the benefits, there are options.

What actually got me on the whole spaced repetition bandwagon is a USMLE Step 1 resource that my good friend Theo at U. of Washington sent me the other day.

It's called GunnerTraining (Funny name, I know). GT was founded by some Harvard residents in 2009 and has quickly become a favorite of med students across the country. I count myself as one of them. GT is a web-based knowledge database that uses the principles of spaced repetition to help students study for the Step 1. It's got flashcards with snippets of high yield knowledge.

The process goes like this:

(1) Study some flash cards
(2) Add pre-made review cards to your personal review bank
(3) Do an immediate review of the cards and rate their difficulty
(4) GT then schedules when you next need to review those cards



GT generates a daily schedule for you to study those cards. Just come back when you have review cards. At the same time, you can move forward and study more cards and put those in your bank, repeat the process. So you're review old cards and learning new ones at the same time, and you're doing it in a way that optimizes the use of your time and your ability to remember your knowledge.

The caveat for all of these SR-based programs is that they are for the long term. You could use GT's resources in a month, but you'd lose most of the benefits that SR offers in terms of long term storage. I'm so happy I found this in the beginning of 1st year. I can do a slow and steady review concurrently with my coursework. I can study the same topics so that I'm not only studying for Step 1 but I'm also reinforcing things I'm learning in class. Two years from now, hopefully I'll be a Step 1 machine : )

So that's what I'm up to these days. I'm passionate about finding new ways to learn and about sharing what I learn with others. I hope someone benefits from this post. If you have any of your own methods that you want to share, please go ahead and start a conversation on this post.

Happy Studying.




UPDATE (12/17/11): It's been more than  year since I wrote this post. Some things have changed. Most notably, I no longer use Gunner Training. I think it's a fine service for many people, especially those who don't want to make their own cards. But I find card-making a valuable experience, and Anki, in my opinion, is a far superior platform that can be used offline, on multiple devices. And I can add my own stuff. And did I mention it's free? And I can add media and such and not be worried about copyright issues. I'm not knocking GT, but I just want to be honest about what my studying actually consists of. There is also a level of redundancy too. There aren't enough hours in the day to do everything. My Anki load is demanding enough as it is.


I'm going to write a more thorough update in a couple days, but for now, that's all.


Crush away :)