#5: Using Anki

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I got a couple of questions this week about the flash card program Anki, and so I decided to do a podcast dedicated specifically to that topic. If you have a topic you’d like me to discuss, email me at info@sholamd.com. I’m not going to do a PDF this week but all of the links we discuss will be included in the show notes, so you don’t have to write anything down.

I. Basics and a Warning
We’ll start with the basics: what is Anki? It’s a free, spaced-repetition flash card program that is extremely popular with medical students. The spaced repetition means that you see the cards you know less often, and the cards you don’t know more often. So it’s a dynamic program that helps you get more efficient with reviewing material, and that’s why people love it.

Now, if you are looking for a tutorial on how to use Anki, it’s all over the web. Today I’m going to give you my personal tips, things that I learned by trial and error over my years of medical school. Hopefully this will save you from having to make these mistakes on your own.

The one warning you need to hear before you start using Anki is that it is time-consuming to make the cards, and time-consuming to review them. If you miss a day of reviews, they can pile up and become very overwhelming. There were definitely days when I questioned whether my flash card system was worth it. So when you start, it might take you a while to get into your personal groove, but it IS worth sticking with it. You can use these cards again when you are studying for Step 1, again for shelf exams 3rd and 4th year, and again for Step 2. You are essentially building your own searchable library of facts and personal mnemonics. To this day I look up facts in my deck, especially because I’ll often have little reminders in there for how I memorized the fact in the first place, or a clinical example, or a good picture that triggers my memory.

II. Shared Decks
Since making your own cards takes a serious time investment, I often hear people asking about using shared Anki decks or Firecracker. I dislike this for a few reasons.
You will waste time reading material you already know. For a deck to be useful for everyone, it has to ask about every fact. I mean, you’re not going to pay for Firecracker if it’s not thorough, right? So say that you find a shared Anki microbiology deck with 1,000 cards. And say 50 of those cards are about Staph. Well, maybe you worked in a lab in undergrad and understand gram staining perfectly, in fact, you are an expert in Staph. You still have to wade through those cards, wasting your precious study time. If it’s not staph for you, it will be something else: something else that you know very well that someone else didn’t know very well. You are looking at material that other people thought was hard, not material that is hard for you. It doesn’t get much more low-yield than that.
These lowest-common-denominator cards focus on buzz words and quick associations. This is not good enough for Step 1, and rewards superficial, short-term knowledge. Your own flash cards should focus on concepts in addition to associations, asking questions in new ways. If you are looking for a generic review, use practice questions to identify weak spots instead of these shared decks.
I don’t trust them. A fallible human being made them, and I find it impossible that there can be a 1,000 card deck without mistakes. If I had to sift through someone else’s mistakes, I would be completely distracted and irritated. My own mistakes don’t bother me – in fact those can be learning opportunities.
There is a shorthand mismatch. What I mean by that is, either the card doesn’t use shorthand and it takes way too long to read (and that’s not efficient), or it has shorthand you may or may not understand, which is frustrating and is going to waste your time when you’re trying to decode someone else’s shorthand.
Making your own flash cards is a way of transforming facts into long-term memory, so it’s actually a good time investment and a way of studying.

So in summary, I encourage making your own flash cards, with just the facts that are new or difficult to YOU, with lots of concepts, and your own shorthand.

III. Tips
I’ve mentioned before that I’m working on an online course, and in that course I have 10 tips for making great Anki cards. For the sake of time, I can only talk about a few of them here.

– My Rule #2 is Keep it simple. I made this mistake when I started out. I would essentially copy and paste huge sections of the course notes into a single flash card, and then I would get annoyed when I couldn’t remember all the parts and had to keep reviewing the same card over and over. It’s much better to keep each card simple. For example, a flash card that says, “describe the virulence mechanisms of staphylococcus” is a beast and you will hate that card every time it comes up. There are enzymes, resistance factors, surface factors, toxins…you’l have to name all of those every time that card comes up. Instead, break it down into bite-sized chunks. For example, “how does S. aureus prevent opsonization?” The answer is that Protein A, a cell surface factor, binds to the Fc portion of IgG. Now it’s just one fact that you have to remember, and the focus is more on the concept of opsonization rather than a laundry list of virulence factors.

– My Rule #3 is Keep it clinical. Remember that your professor and the USMLE writers have to ask the questions with a clinical scenario attached. So you will maximize your time if you focus on the elements that are clinically relevant. For example, say you are learning about how staphylococcus uses enterotoxin. Listen to the difference between these two questions.

  • What do S. aureus enterotoxins do?
  • How would you recognize an S. aureus enterotoxin infection?

The answer to the first is “enterotoxins activate T-cells, causing a massive release of cytokines and chemokines.” The answer to the second is “The massive release of cytokines and chemokines cause GI symptoms like vomiting and diarrhea.” That second card is going to be much better at preparing you for a clinical question like you would see on Step 1.

– My Rule #6 is to use cloze deletion and image occlusion. Cloze deletion is a sentence with its parts missing and replaced by three dots. Anki creates these easily, and it saves you time because you can copy and paste from the lecture notes and you can create multiple easily digestible cards at once. A similar concept is the Image Occlusion Add-On. Now, this wasn’t around when I went through anatomy, but it has since been released and most medical students who use it swear by it. It’s basically cloze deletion for images. For both of these techniques, there are great tutorials already available on the web, and rather than recreate the wheel, I’m going to point you to them. For cloze deletion, it’s a kenwoodh3 YouTube video called Anki Basics 2. For image occlusion, there’s a bitbucket.org URL that I will include in the show notes.

– And finally, my Rule # 8 is Detect and eliminate interference. Interference is when you memorize one thing, but then a similar fact or set of facts makes you forget what you knew. For example, say you have a card that asks “Which Staphylococcus species is most associated with hospital-acquired bacteremia?” and you know the answer is S. epidermidis. You’ve reviewed that flash card a few times and it’s easy to you now. But a week later, you get a new card that says “Which Staphylococcus species is most associated with hospital-acquired pneumonia?” and the answer is S. aureus. Now you might start mixing these two up. Step 1 loves interference. You’ll find yourself choosing between two things you didn’t even know you were confused about. So this is great preparation. When you find interference, find a way to reword the cards, or even to put them on the same card so that your brain is always forced to distinguish between the two.

IV. Logistics
Like I said, you can nerd out about all the add-ons and detailed functionality of Anki by doing an easy Google or YouTube search. I want to give you the lessons I learned personally through trial and error. Specifically, I want to talk about setting the intervals. When you are learning a new card, you can either rate it “Again” if you missed it, “Good,” or “Easy.” Anki will decide when to ask you again based on your rating – that’s the spaced repetition. Each deck has an options menu, and in there you can set how many minutes you want for the different intervals.

Now if you choose “Again,” Anki defaults to showing you that card in 1 minute, and then in 10 minutes if you get it right. Oh that setting just drove me bonkers. I think this default is for people who are casually learning a language and are trying to study for 20 minutes a day. For me, 1 minute usually meant I had only seen like 2 other cards, so I got it right just because of recency. Then 10 minutes later was kind of wasted because I hadn’t paid proper attention the first time around. Also, with the volume of cards I was learning, I didn’t have time to review cards this many times. I figured, if I got it right, don’t ask me again in 10 minutes. Ask me tomorrow or the next day!

So you can change the “1 10” setting to something more medical school friendly. For me, I set it to 1/3 of the total time I was planning to study that day. That way, I could see a really tough card a few times before quitting for the day. So if I was studying flash cards for 2 hours, I would set the “Again” time to 40 minutes.

Then, I made “Good” for at least 2 days, and “Easy” for a week. You’ll need to play with this to see where you are most comfortable, but that gives you an idea of what works for me and why you might want to tweak these settings.

There are a lot more settings that you have control over, and it is worthwhile to look at the Anki manual online and just get a basic understanding what features you can control. This will save you time in the long run. I’ll put a link to that manual and to the Anki site in the show notes.

Thank you for being with me again today. I hope this podcast helped answer your questions about Anki. Check the show notes for the links we discussed, and If you have a comment or question reach out to me at sholamd.com. I will see you next time!

V. Links

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