Dr. Debra Whorms and Dr. Alyssa Ehrlich contributed to this post.
For many of us, our first impression of Anki is that it seems way too complicated and that reviewing cards could be just as time-consuming as making them! But for those who have mastered Anki, or have at least gotten into the habit of using it regularly, it is an indispensable study tool. Personally, I gave into the hype of Anki after starting my USMLE Step 1 dedicated study period, and I now believe it is one of the most useful study resources available for medical students.
The benefits of Anki are many, including the benefit of space-repetition (which we’ve reviewed previously here), something that is not as easy to do with paper flashcards, or even possible in other flashcard apps (including UWorld's built-in flashcard feature). But even for students who have been avid Anki card users, one of their biggest questions is still “How do we make effective Anki cards?” Indeed, the optimal benefit from Anki comes with making and using cards in a way that will allow not only maximum information retention and recall but also retention and recall of the right information, i.e., the facts you need to know to answer questions correctly.
Anki Cards Should be Targeted and Personalized
In studying for the USMLE, you will get the most out of Anki by using it as a very targeted tool—one that targets your personal weaknesses. Accordingly, it is very important to make cards very selectively that address specific gaps in your knowledge. As the sheer amount of content you need to master for either Step 1 or Step 2 CK be overwhelming, you may find yourself with over 10,000 cards for each exam unless you get in the habit of thinking critically about what deserves to be made into a flashcard. With that being said, using large pre-made Anki decks like Zanki and AnKing not only contain an unmanageably large amount of cards (in my opinion), but are also not personalized to address your weaknesses. I, for example, during my short stint trying to use a premade deck, often ran into cards that I thought were obvious or redundant. More importantly, these pre-made decks don't target your personal knowledge gaps, and reviewing these decks will force you to waste countless hours reviewing material you already have a sufficient grasp of from the perspective of answering USMLE questions correctly. But how do we identify those gaps in our knowledge in order to craft a personalized set of Anki cards?
Why It’s Important to Make Your Own Cards
Many students acknowledge the downside of pre-made decks, but question the value of making one’s own cards, and may dread the time commitment it will take to make one's own card. Although it’s important to review your cards and take advantage of spaced repetition, the process of making cards is just as useful for information retention. Making cards—which is a highly active learning process that requires you to think critically about what information is important, and to understand the information well enough in order to essentially teach it to yourself—is one of the best ways to retain content long-term. Manipulating information in the way that is required when you make cards sets you up to retain as much as 95% of this information after two weeks, compared to only 5% information retention at two weeks when you learn passively by listening to a podcast or reading a text(like First Aid!). Active learning is critical for the USMLE, when the demands on your memory are extremely high, and you will be required to retain and recall a very large body of fairly esoteric facts, particularly for Step 1. Furthermore, the time required to make Anki cards is not as much as one might expect—with practice, many students end up spending 5 minutes or fewer per card. Once one acknowledges the importance of making cards, when in one’s studies is it the best time to start making cards?
Treat Anki as a Supplement to UWorld
The best time to make Anki cards is as you go through your UWorld Qbank, and a single pass of UWorld is often all that’s required if you use the Anki flashcard creation method, since you will retain far more information, removing the need to refresh your knowledge by repeating a Qbank. Making Anki cards based only on your incorrects as you move through UWorld allows you to target your Anki card creation to your personal knowledge gaps. Almost all of your Anki cards should come from questions that you get wrong. Occasionally, it can be appropriate to make cards for questions where you feel you completely guessed and got the question correct by chance, but you should be sure to avoid making greater than 1,500 cards total for any given USMLE exam, as a deck larger than this usually becomes unmanageable to review. In general, you want your cards to specifically address misconceptions that led to you getting the question wrong. To figure this out, ask yourself the following questions:
What did I need to know to get this question right?
What was I thinking that made me choose the incorrect answer?
Do I know why the other answer choices are wrong?
The answer to these questions should guide what cards you write. And what questions you ask yourself on each card.
Use Anki Cards to Resolve Misconceptions That Led You Astray
In general, focus on the right answer and the answer that you incorrectly picked, and be sure to address whatever misconceptions you had in answering that question in your cards. Here, I’ll show you how to make an effective card based on the following modified sample question:
A neonate born at 35 weeks’ gestation develops cyanosis and acute respiratory distress. His temperature is 37°C (98.6°F), pulse is 163/min, respiratory rate 37/min, and oxygen saturation is 72% on room air. An echocardiogram shows a patent ductus arteriosus and transposition of the great vessels. Which of the following will best help maximize tissue oxygen delivery until surgical correction can be performed?
A) Alprostadil (Correct)
E) Nitric oxide
In this case:
I need to know what physiological method can be used to maximize systemic oxygen delivery in patients with transposition of the great vessels, and which drugs can be used to achieve that?
Here, when I first answered this question, my confusion was between A and C, because I remembered vaguely that prostaglandins are involved in closure of of PDAs. However, I wasn’t quite sure of the mechanism and whether I would need less or more prostaglandins in order to maximize tissue oxygen delivery in this scenario.
Here, I used the explanation provided by my QBank to formulate my card to allow me to resolve these uncertainties—and to remember the information I need to know in order to get similar questions correct in the future.
Write Anki Cards Sparingly—No More Than One Card Per QBank Question
For each of the questions in UWorld that I answered incorrectly, I got in the habit of writing no more than ONE card. This is very important! You do not want to put every single piece of information you see in your Qbank explanation in your Anki deck! This is a targeted 'treatment', focusing only on improving your knowledge base in a way that will help you answer more questions correctly. As mentioned above, you should target your total deck to have fewer than 1,500 cards; 1,000 to 1,500 cards total is appropriate for most students for both Step 1 and Step 2 CK. In general, questions are designed to have you differentiate between two or three things, while the rest of the answer choices are far less plausible distractors. Focus on covering only the options that stood out to you, as these are more likely to trip you up in the future.
Framing is Key When Writing Your Anki Cards
Once you have decided what subject to write a card on, you should now try to frame your questions on the card in a way that addresses your initial knowledge gaps or thinking errors. I typically recommend 1 to 3 questions per card, in order to address the separate pieces of information or steps in thinking needed to get the question correct. You must also frame the questions in a way that requires that you to understand the concept, rather than simply memorizing the card itself. Abstracting scenarios (I.e., say, a 'middle-aged man, instead of a 56-year-old man, if using a vignette) can help with this significantly. This also means that you should often write the questions on your cards in an open-ended way. Except in specific situations where you recognize an obvious issue with memorizing a random fact that will only be presented to you in a multiple-choice fashion, you need to avoid writing flashcards with just one-word answers and easy fill-in-the-blanks. Your brain will easily learn to recognize the answers to these types of questions when you see it again, even though you may not be able to think about the right answer in clinical vignettes on the exam, when the scenario will be at least slightly different. In the same way that active learning is the most beneficial type of learning, writing “active”, engaging cards is also helpful. Here is an example of a “good” cards that one could write for the above question:
GOOD CARDS: 1) Emphasize pathophysiology; 2) Is open-ended and requires explanatory response 3) Contains some graphics when necessary
When reviewing this card, I would only require myself to say the text highlighted in color, in order to count my response as correct. While I could have provided single-term answers on the back of my card—"PGE analogs” and “NSAIDS”—I have gone through the struggle of actually providing myself with the explanation, to help contextualize the answer. E
WRONG CARDS: 1) Do not explain pathophysiology 2) Have close ended questions with one answer responses 3) Misses the major teaching point
These cards are very close-ended and miss the point about the general role of prostaglandins in the process. Thus, if I were to see another prostaglandin analog in the exam—like misoprostol—I would not know that it is also a correct answer because I did not focus on understanding the physiology here.
Less is More
It can be tempting to put a lot of information in your Anki card (even the example 'good' card here is a bit wordy). Your Qbank will often provide several tables and pictures in the explanations they provide. Notice, while I read the explanation fully to understand why the other answer choices were wrong, I did not focus on writing cards on these since I could easily cross them out. I knew I didn’t need to make myself memorize this information, so I didn’t waste time creating a card for facts I already understood to a sufficient degree to get questions right. However, if you had any thought that dexamethasone or nitric oxide could be a correct answer, do make sure to resolve that in your existing card by making a separate question that forces you to explain why those answer choices are incorrect. In general, you also want to limit the amount of information on a card and also limit the amount of concepts you cover on one card. Aim for no more than 1-3 related ideas on a single card. Here are some more types of cards to avoid:
WRONG CARDS: Far too much information, not clear what I have to say (out loud or internally) to count my response as correct.
This is basically a copy of what’s in a text book. I will not possibly be able to recite all these things when I encounter this card, and so this card will end up being another passive review of information. I also don't need to know all this to get related questions right, so trying to memorize all this would be highly inefficient. Again, too much information to even attempt to recall all at once. Another passive review card—basically a table from FA, which you did not significantly manipulate in order to make the card (and thus, you will not have enhanced your ability to later recall this information through active learning)
In cases like the cards above, while the diseases are related, it is best to make individual cards to address specific concepts (the exception being including a question about why the specific answer choice that you picked was wrong). Here, for example, is a card focusing only on two of the diseases and addressing the disease presentations specifically:
Notice how I have chosen to highlight distinguishing factors that will be the most useful for answering similar questions on test day.
But Too Little Information Isn’t Good Either...
We can sometimes get in the habit of writing really brief cards because, let’s face it, writing Anki cards takes time. But don’t fall victim to writing “one-word” question-and-answer cards. Instead, write questions that are specific and unambiguous.
Tay-Sachs…cherry red macula, no hepatosplenomegaly, GM2 ganglioside, Autosomal recessive? What exactly was I asking about again?
You've Wasted Your Time If You're Not Actually Reviewing Your Cards
Of course, you wouldn’t want to go to the effort of making these cards to not use them. It’s critical to review your cards every day and stay up to date on both your new cards and your reviews. Most students find it works best to review cards in the morning before starting the rest of their studies, and that it can be very helpful to download the Anki mobile app, which allows you to review your cards on the go (think about all the time you spend on your phone—plenty of that time could be spent reviewing Anki cards and making your USMLE studying far more efficient!).
It all boils down to making cards that force you to recall the important information, such that you will answer similar questions correctly in the future. With regards to the USMLE, important information means just the information required for you to get a question right (and to not pick the wrong answer that tricked you before). In truth, there are a lot of different ways to make cards, and different concepts may require different approaches to making cards. And I know this method isn't easy--we often spend a few sessions with tutoring students, helping them learn the method and edit cards they've made in the past.
Remember, the goal of all cards is to help with recall. So picture yourself seeing your cards weeks from now with no context. To ensure cards are effective, ask yourself:
Does my card accurately convey the message or information I was trying to remember?
If applicable, did I explain the relevant pathophysiology in my card?
When I see it weeks from now, outside of this context, will I be able to say the correct answer verbatim, if I've memorized the target fact(s)?
Taking the time to make cards selectively that are targeted to your personal misconceptions, with the proper framing of questions to recall the information in another context, will allow you to maximize the benefit of using Anki for your USMLE Step 1 and Step 2 CK, as well as other exams. The task of making cards might seem overwhelming at first, but you will thank yourself later when you are able to easily and quickly recall the information you spent all that time reviewing, rather than kicking yourself because you’ve forgotten most of what you studied by the time you take your exam!
When done correctly, this method is actually faster than using premade cards. But you might just have to take my word for that--until you try it for yourself!
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