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5 Keys To Rock USMLE Step 1 With Anki/Spaced Repetition (and Not Get Rocked By It)

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by Alec Palmerton, MD in Uncategorized

Anki can be one of the most amazing programs for medical school and the USMLEs. It has single-handedly changed my approach to medicine, and is one of the key factors for me scoring 270 on the USMLE Step 1. However, it can also be overwhelming, and even detrimental to the point of taking away time from doing other, more important things. So what can we do to make sure that we use Anki for its good aspects, but prevent ourselves from being overwhelmed? How can we turn spaced repetition into a tool for good, without being buried under a deluge of flashcards?

Here is a question that I got recently from a student, which could have been from dozens of other students that I’ve heard from, or worked with personally, who struggle with feeling trapped under a mountain of Anki flashcards.

Hey Alec, I have been closely following your website as I prepare for Step 1. Over the last few months, I have accumulated a few thousand Anki cards on a small number of topics (i.e. my reproductive deck alone contains 400 cards), and I am feeling overwhelmed. I was wondering if you could offer advice on how to keep up with numerous decks at once. How many cards approximately should I have in each deck? Should I just be making cards for key topics? And how many cards did you do each day? Specific advice would be greatly appreciated!

I, too, have felt overwhelmed by the number of cards to review. During my second year of medical school, I was doing upwards of 350 to 400 old cards a day, with roughly 45 new cards I was adding to my reviews daily. That may seem like a lot, and it certainly did at the time, but I’ve heard from students who are doing more than 1000 cards in a day, and are feeling burned out and unable to keep up with their current block, let alone all of their old cards from previous blocks.

Here I share 5 tips I’ve picked up to make spaced repetition work for you. If you haven’t had a chance, you can read my previous tutorials on how to make Anki cards, more advanced Anki tips, as well as other frequently asked questions.

1. Make pathogenesis presentation cards to improve retention and reduce the number of cards you make

You’ve probably noticed that the better you know something, the fewer words it takes to describe it.  The same applies to making Anki cards; the more connections you can make, the fewer cards you end up making. On the flip side,  the worse you know a particular subject, and the less depth and integration you have, the more cards it will take to understand it.

Let’s take for example subdural and epidural hematomas. The vast majority of students on forums and other places you will see online simply go to First Aid, and make simple flashcard-type memorization cards on things like pathogenesis, presentation, time course and whether they will cross the falx cerebri or not.  To do this effectively, however, you would have to make separate cards for each of these things, so as to not put too much information on any given card.  For this topic alone, you can easily generate eight cards, forward and reverse for pathogenesis, presentation, time course, as well as radiographic appearance.

Instead, if you can connect the various facts together, you can dramatically reduce the number of cards that you make. For example, in this card that I created for a student several years ago,  you can see that I connected, but because I was able to integrate all of the information together, I only had to make two cards instead of the 8 they had been trying to make.

Pathogenesis to presentation card


For this one example,  I was able to reduce the number of cards I had to make by 75%! Just think if you are able to do this for all of the topics in First Aid,  how many fewer cards you would have to make, and how much better you would know the information for your test!

Granted, this is much easier said than done. One of the biggest reasons why I created the Anki decks is that I was getting emails virtually every day from students asking for my cards, and for help with making pathogenesis to presentation cards. You can get samples of the cards that I made here, as well as links to the decks I have put together of some of my best pathogenesis to presentation cards, so  that you can use them as templates for your own streamlined cards,  and save time on looking up all of the information yourself.  If you haven’t already, make sure you sign up for the Yousmle newsletter, and get a free micro starter deck!

2. Use First Aid to target the most important information

One of the things I struggled with most as a medical student was figuring out what was important to know.  Professors would rarely point out the most important or high-yield facts, and so I was left to my own devices to figure out what was most important. Typically, I would guess wrong, and find out only after weeks/months of studying that a particular point emphasized by my professor wasn’t very important,  but something else they might have breezed past was emphasized heavily on my exams.

To avoid this mistake, make sure that you target the material in First Aid as your priority for things to learn, supplementing it with lecture material, Goljan pathology, Costanzo  physiology, or other top resources.

To learn more about my approach to First Aid, read my article here on the top mistake that students make.

3. Take advantage of downtime to do reviews

Everyone in medicine complains about not having enough time in the day. I thought medical students had it bad, but I can tell you as a resident, finding time in your day for reading or studying does not get any easier.

The beauty of Anki is that with the power of the Anki mobile app, you can study on the go. For example,  some of my best studying is done at the gym, where unencumbered by Internet access and the myriad distractions it brings, I can focus all of my attention on completing my Anki cards, either on the treadmill or stationary bike. On clerkships, I utilized chunks of downtime to make sure that I had finished all of my cards by the time I’d gotten home, giving me relatively peaceful and free evenings to do whatever I wanted.  Even waiting in line at the grocery store can yield a surprising number of cards reviewed.

If you add up all of the 5, 10, or 15 minute chunks of time that you have throughout the day, you would be surprised how many cards you can finish without dedicating a specific amount of time to doing cards.

4.  Set a limit on the number of cards you make in a day

Whenever students talk about how many cards they have to review, I always remind them that it’s a simple numbers game: the more cards you make, the more cards you will have to review. If you are adding 50 new cards to your deck every day, the next day you will have 50 old cards to review, as well as 50 new cards. Then, roughly 4 days after that, when the 50 cards from your first day of review that had a four day time interval are due, you will have the 50 + 50 = 100 old cards to review, as well as the 50 new cards you have been adding each day.  This will continue until those first cards reach their next interval, giving you 150 reviews, and so on.

It’s a simple numbers game: the more cards you make, the more cards you will have to review.

The only way to change this is to reduce the number of new cards you make. Sometimes, you simply have to set a limit on the cards you create, which has the benefit of both focusing your attention on the most important facts, as well as helping you to feel less overwhelmed. This brings me to my final point, which is:

5. Give yourself permission to not remember everything

Most medical students I have ever met have been very hard workers. You need an incredible work ethic (coupled with a dose of masochism) to persevere through the endless years of schooling and training. While generally this is a wonderful trait, it has driven more than a few students to insanity, as well as to fail to use spaced repetition to its full potential.

My goal when I started using Anki wasn’t to learn everything. It quickly became obvious to me that while spaced repetition was amazing, it could easily be my undoing if I tried to make too many cards. As such, I started with much more modest goals for myself. I told myself if I knew roughly 30 to 40% of the information from lecture, but knew it exceedingly well, as well as most of the information in First Aid, I would do just fine.

Just remember your final exams.  So much of the information that we slaved over ended up not being on our test. At most, maybe 30 or 40% of all of the material presented, if even that, ends up on the final exam. The USMLE Step 1 is very similar, in that the vast majority of questions will not be nearly as detailed as what you learned originally.

Remember: you don’t have to remember every single word on every single slide, or every word from your lectures, in order to reach your goals.

Final thoughts

At the end of the day, it’s important to remember that perfect is the enemy of good.  Don’t spend too much time on perfection, trying to make the world’s best pathogenesis presentation card, just like you shouldn’t try to have perfect understanding and knowledge of every single lecture. You will only drive yourself crazy.

And if you’re looking for a boost, you can check out see ever growing Step 1 and 2 decks, which I update on a regular basis, which contain some of my best pathogenesis to presentation cards.

  1. Paul says:

    Hi Alec,

    I have 2 ½ months left until my Step1 exam. I’m 75% through my UWorld and planning to enter a dedicated study period now. I have done my Anki cards on and off and have been religiously making, adding to, and extensively personalizing my Yousmle step1 deck during my review period. Now that I’m done with my full review (with a review course), I pretty much have UWorld and Anki deck left to work through (Also planning on doing another Qbank in my last month). I do however have around 7000 cards in my deck with 2550 unseen, and have to be honest that I do feel slightly overwhelmed by the number. What is your advise on most effectively learning these cards during the remaining couple of months?

    Also, does your Step2 card contain CS content as well?


  2. Junior Bazile says:

    Hi all, I have just downloaded anki on my phone and now I am trying to discover it and find out how to use if efficiently. How do I get the flash cards? Do I need to pay first? Also I am looking for study partners with whom I can review materials, discuss difficult questions and prepare for the USMLE step 1 that I am planning to take sometimes between April and May 2016. Anyone interested in preparing with me?

    1. Yousmle says:

      Thank you for your message. You can get microbiology cards if you sign up for the newsletter. You can make your own cards, or you could also use some of the cards I have created, at the following link:

  3. martinobabs says:

    hi, I started using Anki along with mixed timed uworld test about a month ago. I do an average of 1-2 blocks a day in adding to Anki flashcard review. However, Im a little concerned that my score has been static around 75% 77% 80% 84% per block for a while. Currently at 90th percentile and 78% overall correct. I was expecting my performance to increase to 80s and then to 90s after using anki flash cards which i make from the questions/ concept i got wrong from uworld and firstaid. Please i need any useful tips. Should i just ignore the percentages,continue with my study methods or modify it. Thanks

    1. Yousmle says:

      Great question. Honestly, I don’t read too much into the percentages on your UWorld/Kaplan/Qbank blocks, and to look more at things like improvement in NBME practice scores.

  4. Roger says:

    Hi Alec,

    I appreciate the time you spend in helping others with board prep.

    I have been using Anki for some time, but am unsure the best settings to use for spaced repetition. Do you recommend just keeping the “Default” settings and going through cards that way? I feel as though when I am using Anki to study for class I am not seeing all of my cards enough before an exam. I guess I am looking for advice on how to adjust the settings to study for class vs step 1, or if I should just leave it all on default.

    PS – where do you obtain your pathogenesis information for your cards? Pathoma, Robbins, Goljan?

    1. Yousmle says:

      Great question. You can find the answer to many of your questions here:

      As far as the pathogenesis to presentation information, it came from a variety of sources, including a lot of information from class, Robbins, Goljan, Costanzo, FA, or sometimes even primary literature.

  5. Fahad says:

    Hi Alec,

    Does your deck for Step 1 is enough to increase my score and make a big jump or should I add more flash cards?

    Thank you

    1. Yousmle says:

      Some people just use the deck, but I personally would recommend to add cards for the topics you are weakest at, since the information covered in the decks won’t always be the same. You can do the subject-specific cards first (e.g. do the cardio cards), then if there are other things you’ve learned, then you can add cards. That way you won’t be duplicating information!

  6. Dick says:

    Hi Alec,

    I do a lot of practice questions to study and I take a short note on questions I got right and wrong, similar to a UWorld objective. Do you think it would be beneficial to turn missed questions into Anki cards even if they are not path-to-presentation? Most often when I get a question wrong it’s just something I didn’t memorize well enough and I know discrete fact cards can pile up quickly.



    1. Yousmle says:

      Hi Dick,

      Thank you so much for your question. I definitely would recommend turning missed questions into Anki cards, even if they are not pathogenesis to presentation. If you look at the sample cards that I share from my Step 1 deck, or the Step 1 deck, you will see how I did this.

      Best of luck!


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Want FREE Cardiology Flashcards?

Cardiology is key for impressive USMLE scores. Master cardiology from a Harvard-trained anesthesiologist who scored USMLE 270 with these 130+ high-yield flash cards. You’ll be begging for cardio questions - even if vitals make you queasy.