Med School Anki: Make (or Find) USMLE-Crushing Flashcards

by Alec Palmerton, MD in Beginners

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Most students will have tried Anki in med school. There is a good reason: spaced repetition helps you remember anything, forever. I can still remember (and use) the majority of things I’ve made into cards since my first year at Stanford. I scored 270 on the USMLE Step 1 and received honors on all my 3rd-year shelf exams. As a resident at Harvard-MGH, my ability to help actual patients improved dramatically.

But for every story like mine, there are dozens of students who never use Anki effectively. Instead of Anki improving their understanding, they are stuck memorizing tedium. They’re buried under a mountain of mindless flashcards, some of which they made. Or maybe they cram details from Zanki, Brosencephalon, or other pre-made decks.

Often, students cramming details will find limited success on Boards and in the Match. When faced with real patients, their buzzword knowledge will fail them.

So how can Anki be so effective in some cases, but so awful in others? As an amusing attending once noted: “it’s the wizard, not the wand.”

In other words, even the best tool in the world will fail unless you use it effectively. Anki is no different. Memorize random facts, and you won’t magically apply key concepts on an exam. However, Anki can help you reinforce things you’ve already learned and understood.

In this article, we will discuss:

• Why (good) Anki cards are among the strongest evidence-based study techniques
• Five principles to make better Anki cards to improve your understanding and scores
• The most common mistakes people make when making (or choosing) Anki cards
• Real-life examples of excellent and bad Anki cards
• How to spot good (and bad) pre-made Anki decks
• Much more

Table of Contents

Med School Anki: What’s the Evidence?

You may be contemplating using Anki in med school. You may have heard of successful (or unsuccessful) students who used it. But, before you take the Anki plunge, what is the evidence behind it?

Studies have looked at Anki in med school. They often compare med students’ Anki use vs. “typical” practice. (Med students who use spaced repetition typically do better). However, proving something is BETTER is different from showing something is the BEST.

Instead, there are excellent reviews on the best educational techniques. I’ve adapted one such study, which looked at the learning techniques with the most robust evidence.

Evidence-Based Techniques to Maximize Learning

Med School Anki: Combining the Strongest Evidence-Based Learning Techniques

What do you notice about the most evidence-based learning techniques? Specifically, of your typical day, how much is spent doing “low” vs. “high” utility techniques?

Most medical students spend most of their time on low-utility techniques:

• Taking notes (summarizing your textbooks/lectures; “low” utility)
• Re-reading / re-watching old material (“low” utility)
• Highlighting / underlining notes/books (“low” utility)
• Creating / using mnemonics (“low” utility)

If you’re not using Anki in med school, little of your day may involve:

• Practice testing (“high” utility)
• Distributed practice (“high” utility)
• Elaborative interrogation (“moderate” utility)
• Self-explanation (“moderate” utility)

Most med students do techniques that are “low” utility. (Good) med school Anki cards utilize most of the techniques with the most robust evidence base.

“Low” Utility Methods Are More Dangerous Than Useless Ones

I can already hear the indignation: “but my note-taking technique works!” “Mnemonics are better than the placebo!” “I got a question right on my last test because I re-watched ____ video!”

Yes, I’m sure those are true. The “low” utility techniques aren’t useless. However, less useful methods are much more dangerous than useless ones. Why? Because we would never waste our time if there were no benefit from something. Would you watch the TV program “The Office” to study medicine? No, of course not – because it clearly would not help you learn medicine. Instead, what holds us back are things that give us some benefit.

Re-reading or summarizing a textbook/lecture isn’t BAD. It won’t cause you to forget something. And therein lies the problem. It’s useful enough that it will convince you not to try something new. Something like using Anki in med school.

(To read The Key to Success in Medical School (and Life), click here).

Anki: Why It Combines Many of the Most Useful Learning Techniques

If appropriately used, Anki for med students combines many of the best study methods. How?

First, instead of re-reading information, you are tested on it. (Practice testing). Because of the spaced repetition algorithm, you have distributed practice.

The best cards also force you to use other essential study techniques:

• Elaborative interrogation, explaining “why” something is (rather than just memorizing it)
• Self-explanation, connecting something you’ve learned with another fact

Note that many Anki cards do NOT follow these evidence-based practices. As we’ll discuss later, many Anki cards are “flashcards” that are less useful for Boards mastery.

The Five Rules to Make Boards-Crushing Med School Anki Cards

Next, we will discuss my five rules for making Boards-crushing Anki cards. The first three will help you create basic cards. The last two will make your cards particularly useful for Boards. (And your future clinical practice).

Even if you decide you don’t want to make your own cards, it’s important to know the rules for making good Anki cards. Why? Because if you choose one of the many pre-made Anki decks, you want to choose the best ones.

Here are the five rules behind Boards-crushing med school Anki cards.

Rule #1: Minimize Unrelated Information (1-3 Unconnected Facts)

What’s the common mistake that people make when they start out using Anki cards? Their cards contain way too much information. 

Making cards that are too long hurts you twice:

• First, because you will have to repeat these cards many more times and repeating cards wastes your time as you review facts unnecessarily; and
• Second, because you won’t remember the information as clearly

Let me give you a real-life example:

On the front of the card, this student had as the question:

Differentiate the infections by the causative agent and describe the rashes’ location/direction of spread. Also explain unique findings. 

• • Rubella 
  • Erythema infectiosum 
  • Roseola infantosum 
  • Hand/foot/mouth disease 
  • Scarlet fever 

And as the answer:

• • Rubella (rubella virus) head to trunk to extremities, cervical LAD
  • Erythema infectiosum (5th disease, Parvo B19) – Red rash on cheeks (slapped cheeks), lacelike rash on trunk/extremities
  • Roseola infantosum (6th disease, HHV 6) – rash from trunk to periphery
  • Hand/foot/mouth disease (coxsackievirus type A) – vesicular rash on palms and soles, ulcers on tongue/oral mucosa
  • Scarlet fever (Group A strep) – rash with small papules (sandpaper-like)

Mistake #1: Long Cards Waste Time and Hurt Recall

The above card is well-intentioned. We’ve all been there. We’re studying the viral red rashes of childhood, and want to connect the information. We like seeing everything together without fragmenting it.

Trust me, I get it. However, by making such long cards, we will waste a lot of time repeating information we know already.

For example, let’s say they could recall everything about the first four diseases. Not only did we know the condition, but also the causal agent and its presentation. But what if we forgot the information for Scarlet Fever? If we wanted to ensure we could remember the last disease, we would need to repeat the entire card. We would review 80% of the information we knew well, just to remember the 20% we forgot.

Repeating Things You Know = Waste of Time

Reviewing what you know well already is a waste of time. Imagine you knew 80% of a textbook, but didn’t understand 20%. Would you want to re-read the entire book, just to get the final 20%? Of course not. Then why would you do that with your Anki cards? By making shorter cards, you ensure if you repeat a card, most of the information will be things you didn’t know.

Second, with such long cards, the desire to move on so we don’t have to repeat it is quite strong. Maybe you understood 60% of the card, and you feel time-pressure. It’s easy to lie to convince ourselves and say we know the card when we should really review it again. Thus, we let our standards slip for how well we have to understand the information to hit “good” or even “hard.”

Break Up Long Cards Into Shorter Reviews

The best way to recall information-dense topics is to make separate cards out of the facts. One example would be:

Rubella – Identify the causative agent and describe the location/direction of spread.

Answer:

Rubella virus – head to trunk to extremities, cervical LAD

You could then do the same thing for the other diseases. Making more, but shorter cards:

• Speeds up reviews
• Improves recall for the few facts (as opposed to a cursory recall of many facts) and
• Minimizes unnecessary repetition of information I already know

“But don’t you have to make more cards this way?”

Making shorter cards will increase the number of cards you make. But what really matters isn’t the number of cards, but how long your reviews take. Making more – but shorter – cards actually reduces the review time.

“How do I know if my cards are the right length?”

This may vary person-to-person. As a rough approximation, it should take you roughly:

• 1 hour to review 100 “old” cards. (Cards you have studied previously).
• 1-2 minutes per “new” card (it may take multiple reviews for the information to stick).

So, to review 200 old cards, and 35 new cards in a day should take you roughly 2.5-3 hours.

Rule #2: Each Question Should Have a Single, Unambiguous Answer

Try this sometime: think of a popular song. (E.g., Mary Had a Little Lamb). Now, instead of using the actual tune, tap the rhythm out on the table with your hand. Then get someone to try and guess what song you’re tapping out.

What happens? The person will have no idea what you’re tapping, but you’ll think it is so obvious! Why? Because what is in your head isn’t communicated to the listener.

The same is true when you make flashcards. You’ll make a card and know EXACTLY what you mean. It’ll be so obvious to you what you’re asking. Except that in a couple weeks, you’ll look at the card, and have no idea what you’re asking.

Instead, make a clear question with a single unambiguous answer. Doing this will help you avoid the next two most common med school Anki mistakes.

If your cards don’t have a clear question, you’ll look at it with a blank stare later.

If you make a question without a single, unambiguous answer, you’ll end up staring at it blankly

Mistake #2: Unclear/Ambiguous Question

Here’s a sample card that does NOT have a single, unambiguous answer.

Question:

Oral hairy leukoplakia

Answer:

EBV

To you, it might seem obvious that it is a bad question. However, in reality, I see this problem all the time! Why? Because we assume “future us” will know the answer.

Make Clearer Questions for Better Med School Anki Cards

Like most Anki mistakes, most people will realize their errors eventually. You’ll see the card in a month, and think, “huh, what is this asking?” The solution to ambiguous questions is clear: make clear questions! Instead of asking, “oral hairy leukoplakia” like the question above, try something like,

“Oral hairy leukoplakia – what is the infectious cause?”

Note, however, that you can make questions too obvious. So obvious, in fact, that they take away the difficulty in testing yourself.

Mistake #3: Giving Away too Much Information in the Question

Here is an example of a question that gives away too much information:

Hyperventilation would cause what kind of alkalosis?

Back:

Respiratory alkalosis

Let’s say I was trying to remember the effects of hyperventilation. I would want to remember not only that it would be respiratory and not metabolic. I would also want to remember that it would cause an alkalosis.

While this is an obvious example, it happens too often. I will write a question, only to review it later and find I’d given away the answer!

Instead of the question above, ask:

Front:

Hyperventilation – has what effect on acid-base status? Why?

Back:

Respiratory alkalosis. Hyperventilation → CO2 exhalation ↑ → PaCO2 ↓ (respiratory alkalosis)

Notice how I am testing myself on:

• What kind of acid-base change it is
• Whether it is metabolic or respiratory

The more you’re forced to recall, the more you’ll remember. This brings us to our next rule.

Rule #3: Test Information Explicitly If You Want to Remember It

Finally, I wanted to highlight one common mistake that I made when I began to use Anki. It is a variant of the first mistake (too much information). Specifically, I would cram everything into the answer and expect to remember it all.

This was one of my first cards. (I cringe when I look at it).

Question:

Parainfluenza virus vs. RSV – What are the major syndromes they cause? BONUS: What surface proteins are associated with each?

Answer:

Both PARAMYXOVIRIDAE. Parainfluenza – CROUP (laryngotracheobronchitis) – gradual onset, fever, barking cough, inspiratory stridor (wheezing sound), hoarse voice, variable progression. Has mixed neuraminidase and hemagglutinin, so can agglutinate RBCs. RSV – BRONCHIOLITIS – variable course: tachynpea, grunting & flaring, indrawing & wheezing, cyanosis, apnea in some. NO HEMAGLUTTININ, so do not agglutinate RBCs. Has F (fusion) and G (attachment) proteins – F protein mediates creation of SYNCYTIUM.

Mistake #4: Expecting to Recall Something That Wasn’t Tested

The above card has way too much information. What’s worse, this was the only card I had that listed the viral causes of croup/bronchiolitis.

Do you think I remembered these facts when they counted? Nope. And why? Because I had this misguided thought that if I saw something enough, I wouldn’t forget it.

Remember: you will only remember what you ask yourself to recall.

“But wait! What if I didn’t want to test myself actively on this information, but I might find it useful in the future?”

Let’s say you find a fact that is interesting, but not interesting enough to try and remember. You CAN leave information for yourself in cards, in case you want to reference it later. Just don’t expect to remember it in the future!

Rule #4: Ask, “Why?”

USMLE questions ask you to apply essential concepts. They minimize questions about specific facts. (You can read about the NBME’s question writer’s guide if you don’t believe me).

So what does that mean for your med school Anki cards? That you should ask, “why?” as much as possible. Not only is asking “why?” one of the evidence-based study techniques listed above. It will also help you get a higher Boards score.

Let’s take a simple example from women’s health: syncytiotrophoblasts. (Syncytiotrophoblasts are the cells that cover the chorionic villi in the developing embryo).

A simple card that didn’t ask, “why?” might be something like this:

Front:

Syncytiotrophoblasts – what are they? Where are they located?

Back:

Layer of epithelial cells that surround the chorionic villi in developing embryo

This card isn’t BAD. There’s a clear question, without too much information. It follows the basic med school Anki card-writing rules.

However, do you really understand syncytiotrophoblasts from this card? Is this likely to help you answer Boards questions? Probably not.

Asking, “Why?” Deepens Your Understanding

Instead, let’s see what happens when we ask, “why?”

Front:

Syncytiotrophoblasts – what are they? Where are they located? Why?

Back:

Layer of epithelial cells that surround the chorionic villi in developing embryo

These cells form a syncytium. (Essentially one long giant cell. “Syn” = together, “cyto” = cell, so syncytium literally = “together cell”). Because the cells have fused together to form a giant cell, there are no intercellular gaps. This lack of gaps is what creates the “blood placenta barrier.” Thus, maternal immune cells can’t cross the placenta to attack the developing baby.

What do you notice when you ask, “why?” You finally start to understand! Yes, it might take you longer to make/review this card. However, the payoff for your retention, Boards scores, and clinical practice is immense.

This leads us to our final med school Anki card rule: make connections between concepts.

Rule #5: Make Connections Between Concepts

One reason that learning medicine is so tricky is that everything is related. (It’s also why learning medicine is fascinating). Understanding cardiology before you’ve learned about the lungs is difficult. Yet that’s precisely what a first-/second-year med student must do!

As discussed above, one way to improve our learning is to make connections. The fancy term for this is “self-explanation.” It means that you relate something new you’ve learned with something you already know.

So how can we connect syncytiotrophoblasts with something we already know? By tweaking the previous card to relate it to immunology.

Front:

Syncytiotrophoblasts – use what they are to explain their location. Specifically, explain how they would interact with the maternal immune system.

Back:

Layer of epithelial cells that surround the chorionic villi in developing embryo

These cells form a syncytium. (Essentially one long giant cell. “Syn” = together, “cyto” = cell, so syncytium literally = “together cell”). Because the cells have fused together to form a giant cell, there are no intercellular gaps. (Recall that immune cells migrate BETWEEN cells in a process called diapedesis).

This lack of gaps is what creates the “blood placenta barrier.” Thus, maternal immune cells can’t cross the placenta to attack the developing baby.

How often do you try and relate one topic to another? If you’re like most med students, you don’t see the connections enough. And it’s not your fault! Too few med school lectures explain the “why.” Instead, our professors focus on the “what.”

To read more about how to learn why something is, I recommend:

(To read UWorld + First Aid: 4 Keys to Mastery (#4 Bumped Me to 270 from 236), click here).

Pre-Made Decks: How to Spot Winners?

One med school Anki theme is how hard it is to make your own cards. Even to make basic cards – without asking “why?” or making connections – is difficult. Finding the explanations, then turning them into good Anki cards, is time-consuming.

So it’s tempting to use pre-made Anki decks. I totally understand! You may have heard of Zanki, Brosencephalon, or any number of med student-made Anki decks. Before you use them, however, I caution you to think about the most effective study techniques.

Most med student-made Anki cards are what I call “flashcards.” They are simple and follow the basic med school Anki card-making rules. They’ll have a simple, fact-based question. Here’s a typical example of a pre-made card from one of the above decks on syncytiotrophoblast:

Here is a typical pre-made med school Anki card. Notice how it will help you memorize a fact, but do little else.

Is there anything wrong with this card? No. There may be a question that asks you about choriocarcinoma and hCG. (Although again, such a simple question is unlikely to be on your test). The problem is that it does not help with making connections.

Most Pre-Made Med School Anki Cards Ignore Connections and Don’t Ask, “Why?”

Pre-Made Cards Would Be Better if They Asked, “Why?”

But what does the typical pre-made card NOT do? It doesn’t tell you WHY. There is no connection!

A better, evidence-based card would give you an explanation and a connection. Something like:

Front:

Choriocarcinoma – use what cells it is derived from to explain what hormone is elevated. Why would it make sense that these cells would secrete this hormone in the first place?

Back:

hCG is elevated

Derived from trophoblastic tissue (including syncytiotrophoblasts). Syncytiotrophoblasts secrete hCG to prevent loss of the corpus luteum. Thus this tumor is associated with elevated hCG.

Syncytiotrophoblasts invade the endometrium. Their successful invasion depends on progesterone/estrogen. During the first trimester, progesterone and estrogen are secreted by the corpus luteum. Thus, it makes sense that syncytiotrophoblasts (and choriocarcinomas) secrete hCG.

What do you notice? First, the second card is longer. That might seem like a disadvantage at first. I mean, it is so much SIMPLER just to memorize a fact. And there are some facts you will need to remember.

However, like most things in life, you get what you put in. If you memorize details, don’t expect to understand USMLE vignettes magically. Instead, given the USMLE’s emphasis on mastery, take the time to learn it well the first time. Because the worst studying is studying you’ll repeat since you didn’t learn it well the first time.

Pre-Made Anki Cards with Explanations and Connections

Are you overwhelmed with the idea of making your own Anki cards that explain “why” and not just “what”? Use the Yousmle Cards. Master explanations and connections to maximize your Boards score in the shortest time.

Want to Learn the Right Way From Day 1?

Does this sound familiar? You’ve poured time, energy, and money learning everything only to realize you didn’t learn it right the first time. You ask yourself, “what do I do now? Take more time that I didn’t have in the first place to learn it all again?”

No one wants to be panicked and cramming during their USMLE dedicated study. Yet that’s what happens every year.

What if I told you there is a better way to master the material once – and never forget it?

In the Yousmle Online Course, you’ll learn how to save time, get higher scores, and open the door to more impressive residencies. How? By learning the right way from Day 1.

The Online Course allows you to not only master the most Boards-critical knowledge but gives you the skills to learn anything and remember it forever. The earlier you start the better! If you were training for a marathon and wanted to be at the top would you wait until the last month to get a coach? No! You would start at the beginning with a coach who has the knowledge, experience, and passion to give you the highest possible outcome. Having the right techniques to study smarter and not harder from the beginning is a life-changing opportunity.

To be steps ahead of the competition and master more in less time – sign up for the Online Course today.

Recap

There you have it!  Here are the five rules for making (or finding) Boards-crushing med school Anki cards:

Concluding Thoughts

One of the most common mistakes med students make is they are in a rush. Everyone feels behind. Instead of mastering information, they’ll try to cover it quickly.

Using Anki in med school is no different. Most students will balk at taking the time to understand material and using Anki as a way to remember it. Instead, they’ll take short-cuts. Instead of mastering the material, they’ll try for multiple “passes” of the material. And there are tons of pre-made Anki cards that will cater to this memorization-crowd.

Instead, remember that the best studying you can do is the studying you won’t have to repeat again. Whether you decide to make your own cards – or use a pre-made deck – be sure to make cards that ask, “why?” Even better, try and make connections between concepts. Not only will you learn the material better, you’ll set yourself up for much higher Boards scores.

Photo by Andrew Malone.