A trend in med school is using pre-made Anki decks with 20,000+ cards that promise to cover “everything” on Step 1. These include Zanki, Brosencephalon, and a host of others.
The allure is obvious. “Memorize a gazillion facts, and you’ll do great on Step 1!” However, there are many hidden costs (and questionable assumptions) underlying this approach. Here Adam Nessim describes why he started using Zanki – and why he stopped.
Here is Adam Nessim:
How I Came to Use Zanki
When I first came to medical school, I heard about Anki. It uses spaced repetition so you can memorize enormous amounts of information. You’d do well in your classes and ultimately the USMLE Step 1. However, the devil is in the details.
Anki sounded like a great idea, so I started to use it here and there to memorize a bunch of facts before each of my tests. It helped in the short term. However, I never ended up continuing to review these cards after the tests. Not studying the cards meant I forget them. This defeated the purpose of long-term spaced repetition altogether!
A few months later I started using the Brosencephalon deck. Many medical students claim to have found success with it in the past to prepare for Step 1. This deck covers most of the facts in First Aid but not everything. I actually liked this deck and was able to get through the cards fast.
The one qualm I had is I found myself memorizing the card more than learning the facts themselves. For example, I often knew the answer after reading only 3 words of the question! I could tell this blind memorization wouldn’t translate to boards-style problems.
Towards the end of the year, I heard of this “amazing” new deck called “Zanki” which was 26,000+ cards. It promised to cover everything you need to know. Its sources included First Aid, Pathoma, Sketchy, and Kaplan. I then made what I now feel was a bad decision, and switched to the Zanki deck.
I thought to myself “If I can just learn every single fact in that deck, I must be able to crush Step 1!”
This idea was wrong for 3 main reasons.
(Disclaimer: this post is my opinion. Many claim to use Zanki – and Brosencephalon – with good effect. However, their use conflicted with my study principles. A high Step 1 score is about mastery of the material. For me, mastery of material involves more than memorizing 26,000+ individual facts.)
1. It Was Unsustainable and Driving Me Nuts!
In theory, it sounds great that Zanki has 26,000 cards, and covers everything. However, I quickly realized doing all those cards sucked up all my time.
Over the summer of my first year, I was catching up on topics I had recently done. This included autonomic pharmacology drugs and renal. It wasn’t too bad at first as I knew most of the material already. However, to get through these sections, I was adding 150-200 new cards a day to my Anki deck. Translation: I was adding 150-200 cards I needed to review the next day, the day after that, and so forth.
When I came back for second year, I started my neuro course which was an absolute beast. Before I knew it, I had accumulated almost 4,000 cards that went unreviewed.
Goodbye, spaced repetition!
You see, the entire point of Anki is that you do each card on the day that it is supposed to be reviewed. Otherwise, it defeats the whole point. So if I were supposed to review a renal card in 15 days, then for spaced repetition to work, I would need to see it in 15 days! The problem was, with such a backlog of cards to review, I was never seeing the reviews I needed to. I was only seeing the last day or two worth of cards and forgetting the rest.
Ultimately, this quantity of cards was too much for only having a year to go before Step 1. A year sounds like a long time, but not when you are trying to go through such an enormous number of cards and actually review them all. (Even for students who start early, it’s not uncommon to hear they study 800+ cards per day.) I was burning out from doing Anki cards, and it was causing me stress that was counterproductive.
2. My Memory Was Too Fragmented
A conventional method for making Anki cards is to break down concepts into short flashcards. Zanki does the same. However, I found that Zanki’s way of breaking down content had severe limitations.
By memorizing many little pieces, at best I could recall a specific card. I couldn’t piece it all together. For example, I knew whether minimal change disease was nephrotic or nephritic syndrome. (It’s nephrotic). I could do this for all the other renal glomerular disorders. However, if you were to ask me what the 5 main nephrotic syndromes were, I’d struggle to create a differential. I also couldn’t tell you what the classic presentation for minimal change disease was.
My memory was becoming fragmented. I wasn’t able to group content together which is a proven way of helping memorization. And unless a Boards question asked the exact fact on one of the cards, I was afraid I wouldn’t be able to answer it.
3. It Didn’t Translate Into Mastery of the Material
Memorizing tons of facts does not allow you to think at the level needed to do well on the boards and as a practicing clinician. Yes, I memorized a ton of information. But I couldn’t connect it to disease presentation, pathogenesis, and algorithmic treatment approaches.
Don’t get me wrong, memorizing is still very important to do well in medical school. It’s impossible to make connections when you do not have the basic facts down. However, true mastery of material goes well beyond that. Spending my entire day memorizing facts prevented me from attaining mastery.
Three Changes I Made Since Stopping Zanki
Since stopping using the Zanki deck, I have changed my approach to using Anki. Here are the three significant changes.
1. Reviews First, New Cards Second
First, I am committed to not going too fast with new cards. If it is a decision between finishing my reviews for the day or doing the number of new cards I had planned on doing, then reviews come first. To enforce this, I set my Anki so that all reviews are shown first before I can do new cards. I have come to terms with the fact that I am not going to memorize every single little fact using Anki.
Anki is a great way to supplement your studies, but it should not be the end all be all. Not doing 150-200 new cards a day has given me tremendous amounts of time. I have used this time to do questions from USMLE RX. As I write this, it is November of my second year. My school has covered the basic sciences, immuno, renal, neuro, endocrine, and repro. I do 20 questions a day on these subjects with a thorough review. However, I am by no means consistent with this. Starting January, I will be sure to increase the number of questions I do a day.
2. Cards That Make Connections
My second change is to create cards that force me to make connections. I have been trying to stay away from simple memorization cards. As discussed above, I often memorized the Zanki card itself rather than the information.
Now, I try to connect pieces of information together. For example, a single card may say “what is the presentation of abruptio placentae? What are possible causes?” My answer might be “abrupt, painful bleeding in the third trimester. Possible DIC, maternal shock, and fetal distress.” These longer answers take time to get through, and I have seen my speed decrease by about 33%. However, my understanding and ability to make connections has definitely increased.
I learned the importance of cards that force you to make connections and understand disease presentations. Dr. Palmerton from yousmle.com, calls this understanding the pathogenesis to presentation. Dr. Palmerton has examples of these types of cards on his site and even offers a Step 1 deck which I have been using.
3. Decks That Reinforce Other Resources
Lastly, I have been using the pepper Sketchy micro and pharm decks which I love. Sketchy Medical uses cartoons as mind palaces. This allows you to memorize pharmacology and microbiology better. However, as good as these sketches are, without spaced repetition I eventually forget them. Thus, I have been using these pepper decks which incorporate all the videos from sketchy, so that I won’t forget them.
I have also been using a random deck based on high yield facts from Boards and Beyond. I love the boards and beyond videos as they are a great way to provide context to First Aid. But again, I need to make Anki cards to help me memorize the information. Some of these pre-made cards are good, but I also like to supplement it with making my own cards.
Concluding Thoughts
Are you like me and do NOT have a photographic memory? If so, then spaced repetition is a must when it comes to reviewing for big exams such as the USMLE Step 1. A great way to incorporate spaced repetition into your studying is by using Anki. However, you must use it the right way!
My grades suffered by not using Anki correctly. Like others, I was memorizing tons of facts at a time. And I still do not think I have mastered the use of Anki. However, I am always trying to improve my study habits. As a medical student, you will find that this is half the battle.
Everyone is different. Many students have done well using a variety of study techniques. Don’t be alarmed if your approach is drastically different than mine. I hope through sharing my experience you can take away some valuable information. Maybe you can learn from my own mistakes. Perhaps you’ve never heard of Anki before and are now willing to give it a try! Either way, I wish anyone who is reading this the best of luck with their studies. Please feel free to reach out with any questions.
Adam Nessim is an MD Candidate at the Albert Einstein College of Medicine in the Bronx, New York. He graduated from Cornell University with a Bachelors of Science with High Distinction where he majored in Human Biology, Health, and Society, and minored in health policy. He blogs at All Things Healthcare. He also shares his journey as a medical student on his instagram @allthingshealthcare.
