Zanki: The Promise, Pitfalls, and Best Uses

by Alec Palmerton, MD in Plan

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Nearly every med student in the US has heard of, used, and/or knows someone who uses Anki. Many have used premade decks like Zanki, Brosencephalon, SLy FAux, lolnotacop, or other versions floating around the interwebs. These premade flashcards with Zanki promise to make studying faster by showing you what you should learn and providing the means to retain it.

But are there any downsides to Zanki or other memorization-heavy Anki decks? If so, what are they?

In this article, we will discuss:

• What all USMLE (and med school) studying needs to address,
• The pros and cons of Zanki and other premade med school Anki decks,
• Who likely will benefit the most from Zanki,
• The #1 thing to address before you can get the most out of Zanki, and
• Much more

USMLE Studying: Breadth, Depth, Retention, and Application

Studying for the USMLEs – and for medicine generally – must solve four problems:

1. Breadth: choose what to learn,
2. Depth: know it (well),
3. Retention: remember it,
4. Application: use it in test/clinical settings

The first three – Breadth, Depth, and Retention – are self-explanatory. We need to master enough things – and remember them – to have a chance to do well on any exams/clinical practice.

Application – or transfer – is ultimately the problem all education seeks to solve. Transfer means I can learn information in one context and use it in another.

Zanki and Premade Decks Help with Breadth and Retention; Struggle with Depth/Learning and Transfer

Spaced repetition and flashcards generally help a lot with 3) Retention. Anyone who has used Anki for any period realizes it can help tremendously with recall. Premade decks like Zanki go a step further and help with Breadth – they tell us exactly where we should focus, which is valuable to students deluged with information.

However, anyone who has used Anki has also likely realized that:

• Flashcards may not be great to learn from (they don’t solve Depth on their own), and
• Flashcards don’t necessarily help you with applying it

In other words, while Anki/spaced repetition has natural advantages for Retention, there are few/any natural advantages for application/learning.

The Downsides of Memorization: Fragile Ability to Get Questions Correct

Is it BAD to memorize it? No. However, is it limiting and inefficient? Yes. Let me explain.

Whenever I memorize something, I hope that what I will see on my future test – or clinical practice – will be close enough to what I crammed that I can get the question/scenario correct. But unfortunately, where rote learning falls short is when the context/wording changes.

Let’s say I memorize that pneumonia gives me a cough, dyspnea, fever, and pleuritic chest pain. Then, if I see a patient on oral contraceptives with sudden pleuritic chest pain and dyspnea – no fever/cough – maybe I think pneumonia because I anchor on the pleuritic chest pain buzzword. And perhaps I don’t even consider a more likely condition like pulmonary embolism because my knowledge is so superficial.

When I used to memorize things as details, this sort of false intuition/anchoring happened all the time – and I also see it happen with those who rely on rote learning.

Zanki and Many Premade Decks Tend to Focus on Memorization/Rote Learning

This same issue of memorization > mastery shows up with Zanki and many other premade decks. Here is an example from the Zanki Anki page:

What is the treatment for osteosarcoma?

En bloc resection and chemotherapy

Here we are to memorize that treatment of osteosarcoma is en bloc resection and chemotherapy. Is it true? Most likely! However, I’d argue it’s missing the general principle underlying it – a principle that would allow you to predict the treatment of many/most tumors, given a small amount of information.

I’m not an oncologist, and my view of oncologic treatment is simplistic. Generally, though, you can think of cancer treatment as:

Local disease – resection +/- chemotherapy

Very advanced disease (e.g., Stage 4) – systemic treatment (usually chemotherapy) +/- palliation (e.g., resection if there is a bowel obstruction)

Locally advanced disease (e.g., local lymph nodes positive) falls between these two extremes, often involving surgery if treatment could be potentially curative.

Zanki: How Might You Make an Alternative Card?

Again, how could we make this card differently to solve the problems of Depth, Retention, AND Application – and not just Retention?

Osteosarcoma – typical therapy involves what? How could you think of this?

En bloc resection and chemotherapy. Typical cancer therapy involves surgery, often with chemotherapy, unless:

The disease is widely metastatic, or

There is a particular contraindication to surgery (e.g., poor surgical candidate)

Alternatively, we could even say:

Osteosarcoma – use the general treatment of (not widely metastatic) cancer to explain the typical treatment.

Typically cancer is treated with surgical resection +/- chemotherapy. Osteosarcoma follows this general rule.

Now, with these cards, if I get asked about the therapy for non-metastatic esophageal cancer, I’d have a good chance of answering it on the USMLEs or the wards. Will it make me an oncologist? No. However, even oncologists struggle to keep up with the vast number of studies and changing protocols for treating each cancer.

In other words, ideally, our cards can help us develop greater Depth and Application – not just Retention.

Zanki: Is It ALL Memorization?

In fairness to Zanki, it is not ALL memorization. However, as I scanned the cards, I saw a reasonable number of explanations of “why?”

For example:

11β-hydroxylase deficiency presents with {{c1::hypokalemia}} (K+) and {{c2::hypertension}} (blood pressure)

due to increased mineralocorticoids; there is no salt wasting, which is seen with 21β-hydroxylase deficiency

While the explanations may not be enough to learn in-depth, these cards provide valuable Breadth and Retention for the right person who knew it well already – or could make the connections themselves.

Zanki: Who Benefits the Most?

So, who will benefit most from Zanki? Considering our four problems – Breadth, Depth, Retention, and Application – the people who gain the most are those who already have/can quickly develop good Depth and Application. A previous commenter on a student’s review of Zanki pointed out that Zanki is a way to help narrow the universe of facts to know – Qbanks are there to help with the application.

Generally, I agree – every single resource doesn’t NECESSARILY have to solve all of our four problems. However, QBanks like UWorld are excellent for Application and can cover many of the deficits that Zanki has. This Zanki-QBank is especially true if you are naturally brilliant and/or adept at figuring things out independently.

In addition, people who do Zanki should be very, very diligent. Taking a fact-/memorization-heavy approach naturally means that you will be doing a lot more cards. If you take the osteosarcoma example, I’d have to make a card for every malignancy to understand the management of every cancer. That is a ton of cards.

Instead, if I were to understand a single principle – MOST localized tumors are treated with surgery +/- chemotherapy – I could save myself dozens (if not more) cards. And that is just for one disease type.

Zanki: What Should You Do to Get the Most Out of It?

Are you the kind of person who tries to figure out why something is? If not – and if you want to use Zanki – you should strongly consider becoming such a person.

In other words, my most vital advice for using premade flashcards is to go BEYOND the words in them to develop genuine understanding. It’s very convenient to have something that will provide Breadth and Retention – adding on Depth (and, in particular, broadly-applicable concepts) is even better.

I tried using decks like that, particularly early on. I didn’t feel confident in my ability to choose/know what was “high-yield” and felt relief in relying on someone else to do that for me. Ultimately, though, over time, I realized that the premade cards were the ones I forgot – and had to repeat – the most. Why? Since I never understood them, remembering and applying them was much harder. In other words, I ran headlong into the problem of Depth and Application – which eventually hurt my Retention.

Concluding Thoughts

So, should you use Zanki or other premade decks? Only you can decide for yourself.

No matter your approach – and the resources you use – the better you can understand, integrate, and apply information, the better you will do.

What do you think? Do the pros of Zanki outweigh the significant number of reviews you need? What trade-offs are you willing to make for the convenience of Breadth and Retention? Let us know in the comments!