Saturday, November 2, 2013

How to Study in Medical School

In an older post, I wrote a little bit about my search for efficient study tools for medical school, and how I eventually discovered Anki and OneNote. To briefly summarize, I spent part of the summer before school started trying to figure out how I was going to study. I knew it would be a different ballgame than undergrad (and that turned out to be true), so I figured my old methods wouldn't work so well (which would also be true...). In undergrad, I usually just went to class, took notes in a binder, read any assigned reading, and reviewed everything once or twice in the day or two before the exam, depending on the class. For medical school, though, I knew that I would need a way to take in more information, organize it, and review it more than once or twice.

After poking around the internet a bit, I settled on Microsoft’s OneNote to take notes (if you have a PC, I highly recommend this program. If you have a Mac, I don't think it's available. I have heard good things about Evernote, though, which is available on both platforms. That said, I prefer the organizational structure of OneNote over Evernote – both are good programs, however). This was a great way to 1) cut down on what I actually had to lug around 2) organize everything in one searchable, legible database (this latter point is important, as my handwriting is chicken-scratch) 3) and take more notes much more quickly than I could write them, while also incorporating various media as needed.

Below is a great video describing how one can use OneNote in medical school. Everyone might do things slightly differently, but this provides a good starting point. 

Note: These aren't my videos, but I think they give a great overview of how to use OneNote and Anki.

If you have a Mac, then I’d suggest checking out Evernote. Click here for a basic overview of how to navigate Evernote.

If you used paper in undergrad, like I did, you might think that you’d rather just keep doing that. And that’s fine. But if you can, I’d really recommend switching to a computer-based note-taking program. I have found it to be much faster and more efficient. It allows me to pretty much have access to every note that I have taken at all times, search the entire database, and sync it all in “the cloud” so that, if I were to lose my laptop, I could be up and running on any other computer in the time that it takes me to log in to SkyDrive. OneNote’s built in screen-capture feature is also a very helpful tool that I use on a daily basis.

So I had a good way of taking notes. Great. But how would I review them? It is a common refrain among medical students that you can expect to forget pretty much everything you learn in the first couple of years. That may be true, but that didn’t sit well with me. I’m sure most of what we learn is irrelevant, and that’s fine, but not all of it is, and a large chunk of what we are learning we’ll have to know for the boards. So I started to wonder if there was a way around that…and found Anki.

Anki is essentially a free flashcard program. You create the cards, review them, and then the program will use a spaced-repetition algorithm that makes certain cards due at various intervals, depending on how well you could recall the information. (Update: I've written a brief Anki Q&A here.)

So, for example, you make a card. Right after making the card, you review it. It’s pretty easy, and you answer it correctly. The next day, the card is due again. Again, you answered it pretty easily, so when Anki gives you the option of choosing how well you recalled the information (generally something along the lines of “again,” “hard,” “good,” or “easy,” with each option being associated with a certain default time interval, like “10 minutes,” “2 days,” “3 days,” or “4 days,” respectively), you select “good.” In three days, the card becomes due again. If you again select "good," this time the time interval might be “5 days,” and so on and so forth.
Taken from this random website

You can see in the graph how this works out over the long term. After we learn something, that knowledge immediately begins to decay. However, we can slow that knowledge decay by exposing ourselves to that information again within a specified window of time. Over time, this spaced review strengthens the memory of whatever it is we are trying to recall. Sounds great… but the trick is to figure out when we need to review the information. With physical flashcards, this quickly becomes tedious (especially when you accumulate thousands of flashcards...). With notes, we might review those a few times before a test, but then probably never really look at them again. With Anki, you don’t even have to think about it. Anki does all of the work, and uses your answers (whether the card is hard, good, or easy, for example) to create a personalized scheduling algorithm for you.

So how do you use this in school? There are many different ways to use it, but I’ll briefly walk through how I’ve been using it. After lecture, I review my notes and find important concepts, ideas, or minutia that I feel I need to know. It’s important here to distinguish between things that only the professor would ever ask, things that you might actually need to know for boards, and things that you simply find interesting and/or helpful. For the most part, you only want to make cards for things that fall into the last two categories. That said, you can make cards for things in the first category and “suspend” them after the test – that way, you reap the benefit, at least in the short term, of spaced repetition while avoiding making your daily reviews in the long term too long.

I would recommend trying to only make 20-50 cards a day (ideally), with an upper limit of 100 new cards per day. When making new cards, there are some rules that you should keep in mind about how to make efficient cards – you can (and should) read them here. If the cards that you make are junk, then Anki will not be beneficial for you. Right after you make the cards, be sure to review them. Additionally, it can be helpful to tag the cards as you make them – so, for example, if you are making cards about the upper extremity in anatomy, you can tag them all under “upper_extremity” so that you could pull all of those cards out later for a dedicated review, if you so desired. You can also tag by source – for example, if you wanted to check what you are learning in your classes against a gold-standard source like First Aid, you can tag any info that is in First Aid with an appropriate tag so that you can review it later or just to remind you not to suspend that card down the road. Again, while it would normally be a waste of time to look at a source like First Aid in your first year, with Anki this is no longer true, because you will actually remember the information. Ideally, this will help you later when you do begin to study for boards.

There are also different types of cards you can make. You can make straight flashcards (e.g. prompt on front, answer on back), you can use something called cloze deletions, or you can use image occlusions. There are many other types of cards, but these are the three types that I primarily use.

Cloze deletion and image occlusion are powerful tools, and are perhaps best illustrated by video. So below are some relevant videos that provide a short introduction to how to use Anki and create those types of cards. I highly recommend taking the time to watch them.

Now you’re ready to get started. Go here to download Anki, and here to see the user manual if you have any other questions – although, if you’ve watched the above videos, you should have a pretty good handle on things.

Finally, if you ever have any problems with Anki, following the instructions in the video below should fix them.

Once you’ve made the cards, make it a point to review them daily. Just get it done – you’ll be glad you did later. It might take a little more time up front to create the cards and spend time reviewing them, but when it comes time for a test, I think you’ll find that you’re a bit less stressed about it and are able to spend less time trying to cram information in your head. Usually for tests I just passively review my old notes once – quickly – just to get a “big picture” review and to go over anything I specifically marked as something I should review (for example, if I didn’t put something in Anki because it is important for the test but for absolutely nothing else in life).

Also, reviewing them can be done on the go. There is an Anki app for both Android (free) and iPhone (not free, but worth it). For example, I start reviewing cards in the morning while eating breakfast, while walking from the parking garage to school (which would otherwise be a waste of 5-10 minutes, and during which time I can get through a bunch of cards), in between classes, etc. This allows me to sometimes be completely finished with my daily review by the time I get home, or at least have a significant portion of it knocked out.

So that’s OneNote and Anki. These are very powerful tools. There are, of course, many ways to get through medical school, but, at least for me, these programs have single-handedly gotten me this far, and I plan on continuing to use them throughout the rest of school.