Wednesday, July 23, 2014

Staying Fit in Medical School

Medical school can be a busy time. The first two years can be managed fairly well if you play your cards right, but as you add things on top of the basic goal of passing your classes (e.g. volunteer activities, research, family, or whatever hobbies you might have), you’ll quickly find your time becomes a precious commodity. To make time for other (often good) pursuits, we sometimes take shortcuts when it comes to our health – we sleep less, eat more, and move less.
Don't do this. Please.

I’ve lifted weights for a few years now, but before medical school I usually worked jobs that kept me pretty physically active on top of just lifting. That translated into not really having to worry much about, for example, what I ate – I could pretty much down whatever I wanted and top it off with two large bowls of ice cream lathered in chocolate syrup and be fine. While that was a blessing (obviously – ice cream is delicious), it also turned out to be a somewhat of a curse. When I got to medical school and suddenly became quite a bit more sedentary, I started to put on a bit of weight. Nothing outrageous, and it wasn’t all of the sudden. I continued to regularly lift, and for a while I told myself that I was just getting “bigger.” But my lack of attention to my food intake caught up with me, and my waistline started to grow. Suddenly, I wasn’t fitting into my clothes quite as well as I used to.  Before long, I was over 190 lb. at about 5 ft. 9 in. and around 22% body fat. Not good.

Time for Change

Before I go any further, I want to take a second and say a couple of things. First, if you are looking to get healthier, that’s great. I personally want to be around for a lot of years so I can spend a lot of time with my wife and family, and want to be able to not get tired out after just a few minutes of wrestling with my son when he is older. Additionally, something like strength training just has a lot of carryover to real life – things that run the gamut from being able to lift heavy things to help friends move, carry in the groceries, or protect my family if the need ever arises. The desire to lose weight, on the other hand, might stem from wanting to improve your various lab profiles, reduce your risk for cardiovascular disease (a big one for me, since I’ve got a pretty strong family history for it), or reduce your risk for all of the other diseases that come hand-in-hand with an expanding waist line.

So if something along those lines is providing you with the intrinsic drive you need to eat less and move more, that’s awesome. However, some people take this whole fitness thing way too far. Being “fit” should not become your identity or sole purpose in life – it’s a means, not an end. Also, don’t be ridiculous about things. Sometimes you might miss a session to hang out with family, or will eat “bad” food when you are out with friends. Whatever. Don’t freak out about it. Enjoy it. While you obviously don’t want to eat crap all of the time, every once in a while (and probably more often than you think), it’s perfectly fine. So relax, and enjoy life a bit. And whatever you do, do NOT go around telling people how they can be healthier, or what they should and shouldn’t eat. I know people like that, and it’s not helpful or pleasant at all. Changing your lifestyle is a personal decision, and if someone actively wants your help, then by all means help them – but don’t force anything on anyone.

Ok. So Now What?

Alright, so back to my waistline. I knew things needed to change. So I started doing a little research. Here is a brief summary of what I found.

Losing the Chub

First off, you have to get something straight – the most important determinant of how lean you are, or even how muscular you are, is not how much “cardio” you do, how much weight you lift (although lifting is important – more on that later), whether or not you eat gluten free, paleo, your micronutrient profile, or whatever. The single most important determinant of your body composition is simply your energy balance – in other words, the calories you take in vs. the calories you expend.

If you want to lose fat, then you have to eat less.

If you want to gain muscle, then you have to eat more and provide the proper stimulus (e.g. weight training).

You can stop reading now if you want. That’s really how important that concept is.

All of the common diets out there – low carb, paleo, Zone, Atkins, Weight Watchers, or whatever – all work. At least for a while. Why? Because in one form or another, they get you to eat less. That is really the crux of the issue when it comes to losing weight. Cutting out carbs, for most people, cuts out a significant food group and thus removes a lot of calories from their daily intake. Eating only so many “points” worth of food each day does the same thing. And so on. Where some of these diets fail, in my opinion, is by failing to hammer home some basic nutritional concepts that help people keep the weight off in the long run. When they add carbs back in, the weight comes back. Or they might start increasing their intake of low-carb foods to the point that they are once again eating a caloric surplus. Once the meal replacements are replaced with real foods, people haven’t learned about portion size, so they just go back to doing what they were doing that made them gain weight in the first place.

So paying attention to the amount of calories you eat is important – that should be clear. Problem is, most people are terrible at estimating how many calories they are eating. They might think they are eating less and are confused as to why they are not losing weight or even still gaining it, but they don’t realize that they are still eating at a surplus, or perhaps have just reduced their intake down to maintenance levels.

So how best to keep track? I started using a free app on my phone called MyFitnessPal. It’s an awesome, easy-to-use way to keep track of things. They have a huge food data base and you can typically just type in whatever you are eating and find it. They have pretty much every major restaurant’s food and a lot of smaller restaurants as well, which makes it convenient when you are eating out. You can also build common meals and save them to use them again later. It remembers what you typically eat, which makes it easier to use the longer you use it. It also can keep track of your weight and other markers as well. For someone like me who likes data points and keeping track of things, it’s awesome. Additionally, it only takes maybe 3-5 minutes a day – tops – to use once you have things down. So it takes minimal time, but it allows you fairly fine control over your caloric intake – which is THE MOST IMPORTANT STEP when it comes to losing fat or gaining muscle.

Of course, as with any data, if your data is trash then your conclusions are useless. Be honest about what you enter. When in doubt, I try to overestimate what I’m eating (because most people usually underestimate).

That said, I’m not a huge fan of weighing or measuring everything you eat. My guess is most people aren’t. It’s just inconvenient. For some who are trying to get into peak condition, it might be necessary. For most of us, though, it’s probably not. You might find it helpful to weigh something once or measure something once just to get an idea of what a cup of this or 12 oz. of that actually looks like, but don’t get too crazy.

Once you’ve downloaded the app (you can just use it on the computer as well, but the app is way more convenient), track your intake for a few days. Be honest. You have to figure out where you are to figure out why you got there and where you are going to go.

Finding Your Numbers

So you have the tools to keep track of your calories, which, if you haven’t caught on by now, is IMPORTANT. Now what?

The next step is to figure out what your goal is. For most people, this will be something like, “Well, I want to lose fat and gain muscle.” That’s great, but with the exception of rank beginners, it’s unlikely to occur. It’s possible, of course, but progress will be exceedingly slow and you are really working at counter-purposes with yourself. Remember, to lose fat you have to eat less, and to gain muscle you have to eat more. You can’t really do that at the same time – you cannot serve two masters. So pick your goal, and go with it.

But getting back to the topic of this section. You need to establish your caloric maintenance requirements – the amount you need to eat to stay the way you are. The calculator I like (which has lots of features, which we’ll talk about later) can be found here. Plug in your numbers, be honest about your activity level, and select which formula you want to use to calculate your caloric needs (I would just choose the one with the most conservative values for starters – it’s easier to add in calories later if needed than it is to remove them). That’s your maintenance caloric requirement.

If your goal is to lose fat, you need to eat less than that number to achieve that. The typical recommendation is to eat 500 calories under your maintenance each day – over a week, these leaves you with a caloric deficient of about 3500 calories. Traditionally, this is the amount that is touted as necessary to lose a pound of fat a week. You can also set your deficit by using a percentage of your maintenance - so, for example, you might decide to eat 20% less calories than your maintenance level each day. If you want more information on choosing the correct deficit, I would recommend reading this article. This one is also a good read on the topic. 

That’s one way to do it. Problem is, over time, as you eat a deficit your metabolism does slow a bit. Additionally, traditional dieting like this tends to lower the levels of a number of important hormones in your body (you can read more about this effect here). All bad things.

Enter the Cycle

One way around this is calorie cycling – eating less one day and more on another such that you still eat at the deficit you need to lose fat, but while sort of “tricking” your body into thinking that you’re not actually starving it – this helps keep it from hanging on to stubborn fat and generally making you feel like crap.

So how do you do this? There are a couple of ways. First, start looking at your calorie requirements over a week rather than just over a day. So, for example, say Person A needs 2500 calories a day. Over a week, that’s 2500 calories x 7 days = 17,500 calories/week. If you wanted to eat at a deficit of 3,500 calories, then that means you need 17,500 calories – 3,500 calories = 14,000 calories over the course of the week. You can then choose to divvy up those calories across the days as you see fit – you might want to eat more on days you work out and less on rest days, or save some calories for that meal out with some friends. You can wave your calories throughout the week to avoid the pitfalls of straight dieting however you choose. That said, I personally just like to use the old rule of thumb that says eat 10 times your bodyweight in calories on rest days and 12 times your bodyweight in calories on work out days to lose fat. I’ve had the most success with this method, and have so far lost about 20 pounds. You can work out the numbers, but when training 3x a week, this puts me at the perfect deficit.

Alternatively, you can go back to the calculator I gave you earlier and select one of the fat loss options. It will run the numbers for you and show you how much you can expect to lose per week (these are only estimates, of course) and how much you should eat per day on both work out and rest days.

An important note: as you lose weight, you will need to account for this. Recalculate your caloric requirements every 5-10 lb. Otherwise, your deficit will over time become your maintenance.

One More Important Tool

One final thing I will say here is that, for weight loss in particular, one tool that I’ve found particularly helpful is something called Intermittent Fasting (IF). This isn’t a diet – it’s more of a pattern of eating. The basic idea is that you set up an “eating window” – typically something like 4-9 hours – and then fast until your next eating window. It may have some health benefits in terms of reducing risks for various diseases and improving lipid profiles and speeding up fat loss, but more than anything it’s just darn convenient. A typical way to go about it is to eat from, for example, noon to 8 pm and then fast for 16 hours until noon the next day. It takes a little getting used to at first, but after a while some people report increased mental clarity and focus, as well as a feeling of well-being, during the morning part of the fast. I’ve found that to be true, as well.

But what about breakfast? Isn’t that the most important meal of the day? And don’t I need to eat every 2-3 hours to keep my metabolism speeding along? My body will consume itself!!!

Slow down. All are valid concerns, but have been addressed elsewhere. I recommend reading this for a great overview of IF and answers to many common questions. This is a good overview too. Another great read can be found here - it discusses some of the common myths surrounding fasting. Also here. This is a great overview and analysis of different ways to go about fasting. If you're going to do IF, I'd recommend taking a few minutes to read through those links. (Update 2/18/15: A comprehensive guide about how to "do" intermittent fasting can also be found here. In the interest of full disclosure, I'll note that the owner of the site contacted me about listing his link here, but it seems like a solid website that's definitely worth looking over if you are interested.)

One of the things I like about IF, especially while eating at a deficit, is simply that it allows me to “save” a lot of calories for later so that, when I do eat, I get to eat a couple of larger meals instead of eating like a bird throughout the day. Also, it’s a lot easier to get out of the door in the morning not having to worry about making and eating breakfast.

A brief note about weight lifting while using IF – there are several ways to go about this, most of which are addressed in the links above (which you should read if you are going to do this). I personally tend to usually only fast on rest days, since I tend to lift weights in the mornings (which means a whey protein shake beforehand and then a meal after working out) and am not a fan of stopping eating at 3 pm in the afternoon to keep my “eating window” intact. And it’s ok. Do what you can. If you work out in the evenings anyway, then this won’t be an issue.

Keeping Track

So you have the tools for fat loss. I’ll talk a bit about weight training here in a bit, but first let’s talk about tracking your progress.

The first thing I’ll say is that changing your body composition takes time. Weeks, months, even years. So don’t be discouraged if you don’t see changes right away. When you make a change, give it at least three weeks or so – preferably more – to see if something happens.

But how do you know if something is happening? By seeing if your metrics are changing. Personally, I use the scale, calipers, and the mirror. The scale is great for keeping track of weight changes, but doesn’t tell you if you are losing or gaining fat or muscle. That’s where calipers come in. Get a cheap pair of reliable calipers (I use the Accu-Measure Fitness 3000 Calipers - they are about six bucks and well-regarded), and learn how to use them (this website is great for both learning how to use them and calculating your body fat percentage). Note that the body fat percentage might not be spot on accurate, but it’s more important that you are consistent so that you can track changes. I’d recommend weighing and taking caliper measurements once a week under the same conditions – I do this Saturday mornings, after getting up and using the restroom and before eating or drinking anything. Once again, be patient. It takes time for your body to change.

Note for females: you might find that you retain water differently throughout your monthly cycle, so your weight may vary from week to week. Thus, it might be more helpful to compare weights/body fat measurements from week 1 of cycle 1 to week 1 of cycle 2, week 2 of cycle 1 to week 2 of cycle 2, and so on.
One More Word about Diet

Image courtesy of Home Fitness Life
So you know how important calories are, how to keep track of them, a bit about intermittent fasting, and how to keep track of changes in your body composition. I haven’t discussed much yet though about what to actually eat. I won’t say much about this except that I really just make sure my protein intake is on par (at least 1.5 g/kg body weight) and let the rest (carbs, fat, etc.) fall where they may while generally eating quality foods. Also, drink plenty of water – you want at least five clear/light yellow pees a day. That’s the easiest way of doing it, in my opinion. You can get a little more crazy with this if you want to – see this website for more information.

I will say that I typically still eat ice cream, albeit in smaller portions, fairly regularly. Remember, at the end of the day, your goal is to meet your calorie requirements for whatever you are trying to do. If you can squeeze in a cup or two of ice cream into your calorie log, so much the better. Like I said before, you don’t want to eat crap all of time, but life is too short to go too crazy with this stuff and you can change your body composition successfully while still enjoying yourself.

To Gain or to Lose?

If you aren’t sure where to go from here, figure out where you are at first. For guys, a healthy body fat percentage is about 10-15%. For gals, that can be more like 18-25%. If you are a guy who wants to gain muscle, but are at 19%, then you need to lose some weight first. This is for a variety of reasons, but for now I’ll just say that first, fat is not functional tissue. It does not make you stronger; it just slows you down. Second, the fatter you are, the more likely your body is to just gain more fat. The leaner you are, the more like your body is to gain muscle (see here for more). Conversely, the fatter you are, the easier it will be to lose fat. The leaner you are, the harder it is to lose fat (unfortunately). So, getting down to a leaner you will, on a lot of levels, be better for your overall progress. I would recommend getting down to at least 10% or so before starting to gain weight again. Hold your diet there at maintenance levels for about two weeks to allow your body to “settle.” When you decide to gain, try to only gain about one pound per week (will be some fat and some muscle) until you get up to around 15% body fat or so. Again, hold there for two weeks before starting to cut weight again. Repeat until satisfied.  

As far as eating for weight gain goes, just eat more. I would recommend calorie cycling still – use the calculator above to figure out what you need to eat on rest and work out days for weight gain. Keep track of your progress weekly, and don’t let things get out of hand.

A Brief Word on Weight Training

Weight training is an important component of any exercise program. Or, at the very least, it’s a very valuable addition. Obviously, be realistic and consult with your physician if you have any question about whether weights, or any exercise for that matter, is right for you.

I also want to make a note that weight training is for both men and women. Women sometimes fear that it will make them bulky, but short of using exogenous hormones, they just don’t have the hormone profile for this to be even remotely true. Guys, similarly, sometimes don’t want to get too big. Don’t worry – you won’t just wake up huge. These things take time. That said getting stronger has multiple benefits for life in general and can be just darn helpful.

I’m a big believer in safely performing basic compound exercises – squats, deadlifts, bench press, overhead press, rows, dips, and chins. Do those, increase your weight over time, and you will get stronger. If you are just starting out, I would recommend something like Starting Strength (can be found here; I like the Practical Programming version) or Stronglifts (can be found here). After you’ve progressed as far as you can on those, check out Jim Wendler’s 5/3/1 (the basic program can be found in various places online, but you should buy and read the book Beyond 5/3/1: Simple Training for Extraordinary Results and pick your variation) or some of Paul Carter’s programs. I wish I had progressed like that when I first started.

(Edit: Since I wrote this, some excellent resources have been put out by Greg Nuckols - a very strong and very smart guy. Head on over to his website (a good place to start is here) and enter your email [don't worry - this guy is legit. The worst he'll do is send you some awesome information that you can unsubscribe from at any time] to get his free training programs. He'll send you an excel file with a bunch of programs that can be used at essentially any level and that you can progress through as you get stronger. That is probably one of the best ways that anyone could get started on their strength-training journey.)

Note that I said that I’m a believer in SAFELY performing these exercises. Spend some time learning and refining your technique before adding much weight. These exercises are not inherently dangerous or bad for you – unless you are doing them wrong. Check out ExRx for pointers. Also, I really like these articles for technique:

Squat: read this.
Deadlift: read this and this.
Bench Press: READ THIS – Part 1, Part 2, this, and this.

Check out ExRx for form instructions for the other exercises.

A Brief Word on Cardio

“Cardio” is what people typically first think of when they think of trying to lose weight. By now you should know that that is not necessarily the case – calories are most important. That said, you can use cardio to help create your deficit, and it’s also useful for increasing your overall work capacity. It’s useless to be strong but unable to walk down the block without doubling over or finish a fight. I try to lift three times a week, and fit in at least two cardio sessions. What you do isn’t really that important. Swim, ride a bike, do bag work, sprint, go for a walk. Just be active and do something you enjoy. Set a goal and achieve it. I used to be a lifeguard, and at least once a week we had to swim a 500 (20 laps in a 25 meter pool). I used to be able to knock that out without a second thought – now I can barely get 10 continuous laps. So that’s my goal. I try and hit the pool twice a week, and am working towards getting better every time.


So that’s that. Medical school is busy, but it’s entirely possible to set up a routine that has you lifting two to three times a week and doing some form of cardio at least twice a week. Controlling your food intake is made much easier by using the tools that I discussed above, and after a while won’t take much thought at all. Getting started is the hardest part, but once you’ve overcome that initial inertia, it will begin to work in your favor. Good luck.

Tuesday, July 15, 2014

Anki Q&A: Part 2

Since my last Anki Q&A post, I’ve received several more questions on how I’ve been using Anki and how to integrate the program into the workflow of medical school. For those of you who are interested, I’ve put together some of the questions (slightly edited for brevity’s sake) and my replies below.

Q: So prior to class, you upload the PowerPoint slides into OneNote, annotate them during the lecture, and review things afterwards, correct? Are you taking extensive notes during class or just focusing on the big picture and highlighting things the instructors stress? Do you also create review notes in OneNote as well? Or do you use Anki exclusively as your studying and reviewing tool? How do you know what to put into Anki? Do you use First Aid?

A: Some of the details of how I studied for each class varied, but the general process was something like upload PPT slides to OneNote the night before, go to class in the morning, take notes (I usually took pretty extensive notes in class, but since I’m typing notes this really isn't too bad. In undergrad, I took handwritten notes, but that wouldn't work for me now. Some people do it, though…), and go home/wherever I'm going to study. By this point, I've usually finished or at least started reviewing my old cards. If I haven't, then I do that now. Once that's done, I'll start making new cards – this is where I would go back over my notes for the lecture (not necessarily watching it again, but you could) and try to integrate things. I know of at least one person who makes Anki cards while sitting in class. I personally couldn't do that, just because I feel like sometimes the professor will say something or show a slide that makes something he or she said 20 slides ago make much more sense.

Anyway, this is the time where I really integrate the details. I usually walk out of lecture with a decent idea of the big picture, but how all of the details come together is often still a bit fuzzy. While I'm going over the details of my notes and making sure I understand things, I’m also bringing in other resources as needed (e.g. BRS for physio or your text of choice).

How I make cards has changed a bit over the past year. I used to make a lot of basic, front/back flashcards. Which are fine, depending on the subject. I started using a lot of image occlusion for anatomy, which is where Anki really shines. For more process-oriented subjects like physiology, I started using more cloze deletions at first, and then started basically creating mega cards in OneNote (e.g. compiling all of the information I need to know or found interesting about, say, sodium handling in the nephron - usually in the form of words and a few pictures - on one screen-sized page, screen-capturing it (using OneNote's super-helpful screen capture tool), and then using image occlusion over that.

Now, technically speaking, that's a really bad card. Personally, though, I found it helpful in terms of keeping enough details in one place such that it was reviewable three months later when the details might start getting a little fuzzy. I have an image-occluded answer that I have to answer, but then I also have context surrounding it that brings that answer to life if I forget why it's right. Again, your mileage may vary. That's something I found helpful, but different things are obviously going to be more helpful for different people, as you mentioned.

As far as what I try to include, I just put in there anything the professor stresses, anything that's in First Aid or a USMLE-oriented review source like BRS Physio, anything I need to understand the concept, or just anything that I find interesting. Again, one advantage of the mega card is that I can have more information on one screen than I actually need to memorize (that is, I don't need to cover over a word in every sentence or over every item in every figure - just over some of the key points. Then, if I need to remind myself of why those key points are important later on, I can just read the context for a quick review).

I hope that made sense. I know the mega card concept might be a bit confusing, so I've included some pictures below. Basically, for a card about renal sodium handling, I might write up a few short paragraphs about the process, throw in a couple of pictures that proved helpful, and screen-capture the whole thing, using the image occlusion tool to then block out of a few key words or image labels (basically using it as a cloze tool for the paragraphs).

The first year is over now, and looking back I'm super glad I used Anki. It made it much easier to review for tests (since I'd already seen the info several times using Anki, I usually would just do a quick review of my notes in the couple of days before a test), and score-wise on tests things went great. So it seemed to work. Now the test will be to see how it helps me retain things long term, and it will be interesting to see what, if any, tweaks to the process I make next year.

Q: I have a question for you about when you said you "looked back at your notes". I ask because some people first do a megareview sheet that compiles class notes, FA material and review books (ie BRS Physio, Lippincott's Biochem etc) before transferring some/most of that info into Anki cards. Did you use Anki as your primary review source like that youtube video in your blog of that student who annotated his notes in OneNote and then made Anki cards as he went along or did you have a separate review sheet? 

A: I didn't really make a separate review sheet per se. What I did do was sit down with my OneNote notes and review books after lecture and, within the OneNote program, create a “megacard” that covered part of the lecture. I might make 3-8 megacards per lecture, depending on what we covered. I would then screen-capture the megacard and use image occlusion to make cards out of it (note: in the videos I posted, you might remember there were two ways to use image occlusion - in one way, depending on the button you pressed to create the cards, if you had occluded, say, 15 words in a megacard, all of them are whited out except for the one you are reviewing. If you use the other way, then you can see all of the other answers while reviewing the one card you are actually on. It's not super important right now, except to say as a side note that I've found it more helpful to use the latter option - it's not very helpful three months down the road when you are reading over the entirety of a megacard to grease the wheels a bit and half of it is whited out. Sure, it might make the first review a little easier, since all of the answers are right there, but some would argue that you really don't need that review anyway....).

Within OneNote, I would just make a note to myself within that lecture of which pages the megacards were on, just so that when I came back around right before the test I wouldn’t have to flip through all 40 pages within a lecture - just the few that I had created the megacards on. Other than that, I never really used them. They're there, though, I suppose, in case I ever needed to reference them. But again, my primary purpose in making them was to create something I could make a card out of rather than make a review sheet. I never really was big into making review sheets, personally, except for things like some of the metabolic pathways. So all that to say that, yes, I did review my notes at least once before tests, but really Anki was my primary study source.

Note: To help explain the “megacard” concept, I’ve included some pictures below.

Q: How do you know what is important and what is not? That is like the million dollar question but I believe you had said that after your exams you turn off some of the review cards because it was stuff that your Prof has said that were exclusive to the class/exam. Is it just by asking upperclassmen? 

A: That is indeed the million dollar question. I personally chose to border on the side of making too many cards. Of course, that meant that there were seasons where I was reviewing 500 or so old cards per day (usually took about 1-2 hours, depending on the material). That's a good way to burn out, but again, it's also my primary method of studying, so there's that. I've said before that 20-50 cards per lecture is a good target, and that's true, but there are just some lectures that require 150 cards. Of course, part of that is just me learning how to make good cards and separating the wheat from the chaff, and part of that is the fact that some lecturers try to cram a huge amount of information into an hour long lecture.

In the beginning, you really won't know exactly what's important. You'll learn quickly, though, based on how your teachers test and what they emphasize. As a baseline, I'd recommend getting the bulk of what's in First Aid for whatever topic you're studying. You can also include information from a relevant review book that's directed at Step 1 prep, since FA can be sparse at times with respect to M1 material (which is also somewhat of a hint about what's important...that said, it is important to have a good foundation, especially when it comes to a course like physiology).

So I guess in order of importance I would definitely try to get information from FA (if any), then get most of the stuff on the topic from a review book (if you can get access to a digital copy, that works great for incorporating them into megacards), then include any major stuff that your professors emphasize that's not in those resources. That's a decent baseline. After that, you can debate with yourself about including stuff that is extraneous or perhaps that you just find interesting. As a side note, again, the cool thing about megacards is that you can include all of that stuff (the baseline stuff + the interesting stuff/extra explanations/etc. that really don't merit their own card) on one megacard, but just make actual cards out of the important stuff. The extra stuff, then, is just there to review at your leisure.

Q: I kind of get what you meant about the OneNote megacards – could you possibly print screen a few of your cards to clarify? Also, I am new to OneNote but am impressed by the interface and like it much better than EverNote. However, my problem is this: let’s say that your class notes are in one tab and your personal notes are in another tab or section, can one open your class notes in a new window and have them next to your personal review sheet in terms of referencing and creating these Megacards? I hope that makes sense. Also, are you using Office 365? I ask because I am wondering how one can backup their OneNote data and/or be able to access it from a remote computer if needed. By the way, do you have Windows 8? If so, how do you like it compared to Windows 7?

A: Pictures definitely help. I attached a couple of pictures from my review today as an example. In the "Card Front" picture, I just took a screen shot of Anki - you can see that there is a megacard on hormonal changes during pregnancy, in this example. For this card, I used image occlusion to block out a word on the top right - that's the red box. When I answer the question, the box disappears and the correct answer is revealed. I probably have 10-15 cards or so within this one megacard, so not only do I see all of the information repeatedly (though I don't necessarily take the time to read through everything that's not related to the question at hand), but the individual "cards" are located within the context of the overall subject. In this case, for example, if I forget what some of the other hormones are doing, I can just read the megacard to find out. 
Card Front
Card Back
On a side note, for this card I basically just screen-captured some text from BRS Physio. It's a review book, so it doesn't necessarily have all of the detail necessary for class, but I found it helpful for capturing the big picture. So in this case, I might make a similar card using class notes with more detail, but also make this one as a general overview, making sure that the cards complement each other rather than just making a bunch of duplicates.

For OneNote: I make a new notebook for each class. Within each notebook, I make a new tab for each lecture. Within each lecture, on the sidebar, I'll have a spot for the handout and the lecture PPT. You can see this in the attached picture "OneNote Image 1." 
OneNote Image 1
During lecture, I'll follow along with the PPT and take notes next to the individual PowerPoint slides. You can see an example of this in "OneNote Image 2."
OneNote Image 2
After lecture, I'll start reviewing the lecture and make Anki cards. Part of this is creating the megacards, if the lecture/class/topic calls for it. You can see in the first OneNote image how, under the handout of the Complement lecture, I've written "Review" in some of the page titles. Those are the pages where I've created megacards. If I were to click on that page, it would bring up the handout page, but if I scroll to the right, I would see what you can see in "OneNote Image 3" - a megacard. I would screen capture this to use it in Anki, and then come back to it later just before the test to review it. 
OneNote Image 3
As far as backup goes, OneNote is tied in with OneDrive (formerly Skydrive), which is a cloud storage option with Microsoft. If you log into your OneDrive account online, you can theoretically remotely access your Notebooks. I honestly don't use this that much. But it's there. I also back up my notebooks to my computer in a separate file, and my entire computer is backed up using a program called Carbonite. So I'm not too worried about losing any data, but you never know.

I bought a computer before medical school, and it does run Windows 8. I really liked Windows 7, and wasn't too excited about switching, but I was surprised at how much I actually ended up liking it. It takes a little getting used to. I spent some time watching videos online about how to use it and navigate the system efficiently, since it's really not as intuitive as Microsoft likes to think it is. I probably wouldn't like it as much if my computer wasn't a touchscreen, although it really shouldn't make much of a difference.

Q: I'll keep this short; I'm a busy student myself! Here's a link to a paper. If you have time, there is some interesting information there. One part that stood out to me was the superiority of free-recall vs. Cloze deletions in strengthening of memory in one of the papers cited.

A: Great article – thanks for sending that along. I will just briefly say two things about this: first, in the paper in question (Glover, 1989), free recall techniques were in fact shown to be more effective than cloze deletions (“cued recall” in the paper). That said, cloze deletion was still shown to be a superior method of learning for the purpose of retaining information. Second, there are always “better” ways of doing things, but in life – and particularly in a busy environment like med school – sometimes being efficient means striking a balance between “best” and “good” ways of doing things in order to maximize the time you have available. In an ideal world, sure, free recall is probably best for most things, but I’ve found that, practically speaking, cloze deletions get the job done and allow me to do well on tests while retaining information and still spend time with my family at night. At the end of the day, that’s a win in my book. Other students might find other methods to be more suited to their preferences and goals. That said, this is a pretty awesome paper in that it really goes into detail about the “why” behind the theory of spaced learning.