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.


  1. Hi, I found your blog and have a question or two for you! I will be starting med school this fall and throughout undergrad I found the best study method for me was to take a professor's notes and place blanks (like this ______) throughout the notes. By removing key terms, I was able to study the material and when I reached the point that I could talk myself through the notes and fill in all the blanks, I was ready for the exam. It kind of seems like your mega cards. Do you think Anki (or any other app/website) would work for this type of study? Removing the blanks and typing in dashes took a lot of time in undergrad and I also think medical school will be more power points that I may want to do this to. The only issue I see with Anki is having to screen shot everything but that may still be faster than deleting and typing blanks.

    Thanks in advance for any help. I enjoy your blog!

    1. Congrats on starting medical school!

      I think that rehashing your way through material in your own words (e.g. pretending to teach yourself, or the wall, or your dog, etc.) is a great way to study and cement the material in your mind. My personal feeling is it makes it easier to access the material down the road if you have a personal "concept" of whatever you are trying to recall, rather than trying to simply remember words in a textbook or lecture notes that somebody else wrote. If that makes any sense.

      In any case, if you wanted to use Anki in your studies but still continue with that method, I would recommend looking into cloze deletion. In the interest of time, you can just copy sentences or short paragraphs into the program from your notes, highlight the words or phrases you want to "blank out" using the cloze feature, and Anki will create a card out of it.

      For example - say I had something in my notes like, "Type 1 Diabetes Mellitis is a disease of insulin deficiency, while T2DM is initially a disease of end-organ insulin resistance."

      Using the cloze feature, I could make one or two cards out of that sentence by selecting the phrases I wanted the program to hide. It would then look something like this as a card:

      "Type 1 Diabetes Mellitis is a disease of [...], while T2DM is initially a disease of [...]."

      Once I hit the button to show the answer, the phrases would fill in so that I can confirm that I answered it accordingly and then select how easy the answer was.

      This way, you can still continue your method of studying with the added effect of spaced repetition.

      Here's a short video I found that goes over the process of making cloze deletion cards in Anki: https://www.youtube.com/watch?v=FnrigOzpJQo

      Let me know if you have any other questions. Good luck!

  2. Thanks so much for your fast response!! I think I'm going to like the cloze deletion a lot. I just realized that I didn't mention, but I'll be at Loyola this fall. So I have an extra appreciation for your insight, since I'll be going through the similar curriculum!

    1. Awesome! I think you'll enjoy it. I've had a great time here.


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