At the beginning of first year, I was strongly opposed to Anki. Blasting through hundreds of flash cards daily seemed like a lazy, inefficient, and noncomprehensive way to study the content. In undergrad, the easiest way to study was to simply memorize all of the PowerPoint slides the night before the test. I thought that this method would be just as effective in medical school... By Hematology and Lymphatic Systems, the sheer volume of content already forgotten was overwhelming.

In 2019, it was hard enough to justify spending countless hours studying Anki cards knowing that class was "unranked" and pass/fail. However, the looming threat of a Step 1 score provided motivation to complete the daily reviews. With pass/fail M1, M2, and Step 1, it is even more difficult to justify this sacrifice. However, there are some important considerations that must weigh into the decision: • AOA status is still highly regarded by many residency programs, and is in part related to academic standing. • While likely less efficient than studying without Anki, the threat of building reviews for each Anki day skipped is motivation to study every day, improving retention. • Long term retention of knowledge is one of the greatest features of Anki. Daily reviews ensure continued retention of all past knowledge. • Shelf exams after each M3 clinical rotation build on the foundational knowledge learned during the first two years of medical school. Starting from scratch (or from a passing threshold of knowledge with no further review) would be very challenging. • Many report Steps 2 and 3 also build from the foundational knowledge gained when preparing for step 1. • On the wards, it is very common to get asked questions that probe understanding of either foundational concepts or commonly memorized lists necessary for step 1.

Anki is a somewhat crudely designed spaced repetition platform that allows for the learning and retention of information stored on special flashcards. Anki determines which cards should be reviewed each day based on the input from prior reviews. If a card reviewed is known, the time until that card is reviewed again increases. Conversely, if a card reviewed has been forgotten, than the card will be seen more frequently, allowing the user to relearn the card.

Anki cards store information that is worth remembering. Within Anki, this information is stored as a note. For instance, it might be important to know that “mitochondria are the powerhouse of the cell.” In Anki, a note can be created that contains this information: Mitochondria are the powerhouse of the cell. From the note, Anki creates one or more cards that contain cloze fields: {{c1: Mitochondria::Cell Type?}} are the {{c2: powerhouse of the cell.}} Which will create the following cards: [Cell Type?] are the powerhouse of the cell. And: Mitochondria are the [. . . ] of the cell. As stated earlier, these cards will be shown repetitively based on their interval, which is the number of days until the card is to be reviewed again. As the card is learned, the interval will increase. If the card is forgotten, the interval will either be reset, or the interval will decrease by some specified factor. The Anki library consists of suspended and unsuspended cards. Cards that are suspended are highlighted yellow within the browse function. These suspended cards are simply stored and will not appear for review unless they are unsuspended. Each day, Anki will add a specified number of new cards from the unsuspended pool to the pool to be reviewed. The user will provide feedback on whether each card needs to be seen again, or if the card was known and hard, good, or easy. This feedback allows Anki to appropriately modify the card’s interval. Each subsequent day, Anki will pull another chunk of new cards from the unsuspended library for review. Additionally, Anki will show all cards due for review based on each card’s interval and last review date. If a day of review is skipped, Anki adds the skipped day’s reviews onto the following day.

There are two schools of thought: make your own Anki cards or find a pre-made deck online. I am a proponent of the latter; however, you will need to do some research to determine the best premade deck for you. It might be tempting to make your own cards, especially after you discover ‘image occlusion;’ however, again, I strongly discourage this. After months of review, many find old image occluded cards to be tedious, and low-yield.

1. Download Anki from AnkiWeb . If you already have the program installed, make sure you have the newest version. 2. Download the following addons by going to tools -> add-ons -> get add-ons. a. Paste the following codes individually i. 24411424 ii. 594329229 iii. 395343016 iv. 1102281552 b. Go to the following link and click the downloaded file with Anki running: https://www.google.com/url?q=https://github.com/glutanimate/review-heatmap/releases/download/v1.0.0-beta.1/review-heatmap-v1.0.0-beta.1-anki21.ankiaddon&sa=D&source=apps-viewer-frontend&ust=1704164212056966&usg=AOvVaw3rX_XqhEgBvilAjj4CF99L&hl=en c. Set up the add-on ‘Customize Keyboard Shortcuts’ by clicking on the add-on and clicking [config]. i. Replace all of the text with the text in the following link: https://docs.google.com/document/d/1Cv6rtU3y0xnH2mG7IzD8XgKRHuB9ik6izPFKMHkXPQs/edit 3. Restart Anki 4. If you have a downloaded deck, make sure that all of the decks are under one ‘parent’ deck. a. At the bottom, click ‘Create Deck’ and name it something. Then click and drag all of the other decks under this parent deck. 5. Click the cogwheel to the right of the parent deck. Go to options: a. Daily Limits i. New cards per day: 150. Change it later to 100-115 as the work- load increases. ii. Max reviews per day: 9999. This is critical for Anki to work as designed. You will not see 9999 cards per day, but it will allow Anki to show you all of your cards due for review each day. b. New Cards i. Learning Steps: 20m 1d ii. Graduating Interval: 3 c. Lapses i. Leech Action: Suspend card. After missing a card 8 times, this card will be deemed a leech and be suspended. 6. Click SAVE at the top (or ctrl-enter).

After downloading an appropriate deck and configuring Anki, browse the library of new cards by selecting ‘Browse’ at the top, or by clicking B on the keyboard. All newly added cards are unsuspended by default. Select all of these cards (ctrl/cmd-A) and then suspend them by right clicking and selecting ‘toggle suspended,’ or use the shortcut ctrl-J/cmd-J. Finding relevant cards can be done either via searching individual decks, sifting through various sub-decks, or via the tag system on the left pane of the browse window. When searching, search for words (mitochondria), parts of words (mito), exclude words (-mitochondria), or filter by card state (-is:suspended). Every day, click the parent deck and begin reviewing. When reviewing, the space bar or enter will reveal the hidden cloze, and also select ‘good’ for when you know the card. Clicking 1 or ] will select ‘again.’ Clicking z or [ will undo the previous action. Left handed keys : space, z , and 1 . Right handed keys : enter , [ , and ] . This sounds very silly until you have clicked these keys hundreds of times per day for a few weeks.

Anki allows the user to sync their reviews to a database for free. This database can be shared with your mobile phone, allowing for on-the-go Anki reviewing. There are two caveats. First, the app costs $20 on Apple phones. Second, large decks take up a large amount of storage. Regardless, the use of a mobile Anki app in conjunction with the desktop version is strongly recommended.

1. Don’t unsuspend a massive load of cards at once. Limit to about one week’s worth of new cards. (150 * 7 ˜ 1000) 2. On a desktop or laptop, narrow the reviewing window so that there are 7-10 words per line. This allows for less fatigue when reviewing as the eyes generally don’t need to move side to side to read the cards. 3. Don’t be a hero. Don’t do more than 200 new cards per day. It adds up. 4. Don’t click anything but ‘good’ and ‘again’. Clicking hard or easy can mess up the interval system. 5. Don’t cheat. If you don’t know the card, click again. 6. Do all reviews every day always.