the lazy man’s study method
“I don’t think you’re going to pass the board exam”
That’s not exactly what was said, but that’s essentially what the program director told me. I thought residency was a place to learn. Apparently not. Despite my best efforts, I didn’t get into his residency.
This was probably for the best since I am now board certified in internal medicine. I passed those tests and have passed board exams for echocardiography and nuclear cardiology. Not easy feats when I was also working more than a full time job.
I’m definitely not the smartest person, but what I will say is that I focus more on creating systems to help me learn.
How did I go from residency reject to passing these tough exams the program director didn’t think I’d pass? Lots of reading, flashcards, and developing a habit of learning.
I didn’t really know how to study in college or medical school. To be honest, I should have studied more and spent less time in the gym. But I couldn’t afford to skip the gym as it was my only source of stress relief. I needed something to break up the monotony of sitting in lectures and study sessions.
I had a hard time studying in medical school not only because of the time constraints, but because there is so much information. There is a lot of truth in the adage, “the deeper you go, the deeper it gets.” There were so many books even on the same topic that I kept bouncing from book to book without finishing any of them.
I would read as much as I could, do as many questions as I could, and hope that something stuck when it came time to take the tests. My hope strategy helped me scrape by. It wasn’t until residency and I needed to balance really long work hours with studying for the board exams that I stumbled on my strategy for success. This strategy helped me passed my board exams for the American Board of Internal Medicine, the National Board of Echocardiography, and the Certification Board of Nuclear Cardiology even though I was dealing with residency work hours, getting a Master’s, and fellowship.
While it is possible, pulling caffeine fueled all-nighter wasn’t the best option to learn vast amounts of information. These exams cost thousands of dollars so they’re expensive exams to have to retake.
My dream was to not have to panic for exams. To be able to go to bed early the night before these exams knowing that I had studied as much as I should have for the test, and to, of course, pass the exams.
I really set the bar high, didn’t I?
Active Recall
My strategy for success was based on something most medical students learn quickly, something that took me way too long to learn. Doing practice questions is the easiest way to learn material. Medical students seem to do better when they spend more time practicing board questions than reading textbooks.
Reading texts books doesn’t seem to work anymore when competition is cutthroat and 99.9% dependent on board scores - so why learn focus on anything else? Yes there are plenty of terrible of physicians that have great board scores. There are also plenty of great physicians with terrible board scores. But the former has a much easier time getting into the specialties they want.
Active recall pushed me towards flashcards, something I hadn’t used since college. Flashcards are great because they force you to recall and engage actively with information, as opposed to passively reading books or watching videos.
Flashcards were really helpful to me as they helped me take advantage of small gaps in my day during residency. I could easily study with small chunks of dead time in my day: whenever patients were late to clinic, preceptors kept me waiting, or I was bored in lectures.
As annoyingly obvious as it sounds, the process worked. I was able to make and review flashcards on a regular basis and pass my tests even with a very busy schedule.
Spaced Repetition
We improve our memory with repetition, which ingrains certain pathways in our brain to recall random facts. This was first studied in 1885. Learning facts over a longer period of time beats trying to memorize them during an all-nighter; helpful when practicing medicine since you never know when you’ll need to recall a random fact about how the kidneys handle sodium.
When I was in college, I would cycle through my flashcards on different amino acids everyday. Thankfully the list is limited. In residency I ran into a problem of having too many flashcards. Now I have 20,015 flashcards. Studying each of these everyday is impossible.
Spacing out flashcards helps manage all 20,000 flashcards that I have.
A German scientist, Sebastian Leitner, popularized a method of spacing flashcards in 1972 by placing cards in a series of boxes depending on how well-known a card is. This allowed Leitner to focus more on material he didn’t know and less on material that was mastered.
Integrating a system like this formed the cornerstone of my studies as it allowed me to worry less about the material I knew well and focus more on the weaknesses that will pop up on test day.
Computer programmers have taken the concept of spaced repetition and fulling integrated it into different learning applications. It’s relatively easy to code a computer system to track the ideal time to review information based on how easy or hard it was the last time you reviewed it. This allows you to review information at the optimal time for you to review it, minimizing time reviewing information you already know.
Automating flashcards
Anki is a flashcard application that is very popular with medical students. I found it in residency and it was integral in my success at clicking buttons to pass exams. The program makes everything about flashcards easier.
I wish I had known about it when I was a student. If I had, I think I would have done a lot better. Instead of making flashcards on a 3x5 notecard and lugging them around in a ziplock bag, Anki is a free app you can put on your phone (iphone version costs $25), online, or computer and always have your study materials with you.
Anki forces you to remember what you learn through the two main concepts we talked about before, active recall and spaced repetition.
While there are other apps and websites that can be used for the same purpose (Quizlet and Memrise, I tried both), Anki beats the competition with better versatility over different dimensions like: use of audio and video, add ons, open source, and customization controls.
In Anki, you can either download pre-made decks or make your own flashcards to study. I started making my own decks based on what I was studying for internal medicine. And I may have gone a bit overboard.
I now have a total of 20,015 flashcards covering languages, medicine, geography and more. Through active recall and spaced repetition, I study on average 236 cards everyday. doing this every day is a grind, but it’s better than cramming at the last minute and it decreases my social media time.
Benefits of Anki:
flashcards go everywhere my phone and computer goes
integrate pictures, gifs, and audio into my studying (very helpful for languages and echocardiography)
only practice information that I’m about to forget
waste less time figuring out what to study and when
can fit bits of studying into small amounts of time the same way that social media fits into small pieces of time- very helpful during residency
great place to store notes and not worry when I will review the information, because the application will decide.
There are lots of add ons to make the program easier and more useful.
While I love the process of Anki and continuously persuade my co-workers to use it, I’m not against regular flashcards. If you’re old fashioned, you can use the same principles with physical note cards by dividing your cards into 4 piles as you review your flashcards: review now, review again today, review tomorrow, review the day after tomorrow.
The same concept applies - don’t spend too much time reviewing information you already know. Instead, spend your valuable time reviewing information you struggle with.
As another big test is coming up in October, I plan to keep using Anki for flashcards. I’m fortunate to have used the program, almost everyday, for the past 3 years. I brushed up on geography, the NATO phonetic alphabet, my multiplication tables (since I’m still bad at arithmetic), internal medicine, and cardiology.
Learning is essentially about the number of times you encounter information. Just like in weightlifting, it’s all about the reps. Anki makes this process as painless as possible.
““If knowledge is power, then learning is your superpower” ”