Spring and summer of 2013 were eventful seasons in my life. Branislav Ivanovic scored one of the most iconic Chelsea headers in recent years and the NBA season came to an exhilarating end, with the Toronto Raptors breaking a 7 year streak of no postseason basketball. But most importantly, I found myself transitioning into the second year of medical school — the infamous ‘darkest year,’ as many have put it.

I did well in first year. I stuck to what kept me afloat as a physiology student in undergrad but still found myself at a fork in the road with room to improve. I held a strong desire to become a better learner and to be more efficient with my time. Taking stock, I identified three key elements of my workflow that I could invest more time into: reinforcing the material, applying my knowledge, and taking better care of myself. It was clear that I needed to make these improvements as I moved forward.

Reddit.com’s medical school forum was smaller back then, but it was still an active hub where students exchanged study habits, resources, and advice. One suggestion that struck a chord with me was digital flashcards, namely via Anki, a free, open-source, cross-platform, spaced repetition flashcard program. With digital flashcards, I saw the potential boost they could bring to my efficiency and was further attracted to their flexibility. Not only could they function as a substitute for classical note taking, a mechanical study habit that I felt was slowing me down in first year, but they would also give me the means to easily access material and test my knowledge anywhere, anytime. Anki was a very niche interest in the medical school community at that time, and arguably still is, but nevertheless I felt inclined to give it a try. Except there was one problem: I had no idea what I was doing.

That was when I turned to educational literature and pedagogy, and what I learned had a profound impact on my approach to knowledge acquisition. A quick Google search first brought me to Gwern Branwen’s literature review of spaced repetition, a learning technique that leverages the spacing effect, and incorporates review of learned material over increasing intervals of time to maximize memory and understanding. I was then pointed towards Wozniak’s ‘Twenty rules of formulating knowledge’, which provided insight into how to structure material for review through spaced repetition. I quickly learned the benefits of spaced repetition and theorized how I could format these flashcards and subsequently fit them into my workflow. The plan was simple: take in the day’s lectures and then read over associated slides and textbook chapters while creating flashcards for everything I wanted to reinforce. At first I opted to write simple Cloze-deletion (i.e. fill-in-the-blank) flashcards, but that eventually changed.

An early Cloze deletion (fill-in-the-blank) flashcard made during introductory pathology.

As I continued to read textbooks, accumulate more flashcards, and review them through Anki’s spaced repetition algorithm, I saw significant improvements in my performance. My memory retention increased and I felt a concurrent strengthening of my conceptual knowledge. While the tangible improvements in my test scores were likely the most convincing, what surprised me the most was the time I gained away from studying — perhaps underlining the importance of formulating a scheduled workflow, sticking to it, and later optimizing it. The more effort and discipline I put in on the front-end seemed to yield more efficiency and free time on the back-end. Fewer of my weekends were dedicated to catching up from the week that had just passed, meaning I had more time to maintain hobbies, read, or workout as flashcard review streamlined my studying. In the lead up to exam period, that extra time could be diverted towards refining weaknesses, completing practice questions, or training for the challenges of standardized testing as a whole.

About a third of the way through second year I had fully adopted this new workflow forged through evidence-based strategies, and I had no intention of looking back. The next step was clear to me: I had to optimize my approach, which was when I returned to educational literature. This was when I began exploring the testing effect and active recall — two learning and memory techniques who together state that long-term memory is increased through the active retrieval of knowledge guided by testing or questioning with feedback. It was evident how flashcards stood as a convenient method of applying the above two strategies. In addition to Anki’s spaced repetition algorithm and the workflow I had already established for myself, I saw an opportunity where I could combine the three of these evidence-based strategies altogether into my studying through flashcards.

Taking things further, my reading introduced me to suggestions in the literature that not only supported my new approach, but also guided how I could improve the format of my flashcards. For example, simple, active recall can yield stronger learning than more elaborate studying, and is effective in complex conceptual knowledge. In terms of formatting, short answer questions are thought to be superior as more challenging retrieval yields greater benefits for long-term retention. These type of findings saw me transition towards writing short-answer-type questions, and to alter fill-in-the-blank-type flashcards to have enough context and memory cues to keep retrieval guided but remain challenging. As the year progressed, I refined my flashcard writing through trial and error while continuing to draw guidance from educational literature.

A simple short answer question made during the gastrointestinal block. Question stems got more elaborate through inclusion of memory cues and multiple facts as my card-writing ability improved.

Coming into the end of second year, I confidently looked forward with clarity. Spaced repetition and flashcards could continue to be a powerful element of my workflow to supplement and reinforce my learning. However what I had absolutely no clue about was everything that unfolded from here.