The inert knowledge problem

Anki Learning Effectively
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I like Anki, but sometimes I feel I’m not using it right, even though I’m following the “rules for formulating knowledge”. My goal is: to memorize fact X and bring it to my working memory whenever it is relevant. However, what I found was: If I memorize fact X it doesn’t mean I will recognize an opportunity to utilize the fact X when it is relevant.

For example, see this card:

{{c1::Amiodarone::Antiarrhythmic}} can cause hypo-hyper thyroidism.

According to popular rules, this card is atomic, precise, and perfect for Anki learning. I was answering it correctly. However, I faced a question asking me Which of the following tests should be performed before starting amiodarone?; thyroid function test was one of the options, but I didn’t recognize the opportunity to utilize this fact. I felt upset that I didn’t get the answer correctly even though I’m answering the card correctly and I know the piece of knowledge that is the key to answer.

Any advice to combat this issue? Am I doing something wrong?

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You’ve fallen into the classic ‘cloze-deletion trap’. A flashcard with a blank space that you can answer in your sleep (whether because you know the content or because you recognise the pattern …) does not result in knowledge that you can apply outside that context. Unfortunately, this happens very often and is the biggest drawback of cloze deletion.

What helps?

Flashcards that require you to actively recapitulate the content:

  • What is a common side effect of amiodarone? → Thyroid dysfunction (list amiodarone-induced hypothyroidism and amiodarone-induced thyrotoxicosis as additional information on the back of your flashcard)
  • What causes thyroid dysfunction when amiodarone is used? → high iodine content in amiodarone
  • What diagnostic tests are required before prescribing amiodarone? → ECG and TSH (extra content: why)
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I don’t like the phrase “can cause” used by medical professionals. Does it merely have the potential to cause it, or does it definitely cause it?
If it’s just a possibility, we could denote it as “A–>B,” but there could be plenty of such connections—say, “A–>C.” There ought to be a list ranked by the significance of the connections, with the less important ones at the end. The “important” ones are those that have the most negative impact on the patient. It is likely these significant potential connections that you need to verify through testing. I’m not a medical professional, but that is the logic I see at play here.
So, when would we actually register this? Presumably when a connection like “A → B” leads to the patient’s condition worsening, or to their death, and so on :slight_smile:
I dislike the phrase “can cause” used by medical professionals. Does it merely have the potential to cause something, or does it definitely cause it?
From the standpoint of memorizing facts: the mere possibility of a connection doesn’t necessarily mean you needed to test for it.
Let me explain: imagine traveling from point A to point B when there are multiple paths to that same destination. You tend to remember the route you take most often, not all of them. You could memorize every route, but to do so, you’d need to visualize point B and look back to see which paths are visible. Think of it like translation: there’s forward translation and reverse translation—two different things. It’s the same for you: you might memorize one connection (the road to B), but can you traverse it in the opposite direction? It’s like counting: 1, 2, 3, and so on. Yet, if I ask a primary school girl to count backward from 30 to 0, she might find it difficult or even refuse to do it. The brain memorizes things in a specific sequence, but that doesn’t mean it will easily recall them in reverse order or pluck a fact from the middle of a logical chain like “A–>B–>C–>D–>E.”
Anki is great because it can present cards randomly; however, I believe that for the initial memorization phase, it is beneficial to study facts sequentially, and only later test yourself on the reverse order or random selection.

In short: create separate cards for different connections—such as “A → B” versus “C → B.” Create a specific card if you have grouped a set of connections for B—for instance, “three critical, high-risk facts (connections) for B”—and a different card for another grouping, like “the three connections for B that appear most frequently in your practice.” Create a separate card if you need to navigate the reverse path—“B → … → A”—since this route isn’t necessarily the same as the forward path—“A → … → B.” You won’t necessarily recall every possible path between two points; you’ll remember a path if it is unique, if it is the only one, or if you have traversed it frequently. Conversely, you might struggle to recall—or completely forget—an alternative route. Consider this example: you placed a book on the table today, and you remember doing so. But what about yesterday? And can you recall every single item you placed on that table over the course of the entire year? The specific association between two objects (table and book) gets overwritten if you place something else in that spot. However, you can think about the table and visualize (recall) whatever is currently sitting on it; likewise, you can think about the book and remember reading it in bed, realizing it must be somewhere over there. This mechanism allows us to remember unique objects and their locations, but it also erases the memory of our past actions. To recall the past, we must reconstruct the sequence of events and thoughts, logically filling in the gaps where details were forgotten or went unnoticed—reasoning, for example: “I was reading there, so I must have left the book somewhere nearby; that’s where I should look for it.”

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I know nothing about this medical jargon, but the cloze tests you on the amiodarone thingy and shows the thyroid thingy, while the question is the opposite in some sense.

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Should try more practice questions, they will guide your card creation skills to figure out which cards you should be making, or ask AI to create high yield cards

i personally don’t like the Cloze cards like sentences, but i do use them as Q/A with hints

Which Antiarrhythmic can cause hypo-hyper thyroidism?
{{c1::Amiodarone}}

This example does not need hints, however you could do {{c1::Amiodarone::Class III}}

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Reversing the card could help, but sometimes reversing is not possible or inefficient. How do you formulate it? Amiodarone can cause ...... this question is so broad and allows multiple correct answers. Even if you put a hint in the clozed part you still have the problem that the real world will not give you hints.

Sorry about the jargon btw :slight_smile:

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Hi there,

There is nothing wrong with what you’re doing, and with medicine, this is an issue happens that is only remedied after years and years of experience to fully connect things together

This happens with me as well, for example, I remember doing cards about esophageal perforation for probably a year. The first question in UWorld I got on it, I got it completely wrong and so wrong in fact I didn’t even realize esophageal perf was the presentation

I will say one way to combat this is to utilize the extra sections of your cards to draw concepts together. For example, what is this card telling you in the greater scheme of things? It is telling you that amiodarone can cause hypo/hyperthyroidism → in the context of a patient you are taking care of, what would be your first step to see if this might be an issue? → order a TFT

Not sure if you use the AnKing deck, but reading the extra sections of the cards there helped me a lot to understand and connect the “okay but why is this important?”. You can apply to this thinking to a lot of the cards you make or study

This is also why Anki is never the only solution (at least in medicine), you have to pair it with something like a question bank to form these connections you didn’t think about before. But once you get something wrong once, make a card to connect this concept, so in your case, I would make a card that tests this association to solidify it.

Also, this comes with time. Now, any drug that can cause hypo/hyperthyroidism, you will have a small connection in your brain that reminds you “oh okay, I need to be wary that II need a TFT to assess this”

And same goes on with other concepts, drug causes kidney damage? I’ll order creatinine. Drug causes liver damage? I’ll order LFTs, so this atomic fact that amiodarone causes hypo/hyperthyroidism is perfect, all you need is the “bigger picture connection” which is especially important in medicine

TLDR: Don’t worry, you are not doing anything wrong!

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I didn’t say that it’s possible to reverse it, only that it’s not exactly the card’s fault that you got the question wrong.

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