Is There Utility for Implementing Digital Flash Card Applications in Pathology Undergraduate and Graduate Medical Education?

To the Editor.—We have read with great interest “Medical Education in Pathology: General Concepts and Strategies for Implementation” by Koch et al.¹  Although we congratulate the authors on their original research regarding evidence-based strategies to decrease cognitive load in pathology undergraduate medical education (UME) and graduate medical education (GME) curricula,¹  we wish to highlight 1 strategy not previously discussed: spaced repetition with digital flash card applications. In particular, we would like to highlight several currently popular digital flash card applications used by medical trainees, such as Anki (AnkiWeb),²  Quizlet (Quizlet Inc),³  and Brainscape (Bold Learning Solutions Inc).⁴ 

According to an article by Marinelli et al⁵  in 2022, spaced repetition “entails the repeated exposure to learned material over successive iterations” to make new or difficult concepts easy over time. This process challenges people to test themselves more frequently on their weaker content areas until eventually those knowledge gaps minimize.⁵  In other words, spaced repetition embraces the saying “practice makes perfect.”⁵  This technique for efficient memorization uses fixed, algorithmic time schedules, which improve long-term retention, similarly to how brains naturally encode memories.^2,5 

Anki is available free of charge for computers ($25 for a phone version) and uses an intuitive organizational structure for learning that ranges from individually created to community-sourced flash card decks.²  It operates on the premise of a spaced repetition algorithm that can adjust accordingly to learners' perceived ease of recall for each flash card.²  In other words, “easy” flash cards are deferred for longer time intervals, whereas “hard” flash cards are more frequently reviewed until they become “easy.”² 

Quizlet is a free-access Web site and mobile application in which users can create and share digital flash cards too.³  It takes a more simplistic approach to learning that features a user-friendly interface and multiple learning styles, such as varied question types, goal setting, and options for “gamification” of studying (ie, it produces short quizzes based on created flash cards in any given deck).³  Although a paid subscription exists to enhance some of these features, Quizlet does not explicitly promote a spaced repetition algorithm but does promote active recall when used.³ 

Brainscape is a primarily paid subscription-based Web site and mobile application that uses a spaced repetition algorithm, similar to Anki.⁴  However, the emphasis is more on “mastery” of content that operates independently of user-determined time intervals for each card.⁴  Regardless of the application used (ie, Anki, Quizlet, and/or Brainscape), we hope to accentuate the utility of digital flash cards as a potential learning tool and mitigation strategy to decrease cognitive load and improve educational outcomes in pathology UME and GME.

According to Khan, use of spaced repetition via a digital flash card application may “prevent[s] natural forgetting” and, when used intentionally, helps users “commit information into long-term memory” and learn higher-level concepts more effectively.²  A study by Lu et al⁶  in 2021 supported this by demonstrating that medical students who reported more frequent use of Anki exhibited a greater perceived level of knowledge retention and statistically significant increases in US Medical Licensing Examination (USMLE) Step 1 scores. Although USMLE Step 1 and its osteopathic equivalent, Comprehensive Osteopathic Medical Licensing Examination Level 1, recently converted to a “pass/fail” scoring system, we feel there is evidence to support the integration of digital flash card applications into pathology medical education curricula given the subject's high subject volume, cognitive load, and correlative clinical relevance.

A 2020 article by Pumilia et al⁷  argued that “traditional” learning (ie, textbook reading) in medical school rarely ensures long-term content retention into residency. Furthermore, daily spaced repetition learning with digital flash cards has been shown to be more effective in promoting efficient (up to 1000% per card), longitudinal learning compared with conventional learning methods (eg, textbook).²  The efficaciousness of digital flash card applications thus may be able to address both time constraints and volume-of-information constraints that medical students and pathology residents often face throughout their training.⁸ 

Table 1 in the article by Koch et al¹  shows mitigation strategies that the authors suggest should be used to decrease the cognitive load of pathology education: “Summarize and limit take-home points,” “Break down big concepts into smaller ones,” “Draw connections to existing knowledge,” and “Minimize words on a slide.”¹  Limiting the number of salient points and drawing connections between pathologic principles affecting different tissues and/or organ systems are appropriate strategies that capable pathology educators are increasingly using, especially given the apparent reduced emphasis in biomedical sciences seen in recent years with medical curricular revisions.⁹ 

In this way, digital flash card applications may reinforce pedagogic methods currently being used to teach pathology curricula in UME settings.¹⁰  Each card is ideally a brief and focused review of 1 specific topic, essentially serving as a single snapshot of a big-picture concept.²  Furthermore, decks can be individually created or downloaded from the Web based on presentation slides, review books, study guides, etc.^2–4  In this regard, voluntarily creating supplemental decks to coincide with UME/GME pathology lectures, topics, or courses, such as for PathElective.com,¹¹  may be excellent ways for medical students interested in pathology and current pathology residents/faculty to demonstrate their commitment to enhancing education within the specialty.

There are potential drawbacks to using Anki and other digital flash card applications, however, that learners may face. A 2022 study conducted by Jape et al¹²  found that the most reported critiques of Anki specifically among study participants were the perceived “intimidating” learning curve of the application and the sheer number of cards to be learned and reviewed. Most students also reported using Anki less frequently than “traditional” learning methods, like course materials and note-taking.¹²  Cons of Quizlet and Brainscape include the difficulty in customizing study sessions (ie, tailoring cards to address learners' specific weak points) and inabilities to save (or “archive”) decks for future use, respectively.¹³  Overall, the initial time commitment to learning via these methods could be a limiting factor in their effectiveness, especially as learners navigate each application's respective interfaces, but providing students and residents with proper tutorials, premade cards, and time management strategies could potentially limit these drawbacks.

Although there is currently limited literature related to digital flash card application use among GME pathology programs, there are some studies that point to the potential impact of digital flash card use in improving residency training. For example, an educational study by Tsai et al¹⁴  used a premade spaced-repetition flash card system for a cohort of obstetrics and gynecology (ob-gyn) residents as a study aid for in-training examinations. One hundred percent of study participants who used the flash cards (n = 18 of 31 residents) reported them to be a helpful study resource and would recommend this method to other ob-gyn residents, although use of this method did not equate to statistically significant improvements in examination scores when compared to non–flash card users in the same study cohort.¹⁴  Furthermore, 72% of flash card users in this study (n = 13 of 18 residents) indicated they would continue to use this resource in the future, and most users mentioned the “convenience” and “accessibility of cards” as strengths that allowed for more effective incorporation of studying into their daily, busy activities.¹⁴ 

An article published by Koenig et al¹⁵  in 2022 promotes supportive reasons, methodology, and the initial approach taken at West Virginia University for incorporating comprehensive digital flash cards to promote enhanced spaced repetition for plastic surgery residents as well. Although there is currently limited literature that shows how pathology residents are using digital flash card applications to help supplement their studies, more research on this topic should be performed to help better understand the implementation of this learning strategy within pathology GME curricula.

Although the distinctive relationships and perceived advantages and disadvantages of digital flash card use among UME and GME curricula warrant further investigation, evidence from these and other studies supports the integration of digital flash card applications as a beneficial supplement to pathology medical education at both levels. To conclude, we agree with the strategies and comments made by Koch et al,¹  and we wish to highlight the use of digital flash card applications as another potential mitigation strategy to help decrease cognitive load within the field.