Who and What is Brosencephalon?
In the thick of medical school I developed a tool for self-study, shared it with my peers online, and saw it unexpectedly spread worldwide. Years later, this resource has spread vastly to both students and educators in the middle of a new trend in medical education. Today I’m often asked about how all of this unfolded— this is that story and what it all means to me.
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.
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.
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.
By the end of second year I was already an active member of Reddit.com’s medical school community under the pseudonym ‘Brosencephalon.’ At that time, many students were sharing their own self-study tools — from videos, to PDFs, to concept maps and diagrams, and so on. But when it came to spaced repetition and flashcards, there was not much being shared in the community despite a growing interest.
With my vision shifting focus to Step 1 and the upcoming clinical years, I felt it would be prudent to seek feedback on the ~16,000 pre-clinical flashcard collection I had put together. While already effective for myself and some close friends during the basic sciences, I wanted to solicit opinions on how I could improve this further, on whether or not this would be an approach worth continuing during my clinical years, and quite simply, if anyone else would find this useful.
Given the small niche of Anki, I shared this resource with my peers having the expectation that only a handful of people would check it out and share their thoughts. However the community’s response surpassed all of my expectations. I saw my flashcards quickly gain the attention of the whole subreddit community. Soon enough, the ‘Brosencephalon flashcards’ became it’s own name and spread to other medical student forums such as The Student Doctor Network. In the time that followed, students around the world were chiming in with comments and messages expressing everything from gratitude, to curiosity, to frustration. Seeing this resource in the toolkit of students from every corner of the world still amazes me today.
While all of this was unexpected and even overwhelming at times, what surprised me most was how the medical school community engaged with my resource — shining light onto a growing trend in modern medical education. As the ‘Brosencephalon flashcards’ continued to spread, the open-source nature of the resource saw it become a community project. Members of the /r/MedicalSchool community on Reddit.com began collectively curating and improving my work, even going so far as to releasing updated iterations. As word kept spreading more students joined the project, and today there are many students creating, collaborating, and sharing flashcard resources of their own with their peers online. The momentum has now grown to the point of generating a dedicated community on Reddit catered towards the use, improvement, and curation of Anki and spaced repetition resources in medical school. The emergence of various third-party medical education platforms have also begun to leverage the trend of peer-to-peer collaboration, as they implement functionality and tools catered to this movement.
Since that life-changing Reddit post, I feel extremely fortunate to have had such a profound impact on the learning of so many of my peers around the world. The reception my work has gained let me realize a passion I never knew I had, and there have been messages from a few of you that have brought me a sense of fulfillment like no other. From being part of why some of you have effectively restructured your approaches to learning to simply being able to offer you another tool, this endeavour has taught me the impact that optimized medical education can have on a learner’s experience and success. And in a setting that is permeated with mental health issues stemming from the rigors of our training, this optimization stands as a possible avenue through which these strains can be mitigated. I also realized the potential of peer-to-peer collaboration between medical students — where collective content creation and curation can both provide effective learning for an individual and generate a powerful and accessible resource for many others.
This endeavour has also allowed me to bloom into someone holding clear purpose. A purpose that now guides my vision towards the future and involves this endeavour continuing to grow. I want to continue to create accessible and useful content while engaging in discourse that can help modern medical students and contribute to improvements in medical education.
The first step was eliminating barriers and centralizing my work, something I achieved recently by building my website Brosencephalon.com.
The second was to start writing, beginning with this story and ‘The Brosencephalon Edition’ — a Medium publication where I will centralize my thoughts.
The next steps? I have ideas I want to share on how we can optimize spaced repetition application and potentially bring it into the toolkit of even more students, how we can build and improve platforms that support collaborative learning and content creation, and simply how we can improve medical education together.
Because better medical education must certainly lead to better patient care and medicine.
And better medicine could lead to — well, that goes without saying.
— Amreet Sidhu, aka @Brosencephalon
