I've done 35,000+ Anki card reviews over the years, and I strongly suspect that most of the obvious and encouraged ways of using Anki are counterproductive. (Full disclosure: The following thoughts are heavily influenced by using Anki for language learning, and may not fully generalize to subjects like medicine.)

- Use Anki as an "exposure amplifier", not a database of raw facts to memorize. Think "tampering with the relative frequency of input to your brain", not "I will memorize every fact."

- Automate card creation as a much as possible. This will almost always require custom tooling. Card creation is part of the learning process, but you still want to automate everything you can possibly automate. Imagine tools to turn ebook highlights into cards, or to turn entire movies worth of subtitles into listening cards.

- Delete cards ruthlessly. If a card makes you say "Ugh", just delete it. If you're automating as much of card creation as possible, and if you're treating Anki as an "exposure amplifier", then deleting cards is cheap. And a significant amount of review pain comes from a small minority of the cards. Cull them, and reviews start to feel like popping bubblewrap, and not like getting a root canal.

- Prioritize large context and small active recall. For language learning, you might capture several sentences of context from a book or web page you're reading. Read or ignore the context depending on your mood. The active recall portion of a card significantly boosts how much you retain. But oddly, it seems OK to make the active recall portion really small. Try hiding half a word, or a single preposition in a phrase. For passive cards, just boldface an interesting expression in context, and mark the card as passed if you mostly understand it in that context.

- Introduce new cards slowly. Total review burden will stabilize around 5-6 times the number of new cards you learn a day. So 10 cards is a good default, and 20 is a significant commitment.

- The critical window seems to happen around 20-30 days after you introduce a card. This is when either your memory magically "consolidates" somehow (and formerly challenging cards suddenly become blindly obvious), or when a card enters repeated failure territory (and should thus be deleted ruthlessly). You could probably do just fine if you auto-suspended any card that you successfully recalled after a 20- or 30-day gap.

Also, this kind of tooling is the sort of thing you could just vibe code these days. If you do, make the "Delete" button really big.

Creating flashcards is also such a chore!

For the recall part of education, the book's exercise, or simply covering up the relevant part with hand and forcing a recall, writing about what you learned, teaching someone else - all work great, and the flow is much more natural.

Consolidation != memorization.

Memorising some examples is a prerequisite to deep understanding. Anki and pen+ paper reasoning are complementary.

It took me far too long to realise that writing on paper is better than typing.

Notes on pen and paper do help retention, but there are pros and cons. I know people who write on touchscreens or take photos of handwritten notes for portability to get the best of both.

One to one teaching and self teaching are much better than a good teacher in a class though.

Technology can be very useful - research, resources, ebooks, visualisations, interactivity etc.