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Overcoming the Note-Taking Burden: How I Slept 8 Hours + Raised My USMLE Step 1 Score by 30+



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USMLE Step 1 Note-Taking Sleep 8 hrs

This is a question I get a lot from students preparing for the USMLE Step 1 re: efficient note-taking.  An abbreviated sample message is below:

Hello Alec,

I am extremely sorry to be bothering you again. But this thing has been troubling me a lot. Could you kindly tell me if you had taken UWorld notes? I’ve been writing down all UWorld stuff and it is taking forever. I feel like just reading through the explanations and saving time. Kindly help!. I am so sorry to be bothering you again.

Dear S.,
That is a fantastic question.  Yours is a very typical approach: taking extensive notes on everything you find in the USMLE World explanations when reading through, either by writing the notes in a separate notebook, or annotating it directly into First Aid.  I, like many other students, have encountered many of the same issues you have described.  These issues have real consequences: less efficient learning of material, diminished sleep, and worse retention of the most important topics.  Here, I detail exactly what I did to overcome many of those inefficiencies.
Too many notes → sleep ↓.  Too few notes → retention ↓.  What is the best way??

Too many notes → sleep ↓. Too few notes → retention ↓. What is the best way??

The Mistake: Extensive USMLE World Notes > Doing UWorld

There are several problems to this note-taking approach (you have already noted one):
  1. It takes a long time
  2. With the little time remaining, there is no time to go back and read the notes
  3. Even if there were time, as the notes grow, it becomes virtually impossible to FIND the notes

Let’s use an example to illustrate this third point.  Let’s say that I took notes on Addison’s disease, and annotated my First Aid copy as so many people do.  But, first, WHERE do I annotate my First Aid?  There are so many different places that a disease like Addison’s will be mentioned in First Aid, finding the most logical place becomes more difficult than you would imagine.  Even when I find a suitable space to write my notes, the same issue arises when I try to FIND my notes. Plenty of friends would complain constantly about how messy/disorganized First Aid became as they annotated it more and more, and that they were spending more time trying to FIND their notes than they were actually studying.  Sadly, they are not alone.

The Solution: Introduce Anki Into Your Studying

While it is tempting to see the amount of time spent taking extensive notes on USMLE World and give up on taking ANY notes, there is still valuable information that is worth the investment of time.  Whatever our solution, we want it to accomplish three goals.  We want it to be:

  1. Focused on the highest-yield information (i.e. what will help us best maximize our score)
  2. Easily and quickly referenced
  3. Retained in the least time possible

Turns out, there IS something that accomplishes all three goals: Anki. What is Anki?  I’ve written about this before (e.g. here, and here): basically Anki is a program that is based off of spaced repetition, and will show you questions that you make in such a way that you will remember things indefinitely, in as little time as possible. It really works, and is one of the main reasons I was able to score 270 on the USMLE Step 1. If you want examples of higher-level Anki cards that will help you to integrate and apply information, just like you will need to do on the USMLE Step 1, go to the Table of Contents, or see examples herehere, or here. Most medical students, if they don’t immediately jump for joy upon hearing about Anki, will say something like the following:

Anki sounds great, and I wish I’d heard about it months ago, but I don’t have time for it currently, and will use it for the USMLE Step 2CK, etc.

For ANY USMLE Step exam, you can’t afford NOT to use Anki.

While there is a bit of a learning curve involved, if you had even 3 weeks before your exam, I would recommend using it.  In fact, if you’re studying for ANY USMLE Step exam, you can’t afford NOT to use Anki.  To speed up the learning process, I wrote Basic Anki Card Creation: The Complete Guide for Med School and the USMLE Step Exams.

Turn Educational Objectives into Anki Cards

So how do I use Anki, and how does it accomplish the three goals we laid out previously?  First of all, most medical students assume that to use Anki effectively, you have to copy a bunch of facts into your cards BEFORE you even open a QBank.  This is patently false.

I would NOT just copy First Aid into Anki cards – you may already know a fair amount of First Aid, and more than that, memorizing straight facts for the USMLE Step 1 has never been an effective way to maximize our scoresIn the beginning, make it simple.  I had a friend who had a simple rule for Step 1 studying: he never wrote more than 1-2 lines of notes for any given USMLE World question.  While this saved him a ton of time, he complained that as his notebook grew, his nightly review of the facts became less and less regular. What if, instead of taking 1-2 lines of notes/question in a small notebook, you put those notes into Anki.  Then, instead of passively reading your notebook, you made 1-2 simple Anki cards, and made sure to review those cards every day.  You might make 30 cards a day, which would take you no more time than writing down the notes into a notebook, while reviewing those cards would take 30-60 minutes the first several days, then 1-2 hours every day thereafter. Even though this may be an overestimate of the time it takes (I typically budget 1 hr per 100 cards of review, with 1-2 minutes if it’s a new card I haven’t seen before), the benefit is that you will have indefinite recall of the notes you take with minimal time use, and can reference your notes quickly and efficiently.

Efficient Referencing → Sleep ↑, USMLE Step 1 Score ↑

Here is an example of the magic of using Anki to reference ANY note I have written.  Let’s say I forgot whether Addison’s was linked to hyperkalemia or hypokalemia.  If I had annotated that into First Aid, it would have taken me a good 2-10 minutes just to go to the index, find all the listings for “Addison’s” then go through all the pages just to find the page where I’d written my notes.  It wouldn’t be better if I’d taken my notes into a separate notebook – how long did my friend spend digging through his notes just trying to find a factoid.USMLE Step 1 Anki Medical School Reference

It took me less than 15 seconds to find this card, rather than several minutes. Over the course of a week, you do the math.

Even though I have >15,000 cards, it took me <15 seconds to find my card that links Addison’s disease w/ hyperkalemia (all I typed was “Addison” and “kalemia”).  I used to reference upwards of 10-20 cards every day, which saved me at least several minutes every time I did so.  Plus, along with the amount of time I gained by never forgetting my notes created a gigantic snowball as it rolled down the proverbial hill. The time saved with Anki adds up in a huge way, and increases the amount of time I can allocate for studying, sleeping, and having a life.

What to do next?

So to answer your question, remember to always ask, “Maybe activity X may increase my score, but what is the best way to maximize it?”  I hope I’ve given you some ideas that you can use!  Next, you should:

  1. Download Anki, if you haven’t already, and read the tutorial for making basic cards
  2. Start slow by making 1-2 cards per question you get wrong in a QBank
  3. Make sure to do your cards every day
  4. Check out the Step 1 Cheat Sheets, which are constantly updated
  5. Say hi on Facebook!
  6. Sign up for updates via e-mail to get your FREE Starter Deck (see below)
  7. Check out the Resources page to see what I used to efficiently boost my Step 1 score.
  • John


    Life, that would be candy land.

    • yousmle

      Absolutely – I couldn't agree more! There is no better feeling than going to bed (early!) after doing everything you set out to do that day. How has your sleep been lately?

  • tabatch89 .

    What if I’m taking too fast to review my cards? Is there something wrong with what I’m doing?

    • Yousmle

      The more important question is: how effective are the cards I’m making? If you find that when you learn something, and you get another question on that same topic and you can recall all the important information you put in your cards, then usually it means you’re making good cards.

      How many questions do you review over what time period?

      I use 100 old cards/hour as a rough estimate, but usually it’s a little bit faster for me – maybe 2-3 cards/minute. The bigger concern is if your cards are taking too long, since that usually means that you’re putting too much information on each card, which a) makes each card take longer to review, and b) increases the likelihood that you will get each question wrong, and thus have to repeat them, creating more reviews for yourself every day.

      • tabatch89 .

        Thank you so much, Alec! Another question, if I may? Using UWorld- do you only include the “educational objective” in your Anki cards? or do you include the explanations for the wrong answers as well? Sometimes I think “what a waste!” if I exclude the 80% content of the explanation… Sorry for the many questions?

        • Yousmle

          Of course! One of the biggest issues I had was making too many cards w/ too much information. To “limit” myself, and keep myself from going too crazy w/ cards, I would try and only include the information from the educational objectives.

          Remember – all of the information that you put into your cards you will have to review, which is time you are taking away from doing questions, etc. There is a balance that I tried to strike between those two activities, and if I put too much information (the 80% you refer to), I create so many cards it becomes VERY hard to actually DO questions.

  • Jy

    Hi Alec, I hope you’re doing great. Yesterday was my first day of using uworld, and i just wanted to get a feel of making anki cards from the questions and to see how best i could use Uworld as an “effective” learning tool” right from the the start of my step 1 prep. On my first day i ended up spending 30 minutes on making Anki cards from just 1 question and its wrong answer explanations, and today i spent about 2 hours on making cards from just 6 questions. (so far 49 cards from just 7 questions that are loaded with info)k which has made this whole thing really intimidating. My initial plan was to allot 2 hours each day to Uworld, in which i would solve 30 qs a day, and make anki cards on them. I never expected it to take me so long. I thought about just making a card on the educational objective and ignoring the rest, but i feel really guilty about throwing all the valuable wrong answer explanations away. As it’s just my beginning of doing Uworld, I m not sure what to expect. Will these wrong answer explanations appear as educational objectives in future questions and be covered? I’m really confused about what to do. What will your advice be please?

    • Yousmle

      Great question. Why not put EVERYTHING into Anki, right? If a little is good, then more must be better.

      That’s the trap.

      You COULD try and put everything into Anki, but you’d quickly overwhelm yourself. It’s your choice, but if it were me, I’d focus on mastering a smaller amount of information, starting with the educational objective, and leave most of the other answer choices. It’s up to you, though, to find a method that will work for your objectives.

      Hope this helps!

  • Shawn

    I have some questions about the home stretch of my study prep in regards to completing uWorld properly.

    I went to Pass Program in August and since then have completed USMLE Rx (70-80%) and made 1 pass thru the PASS Program Course material and 1 complete pass of First Aid 2014 with a study partner (very detailed passes talking things out and writing things out on a white board, drilling each other on topics, etc)

    Now from late October until December 31, I plan on doing Kaplan QBank and UWorld QBank by subjects. I have finished recently uWorld endocrine and renal and took extensive notes on Microsoft Word (which allows me to search thru the notes). My notes for each question from uWorld consist of getting the gist of the question and any relevant material that I deem is worth while to understanding.

    My daily schedule consists of waking up early, doing Anki decks (your deck and another deck used by many of my class mates to cover Pathoma and First Aid for each section) then i spend 3-4 days doing uWorld questions in the morning from that specific topic and I take notes.

    And then in the evening, I do Kaplan questions with my friend (we read the question, select an answer, then spend time discussing the answers afterwards). Then after we finish that section in Kaplan QBank we spend one to two nights (4-5 hours) discussing and talking out my extensive uWorld notes.

    I plan on finishing both uWorld and Kaplan (with at least a second pass of uWorld question notes with my friend) by December 31. Then I plan on spending from Jan 1-Jan 31 doing 2-3 mixed blocks a day in the morning and spending the evening drilling First Aid thru your deck and another anki deck. I really want to take the test by January 31 and my school is pressuring me to do so as well.

    Do you think my study plan is sufficient and do you think that it will yield solid results?

    Btw right now I am scoring bw 55-70% on my uWorld blocks alone and roughly 75-80% on Kaplan with my friend (once we have finished studying and mastering that specific topic via Anki decks)

    My last two NBME have hovered bw 195-240 but I hope that these next 3 months will raise that score by 30-50 points and I will produce great results.

    Any help is greatly appreciated and once again thank you for providing all the resources and advice on your site



With the FREE micro deck of more than 130+ Anki cards you will be practically BEGGING to get as many micro questions on your exam as possible.

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100% privacy guaranteed, no messin' around