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UWorld Note-Taking: Annotate First Aid vs. UWorld Journal? Do This Instead.

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by Alec Palmerton, MD in Plan

UWorld is one of the most essential resources for your USMLE prep. Testing yourself has a robust evidence-base. But knowing that you should use UWorld and knowing how to take notes on it are two different things. Specifically, once you’re done with the questions, how do you take notes, so you don’t forget it? Getting a question wrong on a practice question is one thing. We don’t want to get the item wrong on our actual test!

In this article, you will learn:

    • Evidence-based learning strategies backed by decades of research
    • Why “just do questions” is terrible (incomplete) advice
    • Why most note-taking techniques – including annotating First Aid – are low-yield
    • How the “UWorld Journal” is a beautiful theory but a poor practice
    • How students waste time in their UWorld reviews
    • How to remember anything from UWorld in less time so you can sleep more and score higher
    • Much more

“Do UWorld” Doesn’t Tell You How to Review It

Do you ever wonder about the quality of advice med students give to each other? Very often, suggestions are very heavy on study materials. However, they’re light on technique.

For example, someone might say,

You’re just supposed to do UWorld questions. Everyone knows that!

However, what they don’t explain is:

  • When should you start UWorld? With your classes or wait until dedicated study?
  • How many questions should you do?
  • Timed or tutor mode?
  • Should you study subject-wise? Or mixed?
  • Are you supposed to take notes?

See what I mean? Knowing we should use a resource is very different from how to use that resource.

We’ve discussed at length the mistakes most people use with UWorld. Today, I want to discuss something else: how to take UWorld notes.

The Standard UWorld Note-Taking Advice/Practice

Let’s start with the two most common UWorld note-taking practices:

  • Re-writing most of the UWorld explanations, sometimes into First Aid
  • The UWorld journal
Re-Writing UWorld Explanations

The most common UWorld note-taking technique is to write down everything in the QBank. In other words, they’ll write down anything they didn’t know in the question explanation. (The question explanation is what you see once you’ve answered a question. It explains the background of the concept, and why the answer choices were right/wrong).

Where do they take their UWorld notes? It might be electronic, in a journal. Often they will annotate their notes into a paper copy of First Aid.

The Mistake: Extensive UWorld Notes > Doing UWorld

There are several problems to this note-taking approach:

  • It takes a long time
  • With the little time remaining, there is no time to go back and read the notes
  • 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 like so many people do.

First, WHERE do I annotate my First Aid? First Aid mentions Addison’s in numerous places. Finding the most logical place becomes more complicated 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. The more you annotate First Aid, the more messy/disorganized it becomes. You may spend more time trying to FIND a particular note it takes to study it.

UWorld has a lot of good explanations. However, that doesn’t mean you should spend your time memorizing everything in them!

Let me explain. You have 24 hours in a day. The more time you spend taking UWorld notes, the less time you’ll have actually to DO UWorld. And as we’ll discuss later, doing UWorld is more important than reading explanations.

Plus, the more notes you make, the more you’ll have to review. Very soon, you’ll be buried under annotations that you’ll never look at again.

This leads to the second-most common UWorld note-taking technique: the UWorld journal.

UWorld Journal: One (Short) Entry Per Question

A UWorld journal is a collection of the highest-yield notes from the QBank. It is often composed of things you didn’t know from the “educational objective.” (The question’s educational objective is the 1-3 sentence “take home message”).

The rationale behind the UWorld Journal is in the right direction. Should you write everything down from UWorld? No, as we discussed above. However, if we shouldn’t write down everything, what about only the “high yield” material?

In short, no. The issue with UWorld note-taking is in part WHAT we choose to write down. In this, the UWorld journal concept is spot-on. However, I will argue that writing down high-yield facts in a notebook is a low-yield approach.

Evidence-Based Note-Taking to Maximize UWorld Retention

Few activities are useless. A high school biology class might help you get some USMLE genetics question right. Reading Robbins Pathology might help you answer questions on Step 2 CS. However, that doesn’t mean you should do it. Why? Just because something can help you answer SOME questions doesn’t make it a high-yield use of time.

The best UWorld note-taking should maximize efficiency. So what are the highest-yield uses of time? Decades of educational research can give us insight into the best study techniques. Even better, many review articles summarize the most essential techniques. Here is one such summary not only of study methods but their relative effectiveness.

Evidence-Based Techniques to Maximize Learning

SummarizationWriting summaries (of various lengths) of to-be-learned textsLow
Highlighting/underliningMarking potentially important portions of to-be-learned materials while readingLow
Keyword mnemonicUsing keywords and mental imagery to associate verbal materialsLow
Imagery for textAttempting to form mental images of text materials while reading or listeningLow
RereadingRestudying text material again after an initial readingLow
Elaborative interrogationGenerating an explanation for why an explicitly stated fact or concept is trueModerate
Self-explanationExplaining how new information is related to known information, or explaining steps taken during problem solvingModerate
Interleaved practiceImplementing a schedule of practice that mixes different kinds of problems, or a schedule of study that mixes different kinds of material, within a single study sessionModerate
Practice testingSelf-testing or taking practice tests over to-be-learned materialHigh
Distributed practiceImplementing a schedule of practice that spreads out study activities over timeHigh
Adapted from: Dunlosky, John et al. “Improving Students' Learning With Effective Learning Techniques: Promising Directions From Cognitive and Educational Psychology.” Psychological science in the public interest: a journal of the American Psychological Society 14 1 (2013): 4-58.

What do you notice? First, what many of us do falls under the “low” utility category. I remember spending hours cramming mnemonics. I’d take extensive notes of my lectures, then re-write them before each exam. It would work in the short-term, but in retrospect, I wasted a lot of time.

Making Connections Maximizes Retention and USMLE Scores

Eventually, I discovered that if I made more connections, I’d remember the topic better. As a bonus, I’d also reinforce other essential concepts, as well.

For example, let’s say I was learning about gonadal tumors. At one point, I’d memorized:

  • Most ovarian malignancies are surface tumors and occur later in age
  • Most testicular tumors are germ cell and occur starting in puberty

Easy, right? Just memorize some words, and I’m done! Wrong. I mixed up the information, and couldn’t use it. Instead, I learned to explain, “why?” and make connections between topics.

Find the Underlying Explanation

So how would this look? First, let’s consider what a testicular germ cell is. It’s the cell that divides during meiosis to form sperm. Second, remember that dividing cells accumulate DNA errors during replication. Finally, remember that boys start making sperm during puberty.

Put it all together? Testicular germ cells start dividing rapidly during puberty to make sperm. Thus, the risk of testicular germ cell tumors rises during puberty. Testicular cancer risk tails off in later ages as sperm production falls.

In contrast, female germ cells (that make eggs) stop dividing before birth. (Oocytes arrest in prophase I before puberty). Thus, females germ cell tumors are rare. (Their germ cells stop reproducing before they’re born!).

Instead, female “ovarian” cancer is most often found on the surface. I say “ovarian” cancer because most cancer found in the ovaries isn’t thought to start there. Instead, it comes from metastatic spread. For example, serous ovarian cystadenocarcinoma is believed to originate in the fallopian tubes. (For more, click here.)

Asking, “why?” and connecting different topics made learning enjoyable and time-efficient. I started looking forward to studying. As a bonus, I started sleeping more, which made my studying even better.

But knowing, “why,” and integrating concepts is only the first step. To make the most effective UWorld notes, you should make Anki cards.

The Solution: Make Focused, Integrated Anki Cards

I know what you’re thinking: making Anki cards doesn’t sound like taking notes. But whether you take the notes into a notebook, or into Anki cards, the goals are the same.

The ideal UWorld note-taking solution should accomplish three things:

  • Focus on the highest-yield information (i.e., what will help us best maximize our score)
  • Be a quick and easy reference
  • Maximize retention in the least amount of time

Turns out, there IS something that accomplishes all three goals: Anki.

What is Anki? I’ve written about this before. Anki is a spaced repetition-based computer program that maximizes your retention. It really works and is one of the main reasons I was able to score 270 on the USMLE Step 1.

(To read Med School Anki: Make (or Find) USMLE-Crushing Flashcards, click here).

Is It Too Late to Start Anki?

Most people wonder if it’s too late to start Anki. “I didn’t start this during my month of medical school. I can’t start now, so close to my exam! I’ll use Anki later.”

There is a bit of a learning curve involved. That said, 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, read this or check out the Yousmle Anki Cards.

UWorld Note-Taking with Anki: Turn Educational Objectives Anki Cards

So how do I use Anki to take better UWorld notes? First, don’t start blindly copying everything in UWorld into your cards. You likely know a lot of UWorld. Even if you don’t, memorization is not the way to improve your score.

Instead, in the beginning, make it simple. Like a UWorld journal, focus only on the highest-yield information. A simple place to start is the educational objective.

But instead of taking 1-2 lines of notes per question in a notebook, you put those notes into Anki. Then, instead of passively reading your journal, you review the cards daily. Again, the point is to minimize low-utility study techniques. And the summarizing-re-reading method is a low-utility use of your time.

Instead, by using Anki, you can keep testing yourself on the information. (Remember, “practice testing” is one of the most effective learning techniques). Add to that “distributed practice” method that Anki uses and your effectiveness skyrockets.

Med School Anki Theory vs. Practice

Most med students do techniques that are “low” utility. (Good) med school Anki cards utilize most of the techniques with the most robust evidence base.

How Many Cards Should You Make? How Long Will It Take?

Let’s make conservative estimates on how long it takes to make/review your cards. You might make 30 cards a day. Making the cards takes no more time than you would have if you’d annotated First Aid. Reviewing those cards would take 30-60 minutes the first several days. After a week or so, it might be 1-2 hours every day after that.

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. This might seem like a lot. But what is the alternative? Not reviewing the UWorld notes/First Aid annotations takes no time. But what’s the point of taking notes if you never look at them again? Instead, with a modest time investment, you can remember your notes. Forever.

Remember, the best studying is studying you won’t have to repeat later. Mastering things – and never forgetting them – saves time and maximizes your score.

(To read Med School Anki: FAQ for the USMLE Steps, Shelf Exams, and Clerkships, click here).

Efficient Referencing → Sleep ↑, USMLE Step 1 Score ↑

Not do good Anki cards maximize your score. They also make referencing any notes you’ve taken a breeze.

Here is an example of the magic of using Anki to reference ANY note I have written. Let’s say I forgot why germ cell tumors are more common in males than females. All I have to type is “germ cell oocyte,” and I can find the exact cards, every time.

UWorld Note-Taking Using Anki Cards Makes Referencing Lightning-Fast

UWorld Note-Taking Using Anki Cards Makes Referencing Lightning-Fast.

If I’d annotated UWorld into First Aid? Just to find my FA annotation, I would have had to:

  • Go to the index,
  • Find all the listings for “ovary” or “germ cell,”
  • Go through all the pages,
  • Read each hand-written explanation until I found the right one

It took me five seconds to find this card. How many times do you need to reference a fact? During my peak, I used to reference upwards of 10-20 cards every day. The time-savings alone from lightening-fast Anki referencing are immense. Not to mention the enormous benefits of using Anki to test yourself on the information.

Concluding Thoughts

The time saved – and mastery accrued – with Anki adds up considerably. This increases the amount of time for studying, sleeping, and having a life. This is particularly important if your exam is approaching soon.

If you’re looking for tips on how to make better cards, read this. If you still have questions about Anki, in general, read this.

Finally, does the idea of using Anki appeal to you, but you are unsure of making your own cards? Check out the Yousmle Step 1, Step 2, and Pharmacology cards. They have searchable, integrated cards that explain, “why?” for the most challenging USMLE concepts.

What do you think? Do you still plan to annotate First Aid? What have you found the best UWorld note-taking technique to be? Let us know in the comments!

  1. Shawn says:

    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

  2. Jy says:

    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?

    1. Yousmle says:

      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!

  3. tabatch89 . says:

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

    1. Yousmle says:

      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.

      1. tabatch89 . says:

        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?

        1. Yousmle says:

          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.

  4. John says:


    Life, that would be candy land.

    1. Alec Palmerton, MD says:

      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?

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Want FREE Cardiology Flashcards?

Cardiology is key for impressive USMLE scores. Master cardiology from a Harvard-trained anesthesiologist who scored USMLE 270 with these 130+ high-yield flash cards. You’ll be begging for cardio questions - even if vitals make you queasy.