Academic pharmacy programs continue to diversify in student population. While the challenges of non-native language speakers have been opined, there is scant research on their performance in comparison with native language speakers nor is there much information on differences in the processes used in academic preparation, such as on note-taking.The objectives of this study were to: (1) identify differences in test performance between native English speakers and students for whom English is a foreign language (EFL) in a health systems PharmD course, and (2) examine differences between these two groups in note-taking attitudes and behaviors.Students' self-reported data as native English-speaking or EFL were acquired from the University Office of Admissions. Students' performance was measured on examinations covering lecture content, with independent-sample t tests discerning differences on all 3 examinations. T-tests were also used to ascertain differences on examination scores by student race/ethnicity and on differences in their response to a survey on attitudes, behaviors, and satisfaction with note-taking.EFL students scored significantly lower on the latter two examinations and on the average of the three examinations by over 7%. EFL students reported lower satisfaction with the accuracy and completeness of their notes and indicated that peers were less likely to borrow their notes. They also reported being more likely to be distracted in class by peers' laptop note-taking, even though there were many similarities between the two groups in how they approached note-taking.EFL student performance was lower than that of native English speakers on examinations. EFL students were less satisfied with the quality of their notes. Further research is needed to identify effective strategies for improving the learning experience of EFL students. Academic administration can identify mechanisms to facilitate a learning environment conducive for their success.