Metacognition in medicine: judging your reasoning
You end the week with the feeling that cardiology is mastered and neurology still needs work. But where does the feeling come from? From how many classes you watched, from how much time you spent on the topic or from how many cases you got right? Metacognition is the ability to answer that question with data, and not just with impression.
NEXO is a daily medical diagnosis game: one clinical case a day, six progressive clues, and ICD-10 proximity feedback across five levels.
This guide explains what metacognition is, shows the cycle of planning, monitoring and evaluating study, summarizes what studies find in medical students and proposes a weekly exercise of predicting before and checking after.
Key points
- Metacognition is thinking about your own thinking: knowing what you know and regulating how you study.
- It has two parts, knowledge about your own cognition and regulation of study, and both were related to student performance.
- Students tend to monitor a lot and plan and evaluate less.
- In simulation, explicit support for self-regulation showed a trend of small benefit.
- Comparing the prediction with the result puts a piece of data next to the feeling.
Summary
- What metacognition is
- The cycle: plan, monitor, evaluate
- What studies show in students
- Why impression is not enough
- The exercise: predict before, check after
- The NEXO home screen as a record
- Frequently asked questions
- Weekly metacognition checklist
What metacognition is
Metacognition is the knowledge and control you have over your own thinking. In practice, it involves two things: knowing what you know and what you do not know, and using that information to decide what to study, how and for how long.
In medicine, metacognition appears in study and in care. In study, it decides where your time goes. In care, it is the voice that asks whether the main hypothesis explains everything or whether something is missing. The guide on how to track your progress deals with measurement; this text deals with what to do with it.
The cycle: plan, monitor, evaluate
Plan
Before studying, define the goal and the criterion for success. "Study cardiology" is vague; "get most of this week's chest pain cases right" is a goal that can be checked.
Monitor
During study, track whether it is working. Are you getting things right? Are you getting them right early or only after a lot of information? Are you understanding the why or just recognizing the answer?
Evaluate
At the end, compare the result with the goal and decide the next step: keep going, change the method or change the topic. It is the phase that is most often left out.
What studies show in students
Regulation changes over the year
In a study with 159 first-year medical students in Malaysia, metacognitive regulation changed between the start and the end of the year, while metacognitive knowledge did not change (Hong et al., 2015). Both dimensions had a moderate correlation with academic outcome (Hong et al., 2015).
A lot of monitoring, little planning and evaluation
In a qualitative study in which third-year students thought out loud while solving a task, the general focus was on monitoring, and less on planning and evaluation (Versteeg et al., 2021). Some participants asked for more clarity about their own level of knowledge, and the authors recommend teaching metacognition explicitly (Versteeg et al., 2021).
What happens when solving questions
In a study with 44 clerkship students who solved practice questions, 45% mentioned prioritizing relevant data as a strategy before starting (Andrews et al., 2023). In the final reflection, 93% attributed the error to management reasoning, and fewer than 10% said they would change their own diagnostic process for those questions (Andrews et al., 2023).
Support for self-regulation
A systematic review on self-regulation in the clinical setting found interventions of three types, coaching, learning scripts and support tools, all centered on defining goals and monitoring, and none on supporting self-assessment (van Houten-Schat et al., 2018). In simulation, a meta-analysis found that interventions with explicit support for self-regulation had a small benefit compared with those without support, with an effect size of 0.44 on retention tests, without statistical significance (Brydges et al., 2015).
Why impression is not enough
Confidence and accuracy come apart
In a surgery exam with 251 graduates, about 12% showed relevant overconfidence, and underconfidence appeared more among the highest-performing students (Borracci and Arribalzaga, 2018). The impression about one's own performance, therefore, can be wrong in both directions.
Feedback helps when the level is right
In a study with 69 residents who diagnosed difficult cases, seeing the correct diagnosis after each case did not improve their assessment of their own accuracy (Kuhn et al., 2022). The authors suggest that, faced with many errors, the residents lowered their confidence in their correct answers too (Kuhn et al., 2022). For metacognition, the lesson is to train with cases close to your level, where the comparison between prediction and outcome stays readable.
The exercise: predict first, check later
Sunday: the prediction
Before starting the week, write three short predictions:
- In which area you think you will get more right.
- At what point in the case you usually reach the diagnosis.
- How many days you will manage to study.
During the week: the record
Study as usual. Do not check the prediction along the way; the goal is to see the distance at the end.
Saturday: the review
Compare each prediction with the week's record. Where the prediction was right, your reading of yourself is good. Where it was wrong, there is the most useful metacognitive data of the week.
The decision
Close with one sentence: what will change next week because of the difference you found. That sentence is the evaluation phase of the cycle. The error notebook guide helps you record what to do with each error.
The NEXO home screen as a record
The NEXO home screen brings the numbers the exercise asks for. The distribution of correct answers by clue shows at what point in the case you usually reach the diagnosis; the three specialties where you get the most right show where recognition is firmest; games and correct answers give the volume; streak and record show consistency.
To use it in the exercise, make the prediction on Sunday without looking at the screen, and check on Saturday. If you expected to get it right on the second clue and the distribution shows the fourth, there is a reading adjustment. If the specialty you judged strongest does not appear among the top three, it is worth understanding why. The case arrives in up to six clues, and the proximity in ICD-10 for each guess shows where the hypothesis stood in each case. To get to know the game, read what NEXO is.
If you coordinate a medical school, a student league or a residency program and want to propose the exercise to the class, get to know NEXO Closer. Researchers who study metacognition and self-regulation can propose studies through NEXO Researcher. Physicians who review cases in their specialty take part through NEXO Curator, and those who create health content on social media can take part through NEXO Creators.
Frequently asked questions
What is metacognition in medicine?
It is knowing what you know and using that to regulate study and reasoning. In first-year students, metacognitive regulation was related to academic outcome (Hong et al., 2015).
What are the phases of self-regulation?
Plan, monitor and evaluate. Students tend to focus on monitoring (Versteeg et al., 2021).
Can metacognition be trained?
Regulation changed over the course of a year in students (Hong et al., 2015), and explicit support for self-regulation showed a trend of small benefit in simulation (Brydges et al., 2015).
How do I do the prediction exercise?
On Sunday, write where you think you will get more right, at what point in the case you usually get it right and how many days you will study; on Saturday, compare with the record.
Which NEXO numbers do I use in the exercise?
Those on the home screen: distribution of correct answers by clue, games, correct answers, streak, record and the three specialties where you get the most right.
Weekly metacognition checklist
- Set a checkable goal for the week.
- Write the three predictions without looking at the numbers.
- Study without checking along the way.
- Compare prediction and record at the end of the week.
- Note the biggest difference.
- Decide on one change for the following week.
- Choose cases close to your level so the comparison stays readable.
Want numbers to check your prediction? Play the case of the day on NEXO.
References
- Hong WH, Vadivelu J, Daniel EG, Sim JH. Thinking about thinking: changes in first-year medical students' metacognition and its relation to performance. Med Educ Online. 2015. https://pubmed.ncbi.nlm.nih.gov/26314338/
- Versteeg M, Bressers G, Wijnen-Meijer M, et al. What Were You Thinking? Medical Students' Metacognition and Perceptions of Self-Regulated Learning. Teach Learn Med. 2021. https://pubmed.ncbi.nlm.nih.gov/33722115/
- Andrews MA, Okuliar CA, Whelton SA, et al. Using Self-Regulated Learning Microanalysis to Examine Regulatory Processes in Clerkship Students Engaged in Practice Questions. Perspect Med Educ. 2023. https://pubmed.ncbi.nlm.nih.gov/37840648/
- van Houten-Schat MA, Berkhout JJ, van Dijk N, et al. Self-regulated learning in the clinical context: a systematic review. Med Educ. 2018. https://pubmed.ncbi.nlm.nih.gov/29943415/
- Brydges R, Manzone J, Shanks D, et al. Self-regulated learning in simulation-based training: a systematic review and meta-analysis. Med Educ. 2015. https://pubmed.ncbi.nlm.nih.gov/25800297/
- Borracci RA, Arribalzaga EB. The Incidence of Overconfidence and Underconfidence Effects in Medical Student Examinations. J Surg Educ. 2018. https://pubmed.ncbi.nlm.nih.gov/29397355/
- Kuhn J, van den Berg P, Mamede S, et al. Improving medical residents' self-assessment of their diagnostic accuracy: does feedback help? Adv Health Sci Educ Theory Pract. 2022. https://pubmed.ncbi.nlm.nih.gov/34739632/