https://www.ncbi.nlm.nih.

gov/pmc/articles/PMC5468716/

Strategies for Improving Learner Metacognition in Health

Professional Education
Melissa S. Medina, EdD,a Ashley N. Castleberry, PharmD, MAEd,b and Adam M. Persky, PhD c

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This article has been cited by other articles in PMC.

Abstract
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INTRODUCTION
Imagine the following situation: You ask your class to find and review a journal article. One of
your learners, Morgan, begins the assignment the night before the assignment due date. She is
unsure where to search for primary literature. Once she finds an article, she underestimates the
review time. She spends several hours reviewing and finishes the assignment in the early
morning. When the instructor graded the assignment, she receives a poor grade because most
questions were not directly and concisely answered. Morgan is surprised by her grade because
she spent several hours working on the assignment, which was more than she thought would be
necessary.
While many things could explain Morgan’s behavior, at the foundation Morgan may have
trouble with metacognition. She failed to plan. She did not know where to look for information.
She misjudged time. She did not check her work for accuracy. She was overconfident in her
predicted grade. All these elements point to poor metacognitive skills.

What is Metacognition?
We can define metacognition as the “thinking about thinking.” Because it refers to a person’s
“knowledge and cognition about cognitive phenomena.”1,2 This type of cognition regulates
thinking and learning and consists of three self-assessment skills: planning, monitoring, and
evaluating. In the case of Morgan, she failed to lay out a plan for her article review; during the
process, did not monitor whether she was accomplishing the goal; and once done, did not
evaluate her work for correctness.
Researchers have investigated three aspects of metacognition: metacognitive knowledge,
metacognitive monitoring, and metacognitive control.3 Metacognitive knowledge is the
information you consult when thinking about an idea; it includes the basic facts and concepts.
Metacognitive monitoring is the ability to assess cognitive activity whereas metacognitive
control is the ability to regulate cognitive activity. In the example above, Morgan may have
lacked the knowledge of where to look for an article or how to review an article (metacognitive
knowledge). She may have lacked the ability to assess whether she was answering the relevant
questions (metacognitive monitoring). She also may be deficient in the control of metacognition
by allowing insufficient time for this activity (metacognitive control).

Importance of Metacognition
Metacognition is important to every profession. There are many reasons why metacognition is
important in the health sciences, including from being a better learner to becoming a better
clinician. During the learning process, metacognition guides our learning strategies. If learners
know what they know and do not know, they can focus on acquiring the knowledge they are
lacking. Metacognitive skills also have a role in critical thinking and problem solving. If you
know what you know and do not know, your metacognitive skills help drive you to obtain the
missing information, which we refer to as self-directed or self-regulated learning. Finally, being
mindful or metacognitively aware can prevent medication errors in clinical settings because of
increases in awareness of our thought process leading to better critical thinking and monitoring
of actions. As an example, self-assessment errors routinely occur among physicians, nurses,
pharmacists and other health care providers.4

Metacognition in Medical Errors

Medical errors are one of the leading causes of death in many countries.5 Researchers have
argued that medical error is partly a cognitive issue.6 Medication order entry errors were the
fourth leading cause of medication errors in 2003.7 These types of errors can occur because the
pharmacist did not ask “do the orders make sense for the indication?” (ie, metacognitive
monitoring) or “did I check to ensure I entered things correctly?” (ie, evaluation of medical
orders or evaluation of entered data). One study cited that most medication errors occur at the
prescription and found 40% of errors were related to prescribing the wrong dose and 18% from
omitted information.8
In addition, physicians, pharmacists, and other health care providers can be overconfident in their
assessments leading to medical errors which can lead to hindsight bias which may further hinder
learning. Hindsight bias is the “knew it all along” effect and is the belief that an event is more
predictable after it becomes known than it was before it became known. During hindsight bias,
we lose the ability to recollect the feeling of uncertainty that preceded an event. This bias hinders
our appraisal of past events.
Part of the cause of hindsight bias is the subjective feeling of ease associated when we make
judgments – a metacognitive function. When people find it easy to come to a conclusion about a
particular outcome, they will show greater hindsight bias, particularly regarding foreseeability
(“I knew that would happen.”). One reason is that people attribute the subjective ease of the
judgment to the certainty of being correct – the answer came easily and thus must be correct. In
one study, physicians were asked to guess the likelihood that they would get the correct
diagnosis in the future (prospective or foresight) and in the past (retrospectively or
hindsight).9 The less experienced physicians gave significantly higher estimates in hindsight than
in foresight. For easier cases, the more experienced physicians demonstrated hindsight bias;
however, for more difficult cases they did not give higher estimates than in foresight. In another
study, physicians were asked their confidence and accuracy during right heart
catheterization.10 Physicians were confident of their estimates, but there was no relationship
between confidence and accuracy. Experienced physicians were no more accurate than less
experienced ones, although they were significantly more confident. These are two examples of
how metacognitive skills may affect clinical judgments.

Metacognition and Study Skills

Metacognition is crucial in controlling and guiding thinking.1 Dunlosky proposed a model of
how metacognitive control impacts study time.11 This model included study preparation (self-
efficacy evaluation, task appraisal, and initial strategy selection) followed by monitoring and
assessing whether the to-be-learned items has been learned and feeding back into the cycle to re-
study unlearned material. Several investigators found that learners are unaware of effective study
strategies which impact performance.12-14
College learners have displayed overconfidence in self-chosen study strategies about academic
performance and have demonstrated low correlations between self-predicted and actual
performance on learning assessments.15,16 This pattern of overconfidence may be more apparent in
low-performing learners.17,18 The issue of selecting study strategies is complicated because a
requirement for selecting a learning strategy is metacognitive knowledge about which learning
strategies are beneficial for long-term memory. Several studies report learners using low-impact
study strategies such as rereading or highlighting notes.12,19,20 In one study, 80% of undergraduates
reported that the study skills they use were learned on their own and not taught to them in a
formal manner by teachers.16 These findings are consistent with the health science literature that
also found rereading a prominent learning strategy.20,21 The selection of poor study strategies
raises questions of whether those improvised strategies, presumably based on intuition or
metacognitive feedback, are consistent with the evidence. This hypothesis raises a second
question whether instruction on learning and memory topics could improve metacognitive
awareness of successful learning strategies. Recently it was documented that learners who have
engaged in their study skills development use better strategies, but low impact strategies still
predominate.20 As a result, faculty members are advised to teach study skills formally to
learners.22

Metacognition and Self-Directed Learning

Most health-professional organizations and accrediting bodies encourage lifelong learning
because of the ever-changing biomedical landscape. Lifelong learning requires self-direction and
self-regulation. Self-directed learning is the result of allowing learners to make decisions about
the information they want to experience or learn.23 In a realistic learning situation, self-directed
learning is difficult and in a formal education setting, information selection is limited and
governed by the instructor.24 While this is limiting, instructors need to set learning objectives for
novice learners because these learners are not in a position to be self-directed. They do not know
the skills and knowledge needed to become a health professional; also, limiting resources to find
information may be appropriate early on to help build efficiency into the learning process (ie,
learners do not have to spend large amounts of time searching for relevant information).
Providing guidance can lead to a “passive learning environment.” However, within a passive
learning environment, learners selectively attend to different environmental cues.25 As an
example of a passive environment, learners actively evaluate what has been said, or engage in
self-explanation to decide what other information is required.24 Self-directed learning differs
from self-regulation. For example, if the article Morgan found was interesting, she could be self-
directed in learning more about the topic. However, she would be self-regulated when balancing
this additional learning with her required course learning.
Self-regulation is how individuals guide their goal-directed activities over time. It is designed to
maximize the long-term best interests of an individual, resulting in learners controlling their
impulses and looking out for their well-being.26 Self-regulated learning modulates various
processes (eg, cognitive, behavioral) to reach the desired goal. These regulatory mechanisms are
the essentials of self-regulated learning because they are under the control of the learners and
would be the basis for future professional development (ie, continual professional development).
The self-regulated behaviors include planning, monitoring, attention, and effort.
Both planning and monitoring are components of metacognition. When learners engage in
planning activities, they think through what they need to learn and set task-specific
goals.27,28 Once they plan, they need to monitor. Monitoring refers to paying attention to one’s
performance and understanding of the course material.29 Monitoring is a critical component of
self-regulation because it provides awareness of one’s knowledge level, which then leads to
changes in one’s affect, cognition, and behavior.27 Accurate monitoring enhances the regulation
of learning because it provides feedback to what trainees already know and where they need to
focus their resources.28,30

Metacognition and Critical Thinking

Critical thinking involves cognitive, dispositional and metacognitive components. The cognitive
component represents the abilities to comprehend a problem and apply cognitive skills to make
sound judgments. The disposition component influences the patterns of intellectual activity;
these can include the enjoyment of thinking, an open attitude, a careful approach and a mindset
for truth seeking.31,32 Metacognitive strategies enable learners to supervise and control their
thinking processes. At its core, a critical thinker is one in charge of their thinking processes,
while metacognitive strategies enable such control to take place. The metacognitive aspects
interact with a variety of internal and external factors like type of instruction, motivation, and
socio-economic status (Figure 1).
Figure 1.
Influence of Internal and External Factors in Cognition
Metacognition is the ability to monitor thinking to use skills and strategies appropriately to
achieve a desirable outcome. We discussed this regarding learning strategies and parallels can be
made for critical thinking skills. Halpern defines a critical thinker as one who applies appropriate
skills and strategies to achieve a desirable outcome.33 As such, critical thinkers strategically use
cognitive skills that are best suited to a particular situation. They are aware of their thinking and
thus control their thinking processes. Metacognitive strategies are an important variable during
thinking processes.33 These skills need to be made explicit and public to develop critical thinking
skills.33

Metacognition and the Accreditation Process

Accreditation standards for pharmacy (ACPE) and medicine (AAMC) emphasize metacognitive
skills as a critical part of health professional training. For pharmacy education, the college or
school provides an environment and culture that promotes self-awareness, self-directed lifelong
learning, professional behavior, leadership, collegial relationships, and collaboration within and
across academic units, disciplines, and professions. (Standards 4 and 9). The experiential
curriculum should provide an inculcation of habits of self-directed lifelong learning (Standard
12). Standard 4 explicitly states self-awareness as a key factor and that learners use
metacognitive practice to regulate their learning. The appendices further emphasize self-directed
and lifelong learning including continuous professional development. Similarly, in medicine we
see an emphasis on self-directed learning. The faculty of a medical school should ensure that the
medical curriculum includes self-directed learning experiences and time for independent study to
allow medical learners to develop the skills of lifelong learning. Self-directed learning involves
medical learners’ self-assessment of learning needs; independent identification, analysis, and
synthesis of relevant information; and appraisal of the credibility of information sources
(Standard 6.3).

Overview of Instructional Approaches to Teach Metacognition

Metacognitive processes are best taught in conjunction and alignment with cognitive processes
and separating the two processes is challenging.34 One key instructional strategy in developing
metacognition is cognitive apprenticeship. Cognitive apprenticeship is “learning through guided
experience.” In this model, the expert’s cognitive and metacognitive processes and skills used
when performing a task are explicit and public and are the focus of teaching activities.35 There
are four dimensions to this model that reflect the three dimensions of metacognition.
The first dimension includes content knowledge (concepts, facts, procedures) and strategic
knowledge (heuristic, metacognitive, learning). To think through a process, one must have the
content knowledge to think about something. One also needs to have a heuristic (short-cut) or
algorithm (formula) to follow to develop the skill. Thus, instruction should have a content
component and direct instruction on how to work through a process.
The second dimension of cognitive apprenticeship has a method to demonstrate metacognition.
The expert or instructor should model the process – externalizing the thought process. The
concept of coaching is appropriate as the expert should help demonstrate and coach learners
through the process. Within this procedure, learners reflect on their thoughts, verbalizing their
motives and assumptions.34 The process should be scaffolded, ie, offering early examples or
demonstrations in a more supportive model leading to a level of independence.
The third dimension of cognitive apprenticeship is an extension of scaffolding, and this concept
is the importance of sequencing: increasing task complexity, diversity of problems, and
migrating from global to local skills. Task complexity starts with straightforward problems and
building complexity with experience. The diversity of problems helps learners build more
generalizable knowledge and skills. When we use a diversity of problems, we are approaching
similar problems from different contexts to help build context-independent knowledge and skills.
When we learn, we form a memory trace for that information. This memory is dependent on the
cues available during the learning context.36 We can recall this information only if we receive the
correct cues. If we see the content or skill (or thought process) with a wide array of problems, we
can retrieve the information from a variety of cues and contexts and start to make generalities.
Finally, after faculty scaffold and sequence appropriately, they move the learners from global
skills to local skills. At this point, learners should have a clear conceptual model of the task or
process before executing its parts. Developing global skills reflects the idea that seeing the
overall structure of the problem or content helps in understanding the individual parts because
we can draw on relationships to help reinforce the learning.37
The fourth dimension of cognitive apprenticeship is the sociology of learning and includes
situated learning, a community of practice, intrinsic motivation, and exploiting cooperation. This
idea is consistent with factors of motivation especially relatedness – we are more motivated to
learn or perform when we can relate to the situation or the person. The authenticity of the
learning environment (experiential vs. classroom) or the problem (patient case vs. foundational
science) helps frame the real-world context which increases motivation. Therefore, situated
learning (environment reflects the real-world) increases motivation.38-40 The last components are
social in nature but also consistent with effective learning strategies: a community of practice
(engaging in a community to achieve goals) and cooperation (cooperation between learners in
problem solving). These methods are real-world since health care is a team process and the
research consistently show that learners teaching other learners is an effective strategy (effect
sizes above 0.70).41 Cooperative learning allows for a variety of positive attributes including
feedback and communication which help in the metacognitive process.

Strategies to Enhance Metacognition in the Classroom

Several methods can be used to enhance learners’ metacognition in the classroom. Methods used
during any part of normal instructional approaches include lecture, active learning exercises, or
pre-planned activities outside of the classroom. Example methods can be modified based on the
knowledge level of the learner and number of learners in the classroom in combination with
scaffolding. To note, developing metacognition within learners is not an easy task.34 Appendix
1 contains some sample metacognitive learning objectives.

General Planning
Learners plan better and learn when their attention focuses on learning objectives established by
the instructor. The explicit discussion of the learning objectives starts the metacognitive process
by prioritizing the importance of thinking about the learning process over the content. To
activate prior knowledge, prompt the learners to think about what they already know that is
related to the content of that day and what relevant knowledge they lack.42 Next, lead the learners
to analyze the distinctions between contrasting information and focus more on these differences
rather than the similarity between concepts.43,44 Have learners assess the time it will take to
complete this activity and where they will find the resources for successful completion of the
task to help them think about the process of studying. Additional self-questions to promote
learner metacognition about learning can be found in Table 1.45
Table 1.
Sample Self-Questions to Promote Learner Metacognition About Learning45,66-68
General Monitoring
Learners benefit from monitoring their understanding (ie, metacognitive awareness) during
teaching activities.46-48 By checking learning behavior throughout the lecture or teaching activity,
learners are reminded of the importance of the learning process. Learners can accomplish this by
noting important concepts and writing down questions during the lecture or activity.45 Jotting
down questions can be facilitated by dividing content into 10-15 minute segments and offering
activities to refocus attention to the learning objectives and reflecting on their comprehension of
the material. The instructor can help learners learn strategies for retaining information such as
chunking, connecting, and elaborating and assist them in organizing the material in ways to
recognize patterns and associations. They may regulate the difficulty of the material by breaking
down the problem into simpler steps for learners to clearly see the thought process of problem-
solving.43 After some practice with simpler questions, incrementally increase the difficulty of the
problem. Another way to assist learners in monitoring their thought processes is to provide half-
done examples and have learners solve them then discuss possible conclusions. By monitoring
smaller pieces of an assignment, the instructor and learners are better able to identify and correct
errors in thinking. (Table 1).

General Evaluating
By evaluating metacognitive skills, learners become more aware of this process and its impact on
learning. Creating checklists, rating scales, and rubrics for distribution before the assignment can
help learners monitor and evaluate their thinking as they are working. Additionally,
administering a metacognitive questionnaire during an exam can help learners evaluate their
thinking during the exam and make corrections accordingly (Appendix 2 provides an
example).49 Reviewing this questionnaire after the exam along with individual results can also be
helpful to identify patterns of incorrect thinking or gaps in preparation and study time. Having
learners evaluate their learning is powerful and can lead to change for future learning (Table 1).

Other Strategies Examination Reviews

Examinations themselves can be a metacognitive method.50,51 Reviewing an examination with
learners after grades are released can be a powerful way to help them start thinking about their
thought process during the examination. Examination reviews occur in a group setting with the
entire class or during a one-on-one or small group interaction with learners. During this session,
have learners reflect on their answer choice and the actual correct answer. Ask them to reflect on
why they got the item incorrect and specifically why this occurred. Ask prompting questions
such as: What were your assumptions about this item? What are some alternative ways to
approach this question? What piece of knowledge were you missing? By forcing learners to
identify the problem in their thought process for each item, you might be able to discern a pattern
in behaviors and offer strategies to remedy this. In addition, the small delay in feedback also can
enhance learning.52
In addition to reviewing the exam after administration and scoring, a review before the exam can
help learners assess their learning strategies and adjust accordingly before the exam. Doing an
exam review a couple of days before the exam still gives learners time to change their studying
and enhance weak areas. By using questions similar to the format of an examination question,
learners familiarize themselves with the examination requirements. Using active learning
strategies paired with a group discussion on questions that require critical thinking can be a
powerful review tool for learners. A review before and after an examination can benefit learner
learning.

Thinking out Loud

A form of modeling is thinking out loud, and this occurs in the classroom.43 For example, provide
learners with a complex question or case scenario and let them think about their approach to
solving the issue. Then think out loud to model your thought process for how you would solve
this issue as a content expert. Have learners compare their thought process to yours to identify
gaps, errors, or alignment to improve their thinking. This method also benefits learners in
experiential training such as clinical rotations or shadowing experiences. Expert thinking is often
internal and not portrayed to learner learners who can negatively reinforce wrong thinking. For
example, when experts are problem-solving, they silently sort relevant and irrelevant information
before generating a solution. To a novice learner, all of the information can appear important,
which can hinder their problem solving. Experts should instead think out loud so novices can
better understand what is irrelevant in certain problem-solving situations. By thinking out loud,
you show learners how to approach situations and model the process of monitoring your
behaviors in professional practice.

Reflection
Reflection is simply the intentional and dynamic process that allows improvement in one’s
actions, abilities, and knowledge by learning from past experiences.53 To reflect, think back on an
experience and analyze the situation. By getting learners to reflect, they think about their actions,
abilities, and knowledge and assess improvement in these areas moving forward. Reflection
assignments following learning activities (whether in the classroom, simulation, or practice) can
help learners think about their thinking and develop plans to grow in these areas. Reflective
writing assignments can include responses to three questions: What worked well when preparing
for this exam/quiz/assignment? What did not work well when preparing for this
exam/quiz/assignment? What will I change before my next exam/quiz/assignment?45
Reflection using the “Muddiest Point” allows learners to identify confusion during a lecture or
learning activity.45 Have learners write down what part of the material remains confusing to
them. Then have the learners investigate the issue further to encourage exploration of knowledge
and self-directed learning. This quick exercise can have a high yield for metacognitive practice.
Another reflective method is self-explanation. When learners use self-explanation, they are
asking themselves to explain their process and what they can do next time. This technique has
been used to facilitate the transfer of learning and problem solving.54

Adding Judgments of Understanding

Asking learners to prospectively make judgments (eg, I predict my score on this exam to be…)
or retrospectively make judgments (eg, for the test question I just completed, my confidence in
my answer is…) can help learners monitor or evaluate their learning. These types of judgments
have been used within higher education and courses in pharmacy.17,18,55 When asked these
questions, learner accuracy in predicting grades improves and moves from being overconfident
to underconfident with reductions in bias.18,49 See Appendix 3 for an example of a weekly
monitoring exercise with judgments of understanding.

Strategies to Enhance Metacognition in the Experiential Setting

In addition to classroom instruction, raising learners’ metacognition is important in the
experiential setting. To date, there is less research in this educational setting, but opportunities
exist to develop and research metacognitive development.

Mastery Goal Setting

Artino and colleagues in 2012 found that learners’ metacognitive skills (planning, goal setting,
monitoring comprehension, and evaluating learning) correlated positively with mastery goal
structures, which are environments that emphasize developing competence, mastering new skills
and learning to understand.56 Mastery goal structures contrast with performance-approach goal
structures that focus on demonstrating proficiency and peer comparison and performance-avoid
goal structures that encourage avoiding looking incompetent.56 Both performance-approach and
avoidance structures are associated with procrastination, avoidance of help-seeking, and poor
grades, which are goal orientations that become predominant in the experiential
setting.56 Learners in the experiential setting may resort to these goal orientations because it is a
time when the bulk of learners’ grades are derived directly from observation instead of tests, and
they may adapt behaviors to avoid looking incompetent.56 Based on these findings, preceptors
should consider encouraging learners to adapt mastery-oriented goals and seek help when
needed. One way preceptors support mastery goal structures is to offer formative assessments
paired with feedback that emphasizes progress and mastery of knowledge, skills, and
attitudes.56 These formative assessments can take a variety of forms from case discussions,
journal clubs, or presentations – typically practices that normally occur during experiential
rotations. These should regularly occur to help the learner develop. These feedback sessions may
be an opportunity to use the verbalization strategies found in Appendix 4.

Questioning and Feedback

Another way preceptors can help their learners on rotation is to emphasize metacognitive skills
from the beginning of training coupled with immediate feedback regarding technique. This
method was shown to help novice medical learners on a surgery rotation learn laparoscopic
surgery skills using simulation software.57 There are questions that preceptors regularly can ask
learners to promote metacognitive awareness, including questions related to planning,
monitoring, and evaluating. Research with elementary school learners showed that when teachers
asked learners two questions, “what did you learn about yourself today regarding the subject
area?” and “What did you learn that you can consistently replicate well?” their metacognitive
awareness increased.58 Based on these results, preceptors could ask learners questions found
in Table 2.
Table 2.
Questions to Ask During Experiential Settings
Another important aspect of experiential education is the purpose of asking questions. Often we
might hear of preceptors “pimping” learners – that is to ask questions under the guise of
educating them but the real purpose is to determine hierarchy. Questioning should be Socratic
and developmental compared to evaluative and demeaning (Table 3).59-62
Table 3.
Comparison of the Socratic Teaching Method vs Clinical “Pimping”

To effectively ask questions, preceptors should do the following:59 diagnose the learners (ie, what
level are they at) and teach to that level; avoid asking questions for questions’ sake (for eg,
questions about trivia, historical facts, non-meaningful eponyms, and impossible, guess-what-
I’m-thinking questions); tell learners your goal in asking questions; emphasize important
learning points; and do not attempt to embarrass intentionally or humiliate the learners.

Clinical Documentation with Explanation

Written and verbal communication require an explanation of the thought process. For example, if
you are making a recommendation to a physician for a specific drug, you should explain why
you chose that drug (drug allergy to another drug, lab levels, adverse effects, other disease
states). By explicitly documenting reasoning, metacognition is modeled and could lead to better
communication and patient outcomes. As an example, SOAP notes may include an additional
page that documents the rationalization and resources used to arrive at the plan. SOAP notes
have been used to improve reflection and learning in medical physiology in medical learners and
help faculty reflect on learning in dental hygiene education.63 The use of clinical documentation
may be especially impactful when novices can compare their documents to experienced
clinicians and when clinicians verbalize their process as they develop the document.

Experiential Rotation Structure

Finally, the overall structure of experiential education should be scaffolded – both between and
within a rotation. Learners should be started with a more supportive environment and moved
toward more independence; this can support their metacognitive development. This scaffolding
or progressive problem-solving approach is a critical part of developing expertise. It is the
gaining of experience for both content but process that is important. Experts are more
metacognitively aware than novices because the progression of problem solving requires the
cognitive and metacognitive processes.64
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SUMMARY
Metacognition refers to a person’s ability to regulate their thinking and learning and consists of
the self-assessment skills: planning, monitoring, and evaluating. These important skills reduce
self-assessment errors, such as hindsight bias, among health care providers. The new pharmacy,
medical, and nursing education accreditation standards emphasize metacognitive skills and the
related skills in critical thinking and self-directed learning. Studies reporting formal teaching of
these skills are often lacking which further emphasizes the need to teach health care learners
explicitly metacognitive skills during their training. Suggestions for teaching metacognitive
skills in the didactic setting include cognitive apprenticeships, exam reviews, modeling of
metacognitive skills, thinking out loud protocols, reflection assignments, self-explanation
methods, and judgment of understanding assignments. In the experiential setting, faculty
members can emphasize mastery goal setting, use questioning techniques that promote
metacognitive awareness coupled with feedback about learner efforts in this area, request clinical
documentation with an explanation, and scaffold learners during the rotation. Overall, using
these teaching strategies regardless of setting can raise learners’ self-awareness and help
metacognitive thinking to occur more automatically. Metacognition’s role in clinical decision
making is important as it is a means to address “what to learn,” “when to learn,” and “how to
learn.”65
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ACKNOWLEDGMENTS
The authors thank Cindy Stowe and John Dunlosky for their input during manuscript
preparation, and Kayley Lyons, Shelby Hudson, and Tom Angelo for their help during the
editing process.
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Appendix 1. Outcome/Objective Statements

By the end of this course, you should be able to:
Comprehend the limits of your memory for a particular task and create a means of external
support.
Self-monitor your learning strategies and then adapt the strategies if they are effective.
Notice whether you comprehend something you just read and then modify your approach if you
did not comprehend it.
Skim subheadings of unimportant information to get to the information you need.
Rehearse a skill to gain proficiency.
Self-test to see how well you learned something.
Verbalize your thought process for a particular task.
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Appendix 2. Exam Item Assessment

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Appendix 3. Example Weekly Monitoring Exercise

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Appendix 4. Example of Verbalization Techniques to Develop Metacognition

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REFERENCES
1. Flavell JH. Metacognition and cognitive monitoring: a new area of cognitive-developmental
inquiry. Am Psychol. 1979;34(10):906–911. [Google Scholar]
2. Jacobs J, Paris S. Children’s metacognition about reading: issues in definition, measurement,
and instruction. Educ Psychol. 1987;22(3):255–278. [Google Scholar]
3. Dunlosky J, Metcalfe J. Metacognition. Los Angeles, CA: SAGE; 2009. [Google Scholar]
4. Dunning D, Heath C, Suls JM. Flawed self-assessment: implications for health, education, and
the workplace. Psychol Sci. 2004;5(3):69. [PubMed] [Google Scholar]
5. Zineldin M, Zineldin J, Vasicheva V. Approaches for reducing medical errors and increasing
patient safety: TRM, quality and 5 Qs method. TQM Journal. 2014;26(1):63–74. [Google
Scholar]
6. Zhang J, Patel VL, Johnson TR. Medical error: is the solution medical or cognitive? J Amer
Med Inform Assoc. 2002;9(6):S75–S77. [PMC free article] [PubMed] [Google Scholar]
7. Bell C, Moore J, Couldry R, Grauer D. The use of individualized pharmacist performance
reports to reduce pharmacist-related medication order entry errors following electronic medical
record implementation. Hosp Pharm. 2012;47(10):771–775. [Google Scholar]
8. Ibáñez-Garcia S, Rodriguez-Gonzalez CG, Martin-Barbero ML, Sanjurjo-Saez M, Herranz-
Alonso A. Adding value through pharmacy validation: a safety and cost perspective. J Eval Clin
Pract. 2016;22(2):253–260. [PubMed] [Google Scholar]
9. Dawson NV, Arkes HR, Siciliano C, Blinkhorn R, Lakshmanan M, Petrelli M. Hindsight bias:
an impediment to accurate probability estimation in clinicopathologic conferences. Med Decis
Making. 1988;8(4):259–264. [PubMed] [Google Scholar]
10. Dawson NV, Connors AF, Jr, Speroff T, Kemka A, Shaw P, Arkes HR. Hemodynamic
assessment in managing the critically ill: is physician confidence warranted? Med Decis
Making. 1993;13(3):258–266. [PubMed] [Google Scholar]
11. Dunlosky J, Thiede KW. What makes people study more? An evaluation of factors that affect
self-paced study. Acta Psychol. 1998;98(1):37–56. [PubMed] [Google Scholar]
12. Karpicke J, Butler A, Roediger Iii H. Metacognitive strategies in student learning: do
students practise retrieval when they study on their own? Memory. 2009;17(4):471–
479. [PubMed] [Google Scholar]
13. Carrier LM. College students’ choices of study strategies. Percept Motor
Skills. 2003;96(1):54–56. [PubMed] [Google Scholar]
14. Bjork RA, Dunlosky J, Kornell N. Self-regulated learning: beliefs, techniques, and
illusions. Ann Rev Psychol. 2013;64(1):417–444. [PubMed] [Google Scholar]
15. Winne PH, Jamieson-Noel D. Exploring students’ calibration of self reports about study
tactics and achievement. Contemp Educ Psychol. 2002;27(4):551–572. [Google Scholar]
16. Kornell N, Bjork RA. The promise and perils of self-regulated study. Psychon Bull
Rev. 2007;14(2):219–224. [PubMed] [Google Scholar]
17. Hacker DJ, Bol L, Horgan DD, Rakow EA. Test prediction and performance in a classroom
context. J Educ Psychol. 2000;92(1):160–170. [Google Scholar]
18. Hartwig MK, Persky AM. Repeated cumulative testing in a classroom: underconfidence-
with-practice for authentic course material. In preparation.
19. Hartlep KL, Forsyth GA. The effect of self-reference on learning and retention. Teach
Psychol. 2000;27(4):269–271. [Google Scholar]
20. Persky AM, Hudson S. A snapshot of student study strategies across a professional pharmacy
curriculum: are students using evidence-based practice? Curr Teach Learn
Pharm. 2016;8(2):141–147. [Google Scholar]
21. Hagemeier NE, Hess R, Jr, Hagen KS, Sorah EL. Impact of an interprofessional
communication course on nursing, medical, and pharmacy students’ communication skill self-
efficacy beliefs. Am J Pharm Educ. 2014;78(10):Article 186. [PMC free
article] [PubMed] [Google Scholar]
22. Persky AM, Alford EL, Kyle J. Not all hard work leads to learning. Am J Pharm
Educ. 2013;77(5):Article 89. [PMC free article] [PubMed] [Google Scholar]
23. Thiede KW, Dunlosky J. Toward a general model of self-regulated study: an analysis of
selection of items for study and self-paced study time. J Exp Psychol Learn Mem
Cogn. 1999;25(4):1024–1037. [Google Scholar]
24. Gureckis TM, Markant DB. Self-directed learning: a cognitive and computational
perspective. Persp Psychol Sci. 2012;7(5):464–481. [PubMed] [Google Scholar]
25. Rehder B, Hoffman AB. Eyetracking and selective attention in category learning. Cogn
Psychol. 2005;51(1):1–41. [PubMed] [Google Scholar]
26. Sitzmann T, Ely K. A meta-analysis of self-regulated learning in work-related training and
educational attainment: what we know and where we need to go. Psychol Bull. 2011;137(3):421–
442. [PubMed] [Google Scholar]
27. Pintrich PR. Issues in self-regulation theory and research. J Mind Behav. 2000;21(1-2):213–
220. [Google Scholar]
28. Zimmerman BJ. Self-efficacy: an essential motive to learn. Contemp Educ
Psychol. 2000;25(1):82–91. [PubMed] [Google Scholar]
29. Kanfer R, Ackerman PL. Motivation and cognitive abilities – an integrative aptitude
treatment interaction approach to skill acquisiton. J Appl Psychol. 1989;74(4):657–690. [Google
Scholar]
30. Dunlosky J, Kubat-Silman AK, Hertzog C. Training monitoring skills improves older adults’
self-paced associative learning. Psychol Aging. 2003;18(2):340. [PubMed] [Google Scholar]
31. Facione PA, Facione NC. Externalizing the critical thinking in knowledge development and
clinical judgment. Nurs Outlook. 1996;44(3):129–136. [PubMed] [Google Scholar]
32. Ku KYL, Ho IT. Metacognitive strategies that enhance critical thinking. Metacogn
Learn. 2010;5(3):251–267. [Google Scholar]
33. Halpern DF. Teaching vritical thinking for transfer across domains: dispositions, skills,
structure training, and metacognitive monitoring. Am Psychol. 1998;53(4):449–
455. [PubMed] [Google Scholar]
34. Hacker DJ, Dunlosky J. Not all metacognition is created equal. New Dir Teach
Learn. 2003;2003(95):73–79. [Google Scholar]
35. Stalmeijer RE. When I say … cognitive apprenticeship. Med Educ. 2015;49(4):355–
356. [PubMed] [Google Scholar]
36. Gallo DA, Geraci L, Iii HLR. Processing approaches to cognition: the impetus from the
levels-of-processing framework. Memory. 2002;10(5):319–332. [PubMed] [Google Scholar]
37. Bransford JD, Johnson MK. Contextual prerequisites for understanding: some investigations
of comprehension and recall. J Verbal Learn Verbal Behav. 1972;11(6):717–726. [Google
Scholar]
38. Finney S, Pyke J. Content relevance in case-study teaching: the alumni connection and its
effect on student motivation. J Educ Busin. 2008;83(5):251–258. [Google Scholar]
39. Frymier AB, Houser ML. Does making content relevant make a difference in
learning? Commun Res Report. 1998;15(2):121. [Google Scholar]
40. Frymier AB, Shulman GM. What’s in it for me – increasing content relevance to enhances
student motivation. Commun Educ. 1995;44(1):40–50. [Google Scholar]
41. Rosenshine B, Meister C. Reciprocal teaching: a review of the research. Rev Educ
Res. 1994;64(4):479–530. [Google Scholar]
42. Schwartz DL, Bransford JD. A time for telling. Cogn Instruct. 1998;16(4):475–522. [Google
Scholar]
43. Beyer BK. Improving Student Thinking: A Comprehensive Approach. Boston, MA: Allyn
and Bacon; 1997. [Google Scholar]
44. Kalyuga S, Ayres P, Chandler P, Sweller J. The expertise reversal effect. Educ
Psychol. 2003;38(1):23–31. [Google Scholar]
45. Tanner KD. Promoting student metacognition. CBE Life Sci Educ. 2012;11(2):113–
120. [PMC free article] [PubMed] [Google Scholar]
46. Hacker DJ, Bol L, Bahbahani K. Explaining calibration accuracy in classroom contexts: the
effects of incentives, reflection, and explanatory style. Metacog Learn. 2008;3(2):101–
121. [Google Scholar]
47. Hartwig MK, Was CA, Isaacson RM, Dunlosky J. General knowledge monitoring as a
predictor of in-class exam performance. Br J Educ Psychol. 2012;82(3):456–
468. [PubMed] [Google Scholar]
48. Nietfeld JL, Cao L, Osborne JW. The effect of distributed monitoring exercises and feedback
on performance, monitoring accuracy, and self-efficacy. Metacog Learn. 2006;1(2):159–
179. [Google Scholar]
49. Schneider EF, Castleberry AN, Vuk J, Stowe CD. Pharmacy students’ ability to think about
thinking. Am J Pharm Educ. 2014;78(8):Article 148. [PMC free article] [PubMed] [Google
Scholar]
50. Karpicke JD, Blunt JR. Retrieval practice produces more learning than elaborative studying
with concept mapping. Science. 2011. 331(6018):772–775. [PubMed] [Google Scholar]
51. Roediger HL, III, Putnam AL, Smith MA. Ten benefits of testing and their applications to
educational practice. Psychol Learn Motiv Adv Res Theory. 2011;55:1–36. [Google Scholar]
52. Mullet HG, Butler AC, Verdin B, von Borries R, Marsh EJ. Delaying feedback promotes
transfer of knowledge despite student preferences to receive feedback immediately. J Appl Res
Mem Cogn. 2014;3(3):222–229. [Google Scholar]
53. Castleberry AN, Payakachat N, Ashby S, et al. Qualitative analysis of written reflections
during a teaching certificate program. Am J Pharm Educ. 2016;80(1):Article 10. [PMC free
article] [PubMed] [Google Scholar]
54. Aleven VAWMM, Koedinger KR. An effective metacognitive strategy: learning by doing
and explaining with a computer-based cognitive tutor. Cogn Sci. 2002;26(2):147–179. [Google
Scholar]
55. Nietfeld JL, Cao L, Osborne JW. The effect of distributed monitoring exercises and feedback
on performance, monitoring accuracy, and self-efficacy. Metacogn Learn. 2006;1(2):159–
179. [Google Scholar]
56. Artino AR, Jr, Dong T, Dezee KJ, et al. Achievement goal structures and self-regulated
learning: Relationships and changes in medical school. Acad Med. 2012;87(10):1375–
1381. [PubMed] [Google Scholar]
57. Uemura M, Tomikawa M, Nagao Y, et al. Significance of metacognitive skills in
laparoscopic surgery assessed by essential task simulation. Min Invas Therap Allied
Technol. 2014;23(3):165–172. [PubMed] [Google Scholar]
58. Perry NE, VandeKamp KO, Mercer LK, Nordby CJ. Investigating teacher-student
interactions that foster self-regulated learning. Educ Psychol. 2002;37(1):5–15. [Google Scholar]
59. Oh RC, Reamy BV. The Socratic method and pimping: optimizing the use of stress and fear
in instruction. Virtual Mentor. 2014;16(3):182–186. [PubMed] [Google Scholar]
60. Brancati FL. The art of pimping. JAMA. 1989;262(1):89–90. [PubMed] [Google Scholar]
61. Detsky AS. The art of pimping. JAMA. 2009;301(13):1379–1381. [PubMed] [Google
Scholar]
62. Tofade T, Elsner J, Haines ST. Best practice strategies for effective use of questions as a
teaching tool. Am J Pharm Educ. 2013;77(7):Article 155. [PMC free article] [PubMed] [Google
Scholar]
63. Jacks ME, Blue C, Murphy D. Short- and long-term effects of training on dental hygiene
faculty members’ capacity to write SOAP notes. J Dent Educ. 2008;72(6):719–
724. [PubMed] [Google Scholar]
64. Chi MTH, Glaser R, Farr MJ. The Nature of Expertise. Hillsdale, NJ: L. Erlbaum Associates;
1988. [Google Scholar]
65. Marcum JA. An integrated model of clinical reasoning: dual-process theory of cognition and
metacognition. J Eval Clin Pract. 2012;18(5):954–961. [PubMed] [Google Scholar]
66. Ertmer PA, Newby TJ. The expert student: strategic, self-regulated, and reflective. Instruct
Sci. 1996;24(1):1–24. [Google Scholar]
67. Schraw G. Promoting general metacognitive awareness. Instruct Sci. 1998;26(1/2):113–
125. [Google Scholar]
68. Coutinho SA. The relationship between goals, metacognition, and academic
success. Educate. 2007;7(1):39–47. [Google Scholar]
69. Hartman H, Sternberg RJ. A broad BACEIS for improving thinking. Instruct
Sci. 1992;21(5):401–425. [Google Scholar]

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