Have you ever had a patient sitting on your examination table waiting for you to explain what’s wrong with her? You rack your brain, review the test results again, and then simply admit you’d like to refer her to a specialist. At the moment you thought to yourself, “I am not sure I know the answer,” you were engaging in thinking about your own knowledge.
This is a quintessential human ability — to think about thinking, or metacognition. And it’s a necessary one in medicine especially, because metacognition and learning are mutually reinforcing. Do you know what you know and what you don’t know?
Some metacognitive thoughts you may have had:
- I know a lot about high blood pressure, but I know almost nothing about delivering babies.
- I find the procedures used to diagnose sports injuries difficult to do.
- I am a fantastic test-taker.
Metacognition is not just thinking about thinking, though, say developmental psychologists: it’s the ability to control your own cognitive processes. Of course, some people are better at metacognition than others, but even metacognition can be improved if you practice at it.
Metacognition and Learning: Recognizing Your Own Abilities
While you may have been clear about your lack of skills in medical school and residency, you are probably not as sure of what you do and don’t know once you’ve been in practice for a while. Guidelines constantly change, new treatments become available, and patients sometimes present with uncommon syndromes.
Medical education researchers have conducted studies showing that overconfidence, which is essentially a lack of metacognition, is one of the causes of diagnostic and treatment errors. Of course, to we all make mistakes, and it’s impossible to know everything. But taking steps to understand the gaps in your knowledge, for example, the baby step of humbly saying you don’t actually know something — even to yourself! — is a step in the right direction.
Perceiving the Difficulty of a Task
Procedural knowledge or task knowledge is metacognitive in nature because is it self-referential: an assignment may seem difficult to one person but easy to another. In practice, knowing that you find some tasks more difficult than others can maximize your potential to do great medicine.
For example, if you knew that performing physical exams and taking oral histories came naturally to you and you found those tasks easy but found it difficult to remember all the possible differential diagnoses for each set of symptoms remained a difficult process for you, you might (knowing this about yourself) rely more heavily on point-of-care decision-making software. Or you might spend some time every night testing yourself via a question bank, focusing on the aspects of patient care that you find difficult.
Strategies for Learning
Mnemonics, self-testing, reading journal articles, and other strategies for keeping your medical knowledge up-to-date are also metacognitive in nature. The ability to use strategies to learn is metacognitive because it requires you to understand how you’re learning, not just what you’re learning.
Studies have shown that, while testing is the most effective method for remembering, many people believe that “studying” (mainly reading and re-reading) is a more effective way to learn and review information. Both students and professionals misperceive studying as effective because they think they are committing the material to memory while they are reading it over. When they are subsequently tested on the material, however, they often realize that they did not actually memorize the material but merely recognized that they had learned it before. This is a common metacognitive error; real self-awareness occurs when you test yourself and see what you actually know and don’t know.
Metacognition and Learning in NEJM Knowledge+
You’ll find that in NEJM Knowledge+, several aspects of metacognition are evident in using the question bank and reports the platform offers. From the first step of deciding which topic to delve into initially, you may ask yourself, “which topics do I know well, and which topics am I weak in?” Then when you click on a module, say “Endocrinology” or “OB/GYN,” you will have to declare how confident you are on each of the subtopics listed, such as “Diabetes.” Do you know much about diabetes? Sliding the confidence slider down into the red zone will will prime the system to serve you multiple questions that support the same underlying learning objectives about diabetes, so that you may start to close that knowledge gap.
As you answer the multiple-choice and fill-in-the-blank questions, you’ll answer “how confident are you?” (these buttons submit your answer). Choosing your level of confidence requires you to think, however briefly, about your own knowledge. “Do I really know this?” In addition, the system uses your confidence data to help determine which items you need to see again — often in the form of a slightly different question — to reinforce the metacognition and learning. So if you answer correctly but with low confidence, the algorithm will treat that like a wrong answer, and make sure to reinforce that learning.
Finally, in the reports, you’ll see how your confidence aligns (or does not align) with your performance.
Have you tried to improve your metacognitive skills or attempted to close your knowledge gaps? Tell us about your experience with metacognition and learning in the comments.