Self-assessment and metacognition can be practiced with an exam wrapper (EW). EW is a structured, metacognitive, and self-regulated learning strategy that involves guided self-reflection on an exam already taken to improve study habits. This research describes how internal medicine (IM) residents at two tertiary private hospitals performed in written examinations using an EW. The relationship between the residents' metacognition, the exam wrapper, and exam performance was also determined.

This study employed a pre-experimental pre- and post-test design. The EW was constructed and tested for validity and reliability. It included (1) a description of study habits, (2) accuracy in self-efficacy perception and exam score prediction, (3) perceived reasons for exam mistakes, and (4) future study plans of residents. A complete enumeration of 24 IM residents was conducted. Respondents completed the Metacognitive Awareness Inventory (MAI) at the beginning of the study. The intervention consisted of (1) residents taking Exam 1: Gastroenterology, followed by EW; (2) Exam 2: Endocrinology and EW; then (3) Exam 3: Oncology, EW, and MAI. Scores were compared using a paired t-test or analysis of variance (ANOVA). The relationships between metacognition scores, the EW, and exam performance were determined using the Pearson correlation coefficient. The level of significance was set at p < 0.05.

The final EW comprises 16 items, with overall indices of content validity ratio of 0.72 and item-rated content validity of 0.8. The internal consistency coefficient is 0.65 (Kuder-Richardson 20). Nineteen out of 24 residents (79.17%) completed the study. Mean exam percentage scores were 57.97%, 42%, and 51.16% for Exams 1, 2, and 3, respectively. Exam 2 differed significantly from the other two exams (p = 0 and p = 0.04). EWs for the first two exams were not significantly different and revealed: (1) top study habits included studying right before an exam and skimming the textbook; (2) 68.42% vs. 63.16% accuracy of selfefficacy perception; (3) 26.32% vs. 31.58% accuracy of grade estimation; (4) 31.58% vs. 26.32% accuracy of error analysis; (5) most errors were due to not reading about the topic, and (6) most planned to “read more." Mean MAI scores were 36.79 ± 9.10 (pretest) and 36.05 ± 9.44 (post-test) (p = 0.81). All correlations were not statistically significant.

Residents performed poorly during exams, crammed their studies, preferred low-impact learning strategies, and lacked self-reflection skills and metacognition monitoring. Time issues related to reading or studying were common. There is no significant relationship between metacognition score and exam wrapper use or exam performance in IM residency trainees.