Abstract
BACKGROUND: Pharmacy students often struggle with accurate self-assessment of learning outcomes. Many students overestimate exam performance, reflecting poor metacognitive awareness and overconfidence. This study examined the relationships between metacognitive awareness, self-confidence in grade predictions, and academic performance in pharmacy education, thus addressing how these factors interact without inferring causation. METHODS: Pharmacy students (n = 151) at King Saud University participated in this study while enrolled in a Pathophysiology, Drug Action, and Therapeutics course. Surveys were pre-tested and post-tested twice at two midterm examinations to determine their self-reported metacognitive awareness and confidence. Students made predictions for future course grades. These self-tests were then contrasted to actual exam scores. Statistical analysis was performed using R software version 4.3.1, and students were categorized by metacognitive and confidence ability. RESULTS: Despite underperforming on the first exam, students' confidence in their grade predictions remained high. Students with better metacognitive awareness and well-calibrated confidence scored significantly higher on exams (p < 0.01). Metacognitive cognition and confidence were positively associated with academic performance (r = 0.467 and 0.361, p < 0.01), and with each other (r = 0.251, p < 0.01). Gender differences showed higher overall confidence and metacognitive cognition scores in males. DISCUSSION: The results indicate that metacognition and confidence are critical for academic performance. These findings suggest that educational programs targeting self-evaluation warrant further investigation.