Tim J. Wilkinson

Introduction Self‐monitoring of clinical‐decision‐making is essential for health care professional practice. Using certainty in responses to assessment items could allow self‐monitoring of clinical‐decision‐making by medical students to be tracked over time. This research introduces how aspects of insightfulness, safety and efficiency could be based on certainty in, and correctness of, multiple‐choice question (MCQ) responses. We also show how these measures change over time. Methods With each answer on twice yearly MCQ progress tests, medical students provided their certainty of correctness. An insightful student would be more likely to be correct for those answers given with increasing certainty. A safe student would be expected to have a high probability of being correct for answers given with a high certainty. An efficient student would be expected to have a sufficiently low probability of being correct when they have no certainty. The system was developed using first principles and data from one cohort of students. A dataset from a second cohort was then used as an independent validation sample. Results The patterns of aspects of self‐monitoring were similar for both cohorts. Almost all the students met the criteria for insightfulness on all tests. Most students had an undetermined outcome for the safety aspect. When a definitive result for safety was obtained, absence of safety was most prevalent in the middle of the course, while the presence of safety increased later. Most of the students met the criteria for efficiency, with the highest prevalence mid‐course, but efficiency was more likely to be absent later. Discussion Throughout the course, students showed reassuring levels of insightfulness. The results suggest that students may balance safety with efficiency. This may be explained by students learning the positive implications of decisions before the negative implications, making them initially more efficient, but later being more cautious and safer.