Self-directed learning, self-awareness, and metacognition are becoming more heavily emphasized in healthcare education. Metacognitive activities may be used to promote self-awareness and development of effective self-directed learning strategies. Exam wrappers (wrappers) are a metacognitive tool utilized in other areas of higher education that offer students the ability to learn from exam performance by reviewing missed items in a reflective manner. Wrappers encourage structured reflection and planning for future learning.Pharmacy students enrolled in a pathophysiology course were provided structured exam reviews with an opportunity to utilize a wrapper. A baseline questionnaire was given two weeks before the first exam to assess baseline characteristics. Wrappers were provided before Exams 2, 3, 4, and 5, and the effects on exam performance were measured. Mixed effects modeling was utilized for final analysis of effect on student performance.Exam wrapper vs. non-wrapper groups were self-selected, with 53 students participating in at least one wrapper and 35 never utilizing a wrapper. Mixed effects modeling analysis found a non-significant increase in average exam performance (p = 0.142).Wrappers have potential as an additional metacognitive tool for exam review. Further studies are needed to evaluate the effectiveness and impact more broadly in pharmacy education.