Differences between high- and low-achieving pre-clinical medical students: a qualitative instrumental case study from a theory of action perspective

Figures & data

Figure 1. Theory of action [24].

Table 1. Participants’ demographics.

	High achieving students	Low achieving students
Year
1	5	3
2	9	2
Gender
Male	3	0
Female	11	5
Age
19	5	3
20	7	2
21	2	0

Figure 2. Differences in learning processes between high- and low-achieving students from the Theory of Action perspective.

Figure 3. Learning from negative enabling pathway and transforming it to positive enabling pathway.

Table

High achieving students:
I would like to thank you for your willingness to participate in this study. There are no right, wrong, desirable or undesirable answers. Feel comfortable expressing what you think and how you feel. Kindly go through and respond to each question. 1. Personal Profile  a) Name, date of birth, age, unique or special things about yourself, previous academic experiences, and achievements before entering the university.  b) Family background, hometown, parents’ occupation, parents’ academic background, siblings, family members in the medical profession. 2. Reasons for Studying Medicine  a) Why did you choose to study medicine?  b) Did you have any pre-existing knowledge about the medical profession? If yes, what was the source of this information?  c) You had an excellent pre-university result. Why did you not consider choosing other programs?  d) What motivated you to continue your studies?  e) What kind of doctor do you want to be? 3. Reflection    a) i. Which study approach did you use from the start until the end of the academic year?    ii. Did you encounter any problem using this study approach? How did you cope with the problem?    iii. Elaborate on your study style:  • How did you prepare for lectures/teaching sessions?  • What was your attendance (%) for lectures/teaching sessions?  • Describe your attention/behaviour during lectures/teaching sessions.  • What did you do to review the content after lectures/teaching sessions?  • How did you manage your studies and social activities on weekends?  b) i. How was your social life from the start until the end of the academic year?       ii. Did you encounter any problems in your social life? How did you cope with this problem?  c) i. How was your personal life/family relationship from the start until the end of the academic year?       ii. Did you encounter any problems related to personal life/family relationships? How did you cope with this problem?  d) Is there anything else that you would like to share?  e) i. Would you consider any of the stated study approaches/styles to have contributed to your academic success? Please justify your answer.       ii. What did you think and feel about this study approach/style? Why?       iii. What have you learned from that situation?       iv. Why do you think that situation happened?       v. If you were given a chance to change your action, what would you do?       vi. Based on what happened, what is your plan for the current academic year? Describe.       vii. How will you make sure that you carry out your action plan properly? Describe. Thank you for your time and effort.
Low achieving students: Note: Identical questions except: Question 3(e)(i), the phrase “academic success” was changed to “unsuccessful attempt.”

Table

Prior to commencing the interview, both high- and low-achieving students were: Informed of the purpose of interviews. Given a copy of their consent forms. Confidentiality, anonymity, and the right to withdraw were stated in the consent forms. Asked if they had any questions before the interviews started. After obtaining consent, the interviewer began recording the interviews.

High achieving students:

General questions What happened in the previous academic year? When did you realize that you would score well in the exam? How did you feel after receiving the results? What did you do in the previous academic year? How did you approach learning and studying in your previous academic year? Specific questions What did you do before attending teaching activities such as lectures? (Prompt for specific examples) Why did you do so? (Prompt for reasons) What did you do during the teaching activities? Why did you do so? What did you do after attending the teaching activities? Why did you do so? Hypothetical questions If you could start the academic year over again, which attitude/behavior/action/strategy would you maintain? Why? If you had a chance to talk to your juniors, what is the most important piece of advice that you give them in respect to achieving a better performance in their studies? Why?

Low achieving students:

Note: Identical questions except: Question 1, the phrase “score well” was changed to “fail or score poorly.” Question 3, the phrase “would you maintain” was changed to “would you change.”

Table

No.	Domain	Theme	Sub-theme	Representative quotes
				High-achieving students	Low-achieving students
1	Non-academic	Motivation and expectation	Intrinsic motivation	High achieving student, HA2, reflective journal: “I chose medicine mainly due to my interest inhuman body. I always find it fascinating at how complex and unique a human body is compared to other animals.”	Low achieving student, LA1, Interview: “I considered switching to another course because I have better creativity than logical reasoning skill. This thought has been hidden in my mind for a long time. It may be architecture, drawing, or designing. I did not feel I belong here. I felt lost. I did not even know why I was in the class, I did not want to be there and I just wanted to get out as soon as I could.” LA1, Interview: “I was in a dilemma whether to continue in medical school. I did not understand why I could not have free time whereas my friends from other courses were having the time of their lives. Life in medical school was different from what I had imagined before I entered it. I thought I could spend more time with people and do my favourites. On Instagram, I could see engineering and architecture students were enjoying their lives but all we could do was studying endlessly.”
			Academic Expectation	HA2, Interview: “I had a target for myself that I wanted to get Dean’s award… I had an aim. For every exam that I sit, I try to score the best that I can, not to ‘beat’ anybody but to improve myself. It is a competition against myself to achieve the highest target.”	LA2, Reflective Journal: “I just wanted to pass the examination and did the bare minimum to get through it. I had the bare minimum mindset.” LA1, Reflective Journal: “I don’t know if this is a high expectation but I want to score as high as possible and I want to get the Dean’s award. It seems to be an ambitious goal since I failed the first year but I want to get into the Dean’s list.”
2	Academic	Study methods	Study plan	HA4, Interview: “After the lectures, I planned what I should do. I read the lecture notes and made my notes. I had a plan so that I would have enough time to complete everything before the exam. If I did not plan, I would not know my progress. During the weekend, I could study more because there was no class.”	LA2, Interview: “I had no plan. I just did questions and learned as much as I could. I did not have a plan of what I wanted to do because I thought I already made it to medical school, so why should I try harder? I did not have a plan to review the materials and did not take a systematic approach.” LA2, Reflective Journal: “I have learned that medicine isn’t something that I can do well without enough focus and with the last-minute work. It is something that I need to plan if I want to achieve my goals. I need to reassess my priorities and think about my future and try to come up with a plan.”
			Learning Approach	HA6, Interview: “When I studied, I tried to understand the reasoning behind the topics, instead of just memorizing them blindly. It helps me remember and apply them better.” HA2, Interview: “I could not memorize without understanding because at the end of the day, I need to understand what I am doing as a doctor and I can’t just be doing it out of memorization. If a patient came to ask me ‘Dr, why did this situation happen?’, I wouldn’t be able to explain it by just memorizing it. That’s why I need to understand it in order to give better care.”	LA5, Interview: “I would skim through lecture notes aimlessly. It was just for my satisfaction knowing that I had read the lecture notes. It was not for absorbing any knowledge. I would read all the content and notes that I had done on the slides without understanding them.”
3	Non-academic	Self-management	Time management	HA3, Reflective Journal: “Since the beginning of Year 1, I have made a daily and monthly schedule so that I can manage my time wisely and will not miss any lecture notes.”	LA1, Reflective Journal: “I buried myself in all sorts of entertainment such as watching movies, eating unhealthy food and sleeping. My attention was drawn to many distractions in life, so I did not spend time on my studies. I spent most of my time going out and having fun to escape from the work that was piled up.” LA5, Interview: “I want to change how I use my time before the midterm examination, especially the arrangement of my activities and the mindset that I can catch up with whatever I have missed easily. That was the biggest mistake I have made in my life. There is no way that I can repeat the foundation module, it is too much for me to cover. I will try to manage my time better.”
			Consistency	HA2, Reflective Journal: “I studied consistently every day. I made sure that I kept up with lectures and did not lag at any point in time. I also practice my clinical skills by clerking patients in the wards and taking a history from them as well as practicing physical examinations with my friends. I believe that studying consistently is very important for pre-clinical medical students.”	LA3, Reflective Journal: “I started with full passion by paying attention in classes and did revisions. As the days went by and the subjects became more confused and difficult, I put the difficult subjects aside and focussed on subjects that I found easy.”
4	Non-academic	Flexibility of Mindset	Exposure of Vulnerability and Support Seeking	HA11, Reflective Journal: “No man is an island as no one can achieve something great all by himself/herself especially when it comes to medicine, which revolves around multidisciplinary teamwork. That is why we learn faster and more efficiently by forming study groups for knowledge sharing and discussions.”	LA1, Interview: “I was afraid of disappointing people around me and they would look down on me. I think for all medical students, we must have a certain degree of achievement in our academics to enrol in medical school. Some of us felt insecure when people knew we had questions and doubts because they might think we are not smart enough. I had this thought so I did not dare to ask for academic support. I did not dare to ask for help from my friends and parents. I did not dare to ask their advice when I had those thoughts.” LA1, Interview: “I felt good that I was not afraid to ask help from people anymore. I was not afraid to ask my juniors who have just attended the lecture whereas I have gone through it twice. I was not afraid that they would look down on me because I am repeating the year. I was more focussed on trying to understand the content better. It was a small step but I was very happy. After multiple attempts of asking different people, I finally understood the lecture.”
			Willingness to Adapt to Changes	HA2, Interview: “At the beginning of the second module, I was lost and did not know how to study because my pre-university studying methods couldn’t work here. I had to change my studying methods and it contributed to my good results in the midterm examination.”	LA1, Reflective Journal: “I remained the same ways of studying which I’ve been using since I was in secondary school. It did not work but I did not bother to refine it.” LA1, Reflective Journal: “I did not want to deal with the challenges and only wanted to escape the responsibilities as a medical student.”

Argyris C, Schon DA. Theory in practice: Increasing professional effectiveness. San Francisco: Jossey-Bass Publishers; 1974. p. 224.

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Data availability statement

The datasets collected and analyzed during this study are available from the corresponding author on reasonable request.