Abstract
Objectives: To determine the motivation and incentives in education, learning experience and teaching techniques, and expectations about future careers among medical students from a multi-ethnic Asian country.
Methods: Pre-validated questionnaire-based survey with stratified random sampling among medical students. The questionnaire combined qualitative responses with semi-quantitative measures of available alternatives.
Results: The response rate was 83.1%. The most important factor for pursuing university study was ‘prospect of finding an interesting challenging job’ (rank 1–75%). Family made a significant contribution in decision making. Given the chance, a majority (67.2%) of respondents would prefer to study overseas. The main deterring factors were cost (67.7%), distance from home (28%), and local opportunity for post-graduation (23.4%). Despite their inclination of study overseas, the majority (73.9%) of the respondents indicated they were either very satisfied or satisfied with their current choice of university study. Only 20% of students were comfortable in asking questions in classroom as asking questions was deemed ‘too risky’ and ‘unnecessary to get better grades’. Students adopted strategies related to assessment and competition to monitor their study. Senior students reported university education as less relevant to their future careers as compared to junior students (p = 0.002).
Conclusions: Students’ learning behaviour is determined by complex factors such as educational incentives, learning support, assessment and competition. Among several external factors, family, job prospects and expectations about the future play a critical role in education.
Introduction
What motivates students to enter medical schools? What study habits do they have? What are their perceptions about teaching and learning methods that are used in the university? What is the role of grades or assessment in their learning? What excites or inhibits students to participate in the classroom? What are their expectations about their future careers? These are some of the practical questions that continue to intrigue educators and curriculum planners across Asia-Pacific and beyond. Unfortunately, there are not many studies which explore these questions for Asian students.
Studies that explore learning styles or learning behaviour of ‘Asian students’ can be found with relative ease. Tools that are used commonly are Kolb Learning Style Inventories, Biggs’ Study Process Questionnaire (Kember & Gow 2001) and Approaches to Studying Inventory by Entwistle and Ramsden (Smith Citation2001). Generally, these instruments or inventories categorize students’ learning habits or preferences into dimensions such as abstract versus concrete learning, activists versus reflectors, and surface versus deep or achieving. Despite their usage and adaptation, the practical utility and usefulness of these instruments remain debatable as ‘“stereotyping” may be convenient for statistical analysis but it is less helpful in terms of teaching students.’ (Diaz & Cartnal Citation1999).
Recently, the very notion of the existence of a ‘fixed’ learning style was challenged (Walsh Citation2008). Learning styles are context- and topic-dependent and not uniform or holistic (Laurillard Citation1979). It is likely that a learner will change his/her learning style based on the circumstances and challenges posed by a specific learning task. Therefore, it might be more meaningful to explore study habits, motivation and expectations of the learner instead, as these variables are less dependent on a student's circumstantial learning ‘strategy’.
Furthermore, transmigration and international students are growing trends in education. With the increasing affluence of Asian countries, more Asian students are seeking to study in overseas universities. For example, 2007 data from Australia show that there are 210,956 overseas students in higher education in Australia and they constitute 17% of all university students. The majority of these students come from China, Malaysia, and India (Kabe Citation2007).
Therefore, we have adopted a more pragmatic and need-based approach to delineate issues that are of practical value to teachers by initiating a study of a multi-ethnic medical student group in Singapore. Our specific study objectives are to determine motivation for pursuing university study, perception of learning experience and teaching techniques, expectations from the teachers, incentives prevailing in the current educational system, role of assessment in learning and expectations about future careers.
Methods
This was a questionnaire based cross-sectional survey.
Context
This survey was carried out at the Yong Loo Lin School of Medicine at the National University of Singapore (YLLSoM). The University actively promotes multi-culturalism and identifies the diversity of student population as one of its main strengths.
In YLLSoM, students enter after 12 years of pre-university education. Medical students come from varied backgrounds with a majority of the students from the ethnic Chinese community in line with the country's demographics. Other ethnic groups include Indian, Malay and a small minority of other races. The medical school follows a 5-year undergraduate curriculum.
Questionnaire
The questionnaire was developed in association with the University of New South Wales (UNSW), Australia. The questionnaire consists of 32 questions organized in four sections: background (12 questions), motivation for studying at university (4 questions), perception of learning and teaching techniques (14 questions) and expectations about future career (2 questions). Unlike the established tradition of using student questionnaires to analyse, in depth, particular behaviours and beliefs, the questionnaire was purposely broad so that it could be used to analyse various aspects of student learning, and promote interdisciplinary analyses.
A key characteristic of the questionnaire was its combination of qualitative assessment of statements as measured by a Likert scale (e.g. ‘How important is it for you to get a high mark?’: very much, much, indifferent, not much, not at all) with semi-quantitative measures of available alternatives (e.g. ‘Please rank what motivates you most (a) getting high marks, (b) developing research skills, (c) learning about a new subject, (d) being involved in university activities, (e) other – please specify’). This choice was motivated by the fact that it enables us to map student responses directly.
The questionnaire administered at YLLSoM was an adaptation of a survey carried out across most faculties at NUS and UNSW in 2004 and 2005, respectively, as part of an international project focusing on students’ learning experiences and expectations in Singapore and Australia (Tani et al. Citation2006a, 2006b; Tani Citation2008).
Except the questions on background, most of the questions in the remaining sections were predetermined from focus group and pilot surveys.
Study population and sampling
The study was carried out among Year 2, 3, 4 and 5 students of YLLSoM. A random sample representing 30% of the student cohort was drawn up, as, based on an assumed 80% response rate, it would yield a statistically robust confidence interval (75–85%) from which to draw inferences on the larger population of interest.
Data collection and statistical analysis
We asked selected students to complete a paper and pencil version of the questionnaire. A Research Officer collected the data and entered the data into an Excel format. We carried out a second check on the entered data to ensure accuracy and established >99% of correctness of the data.
All statistical analyses were carried out by a qualified statistician (CYH). Apart from descriptive statistics, associations between certain relevant questions (whenever deemed to be appropriate) were assessed using Chi-square or Fisher's Exact tests with statistical significance set at p < 0.05. For example, Question 14 (‘If you were given a choice, would you rather study overseas?’) was cross-tabulated with question 16 (‘Are you satisfied with your choice of University study?’). For questions requiring ranking, we report rank 1, rank 2 and rank 3 for each item under the questionnaire.
Results
Demographics
The overall response rate was 83.1% (192 out of 237). For individual year, the response rate was as follows: Year 2–90% (58 out of 64), Year 3–75.4% (43 out of 57), Year 4–92.9% (53 out of 57) and Year 5–64.4% (38 out of 59). 40.6% students were female and 58.9% were male. 89.1% were ethnic Chinese, the rest were Indian (7.8%), Malay (1.6%) and Eurasian (1.0%). The proportion closely resembles gender and ethnic distributions of the student population in general.
Most (49%) speak English either solely in their home or in combination with another language. 43% of the students have fathers with university degrees and 33% students have mothers with university degrees.
Motivation to undertake university study
The results suggest that ‘Prospect of finding an interesting challenging job’ is the leading motivation for students to pursue university studies. 75% of the students identified this as the top reason to undertake university study. This was followed by ‘Job that pays well’ which was ranked 1 and 2 by 11.5% and 34.5% students, respectively ().
Figure 1. Motivation to undertake university studies according to rank.
We also grouped the responses into most important, important and least important based on their relative importance. summarizes the grouping of the student responses.
Box 1 Motivation for undertaking university studies
As indicated in , the most important considerations for the students surveyed are related to their career choices in the labour market for medical graduates, followed by personal development and the fulfilment of family expectations. Peer pressure does not appear to have a substantial impact on the choices of YLLSoM students.
Studying overseas as an option
A total of 67.2% students (129 out of 191 valid responses) indicated that if they had been given the choice they would rather study overseas. The remaining 32.1% (61 out of 191 valid responses) indicated ‘no’ to this question. Given that a large proportion of students would prefer to study overseas, we explored the issue further. The main reasons that had deterred their overseas study were, in descending order of importance, cost of study (67.7%), distance from home (28.1%), and option to apply for post-graduate study (23.4%). Other less frequent factors identified were: marks below requirements (6.3%), language (6.3%), visa requirements (7.3%) and applied but unsuccessful (8.3%). The cumulative response exceeded 100% as some respondents indicated more than one reason as deterring factors for not pursuing overseas study.
However, despite their inclination to study overseas, the majority (73.9%) of the respondents indicated they were either very satisfied or satisfied with their current choice of university study. Only, 9.6% indicated they were unsatisfied or very unsatisfied with their choice. There was no statistically significant difference (p = 0.675) in level of satisfaction with university study between those who wanted to pursue overseas study and those who did not.
Objectives and importance of education
Students were asked about their objectives of pre-university and university education with a similar set of responses.
The top three reasons identified by the students as their own objectives of pre-university education were to gain knowledge about the future career (rank 1 = 36.4%), to get good grades (rank 1 = 21.5%) and to develop an ability to learn on his/her own (rank 1 = 19.3%) ().
Figure 2. The objective of pre-university education according to ranking.
However, the pattern of responses was slightly different with regards to their university education. Although the top three objectives were the same, they differed in their relative importance. A significantly large number of students (p < 0.05) responded that gaining the knowledge for future career was the most important objective of university education. The top three important objectives of learning in university were: (a) to gain the knowledge for future career (rank 1 = 66.8%), (b) develop ability to learn on my own (rank 1 = 17.4%) and (3) finding out a future career path (rank 1 = 10.5%) ().
Figure 3. The objectives of university education according to ranking.
Characteristics of university teachers
Three questions pertain to teachers and their roles. They are related to characteristics of teachers valued by the students, academic and non-academic roles of the university teachers.
The most important characteristics that the students valued in their teachers, in descending order of importance, were: knowledge about the subject matter (rank 1 = 31.4%), being friendly and approachable (rank 1 = 27%) and organized teaching materials (rank 1 = 21.6%). Of moderate importance were: openness to student discussions and comments, ability to challenge students’ initial perception. The least important factors identified were the methods of assessment and ability to entertain ().
Figure 4. Characteristics of the university teachers valued by students.
Students believed university teachers should facilitate students participation without forcing it, fully and carefully explain the knowledge written in the textbooks and, when necessary, force students to think independently. Of moderate importance were to let students discover without much guidance and solve exercises and past examinations. This result is consistent with that found for medical students at UNSW (Ho & Tani 2006) ().
Figure 5. Academic role of university teachers.
Beyond academic responsibilities, the two most important additional roles of the teachers expected by the students are to provide information about future career prospects (49.7%) and be personable (37.3%). Others such as listening to personal problems and finding a job or vacation job did not get high priority.
Study habits
Four questions in the survey are pertinent to study habits. They are related to monitoring of learning, factors that stimulate learning, classroom questioning habits, and the role of assessment.
A majority of the students (63.1%) indicated that they monitored their understanding of the topic. The methods of monitoring for self-efficacy were versatile. The three most important strategies adopted were all related to assessment and competition: comparing own knowledge with peers (rank 1 = 27.3%), doing class tests and exercises (rank 1 = 21.3%) and reading past exams (rank 1 = 20.2%) ().
Figure 6. Monitoring of study habits (rank 1, 2, and 3).
Students adopted and practised versatile means and preferred multiple enabling factors in the classroom to stimulate their learning. The most important factor identified by the students was ‘I am encouraged or forced to ask questions in lecture’ (rank 1 = 20.2%). Other important factors were researching own topics, working with peers, and teachers creating a friendly atmosphere ().
Box 2 Stimulating learning
As Asian students are generally perceived to be reticent in the classroom and are believed to be not forthcoming in asking questions, we explored this issue in greater detail. Results shows only 20% students actually felt comfortable in asking questions in the classroom, as opposed to 44.2% of the students who did not feel comfortable. The remaining 27.9% students were ambivalent.
Reasons for not asking questions during the lecture are revealing. The two most frequent reasons cited for not asking questions were ‘too risky’ and ‘unnecessary to get better grades’. Students who did not feel comfortable in asking questions were more likely to do so because questioning was ‘too risky’ (p < 0.001) and ‘unnecessary to build up confidence’ (p = 0.07) compared to the students who felt comfortable in asking questions ().
Box 3 Reasons for not asking questions
As expected, for the majority of students (54%) getting a good grade was important. For only 7.4% students it did not matter much. All the items listed in the questionnaire featured prominently in their reasons for pursuing a better grade. In descending order of frequency they were: ‘it makes me feel as capable as my friends’ (67.7%), ‘it meets my family's expectations’ (51.4%), ‘gives me prestige and honour’ (49.2%) and ‘leads to highly paid job’ (47.6%).
Future career
Overall, 91% of the students believed university education was directly relevant to their future careers. However, the Year 5 students who had gone through more practical experience such as direct patient care reported lesser relevance of University education to their future needs as compared to Year 2 students (p = 0.002).
Students believed that the most important factor that the employer valued is ‘ability to think on my own feet’ (rank 1 = 46.2%), followed by ‘university granting the degree’ (rank 1 = 19.9%) and ‘immediacy of knowledge gained’ (rank 1 = 16.1%), and ability to ‘undertake new initiatives’ (rank 1 = 10.2%). Intriguingly, grades that the students received were not seen as an important factor that future employers might consider ().
Figure 7. What employers value (rank 1, 2, and 3).
These results support the view that university students are well aware of what employers expect and look at the formative university years as a necessary step to gain practical knowledge at university, which can be immediately applied upon graduating.
Conclusions
This is one of a very few exploratory surveys from Asia on students’ motivation to pursue higher education in medicine. The survey is unique as the student population is diverse with a mixture of ethnic Chinese, Indian and Malays who are pursuing education at an aspiring global university.
The study vindicates several perceptions about the social structure and psyche of Asian students living and growing up in a cosmopolitan city. Our study validates that the very important role of family in decision making with regard to the choice of university and country in pursuing higher education. An immediate implication of the finding is that a university should take a more proactive role in educating prospective families about careers in medicine.
The study cohort has shown the important role of assessment and competitive behaviour in learning. ‘Not losing my face’ is known to be a deeply ingrained trait among the (Singapore) Asian Chinese population. However, this particular behaviour also makes them less participatory in classroom teaching. Students show great reluctance in asking questions in the classroom because asking questions does not directly add value to their formal grades or asking questions is perceived to be ‘too risky’. Similar findings were also noted by prior researchers (Hawthorne et al. Citation2004).
In this study, a good teacher is defined by content expertise and personal attributes such as being approachable, friendly and having empathy towards the students. This is a more balanced definition of the role of a good teacher – between the traditional authoritarian model and the more facilitatory role espoused by newer learning and teaching paradigms. Given the highly competitive environment and concern for the future career, it is not surprising that the students valued career counselling as one of the most important attributes of the teachers (Buddeberg-Fischer & Herta Citation2006).
It is interesting to note the differing opinions between Year 2 and Year 5 students with regard to the relevance of formal education to future practice. Year 5 students, with more insight into the complex dimension of patient problems, viewed undergraduate education as less relevant to future practice compared to Year 2 students whose education is primarily theory-based. This is perturbing as contextualizing the learning is an essential goal in professional courses such as medicine. This presents definite challenges to the teachers, as there is a need to make learning experiences more meaningful for future practice.
Implications for practice
How do we translate the findings into practical and actionable points that would result in more meaningful education for the students? Given that education is a complex construct it is not surprising that motivation, incentives and perception of study are also multifaceted and any recommendation may appear to be too simplistic. However, in our collective opinion here are some of the more important practice points for educators.
Limitations
We would like to highlight several limitations of this study. This is from a medical school of a single University in Singapore. Extrapolation of this study's findings to the larger population should be done cautiously. Stereotyping of a particular group is unwarranted and discouraged.
We hope this study will result in further conversation around the issues such as student selection, motivation to learn, contextualization and relevance of education and career choice and counselling. This study is not intended to be a substitute for in-depth research and analysis, which it hopes to stimulate.
Acknowledgement
The study was funded by the NUS Provost Office Education Grant. The authors gratefully acknowledge the contribution of the medical students for their time and the Provost Office, National University of Singapore for grant support.
Prior Presentation: Excerpts from this study were presented to ANZAME08 as an abstract.
Ethical approval
The study was approved by the Institutional Review Board (IRB Approval Number 05-109E). All responses were confidential. There was no identifying information.
Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.
Additional information
Notes on contributors
Zubair Amin
Dr ZUBAIR AMIN is an Assistant Professor in Paediatrics and Deputy Head of Medical Education Unit at YLLSoM. His contributions are: study design, implementation, securing funding, data interpretation, writing the first draft of the manuscript and critical review and intellectual enhancement of the manuscript.
Massimiliano Tani
Dr MASSIMILIANO TANI is a Senior Lecturer in the Department of Economics at Macquarie University, New South Wales, Australia. His contributions are: developing the questionnaire, study design, securing funding and critical review and intellectual enhancement of the manuscript.
Khoo Hoon Eng
Dr KHOO HOON ENG was an Associate Professor in Biochemistry and Deputy Head of Medical Education Unit at YLLSoM at the time of this study. She is currently the Vice-President for Academic Planning at the Asian University for Women (AUW) Support Foundation, Cambridge, MA, USA. Her contributions are: study design, implementation, securing funding and critical review and intellectual enhancement of the manuscript.
Dujeepa D Samarasekara
Dr DUJEEPA D SAMARASEKARA was a Senior Medical Educationalist at the Medical Education Unit of YLLSoM at the time of this study. He is currently the Deputy Head of Medical Education. His contributions are: data interpretations and analysis and critical review and intellectual enhancement of the manuscript.
Chan Yiong Huak
Dr CHAN YIONG HUAK is the Head of Section of Biostatics’ at YLLSoM. His contributions are: study design, data analysis and interpretation and intellectual enhancement of the manuscript.
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Appendix: Survey of students’ learning
This survey aims at understanding on how students in Singapore and Australia learn in the context of their backgrounds and expectations of post-university life. Your participation is much appreciated. Your response will remain confidential.
Dr Zubair Amin & A/Prof Khoo Hoon Eng
Part 1: Student background
Part 2: Motivation for studying at university
Choose either one or rank your answers in order of importance (using 1, 2, 3, etc, with 1 = most important), if more than one answer applies for you
Part 3: Perception of learning experience and teaching techniques
Choose either one or rank your answers in order of importance (using 1, 2, 3, etc, with 1 = most important), if more than one answer applies for you
Part 4: Expectations about post-university life
Choose either one or rank your answers in order of importance (using 1, 2, 3, etc, with 1 = most important), if more than one answer applies for you
Many thanks for your time and good luck with your studies!