Medical students’ perceptions of the factors influencing their academic performance: An exploratory interview study with high-achieving and re-sitting medical students

Abstract

Background: Little is known about medical students’ perceptions of the factors that influence their academic performance.

Aim: To detect factors medical students, in the final years of their undergraduate medical studies, believe affect their academic performance.

Methods: We conducted semi-structured interviews with high-achieving and re-sitting students in the final two years of their studies in a London medical school. Interviews were recorded and transcribed. Thematic content analysis was conducted. Similarities and differences in factors perceived to affect the academic performance of high-achieving and re-sitting students were identified.

Results: Eight re-sitting and ten high-achieving students were interviewed. Three core themes were identified: engagement with learning; reflections on learning methods and experiences and the application of learning to future practice. High-achieving students showed a greater awareness of what worked in terms of their approaches to learning and coping with difficulty than re-sitting students. There were also differences in the degree of positive engagement with peers, suggesting the positive contribution of socialising with other medical students.

Conclusions: This exploratory qualitative study identified attitudes, behaviours and motivations that appeared to contribute to success or failure at medical school. Our findings suggest ways to improve appraisal, remediation and support mechanisms for students.

Introduction

Given the consequences of not detecting problems in students who go on to either fail, drop out or qualify as problem doctors, it is of great importance that medical school teachers and advisers know what to look out for in their medical students. Struggling students may often pass unnoticed, and continue in their studies with little guidance and feedback (Sayer et al. 2002; Cleland et al. 2005; Denison et al. 2006). When feedback is provided, it often tends to be reactive and aimed at those who have failed a summative assessment (Cleland et al. 2005). In addition, clinical and research commitments and the strain of increasing student numbers further hinder adequate detection and follow-up of students in difficulty, highlighting that there is a ‘human’ gap in the assessment process (Rivis 1996; Challis et al. 1999; Sayer et al. 2002; Cleland et al. 2008).

A systematic review and partial meta-analysis (Ferguson et al. 2002) reported that, while previous academic performance accounted for 23% of the variance in undergraduate performance, other non-academic criteria such as gender, ethnicity, and elements of personality, also impacted on subsequent academic performance in medical school. Additional studies have investigated the effect on academic performance of age (Arulampalam et al. 2007), having a previous degree (Craig et al. 2004), the student's spoken language (De Champlain et al. 2006; Cuddy et al. 2007) and geographic origin (De Champlain et al. 2006), physical, emotional and mental health (Hojat et al. 2002; Austin et al. 2007), social and economic factors (Cooter et al. 2004; Powis et al. 2007) and institutional effects (Arulampalam 2007), but as yet the studies are too few and methodologically disparate to draw firm conclusions (Stephenson et al. unpublished).

But what of medical students’ perceptions about the factors that influence their progression through medical school? To better understand the issues that they believe have affected their progress, we carried out a series of semi-structured interviews with high-achieving and re-sitting medical students in the final years of their studies. This exploratory interview study aimed at capturing the factors possibly associated with academic performance to assist undergraduate medical educators in the development and delivery of appraisal, remediation, and support mechanisms for students.

Table

Practice points

Interviews help students reflect on their learning. Educators could encourage students to see more explicit linkages between education and professional development. Adopting more student-centred approaches could help teach future doctors patient-Centeredness. Students’ ability to reflect upon how they learn and what needs to be learnt is important for their academic and professional development.

Methods

Setting

Face to face, semi-structured interviews were carried out to explore students’ perceptions of factors affecting their academic performance. The interviews were conducted with students from a large London medical school providing a five year undergraduate programme. The study was performed at campus in June and July of the academic year 2007/2008. Approval for the study was obtained from the college's research ethics committee.

Recruitment and selection criteria

Year 4 students, selected on the basis of their academic performance in formative assessments during their fourth academic year 2007-08, were invited to participate. Specifically, Year 4 students who had failed one or both formative examinations and the equivalent number of students achieving the highest marks for the same assessments were invited. In order to achieve an insight into the perceptions of both high- and low-achieving students and since no Year 4 low achievers responded to the invitation, Year 5 students re-sitting the final year were invited to substitute the low achieving students’ group. Therefore, the final study sample consisted of Year 4 high-achieving students and Year 5 re-sitting students. In order to ensure confidentiality, Year 4 students who met inclusion criteria were informed about the study by email via the School's lead Senior Clinical Adviser. Final year re-sit students were invited by email via the Head of Year. Three reminder emails were sent. Participation was voluntary and no incentives were given for the students to participate, other than the opportunity to help future students through their reflections. Interested students contacted the researchers by email and an interview on campus was arranged.

Data collection

Students gave informed consent to the recording of the one-to-one interviews conducted by either MT or ZT. Both interviewers had the same briefing in qualitative interviewing before initiating data collection and had no prior relationship with any interviewee. Neither MT nor ZT was an educator on the medical programme and this was mentioned prior to the interview. A semi-structured interview schedule explored students’ attitudes and approaches to learning, social relationships and conceptualisations of professional life beyond graduation. The topics covered included the reasons that brought them to medicine, their current motivation to become doctors, things that had gone well and less well during their medical studies, learning habits, social situation, and pastoral issues.

Analysis

The interviews were transcribed verbatim and pseudonyms assigned to each interviewee. All transcripts were coded using qualitative data analysis software (QSR NVIVO version 7) and were analysed using thematic content analysis (Smith 1992). Analysis began with open coding describing each section within the transcripts. Using comparison across the transcripts, the open codes were refined into major themes which provided a coding frame for analysis. Similarities and differences in the factors affecting academic performance between the high-achieving and re-sitting students were sought. MT and ZT initially coded the transcribed interviews in NVIVO independently, and KS later evaluated these codings. Through subsequent discussion KS, MT and ZT narrowed the original NVIVO nodes and sub-modes to identify the emergent themes. Verbatim quotes from the interviews are used to illustrate the findings.

Results

In total, 18 students responded to the study's announcement and volunteered to participate. Eight (of the 22) re-sitters of the final year and ten (of seventeen) high-achievers in Year 4 were interviewed. The final sample was thus formed of interviewees who either volunteered participation after receiving an email invite or contacted the researchers after recommendations by friends who had already been interviewed.

The participants have been given pseudonyms to ensure anonymity, which are presented in Table 1 along with information about gender, student and ethnicity. Three core themes were identified with respect to students’ perceptions about their academic performance: engagement with learning, reflections on learning methods and experiences, and the application of their learning to future practice.

Table 1.  Student participants in the interview study.

	Total	Student	Gender	Student status and ethnicity
Re-sitting students (5^th year)	8	Raj	Male	Home student, Asian British
		Meena	Female	International student, Chinese
		Amy	Female	International student, Chinese
		Gita	Female	Home student, Asian British
		Dave	Male	Home student, White British
		Simon	Male	Home student, White British
		Josna	Female	Home student, British Asian
		Prem	Male	Home student, Asian British
High-achieving students (4th year)	10	Becky	Female	Home student, White British
		Andrew	Male	Home student, White British
		Charlotte	Female	Home student, White British
		Cynthia	Female	Home, White European
		Maggie	Female	Home student, White British
		Astrid	Female	Home student, White European
		Charlie	Male	Home student, White British
		Michelle	Female	Hone student, Chinese British
		Helen	Female	Home student, White British
		Brian	Male	Home student, White British

Theme 1: Engagement with learning

Students’ engagement with learning was expressed through their awareness of their own performance and also how they coped with personal and academic difficulties.

Awareness about performance: Given the students in our study were in their 4th and 5th years of medical school the expectation was that they would express some awareness about their own performance and approaches to learning. Many of the high-achieving students were able to provide detailed accounts of how they studied which embodied both positive attitudes towards learning and good study skills. The following quote by Brian was typical: he recounted how he learnt and the techniques employed.

Well I can’t just read and remember. I am someone who reads and writes and then remembers … I am so regimented; I have a real way of doing things … (Brian, high-achieving student)

In contrast, whilst re-sitting students all acknowledged they were responsible for their own learning indicating an internal locus of control, their narratives illustrated passive accounts of learning experiences rather than being actively engaged with their own learning. For Raj, it was failing that acted as a catalyst to promoting insight and as a consequence prompting a change in his study behaviour.

In my 3rd year I was … expecting things on a plate. I know other students … [who] … would go onto wards and maybe examine patients but that was almost too much effort for me to actually off my own bat go and do that … Throughout my life people who comment on me would say that I have ability, but I just don’t apply [myself]. I manage to scrape through and I just do the minimum that is required. I don’t really apply myself … that was my mentality, the way I approached everything … I was very aware of that I could have done, I just chose not to do it … (Raj, re-sitting student)

Dave, a re-sitting student, explicitly refers to hindsight and a consequent change in behaviour and attitude as a result of this understanding.

The first time I did the 5th year, I could have approached it a lot more differently with hindsight. I think my attitude wasn’t right … thinking back on that now I can see so many reasons why … I failed. I mean, some of it is motivation, some of it is confidence but, there were things, that I know didn’t do properly the first time round and that didn’t go very well … (Dave, re-sitting student)

Thus it would seem that, for re-sitting students, whilst the specific reasons for failing may be different, the recognition that their approach to learning may be problematic tends to emerge once they have failed an assessment, or even far beyond that.

Coping with difficulties: The lack of engagement described by re-sitting students was also reflected in relation to coping with other problems. Difficulties with health and social conditions were described by both groups, yet for passing students a problematic health or social condition was confronted with hard work, leaving less time to dwell on the problem, or seen as a separate issue that was not allowed to interfere with studying.

When I got pneumonia … I was so unwell and I was really worried about missing things … It will be like that when we qualify we have got to get used to it … I am quite a mundane person but I also have quite a positive way of seeing things so if something really bad happens I don’t collapse and go woe is me, I tend to think okay something worse is going to happen in the future so it's good this had happened now … I have just got no money, that's very difficult, and it's quite frightening … I am living in … a box room with no window about the size of this table and it's difficult (Charlotte, high-achieving student)

On the other hand, for re-sitters, reduced academic performance was sometimes attributed to life problems. This is reflected by Prem who identified a series of difficulties.

Failing year 5 … that was a terrible blow … other than that I had a period of illness I had sacroiliitis for … a long period … that was a setback as well … I have had a few when you fail a year, umm, that's, that's not the only stress that you have, there are several other things that immediately fall onto you, collapse onto you as a result, financial stress, you know, … personal life … family … your expectations of the future and then … a lot does come crashing down … (Prem, re-sitting student)

Theme 2: Reflecting on learning methods and experiences

Both groups of students readily shared their experiences, and expressed positive feelings about the interview process. For many of the students, the interviews provided an opportunity to reflect on their learning and experiences. For re-sitting students these appeared to offer new revelations about their own individual learning experiences.

I never really [reflected on] whether I had weaknesses in particular things, I never really sort of looked into myself and [said] ‘what am I weak at?’, ‘what am I strong at?’ … I am arrogant, I didn’t think I could be weak, if I was weak in something it's because I hadn’t put any effort into it and if I did do, then I wouldn’t be weak in it … (Raj, re-sitting student).

Theme 3: The application of learning to future practice

Not all students were strongly motivated to study medicine. Three who re-sat the final year were attracted by characteristics of medicine that were possibly not strong enough to motivate them throughout their studies, for example job security, while two of the re-sitters had an unclear idea of what a medical profession entailed.

I was attracted by the fact that it was a 5 year course, I wanted to get out of my parents’ house, and then obviously science was something I was good at and I quite liked the idea of being a doctor … I didn’t know what medicine was like as a profession before I started … it is quiet common in second generation Asian families … irrespective of what parents do … they push their children to do medicine, law, or dentistry and my parents never did that. They keep on asking me to this day ‘Hopefully you are doing this because you wanted to not because we made you do it’ (Gita, re-sitting student).

The assessments were clearly instrumental in their progression yet, whilst high-achievers could articulate the rationale behind the examinations in terms of what knowledge, understanding and skills were being tested vis-à-vis their future practice, re-sitters appeared to see the assessments as an end in themselves rather than providing the foundation blocks for future practice (i.e. academic performance rather than learning goals). For high-achievers, notions of success were to pass well yet for failing students just to pass was enough.

I am … very motivated, but that's partly because I am quite competitive … I aim high and I would be cross if I don’t get it … I just think I have always being quite an ambitious person … (Cynthia high-achieving student).

I have never aimed for more than average … (Prem, re-sitting student).

The following quote from a high-achieving student captures the requirements for studying medicine that go beyond the accruement of academic and clinical skills, to being a professional.

Different people have different attitudes … a lot of people see it as working for the exam whereas I see it as more for working for a career which I think is different … it annoys me when a lot of students get other people to sign them in and but I just think you are cheating yourself there really, but I guess that's the same point, you see it more of a long term thing rather than a short term goal … (Michelle, high-achieving student).

Discussion

The interview study enabled us to identify a number of attitudes, behaviours and motives that appeared to contribute to success and failure in medical school. Three core themes were identified: engagement with learning; reflecting on learning methods and experiences; and the application of learning to future practice. High-achieving students showed a greater awareness of what worked in terms of their approaches to learning than re-sitting students who were often only prompted to think about this once they had failed. High-achieving students seemed more able to reflect on their learning methods and experiences than re-sitting students and high-achievers appeared to be more learning goal orientated than re-sitting students who were more performance goal orientated.

Two subthemes emerged differentiating the two groups: the first was the different approaches in coping with any kind of difficulty with the high-achievers appearing to cope better with difficulty than the re-sitting students and, second, differences in the degree of positive engagement with peers suggesting the contribution of socialising with other medical students to academic performance. Interviews with high-achieving and re-sitting students in the final years of undergraduate medical education provided the opportunity to verify the influence of the emerging themes from two different perspectives.

The interviews presented opportunities for the students to reflect upon their learning which was generally perceived to be a supportive process, consistent with previous studies (Denison et al. 2006).

However, a distinction emerged between the two groups: the high-achievers were better able than the re-sitting students to articulate how they learnt rather than what was needed to be learnt. This awareness of the high-achieving participants suggests a more active engagement with learning. Graffam (2007) has conceptualised active learning as having three interrelated components: intentional engagement which allows the students to enact what they are required to perform; purposeful observation, relating to observing examples of required performance and critical reflection which enables them to attain meaning from their learning experiences. In applying this framework to our students, it could be argued that whilst all students described experiences which provided opportunities to practice skills, for re-sitting students there was minimal to no consequent critical reflection. In the absence of this, students may fail to change their approach to learning because there is little or no recognition that critical reflection is important.

The concept of reflection is now firmly embedded as an essential skill for the competent medical practitioner and accordingly identified as part of the undergraduate curriculum (General Medical Council 2009). There is a growing body of literature which espouses its benefits in relation to developing professionalism (Cruess & Cruess 2006; Stark et al. 2006; Goldie 2008). Schön (1983) makes a useful distinction between ‘reflection-in-action’ and ‘reflection-on-practice’ with the former characterising the more skilled professional who is able to change or recognise that their ‘usual repertoire’ of skills to solve a problem is ineffective or inappropriate and consequently are able to think differently and do something more relevant. We would suggest that there are parallels with how students behave. Medical education now has a much wider spectrum of subject areas as well as teaching and assessment methods reflecting the importance of both science and the arts and humanities (Newble & Cannon 2001). High-achieving students would seem to ‘learn-in-action’, so that they modify their approach to learning cognisant with the subject being taught and examined. In contrast low-achieving students continue to approach learning with the same repertoire of study skills they have always employed and these may only change when and if reflection takes place as a result of failing.

Our study focused on students’ perspectives in the latter years of their education which perhaps suggests a lack of such strategies. However, clearly further research is required, which adopts a longitudinal perspective, to measure the actual impact of these teaching methods on the student's learning. Self-regulation may also provide a theoretical framework through which to both understand and address students’ lack of engagement with their own learning. Durning et al. (2011) discusses how medical educators can assist students in identifying the beliefs and emotions that contribute to their poor academic performance together with teaching critical self-reflection skills and self-regulatory behaviours that can provide strategies to address their inadequate approach to learning.

The students’ lack of active engagement with their learning may also have consequences for the development of professionalism. Niemi (1997) explores the development of professional identity through the assessment of self-reflection during pre-clinical years and described four types of learning logs: committed reflection; emotional exploration; objective reporting; and scant and avoidant reporting.

Niemi's (1997) research did not explore the relationship between self-reflection and academic performance and focused on medical students’ early education, specifically in relation to patient contact. Since the development of professional identity could be argued as central to understanding the application of learning to future practice, it could be expected that students in the final years of their undergraduate studies are more able to demonstrate an understanding of the profession and the requirements of professional practice. Yet the majority of the final year re-sitting students still failed to make explicit connections between their learning and future practice, in contrast to the majority of the high-achievers, despite the fact that the latter had not yet reached the end of their studies.

Clearly medical educators have a fundamental role in determining the learning experienced by medical students. The importance of teaching reflection is recognised within the curriculum with a variety of pedagogical methods being advocated to enable this (Stark et al. 2006; Wald et al. 2009; Aronson 2011). A systematic review of reflection and reflective practice in health profession education concluded that reflection could be usefully employed as a learning strategy yet its role in learning may actually not be evident to students (Mann et al. 2009). It could also be suggested that it may not be evident to all tutors for whom the notion of pedagogy may be somewhat absent (Rajan 2006).

A key sub-theme that emerged was that medical education was recognised to be a very social process and the ability and opportunity to socialise with fellow students was perceived to have an important impact on learning. This beneficial impact was recognised by many high-achievers, while its absence was also mentioned by a number of re-sitting students.

Difficulties in approaching their peers were identified as a problem by a number of re-sitting re-sitting students, especially international or transfer students. Roccas and Brewer's (2002) social identify complexity theory provides a framework for understanding which medical students may choose to interact with. Significantly, when experiencing stress, students tended to construct simplified identities which increased the list of those considered to be ‘others’, i.e. not part of their group, and thereby inadvertently limiting their resources for support and learning. Medical educators could play an important role in ensuring an infrastructure exists, for example through a student mentoring system that could be helpful in enabling socialisation between all groups.

Medical educators, especially within the context of problem-based learning and peer group learning, need to consider how this aspect of the hidden curriculum may impact on the students’ ability to engage with these learning methods. Learning intrinsic in working together fails to take place for those students working in isolation. Being involved in time-tabled small group activities may more easily facilitate this type of learning, rather than students having to negotiate times to meet and discuss tasks. Ensuring medical educators have an understanding of group work theory and dynamics could mean that some of the negative effects and difficulties of working in isolation could be minimised (Elwyn et al. 2001).

The final sub-theme that emerged from our data was the differences in coping with difficulties between the two groups studied. Although few studies have examined the effects of social variables (Lumb & Vail 2004) and health problems on medical student academic performance, it has been suggested that they may contribute to failure (Frischenschlager et al. 2005).

According to our findings the existence of a health, financial or other social problem is neither a unique characteristic of re-sitting students, nor predictive of the student's performance. What clearly emerged was that the coping mechanisms used will make the difference in whether an unfortunate event will have an impact or not on academic performance. Although some of these coping mechanisms may be inherent to the psychological make-up of individual students, a strong pastoral network could help towards developing such mechanisms in overcoming difficulties with minimum long-term consequences in performance.

In conclusion, the themes identified in our exploratory study further aid medical educators to better understand the complexity of learning and its impact on academic performance. On the basis of our findings we recommend that medical educators need to ensure that core pedagogic principles and theory underpin the curriculum. For students to value the importance of how to learn then this must also be explicit in the teaching and assessment methods. However, this requires medical faculties to ensure that the training and infrastructure is available to enable educators to achieve this task (Graffam 2007; Gibbs et al. 2011).

Further research is required to investigate effective ways of training medical educators to mentor and appraise their students, provide effective feedback and encourage low-achieving students to become aware of their difficulties and accept offers of help. Adopting increasingly more student-centred approaches in medical education could prove to be another way of teaching future doctors the value of patient-centeredness in their professional life.

Limitations:

Our response rate was low and there may be several reasons for this including: lack of incentives other than to help future students through sharing of understandings and experiences; lack of interest; problems with email communication and the timing of the study. The latter had great impact on the number of students recruited, especially Year 4 low-achievers. A delay in the ethics committee approval resulted in the study taking place during the Year 4 end-of-year examination period. As a result Year 5 re-sitters were then invited to comprise the low-achieving group. Although it could be argued that they were in a different state of mind when interviewed as opposed to when they initially failed, having a more mature mindset and previous opportunities to reflect on what had gone wrong, we considered that to be more helpful for the purposes of our study and reinforcing of our findings.

It is interesting that the majority of the re-sitting students were from black minority ethnic (BME) backgrounds (see Table 1, six out of eight re-sitting students). A recent systematic review and meta-analysis reported that BME medical students do significantly underperform when compared with white counterparts (Woolf et al. 2011). However, given that our sample size was small and exploratory in nature, with no claims to representation, we cannot draw any conclusions in this regard, and also significantly none of the interviewees referred to this aspect of their identity in relation to their progression through medical school.

Finally, participation was voluntary so it could be argued that the perspectives of these students could be different from those not willing to participate. Thus combined with the small sample size, the findings cannot make claims to generalisability. However, we would suggest that our findings do have transferability to other student groups and educational settings.

Acknowledgements

The authors wish to thank Dr Richard Philips (Final Year Lead) and Dr Sue Clarke, (Senior Clinical Advisor, now retired) and our interviewees who devoted their time and personal reflections.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

Ethical approval: This study was approved by the King's College London Research Ethics Committee (CREC/07/08-192).