Preclinical and Clinical Medical Students’ Perception of the Learning Environment: A Reference to the Forensic Medicine and Clinical Toxicology Course

Figures & data

Table 1 Demographic and Educational Profiles of the Respondents Who Participated in the Current Study

Age/Gender and Previous Year GPA	Traditional MBBCH System (n=307)		Integrated MSBP-CB System (n=314)		Total (n=621)		Test of Significance	p value
	n	%	n	%	n	%
Age:
< 20 years	9	2.9	309	98.4	318	51.2	χ^2 =566.342	0.000*
≥20 years	298	97.1	5	1.6	303	48.8
Gender:
Male	160	52.1	142	45.2	302	48.6	χ^2 =2.954	0.086
Female	147	47.9	172	54.8	319	51.4
Previous year GPA
Excellent	143	46.6	141	44.9	284	45.7	χ^2 =1.781	0.776
Very good	95	30.9	96	30.6	191	30.8
Good	54	17.6	66	21.0	120	19.3
Fair	10	3.3	7	2.2	17	2.7
Fail	5	1.6	4	1.3	9	1.4

Notes: χ², chi square test. *Significant at <0.05.

Abbreviations: GPA, Grade Point Average; n, number.

Table 2 Comparison Between the Traditional MBBCH and Integrated MSBP-CB Systems Regarding Mean Total DREEM and Its Subscales’ Scores

Total DREEM and its Subscales	Interpretation	Traditional MBBCH System	Integrated MSBP-CB System	Total	Z Score of Mann Whitney U-test	p value
		Mean ± SD	Mean ± SD	Mean ± SD
SPL (maximum=48)	A more positive perception	25.78 ± 4.84	26.57 ± 5.02	26.18 ± 4.94	−2.588	0.010*
SPT (maximum=44)	Moving in the right direction	28.97 ± 5.53	29.16 ± 5.97	29.06 ± 5.75	−0.754	0.451
SAP (maximum=32)	Feeling more on the positive side	18.69 ± 4.82	19.64 ± 4.82	19.17 ± 4.84	−2.648	0.008*
SPA (maximum=48)	A more positive attitude	28.28 ± 6.63	27.64 ± 7.11	27.95 ± 6.87	−0.546	0.585
SSP (maximum=28)	Not too bad	15.98 ± 3.41	16.14 ± 3.26	16.06 ± 3.33	−0.386	0.699
Overall DREEM (maximum=200)	More Positive than Negative	120.25 ± 21.78	121.81 ± 22.91	121.04 ± 22.35	−1.400	0.161

Note: *Significant at <0.05.

Abbreviations: SD, standard deviation; DREEM, Dundee Ready Education Environment Measure; SPL, student’s perceptions of learning; SPT, student’s perceptions of teachers; SAP, student’s academic self-perceptions; SPA, student’s perceptions of atmosphere; SSP, student’s social self-perception.

Table 3 Level of Scores of the DREEM Inventory and Its Subscales Among Participants Enrolled in Both Systems and Recruited in the Current Study

Level of Score Based on Domains	Traditional MBBCH System (n=307)	Integrated MSBP-CB System (n=314)	Total (n=621)	Test of Significance	p value
	n (%)	n (%)	n (%)
Total DREEM
Very poor	2 (0.7%)	2 (0.6%)	4 (0.6%)	χ^2 =2.054	0.561
Plenty of Problems	40 (13.0%)	52 (16.6%)	92 (14.8%)
More Positive than Negative	247 (80.5%)	238 (75.8%)	485 (78.1%)
Excellent	18 (5.8%)	22 (7.0%)	40 (6.4%)
SPL
Very Poor	5 (1.6%)	4 (1.3%)	9 (1.5%)	FE=4.270	0.199
Teaching is viewed negatively	99 (32.2%)	79 (25.2%)	178 (28.7%)
A more positive perception	202 (65.8%)	229 (73.2%)	431 (69.5%)
Teaching highly thought of	1 (0.3%)	1 (0.3%)	2 (0.3%)
SPT
Abysmal	2 (0.7%)	2 (0.6%)	4 (0.6%)	χ^2 =0.757	0.860
In need of some retraining	29 (9.4%)	34 (10.8%)	63 (10.1%)
Moving in the right direction	215 (70.0%)	210 (66.9%)	425 (68.4%)
Model teachers	61 (19.9%)	68 (21.7%)	129 (20.8%)
SAP
Feelings of total failure	8 (2.6%)	5 (1.6%)	13 (2.1%)	χ^2 =4.042	0.275
Many negative aspects	87 (28.3%)	74 (23.6%)	161 (25.9%)
Feeling more on the positive side	183 (59.6%)	194 (61.8%)	377 (60.7%)
Confident	29 (9.4%)	41 (13.1%)	70 (11.3%)
SPA
A terrible environment	5 (1.6%)	10 (3.2%)	15 (2.4%)	χ^2 =3.385	0.280
There are many issues which need changing	72 (23.5%)	88 (28.0%)	160 (25.8%)
A more positive attitude	208 (67.8%)	198 (63.1%)	406 (65.4%)
A good feeling overall	22 (7.2%)	18 (5.7%)	40 (6.4%)
SSP
Miserable	5 (1.6%)	4 (1.3%)	9 (1.4%)	χ^2 =0.742	0.863
Not a nice place	84 (27.4%)	91 (29.0%)	175 (28.2%)
Not too bad	205 (66.8%)	209 (66.6%)	414 (66.7%)
Very good socially	13 (4.2%)	10 (3.2%)	23 (3.7%)

Abbreviations: N, number; χ², chi square; FE, Fischer’s exact test; DREEM, Dundee Ready Education Environment Measure; SPL, student’s perceptions of learning; SPT, student’s perceptions of teachers; SAP, student’s academic self-perceptions; SPA, student’s perceptions of atmosphere; SSP, student’s social self-perception.

Figure 1 Comparing the traditional MBBCH and the integrated MSBP-CB systems regarding mean total DREEM and its subscale scores.

Table 4 Comparison Between the Traditional MBBCH and Integrated MSBP-CB Systems Regarding the Mean Item Scores

Subscale	Item	Mean Item Score			Z Score of Mann Whitney U-test	p value
		Traditional MBBCH System	Integrated MSBP-CB System	Total
SPL	1. I am encouraged to participate in class	2.87	2.93	2.90	−0.299	0.765
	7. The teaching is often stimulating	2.51	2.68	2.60	−2.238	0.025*
	13. The teaching is student-centred	2.45	2.53	2.49	−1.087	0.277
	16. The teaching helps to develop my competence	2.56	2.68	2.62	−1.806	0.071
	20. The teaching is well focused	2.67	2.68	2.68	−0.141	0.888
	22. The teaching helps to develop my confidence	2.43	2.52	2.48	−1.200	0.230
	24. The teaching time is put to good use	2.55	2.29	2.42	−3.173	0.002*
	25. The teaching over emphasizes factual learning ^#	1.45	1.60	1.53	−1.645	0.100
	38. I am clear about the learning objectives of the course	2.60	2.67	2.63	−1.394	0.163
	44. The teaching encourages me to be an active learner	2.44	2.46	2.45	−0.552	0.581
	47. Long-term learning is emphasized over short-term learning	2.30	2.43	2.37	−1.684	0.092
	48. The teaching is too teacher-centered ^#	1.50	1.75	1.63	−3.180	0.001*
SPT	2. The teachers are knowledgeable	3.28	3.21	3.24	−1.298	0.194
	6. The teachers are patient with students	2.79	2.86	2.83	−0.817	0.414
	8. The teachers ridicule the students ^#	2.86	2.97	2.92	−1.279	0.201
	9. The teachers are authoritarian #	2.63	2.75	2.69	−1.217	0.224
	18. The teachers have good communication skills with patients	2.78	2.75	2.76	−0.208	0.825
	29. The teachers are good at providing feedback to students	2.64	2.53	2.58	−1.275	0.202
	32. The teachers provide constructive criticism here	2.34	2.40	2.37	−0.799	0.424
	37. The teachers give clear examples	2.70	2.68	2.69	−0.210	0.833
	39. The teachers get angry in the class ^#	2.21	2.43	2.32	−2.491	0.013*
	40. The teachers are well prepared for their classes	2.71	2.71	2.71	−0.037	0.971
	50. The students irritate the teachers ^#	2.03	1.88	1.95	−1.841	0.066
SAP	5. Learning strategies which worked for me before continue to work for me now	2.39	2.59	2.49	−2.862	0.004*
	10. I am confident about passing this year	2.84	2.89	2.86	−0.374	0.709
	21. I feel I am being well prepared for my profession	2.17	2.24	2.21	−0.716	0.474
	26. Last year’s work has been a good preparation for this year’s work	2.24	2.50	2.37	−3.198	0.001*
	27. I am able to memorize all I need	1.93	1.93	1.93	−0.099	0.921
	31. I have learned a lot about empathy in my profession	2.44	2.57	2.50	−1.716	0.086
	41. My problem-solving skills are being well developed here	2.27	2.39	2.33	−1.268	0.205
	45. Much of what I have to learn seems relevant to a career in healthcare	2.41	2.54	2.48	−1.612	0.107
SPA	11. The atmosphere is relaxed during the ward teaching	2.48	2.42	2.45	−0.368	0.713
	12. This school is well timetabled	2.53	2.11	2.32	−4.301	0.000*
	17. Cheating is a problem in this course ^#	2.00	1.88	1.94	−1.488	0.137
	23. The atmosphere is relaxed during lectures	2.68	2.47	2.57	−2.503	0.012*
	30. There are opportunities for me to develop interpersonal skills	2.26	2.36	2.31	−1.388	0.165
	33. I feel comfortable in class socially	2.52	2.45	2.48	−0.814	0.416
	34. The atmosphere is relaxed during seminars/tutorials	2.55	2.53	2.54	−0.245	0.807
	35. I find the experience disappointing ^#	1.83	2.23	2.03	−4.721	0.000*
	36. I am able to concentrate well	2.34	2.40	2.37	−1.278	0.201
	42. The enjoyment outweighs the stress of the course	2.14	2.12	2.13	−0.291	0.771
	43. The atmosphere motivates me as a learner	2.35	2.20	2.27	−1.305	0.192
	49. I feel able to ask the questions I want	2.60	2.46	2.53	−0.966	0.334
SSP	3. There is a good support system for students who get stressed	2.33	2.48	2.41	−2.294	0.022*
	4. I am too tired to enjoy this course ^#	1.58	1.63	1.61	−0.635	0.526
	14. I am rarely bored on this school	2.20	2.06	2.13	−1.482	0.138
	15. I have good friends in this school	2.83	3.09	2.96	−3.112	0.002*
	19. My social life is good	2.46	2.33	2.40	−1.449	0.147
	28. I seldom feel lonely	2.18	2.07	2.12	−1.230	0.219
	46. My accommodation is pleasant	2.41	2.46	2.44	−1.028	0.304

Notes: ^#Negative statements, *Significant at <0.05.

Abbreviations: FE, Fischer’s exact test; DREEM, Dundee Ready Education Environment Measure; SPL, student’s perceptions of learning; SPT, student’s perceptions of teachers; SAP, student’s academic self-perceptions; SPA, student’s perceptions of atmosphere; SSP, student’s social self-perception.

Figure 2 Items that differed significantly between the traditional MBBCH and the integrated MSBP-CB systems in terms of mean item scores.

Table 5 Mean Score of DREEM Inventory and Its Subscales Based on Gender in Both Study Groups

Total DREEM and its Subscales	Traditional MBBCH System		Integrated MSBP-CB System		Total
	Male	Female	Male	Female	Male	Female
SPL (max=48)
Mean ± SD	25.1 ± 5.4	26.5 ± 4.0	26.4 ± 5.3	26.7 ± 4.8	25.7 ± 5.4	26.6 ± 4.4
Z score of Mann Whitney U-test	−1.862		−0.619		−1.841
p value	0.063		0.536		0.066
SPT (max=44)
Mean ± SD	27.9 ± 5.6	30.1 ± 5.3	28.1 ± 6.2	30.0 ± 5.6	28.0 ± 5.9	30.0 ± 5.4
Z score of Mann Whitney U-test	−3.155		−2.809		−4.255
p value	0.002*		0.005*		0.000*
SAP (max=32)
Mean ± SD	18.6 ± 5.2	18.8 ± 4.4	19.6 ± 5.3	19.7 ± 4.4	19.1 ± 5.2	19.3 ± 4.4
Z score of Mann Whitney U-test	−0.457		−0.003		−0.115
p value	0.647		0.998		0.909
SPA (max=48)
Mean ± SD	27.6 ± 7.0	29.0 ± 6.1	27.5 ± 7.8	27.8 ± 6.5	27.5 ± 7.4	28.4 ± 6.3
Z score of Mann Whitney U-test	−1.272		−0.378		−1.103
p value	0.203		0.706		0.270
SSP (max=28)
Mean ± SD	16.2 ± 3.6	15.8 ± 3.2	16.4 ± 3.2	15.9 ± 3.3	16.3 ± 3.4	15.8 ± 3.2
Z score of Mann Whitney U-test	−1.326		−0.664		−1.401
p value	0.185		0.506		0.161
Overall DREEM (max=200)
Mean ± SD	118.0 ± 23.4	122.7 ± 19.7	120.7 ± 24.9	122.8 ± 21.1	119.3 ± 24.1	122.7 ± 20.4
Z score of Mann Whitney U-test	−1.298		−0.869		−1.684
p value	0.194		0.385		0.092

Note: *Significant at <0.05.

Abbreviations: DREEM, Dundee Ready Education Environment Measure; SPL, student’s perceptions of learning; SPT, student’s perceptions of teachers; SAP, student’s academic self-perceptions; SPA, student’s perceptions of atmosphere; SSP, student’s social self-perception.

Figure 3 Comparing the traditional MBBCH and the integrated MSBP-CB systems regarding the mean student’s perceptions of teacher (SPT) score based on gender.

Table 6 Mean Score of DREEM Inventory and Its Subscales Based on Age in Both Study Groups

Total DREEM and its Subscales	Traditional MBBCH System		Integrated MSBP-CB System		Total
	<20 Years	≥20 Years	<20 Years	≥20 Years	<20 Years	≥20 Years
SPL (max=48)
Mean ± SD	25.1 ± 7.1	25.8 ± 4.7	26.6 ± 5.0	26.6 ± 6.2	26.5 ± 5.1	25.8 ± 4.8
Z score of Mann Whitney U-test	−0.151		−0.465		−2.525
p value	0.880		0.642		0.012*
SPT (max=44)
Mean ± SD	25.4 ± 6.0	29.1 ± 5.5	29.2 ± 5.9	25.2 ± 9.6	29.1 ± 5.9	29.0 ± 5.6
Z score of Mann Whitney U-test	−1.976		−1.383		−0.527
p value	0.048*		0.167		0.598
SAP (max=32)
Mean ± SD	18.3 ± 8.6	18.7 ± 4.7	19.7 ± 4.8	17.8 ± 5.9	19.6 ± 4.9	18.7 ± 4.7
Z score of Mann Whitney U-test	−0.136		−0.807		−2.738
p value	0.892		0.420		0.006*
SPA (max=48)
Mean ± SD	28.6 ± 7.5	28.3 ± 6.6	27.7 ± 7.1	25.2 ± 8.2	27.7 ± 7.1	28.2 ± 6.6
Z score of Mann Whitney U-test	−0.267		−0.721		−0.331
p value	0.789		0.471		0.741
SSP (max=28)
Mean ± SD	17.0 ± 5.5	16.0 ± 3.3	16.1 ± 3.3	16.4 ± 2.5	16.2 ± 3.3	16.0 ± 3.3
Z score of Mann Whitney U-test	−1.061		−0.110		−0.599
p value	0.289		0.913		0.549
Overall DREEM (max=200)
Mean ± SD	116.8 ± 30.5	120.4 ± 21.5	121.9 ± 22.8	114.2 ± 25.8	121.8 ± 23.1	120.3 ± 21.6
Z score of Mann Whitney U-test	−0.137		−0.946		−1.485
p value	0.862		0.344		0.138

Note: *Significant at <0.05.

Abbreviations: DREEM, Dundee Ready Education Environment Measure; SPL, student’s perceptions of learning; SPT, student’s perceptions of teachers; SAP, student’s academic self-perceptions; SPA, student’s perceptions of atmosphere; SSP, student’s social self perception.

Figure 4 Comparing the traditional MBBCH and the integrated MSBP-CB systems regarding the mean scores of SAP, SPT, and SPL based on age.

Table 7 Mean Score of DREEM Inventory and Its Subscales Based on the Previous Year’s GPA in Both Study Groups

Studied Groups	Previous Year GPA	Overall DREEM (Max=200)	SPL (Max=48)	SPT (Max=44)	SAP (Max=32)	SPA (Max=48)	SSP (Max=28)
		Mean ± SD
Total	Excellent	122.9 ± 24.0	26.6 ± 5.2	29.8 ± 6.0	19.5 ± 5.1	28.3 ± 7.3	16.2 ± 3.4
	Very good	120.3 ± 20.4	25.8 ± 4.7	28.3 ± 5.2	19.4 ± 4.5	28.1 ± 6.2	16.1 ± 3.3
	Good	119.9 ± 20.6	26.3 ± 4.4	28.7 ± 5.6	18.7 ± 4.6	27.6 ± 6.5	15.9 ± 3.1
	Fair	114.7 ± 24.8	24.7 ± 5.3	29.1 ± 7.3	17.4 ± 4.7	25.5 ± 8.6	15.8 ± 4.0
	Fail	102.8 ± 14.9	22.0 ± 4.4	26.0 ± 5.7	15.2 ± 3.3	23.4 ± 7.2	14.0 ± 2.3
	Kruskal Wallis H-test	14.133	15.202	11.661	11.763	7.344	5.446
	p value	0.007*	0.004*	0.020*	0.019*	0.119	0.244
Traditional MBBCH system	Excellent	123.5 ±23.5	26.5 ± 5.2	29.9 ± 5.6	19.1 ± 5.2	29.1 ± 7.0	16.3 ± 3.5
	Very good	118.1 ±19.0	25.2 ± 4.4	27.5 ± 5.0	18.8 ± 4.3	28.0 ± 5.8	15.9 ± 3.2
	Good	118.8 ± 20.4	25.8 ± 4.3	29.2 ± 5.2	18.1 ± 4.5	27.6 ± 6.6	15.5 ± 3.2
	Fair	108.0 ± 22.9	22.5 ± 4.3	28.4 ± 7.4	15.8 ± 4.3	23.3 ± 7.2	16.2 ± 4.8
	Fail	108.6 ± 15.1	21.6 ± 4.4	27.6 ± 4.3	16.6 ± 2.6	26.8 ± 5.7	13.8 ± 2.5
	Kruskal Wallis H-test	11.8333	18.799	12.021	7.621	8.186	5.764
	p value	0.019*	0.001*	0.017*	0.106	0.085	0.217
Integrated MSBP-CB system	Excellent	122.4 ± 24.5	26.7 ± 5.3	29.7 ± 6.4	19.8 ± 5.0	27.6 ± 7.5	16.1 ± 3.3
	Very good	122.5 ± 21.6	26.3 ± 4.9	29.2 ± 5.1	19.9 ± 4.6	28.1 ± 6.6	16.3 ± 3.4
	Good	120.9 ± 20.8	26.7 ± 4.5	28.2 ± 5.9	19.3 ± 4.6	27.6 ± 6.5	16.4 ± 2.9
	Fair	124.1 ± 25.8	27.9 ± 5.3	30.0 ± 7.5	19.7 ± 4.5	28.7 ± 9.9	15.3 ± 2.8
	Fail	95.5 ± 12.8	22.5 ± 4.9	24.0 ± 7.2	13.5 ± 3.7	19.3 ± 7.3	14.3 ± 2.4
	Kruskal Wallis H-test	6.481	3.897	4.875	6.811	5.110	3.775
	p value	0.166	0.420	0.300	0.146	0.276	0.437

Note: *Significant at <0.05.

Abbreviations: GPA, grade point average; DREEM, Dundee Ready Education Environment Measure; SPL, student’s perceptions of learning; SPT, student’s perceptions of teachers; SAP, student’s academic self-perceptions; SPA, student’s perceptions of atmosphere; SSP, student’s social self-perception.

Table 8 Correlation Between Score of DREEM and Its Subscales, Age and Previous Year GPA in Both Studied Groups

Studied Groups	DREEM and its Subscale	Previous Year GPA		Age
		r	P value	r	P value
Total	Total DREEM	0.115	0.004*	−0.057	0.157
	SPL	0.099	0.013*	−0.104	0.001*
	SPT	0.109	0.006*	−0.035	0.377
	SAP	0.09	0.019*	−0.101	0.011*
	SPA	0.079	0.048*	0.017	0.671
	SSP	0.044	0.271	−0.004	0.911
Traditional MBBCH system	Total DREEM	0.179	0.002*	0.001	0.864
	SPL	0.194	0.001*	0.008	0.883
	SPT	0.125	0.029*	0.037	0.521
	SAP	0.128	0.025*	0.009	0.877
	SPA	0.130	0.023*	−0.004	0.943
	SSP	0.110	0.054	0.022	0.696
Integrated MSBP-CB system	Total DREEM	0.057	0.313	−0.051	0.386
	SPL	0.017	0.758	−0.081	0.154
	SPT	0.101	0.074	−0.100	0.078
	SAP	0.066	0.242	−0.050	0.374
	SPA	0.031	0.589	−0.007	0.905
	SSP	−0.020	0.722	0.027	0.638

Notes: r, Spearman rho correlation coefficient. *Significant at <0.05.

Abbreviations: GPA, grade point average; DREEM, Dundee Ready Education Environment Measure; SPL, student’s perceptions of learning; SPT, student’s perceptions of teachers; SAP, student’s academic self-perceptions; SPA, student’s perceptions of atmosphere; SSP, student’s social self-perception.

Figure 5 Comparing the traditional MBBCH and the integrated MSBP-CB systems regarding the mean score of SAP, SPT, SPL, and overall DREEM based on the previous year’s GPA.

Table 9 Positive Points and Problematic Areas in the Learning Environment as Illustrated by the Mean Item Scores

Subscale	Items	Mean Item Score			Z Score of Mann Whitney U-test	P value
		Traditional MBBCH System	Integrated MSBP-CB System	Total
	Problematic areas or that need attention:
SPL	25. The teaching over emphasizes factual learning	1.45	1.60	1.53	−1.645	0.100
	48. The teaching is too teacher-centered	1.50	1.75	1.63	−3.179	0.001*
SPT	50. The students irritate the teachers	2.03	1.88	1.95	−1.840	0.066
SAP	27. I am able to memorize all I need	1.93	1.93	1.93	−0.098	0.921
SPA	17. Cheating is a problem in this course	2.00	1.88	1.94	−1.488	0.137
	35. I find the experience disappointing	1.83	2.23	2.03	−4.720	0.000*
SSP	4. I am too tired to enjoy this course	1.58	1.63	1.61	−0.634	0.526
	Positive points **
SPT	2. The teachers are knowledgeable	3.28	3.21	3.24	−1.298	0.194

Notes: *Significant at <0.05, **No items scored more than 3.5, however item 2 shows the highest rank.

Abbreviations: DREEM, Dundee Ready Education Environment Measure; SPL, student’s perceptions of learning; SPT, student’s perceptions of teachers; SAP, student’s academic self-perceptions; SPA, student’s perceptions of atmosphere; SSP, student’s social self-perception.

Table 10 Spearman Correlation Coefficients Between Score of DREEM and Its Subscales, Among Studied Groups

Studied Groups	DREEM and its Subscale	Total DREEM	SPL	SPT	SAP	SPA	SSP
		Spearman rho Correlation Coefficient
Total	Total DREEM	1	0.846	0.733	0.863	0.895	0.713
	SPL		1	0.540	0.714	0.697	0.548
	SPT			1	0.480	0.570	0.361
	SAP				1	0.754	0.619
	SPA					1	0.584
	SSP						1
Traditional MBBCH system	Total DREEM	1	0.830	0.695	0.855	0.883	0.755
	SPL		1	0.493	0.649	0.688	0.582
	SPT			1	0.445	0.530	0.369
	SAP				1	0.727	0.666
	SPA					1	0.594
	SSP						1
Integrated MSBP-CB system	Total DREEM	1	0.855	0.763	0.865	0.908	0.671
	SPL		1	0.579	0.762	0.709	0.509
	SPT			1	0.505	0.607	0.349
	SAP				1	0.766	0.578
	SPA					1	0.568
	SSP						1

Note: P values of all correlation coefficients are < 0.0001.

Abbreviations: DREEM, Dundee Ready Education Environment Measure; SPL, student’s perceptions of learning; SPT, student’s perceptions of teachers; SAP, student’s academic self-perceptions; SPA, student’s perceptions of atmosphere; SSP, student’s social self-perception.

Table 11 Comparison Between the Traditional MBBCH and Integrated MSBP-CB Systems Regarding the Achievements of Students

Achievement of Students	Traditional MBBCH System (n=961)		Integrated MSBP-CB System (n=1076)		Total (n=2037)		Z Score Test	p value
	n	%	n	%	n	%
Excellent	470	48.9	740	68.8	1210	59.4	−9.1143	<0 0.00001*
Very good	244	25.5	256	23.7	500	24.5	0.8368	0 0.4009
Good	108	11.2	61	5.7	169	8.3	4.549	<0 0.00001*
Fair	32	3.3	4	0.37	36	1.8	5.0583.	<0.00001*
Fail	21	2.2	4	0.37	25	1.2	3.711	0.0002*
Absent	86	8.9	11	1.1	97	4.8	8.3863	< 0.00001*

Note: *Significant at <0.05.

Abbreviation: n, number.

Figure 6 Comparing the traditional MBBCH and the integrated MSBP-CB systems regarding the achievements of students.

Table 12 Summary of the Selected Studies Showing Medical Students’ Perceptions Using the DREEM Inventory at National and Worldwide Levels from 2008 to 2021

Research, Publication and Year	College, University and Country	(Response Rate), Student Level or Phase,	Program	Sample Size Number (%) of Male and Female Gender Significance	Overall DREEM Score and its Subscales	The Most Positive Items	The Weakest Items
The current study, 2021	Faculty of Medicine, Tanta University, Egypt	(86.9%) Second year (basic phase) and fourth year (clinical phase) students	Traditional subject-based MBBCH program and an integrated MSBP-CB program	621 students 302 (48.6%) male and 319 (51.4%) female Females showed higher overall DREEM, SPA, SAP, scores and significant higher SPT scores than males. Males should higher SSP	Overall, 121.04 (121.81 for year 2 and 120.25 for year 4)	No items scored >3.5. The highest scored item that ranked above 3 was: 2. The teachers are knowledgeable (3.21 for year 2 and 3.28 for year 4)	Items scored less than 2 were: 4. I am too tired to enjoy this course (1.63 for year 2 and 1.58 for year 4) 17. Cheating is a problem in this course (1.88 for year 2) 25. The teaching over emphasizes factual learning (1.6 for year 2 and 1.45 for year 4) 27. I am able to memorize all I need (1.39 for both years 2 and 4) 48. The teaching is too teacher-centered (1.75 for year 2 and 1.5 for year 4) 50. The students irritate the teachers (1.88 for year 2)
					SPL 26.18 (26.57 for year 2, and 25.78 for year 4)
					SPT 29.06 (29.16 for year 2, and 28.97 for year 4)
					SAP 19.17 (19.64 for year 2, and 18.69 for year 4)
					SPA 27.95 (27.64 for year 2, and 28.28for year 4)
					SSP 16.06 (16.14 for year 2, and 15.98 for year 4)
(Salih et al, 2018)	Faculty of Medicine, University of Bahri, Sudan	24.5% All years, basic and clinical phases (1–6)	Mixed (hybrid) curriculum	347 students More male than female. Male showed significantly higher scores (overall DREEM and in all subscales) than females	Overall, (132)	Not mentioned	Not mentioned
					SPL (32)
					SPT (30)
					SAP (21)
					SPA (26)
					SSP (17)
(Soliman et al, 2017)	College of Medicine at King Saud University, Saudi Arabia	(25.3%) Fifth year (clinical phase)	System-oriented hybrid curriculum	62 students 33 (53.3%) males and 29 (46.7%) females Insignificant differences (overall and in DREEM subscales) between male and females	Overall, (171.57/250) *	The highest scored items more than 4 were: 2. The teachers are knowledgeable (4.01) 10. I am confident about passing this year (4.03) 15. I have good friends in this school (4.33)	The lowest scored item was: 35. I find the experience disappointing (2.7)
					SPL (40.17)
					SPT (33.35)
					SAP (28.4)
					SPA (41.32)
					SSP (24.33)
(Sengupta et al, 2017)	Nil Ratan Sircar Medical College, West Bengal University of Health Sciences (WBUHS) Kolkata, West Bengal, India.	(87.5%) Fifth semester batch	Traditional subject-based program	200 students 125 (62.5%) male and 75 (37.5%) female Gender differences were not assessed	Overall, (119.64)	Not mentioned	Not mentioned
					SPL (28.0995)
					SPT (30.41)
					SAP (19.711)
					SPA (27.45)
					SSP (14.47)
	College of Medicine and Sagore Dutta Hospital, West Bengal University of Health Sciences (WBUHS), Kolkata, West Bengal, India.	(86%) Fifth semester batch	Traditional subject-based program	78 students 53 (67.9%) male and 25 (32.1%) female Gender differences were not assessed	Overall, (119.11)	Not mentioned	Not mentioned
					SPL (29.375)
					SPT (29.56)
					SAP (20.248)
					SPA (25.65)
					SSP (14.675)
(Patil and Chaudhari, 2016)	Terna Medical College, Navi Mumbai, Indi	(85.71%) Fifth semester (paraclinical phase), seventh, and ninth semesters, and interns (clinical phase)	Traditional subject-based program	262 students 121 (46.2%) male and 141 (53.8%) female Gender differences were not assessed	Overall, 123 (135.05 for 5th, 119.00 for 7th, 117.60 for 9th and 120.11for interns)	No items scored > 3.5. The three highest scored items were: 10. I am confident about my passing this year (3.35) 15. I have good friends in this school (3.32) 2. The teachers are knowledgeable (3.02)	Items scored less than 2 were: 9. The teachers are authoritarian (1.84) 25. The teaching over- emphasizes factual learning (1.87) 39. The teachers get angry in class (1.87) 48. The teaching is too teacher-centered (1.94)
					SPL (32.70 for 5th, 27.02 for 7th, 26.93 for 9th and 28.54 for interns)
					SPT (29.10 for 5th 26.18 for 7th, 25.17 for 9th and 25.79 for interns)
					SAP (23.06 for 5th 19.77 for 7th, 20.45 for 9th and 21.34 for interns)
					SPA (31.43 for 5th 28.76 for 7th 28.21for 9th and 27.84 for interns)
					SSP (18.75 for 5th 17.29 for 7th, 16.80 for 9th and 16.59 for interns)
(Bhosale, 2015)	Smt. Kashibai Navale Medical College and General Hospital, Western Maharashtra, India	(92.68%) Three years medical students (year 1, 2, and 3) enrolled for more than three months	Not mentioned	380 students 175 (46.1%) male and 205 (53.9%) female. Female showed significantly higher SPL, SAP and overall DREEM score	Overall, 136 (131.4 for year 1, 141.3 for year 2, and 135.3 for year 3)	Item scored above 3 (in different years) were: 13. The teaching is student-centered 25. The teaching over emphasizes factual learning 27. I am able to memorize all I need 31. I have learned a lot about empathy in my profession 47. Long-term learning is emphasized over short-term learning 48. The teaching is too teacher-centered Highest Scores >3.5 (in different years) were: 2. The teachers are knowledgeable 10. I am confident about passing this year 15. I have good friends in this school 19. My social life is good	Items scored less than 2 (in different years) were: 8. The teachers ridicule the students 16. The teaching helps to develop my competence 28. I seldom feel lonely 44. The teaching encourages me to be an active learner 45. Much of what I have to learn seems relevant to a career in healthcare 46. My accommodation is pleasant Lowest scores (in different years) were: 3. There is a good support system for students who get stressed 4. I am too tired to enjoy this course 9. The teachers are authoritarian 14. I am rarely bored on this school 25. The teaching over emphasizes factual learning 27. I am able to memorize all I need
					SPL 35.5 (34.5 for year 1, 37.8 for year 2, and 34.2 for year 3)
					SPT 30.9 (27.8 for year 1, 31.6 for year 2, and 33.2 for year 3)
					SAP 21 (18.3 for year 1, 22.3 for year 2, and 22.4 for year 3)
					SPA 29.8 (29.2 for year 1, 30.2 for year 2, and 30.1 for year 3)
					SSP 16.1 in (16.6 for year 1, 16.4 for year 2, and 15.4 for year 3)
(Abdulwahab and Abdulbari, 2014)	College of Medicine, University of Basrah, Iraq	(72.8%) Fourth year students (clinical phase)	Traditional subject-based program	91 students 36 (39.56%) males and 55 (60.44%) females Insignificant gender variations (overall and in different subscales)	Overall, (93.5714)	No item scored more than 3.	Items scored less than 2 were: 1. I am encouraged to participate in class (1.93) 3. There is a good support system for students who get stressed (3.04) 4. I am too tired to enjoy this course (0.84) 5. Learning strategies which worked for me before continue to work for me now (1.79) 7. The teaching is often stimulating (1.93) 8. The teachers ridicule the students (0.87) 9. The teachers are authoritarian (0.95) 10. I am confident about passing this year (1.86) 11. The atmosphere is relaxed during the ward teaching (1.64) 14. I am rarely bored on this school (1.20) 16. The teaching helps to develop my competence (1.91) 21. I feel I am being well prepared for my profession (1.57) 23. The atmosphere is relaxed during lectures (1.62) 25. The teaching over emphasizes factual learning (1.98) 26. Last year’s work has been a good preparation for this year’s work (1.50) 28. I seldom feel lonely (1.95) 27. I am able to memorize all I need (1.50) 30. There are opportunities for me to develop interpersonal skills (1.29) 32. The teachers provide constructive criticism here (1.52) 33. I feel comfortable in class socially (1.87) 34. The atmosphere is relaxed during seminars/tutorials (1.70) 37. The teachers give clear examples (1.93) 39. The teachers get angry in the class (1.75) 42. The enjoyment outweighs the stress of the course (1.00) 43. The atmosphere motivates me as a learner (1.29) 48. The teaching is too teacher-centered (1.74) 49. I feel able to ask the questions I want (1.76)
					SPL (23.8901)
					SPT (20.1648)
					SAP (15.3516)
					SPA (20.5055)
					SSP (13.6154)
(Yusoff et al, 2013)	School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia	(77.9%) First year (preclinical phase), third year (paraclinical phase) And fifth year (clinical phase) students	A self-directed, problem-based, integrated, community-oriented curriculum	511 students 175 (34.2%) male and 312 (61.1%) female and 24 (4.7) missed gender data Gender varitions were not assessed	Overall, 128.36 (138.94 for year 1, 122.27 for year 3 and 125.49 for year 5)	Items scored more than 3 in one of years or overall were: 2. The teachers are knowledgeable (3.30 for year 1, 3.16 for year 3, 3.19 for year 5) 18. The teachers have good (3.03 for year 1 and 3.01 for year 5) communication skills with patients 24. The teaching time is put to good use (3.05 for year 1) 37. The teachers give clear examples (3.02 for year 1) 40. The teachers are well-prepared for their teaching sessions (3.05 for year 1) 44. The teaching encourages me to be an active learner (3.03 for year 1)	Items showed less than 2 in one of years or overall were: 8. The teachers ridicule the students (1.94 for year 5) 9. The teachers are authoritarian (1.85 for year 3, and 1.84 for year 5) 11. The atmosphere is relaxed during ward teaching (1.93 for year 3) 17. Cheating is a problem in this school (1.53 for year 5) 25. The teaching over-emphasizes factual learning (1.13 for year 1, 1.36 for year 3 and 1.52 for year 5) 27. I am able to memorize all I need (1.69 for year 3, and 1.74 for year 5) 48. The teaching is too teacher-centred (1.96 for year 1 and 1.97 for year 3) 39. The teachers get angry in teaching (1.86 for year 5) 50. The students irritate the teachers (1.83 for year 5)
					SPL 31.18 (33.33 for year 1, 29.4 for year 3 and 31.3 for year 5)
					SPT 28.04 (30.28 for year 1, 26.77 for year 3 and 27.42 for year 5)
					SAP 20.87 (22.59 for year 1, 19.64 for year 3 and 20.68 for year 5)
					SPA 30.96 (34.21 for year 1, 29.58 for year 3 and 25.48 for year 5)
					SSP 17.30 (18.54 for year 1, 16.87 for year 3 and 16.62 for year 5)
(Zawawi and Elzubeir, 2012)**	College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia	(73%) Final year of 4-years graduate entry curriculum	Hybrid PBL, integrated and traditional program	27 students 100% male Gender comparison was unfeasible	Overall, (131)	Items scored above 3 were: 7. The teaching is often stimulating (3.37) 13. The teaching is student–centered (3.19) 20. The teaching is well focused (3.22) 23. The atmosphere motivates me as a learner (3.07) 41. My problem-solving skills are being well developed here (3.40) 47. Long-term learning is emphasized over short-term learning (3.19)	Not mentioned
					SPL (36.44)
					SPT (25.48)
					SAP (19.81)
					SPA (32.77)
					SSP (16.81)
	College of Medicine, King Saud University, Riyadh, Saudi Arabia	(23%) Final year of 6-years high school entry curriculum	Traditional subject-based program	74 students 61 (82.4%) male, 13 (17.6%) female Female responses were considered as missed data. Gender comparison was not conducted	Overall, (100)	Not mentioned	Items showed less than 2 were: 7. The teaching is often stimulating (1.62) 13. The teaching is student–centered (1.72) 20. The teaching is well focused (1.65) 23. The atmosphere motivates me as a learner (1.77) 41. My problem-solving skills are being well developed here (1.83) 47. Long-term learning is emphasized over short-term learning (1.89)
					SPL (23.18)
					SPT (23.79)
					SAP (13.59)
					SPA (24.66)
					SSP (15.37)
(Nahar et al, 2010)	Fifteen medical colleges in Bangladesh	(100% due to purposive sampling) Clinical years (3rd, 4th, 5th years students) Divided into academic achievers and under-achievers	Not mentioned (seemed traditional)	1610 students 808 (50.2%) males and 802 (49.8%) females Females showed significantly higher scores among both studied groups	Overall, (110.15 for academic achievers and 106.89 for under-achievers)	Items scored above 3 were: 7. The teaching is often stimulating (3.22 for academic achievers and 3.12 for under-achievers) 2. The teachers are knowledgeable (3.11 for academic achievers and 3.02 for under-achievers) 15. I have good friends in this school (3.020 for academic achievers) 33. I feel comfortable in class socially (3.02 for academic achievers)	3. There is a good support system for students who get stressed (1.13 for academic achievers and 1.16 for under-achievers) 4. I am too tired to enjoy this course (1.37 for academic achievers and 1.19 for under-achievers) 8. The teachers ridicule the students (1.15 for academic achievers and 1.03 for under-achievers) 9. The teachers are authoritarian (1.78 for academic achievers and 1.54 for under-achievers) 11. The atmosphere is relaxed during the ward teaching (1.65 for academic achievers and 1.62 for under-achievers) 13. The teaching is student-centred (1.31 for academic achievers and for under-achievers) 14. I am rarely bored on this school (1.78 for academic achievers and 1.93 for under-achievers) 17. Cheating is a problem in this course (1.56 for academic achievers and 1.51 for under-achievers) 23. The atmosphere is relaxed during lectures (1.83 for academic achievers and 1.70 for under-achievers) 25. The teaching over emphasizes factual learning (1.23 for academic achievers and 1.32 for under-achievers) 27. I am able to memorize all I need (1.77 for academic achievers and 1.67 for under-achievers) 35. I find the experience disappointing (1.51 for academic achievers and 1.36 for under-achievers) 39. The teachers get angry in the class (1.72 for academic achievers and 1.49 for under-achievers) 42. The enjoyment outweighs the stress of the course (1.61 for academic achievers and 1.54 for under-achievers) 46. My accommodation is pleasant (1.74 for academic achievers and 1.77 for under-achievers) 48. The teaching is too teacher-centered (1.33 for academic achievers and 1.34 for under-achievers) 49. I feel able to ask the questions I want (1.61 for academic achievers and 1.55 for under-achievers)
					SPL (27.67 for academic achievers and 27.32 for under-achievers)
					SPT (24.28 for academic achievers and 23.47 for under-achievers)
					SAP (19.56 for academic achievers and 18.51 for under-achievers)
					SPA (24.33 for academic achievers and 23.2 for under-achievers)
					SSP (14.35 for academic achievers and 14.25 for under-achievers)
(Aghamolaei and Fazel, 2010)	Hormozgan University of Medical Science, Iran	(86.6%) Students enrolled in pre-clinical pathophysiology course and students enrolled on clinical course.	Traditional system	182 students About 70 (38.5%) male and about 112 (61.5%) females Insignificant gender differences were reported	Overall (99.6)	No items scored 3 or above	Items showed less than 2 were: 1. I am encouraged to participate in class. (1.9) 3. There is a good support system for students who get stressed (1.1) 4. I am too tired to enjoy this course (1.6) 5. Learning strategies which worked for me before continue to work for me now (1.6) 7. The teaching is often stimulating (1.8) 11. The atmosphere is relaxed during the ward teaching (1.9) 12. This school is well timetabled (1.2) 13. The teaching is student-centered (1.7) 21. I feel I am being well prepared for my profession (1.9) 22. The teaching helps to develop my confidence (1.7) 25. The teaching over emphasizes factual learning (1.6) 26. Last year’s work has been a good preparation for this year’s work (1.8) 27. I am able to memorize all I need (1.8) 31. I have learned a lot about empathy in my profession (1.7) 32. The teachers provide constructive criticism here (1.8) 36. I am able to concentrate well (1.9) 38. I am clear about the learning objectives of the course (1.9) 43. The atmosphere motivates me as a learner (1.5) 44. The teaching encourages me to be an active learner (1.7) 47. Long-term learning is emphasized over short-term learning (1.4) 48. The teaching is too teacher-centered (1.5) 49. I feel able to ask the questions I want (1.8)
					SPL (21.2)
					SPT (24.2)
					SAP (15.8)
					SPA (23.8)
					SSP (14.5)
(Bennett et al, 2010)	School of Medicine in University College Cork, Ireland	(100%) Year 3 medical students distributed over six hospitals (small and large) providing clinical teaching	Not mentioned (seemed integrated)	108 students completed 216 surveys, out of them 108 were analyzed 51 (47.2%) male and 57 (52.8%) female. On large hospitals, significant differences were reported between males and females on the academic and social self-perception subscales, with males showing higher scores.	Overall, 149.47 (140.77 for large hospitals and 152.86 for small hospitals)	One item scored above 3 was: 1. I am encouraged to participate during tutorials/tutor teaching/bedside teaching (3.56 for small hospitals)	No items scored below 2
					SPL 36.59 (32.16 for large hospitals and38.13 for small hospitals)
					SPT 34.37 (32.45 for large hospitals and 35.05 for small hospitals)
					SAP 22.66 (23.53 for large hospitals and 22.74 for small hospitals)
					SPA 36.38 (33.53 for large hospitals and 37.37 for small hospitals)
					SSP 19.46 (19.1 for large hospitals and 19.57 for small hospitals)
(Denz-Penhey and Murdoch, 2010)	The Rural Clinical School of Western Australia (RCSWA), Australia	(Response rate was not mentioned) Year 5 and year 6 students, including students trained at Metropolitan hospital, those in training sites with populations of less than 20,000 and those at sites with populations of greater than 30,000	Integrated Community Learning in Rural Communities program (CLERC)	342 students distributed over 10 training sites Gender distribution was not mentioned	Overall, (147.4 for large hospitals and 159.1 for small hospitals)	Not mentioned	Not mentioned
					SPL (34.6 for large hospitals and 39.5 for small hospitals)
					SPT (34.0 for large hospitals and 34.9 for small hospitals)
					SAP (21.1 for large hospitals and 23.3 for small hospitals)
					SPA (37.0 for large hospitals and 38.3 for small hospitals)
					SSP (20.5 for large hospitals and 21.8 for small hospitals)
(Edgren et al, 2010)	Lund University, Sweden	(82% in 203 and 75% in 2005) Same students enrolled in semester 2 S2 (pre-clinical phase), semester 6 S6 (first clinical rotation) and 10 S10 (well- clinical phase before graduation). Scores of 2003 and 2005 were compared	Reformed curriculum (horizontal and vertical integration, PBL based)	201 students about 83 (41.1%) males and 118 (58.9%) females. Gender differences were not mentioned	Overall, (144 for 2003 and 146 for 2005)	Item scored above 3.5 were: 2. The teachers are knowledgeable (3.5 for S4, 2003, 3.5 for S2 and S10 2005) 7. The teaching is often stimulating (3.5 for S2, 2003) 8. The teachers ridicule the students (3.5 for S10, 2003) 15. I have good friends in this school (3.5 for S2, 2005) 16. The teaching is sufficiently concerned to develop my competence (3.5 for S2, 2003) 17. Cheating is a problem in this school (3.5 for S2, 2003, 3.6 for S10, 2003, 3.5 for S2, S10 2005) 19. My social life is good (3.5 for S6, 2005) 30. There are opportunities for me to develop interpersonal skills (3.5 for S10, 2005) 33. I feel comfortable in class socially (3.5 for S2, S6, 2005 and 3.6 for S10, 2005) 39. The teachers get angry in class (3.6 for S2, 2003, 3.7 for S10, 2003, 3.6 for S2, S10, 205) 45. Much of what I have to learn seems relevant to a career in medicine (3.6 for S6, 2003, 3.6 for S6, 2005 and 3.5 for S10, 2005) 46. My accommodation is pleasant (3.5 for S2, 2003, 3.6 for S6, 2003, 3.7 for S10, 2003 and S2, 2005, 3.8 for S6, 2005, 3.6 for S10, 2005)	Items scored below 2 were: 3. There is a good support system for students who get stressed (1.7 for S2, 2003, 1.6 for S6, 2003, 1.5 for S10, 2003, 1.3 for S6, 2005 and 1.7 for S10, 2005) 14. I am rarely bored on this course (1.7 for S10, 2003) 24. The teaching time is put to good use (1.8 for S10, 2003) 29. The teachers are good at providing feedback to students (1.8 for S2, 2003 and S2, 2005, 2 for S6, 2003 and S6, 2005) 32. The teachers provide constructive criticism here (1.4 for S2, 2003, 1.9 for S6, 2003, 2.0 for S10, 2003 and 1.4 for S2, 2005)
					SPL (34 for 2003 and 34 for 2005)
					SPT (30 for 2003 and 31 for 2005)
					SAP (23 for 2003 and 22 for 2005)
					SPA (37 for 2003 and 38 for 2005)
					SSP (20 for 2003 and 21 for 2005)
(Bouhaimed et al, 2009)	Faculty of Medicine, Kuwait University, Kuwait	(86% of the first year and 89% of the second year) First and second years’ students	Curricular reform from a traditional (year 1) to a problem-based learning following Maastricht model program (year 2)	202 students 51 (25.2%) male and 144 (71.3) female while 7 students did not mention their gender. Significant gender differences were noticed where female showed significant less overall score and some less different subscales	Overall, 105 (106 for year 1 and 106 for year 2)	Not mentioned. However, the following items were reported as causes of improved score: 17. Cheating is a problem in this school 23. The atmosphere is relaxed during lectures 34. The atmosphere is relaxed during seminars/tutorials.	Not mentioned. However, the following items were responsible for low scores: 5. Learning strategies which worked for me before continue to work for me now 26. Last year’s work had been a good preparation for this year’s work. 12. This school is well timetabled’ scores for students in the PBL system
					SPL 26 (26 for year 1 and 26 for year 2)
					SPT 24 (24 for year 1 and 24 for year 2)
					SAP 16 (17 for year 1 and 15 for year 2)
					SPA 25 (24 for year 1 and 26 for year 2)
					SSP 14 (15 for year 1 and 14 for year 2)
(Riquelme et al, 2009)	Pontificia Universidad Cato´ lica de Chile Medical School, Chile	(Overall response rate 90.5%) medical students in Years 3, 4 and 5	Major curriculum reform	297 students 159 (53.5%) males and 138 (46.5%) females Gender differences were not assessed	Overall127.5 (128.8 for year 3, 132.5 for year 4, and 119.3 for year 5)	Item scored above 3.5 were: 2. The teachers are knowledgeable (3.65) 15. I have good friends in this school (3.59)	Items scored below 2 were: 3. There is a good support system for students who get stressed (1.16) 4. I am too tired to enjoy the course (1.76) 12. This school is well time-tabled (1.97) 14. I am rarely bored on this course (1.9) 17. Cheating is a problem in this school (1.2) 25. The teaching over-emphasizes factual learning (1.37) 27. I am able to memorize all I need (1.64) 29. The teachers are good at providing feedback to students (1.74) 46. My accommodation is pleasant (1.68)
					SPL 28.7 (29.7 for year3, 29.6 for year 4, and 26.4 for year 5)
					SPT 30.3 (31.1 for year3, 31.2 for year 4, 28.3 and for year 5)
					SAP 22.3 (22.6 for year3, 22.6 for year 4, and21.4 for year 5)
					SPA 30.2 (29.7 for year3, 32.0 for year 4, and 28.3 for year 5)
					SSP 15.9 (15.6 for year3, 17.1 for year 4, and 14.9 for year 5)
(Carmody et al, 2009)	Different clinical training contexts (tertiary, secondary and rural sites) in metropolitan region, Australia	(94%) Year 5 students enrolled in obstetrics and gynecology course	Not mentioned	161 students 73 (45%) male and 88 (55%) female. No significant gender variations.	Overall, 149 (148.8 for tertiary hospitals, 151.9 for secondary/tertiary hospitals, 141.9 for small rural sites and 148.9 for large rural sites)	Not mentioned	Not mentioned
					SPL (36.7 for tertiary hospitals, 37.2 for secondary/tertiary hospitals, 34.4 for small rural sites and 36.9 for large rural sites)
					SPT (34.7 for tertiary hospitals, 35 for secondary/tertiary hospitals, 34.2 for small rural sites and 35.6 for large rural sites)
					SAP (21.6 for tertiary hospitals, 22.9 for secondary/tertiary hospitals, 20.5 for small rural sites and 21.1 for large rural sites)
					SPA (36.3 for tertiary hospitals, 36.8 for secondary/tertiary hospitals, 33.2 for small rural sites and 35.2 for large rural sites)
					SSP (19.5 for tertiary hospitals, 20.2 for secondary/tertiary hospitals, 19.7 for small rural sites and 20.1 for large rural sites)
(Denz-Penhey and Murdoch, 2009)	Rural Clinical School of Western Australia, Australia	(Response rate mentioned as low) year 5 undergraduate students at University of Western Australia and year 3 students at University of Notre Dame during rural training. Students are distributed over 10 sites	Not mentioned	62 students. Gender distribution was not mentioned. Females showed higher overall scores than males, but this difference was insignificant.	Overall (143)	Not mentioned	Scores with lowest scores were: 5. Learning strategies which worked well for me before continue to work for me 27. I am able to memorise all I need 38. I am clear about the learning objectives of the course 50. Students irritate the teachers
					SPL (33.9)
					SPT (32.6)
					SAP (21.5)
					SPA (35.6)
					SSP (19.3)
(McKendree, 2009)	Two different campuses (Hull and York), Hull York Medical School, UK.	(90.6% for Year 1) and (69.8% for Year 2 students)	Integrated PBL-based curriculum	216 students Gender distribution and differences were not mentioned	Overall, 143.3 (145.2 for Hull and 141.4 for York)	Not mentioned	Not mentioned
					SPL 34.2 (35 for Hull and 33.4 for York)
					SPT 32.5 (33 for Hull and 32 for York)
					SAP 21.4 (21.3 for Hull and 21.4 for York)
					SPA 35.5 (35.9 for Hull and 35.1 for York)
					SSP 19.7 (19.9 for Hull and 19.5for York)
(Miles and Leinster, 2009)	University of East Anglia, United Kingdom	(90% for students). Year 1 to year 4 students and staff members**	UEA MB/BS program (PBL-based curriculum)	403 students 73 staff members 158 (39.21%) male and 245 (60.79%) female students. 44 (60.27%) Male and 29 (39.73%) female staff Gender differences were not mentioned	Overall (141 for students and 144 for staff)	Among participating students, no items scored above (3.5) Among staff, one item score was above 3.5: The students are encouraged to participate in class (3.58)	Among participating students, items scored below 2 were: 27. I am able to memorize all I need (1.75) 29. The teachers are good at providing feedback to students (1.82) Among staff, one item scored less than 2 was: The students are able to memorize all they need (1.89)
					SPL (34.04 for students and 36.75 for staff)
					SPT (31.01 for students and 32.99 for staff)
					SAP (21.34 for students and 21.18 for staff)
					SPA (34.54 for students and 35.12 for staff)
					SSP (20.30 for students and 17.90 for staff)
(Abraham et al, 2008)	Melaka Manipal Medical College, Maniapal, India	(100%) First year students and Clinical year students	Not mentioned (seemed traditional)	Out of 226 participated, 211 students’ responses were complete. Out of 211 complete responses, 114 (54.02%) male and 97 (45.98%) female students. Insignificant gender variations were noticed in all studied cohorts. First year showed significant differences in some items with females higher scores than males	Overall, 116.5 (119 for the first year and 114 for the clinical year)	Item scored above 3 were: 2. The course organizers are knowledgeable (3.22 for first year) 10. I am confident about passing this year (3.12 for clinical year) 15. I have good friends in this course (3.21 for first year) 40. The course organizers are well prepared for their teaching sessions (3.06 for first year	Items scored below 2 were: 4. I am too tired to enjoy this course (1.67 for first year, 1.59 for clinical year) 5. Learning strategies which worked for me before continue to work for me now (1.86 for first year) 6. The course organizers espouse a patient centered approach to consulting (1.97 for first year) 8. The course organizers ridicule their registrars (1.94 for first year, 1.88 for clinical year) 9. The course organizers are authoritarian (1.54 for first year, 1.57 for clinical year) 14. I am rarely bored on this course (1.78 for first year, 1.69 for clinical year) 25. The teaching overemphasizes factual learning (1.5 for first year, 1.57 for clinical year) 26. Last years work has been a good preparation for this years work (1.89 for first year). 27. I am able to memorize all I need (1.39 for first year, 1.68 for clinical year) 28. I seldom feel lonely (1.99 for clinical year) 39. The course organizers get angry in teaching sessions (1.55 for clinical year) 42. The enjoyment outweighs the stress of studying medicine (1.76 for first year, 1.62 for clinical year) 48. The teaching is too teacher centered (1.58 for first year, 1.59 for clinical year) 50. I feel able to ask the questions I want (1.96 for clinical year)
					SPL (29 for the first year and 27 for the clinical year)
					SPT (26 for the first year and 30 for the clinical year)
					SAP (19 for the first year and 20 for the clinical year)
					SPA (28 for the first year and 30 for the clinical year)
					SSP (16 for the first year and 15 for the clinical year)
(Demiroren et al, 2008)	Faculty of Medicine, Ankara University Ankara, Turkey	82.8% Year 1, year 3 (preclinical phase) and year 5 (clinical phase)	Recently restructured curriculum	553 students Gender neither mentioned nor assessed	Overall, 117.63 (for the first year and, for the third year, and for the fifth year)	Items scored more than 3 were: 2. The teachers are knowledgeable (3.26) 15. I have good friends in this school (3.18)	Items scored below 2 were: 3. There is a good support system for students who get stressed (1.7) 4. I am too tired to enjoy this course (1.99) 9. The teachers are authoritarian (1.65) 14. I am rarely bored on this school (1.79) 17. Cheating is a problem in this course (1.76) 24. The teaching time is put to good use (1.53) 25. The teaching over emphasizes factual learning (1.89) 26. Last year’s work has been a good preparation for this year’s work (1.97) 27. I am able to memorize all I need (1.45)
					SPL 27.82 (27.75 for the first year and, 29.03 for the third year, and 25.79 for the fifth year)
					SPT 27.51 (27.64 for the first year and, 28.74 for the third year, and 24.96for the fifth year)
					SAP 18.78 (17.99 for the first year and, 19.99for the third year, and 18.50 for the fifth year)
					SPA 27.03 (26.66 for the first year and, 28.51 for the third year, and 25.23 for the fifth year)
					SSP 16.50 (16.49 for the first year and, 17.38 for the third year, and 14.92for the fifth year)
(Al-Ayed and Sheik, 2008)	College of medicine, King Saud University, Riyadh, Saudi Arabia	44.6% All levels including year 1, 2, 3, (preclinical years) and years 4 and 5 students (clinical years)	Pre-changed Traditional subject based program	222 students 155 (69.8%) male and 67 (30.2%) females Insignificant gender differences in overall DREEM and its subscales	Overall, 89.9 (108.6 for 1st, 84.3 for 2nd, 89.3 85.2 for 3rd, 85.2 84.6 for 4th, and 84.6 9.5 for 5th year)	Not mentioned. However, Students’ perception of teachers 48.2% (21.2/44) was the highest obtained. Most students agreed that the teachers are knowledgeable	Not mentioned. However, Student’s perception of atmosphere was 4th least 4.4% (21.3/48). 24.2% felt relaxed during the ward round 39.9% were relaxed during lectures. Only 25% felt that enjoyment outweighed the stress
					SPL 19.5 (25.6 for 1st, 16.8 19.8 for 2nd, 19.8 for 3rd, 18.1 for 4th, and 18.5 for 5th year)
					SPT 21.2 (25.5 for 1st, 20.2 22.4 for 2nd, 22.4 19.9 for 3rd, 19.9 19.3 for 4th, and 19.3 8.9 for 5th year)
					SAP 14.8 (16.9 for 1st, 14.1 for 2nd, 14.3 for 3rd, 14.2 for 4th, and 14.8 for 5th year)
					SPA 21.3 (25.9 for 1st, 20.5 for 2nd, 20.7 for 3rd, 20.0 for 4th, and 19.6 for 5th year)
					SSP 13.0 (14.4 for 1st, 12.7 for 2nd, 12.7 for 3rd, 12.8 for 4th, and 12.2 for 5th year)

Notes: *Overall DREEM was calculated out of 250, **Staff DREEM was used for staff members.

Abbreviations: DREEM, Dundee Ready Education Environment Measure; SPL, student’s perceptions of learning; SPT, student’s perceptions of teachers; SAP, student’s academic self-perceptions; SPA, student’s perceptions of atmosphere; SSP, student’s social self-perception.