2012; 34: e325e331

WEB PAPER
Medical students perceptions of the factors
influencing their academic performance: An
exploratory interview study with high-achieving
and re-sitting medical students
MATHEW TODRES
1
, ZOI TSIMTSIOU
2
, KALWANT SIDHU
1
, ANNE STEPHENSON
1
& ROGER JONES
1
1
Kings College London, UK,
2
Evosmos Health Center, Greece
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 perfor-
mance 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 students 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).
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.
Correspondence: A. Stephenson, Department of Primary Care and Public Health Sciences, 42 Weston Street, Capital House, 4th Floor,
Kings College London, SE1 3QD, London, UK. Tel: 0044 207 848 8704; fax: 0044 207 848 8706; email: anne.stephenson@kcl.ac.uk
ISSN 0142159X print/ISSN 1466187X online/12/0503257 2012 Informa UK Ltd. e325
DOI: 10.3109/0142159X.2012.668626
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 edu-
cators in the development and delivery of appraisal, remedi-
ation, and support mechanisms for students.
Methods
Setting
Face to face, semi-structured interviews were carried out to
explore students perceptions of factors affecting their aca-
demic 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 colleges
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 Schools 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 reflec-
tions. 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 inter-
viewers 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 differ-
ences 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 studys 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.
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 cant just read and remember. I am someone
who reads and writes and then remembers . . . I am
M. Todres et al.
e326
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 dont apply [myself]. I manage to scrape
through and I just do the minimum that is required.
I dont 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 wasnt 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 didnt
do properly the first time round and that didnt 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 con-
fronted 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 dont collapse and go woe is
me, I tend to think okay something worse is going to
happen in the future so its good this had happened
now. . . I have just got no money, thats very difficult,
and its quite frightening . . . I am living in. . . a box
room with no window about the size of this table and
its 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, thats,
thats 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)
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
Medical students perforceptions of their performance
e327
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 weak-
nesses 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 didnt think
I could be weak, if I was weak in something its
because I hadnt put any effort into it and if I did do,
then I wouldnt 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 character-
istics 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 didnt
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 pro-
gression yet, whilst high-achievers could articulate the ratio-
nale behind the examinations in terms of what knowledge,
understanding and skills were being tested vis-a`-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 thats partly because I am
quite competitive . . . I aim high and I would be cross
if I dont get it . . . I just think I have always being
quite an ambitious person . . . (Cynthia high-achiev-
ing student).
I have never aimed for more than
average . . . (Prem, re-sitting student).
The following quote from a high-achieving student cap-
tures 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 thats
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 under-
graduate 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
M. Todres et al.
e328
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). Schon (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 reper-
toire 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 students 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 profes-
sionalism. Niemi (1997) explores the development of profes-
sional identity through the assessment of self-reflection during
pre-clinical years and described four types of learning logs:
committed reflection; emotional exploration; objective report-
ing; and scant and avoidant reporting.
Niemis (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 profes-
sional 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 reflec-
tion 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 Brewers (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 charac-
teristic of re-sitting students, nor predictive of the students
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
Medical students perforceptions of their performance
e329
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 perfor-
mance. 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 Kings
College London Research Ethics Committee (CREC/07/08-192).
Notes on contributors
MATHEW TODRES, BA (Hons), MA, MAIBA is a pre-medical tutor and a
PhD student.
ZOI TSIMTSIOU, PhD, is a Honorary Research Fellow, Kings College
London.
KALWANT SIDHU, DipCOT, PGCHE, MA, PhD, is a Programme Director,
MSc Primary Health Care.
ANNE STEPHENSON, MBChB, MRCGP, Dip. Obst., PhD, is a Director
Community Education and a GP.
ROGER JONES, MA DM FRCGP FMEDSci FHEA, is an Emeritus Professor
and Editor BJGP.
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