Improving medical students’ learning strategies, management of workload and wellbeing: a mixed methods case study in undergraduate medical education | BMC Medical Education

Demographics

We received 141 responses (38.6% of 365). Respondent demographics are listed in Table 1.

Exploration of demographics and experience of the programme

Gender

There was a positive correlation between being female and higher Likert responses to ‘The AT has helped me think critically about my study skills’ (r = 0.19, p = 0.02); and ‘The AT has helped me to think about how I intend to achieve my goals’(r– 0.294, p < 0.001). The reason for stronger reported outcomes for females in these domains was not immediately apparent from qualitative responses, however comments from female participants highlighted that some may not have been asked to think critically about their own goals before:

“It made me think more critically about the best way to achieve my goals as I hadn’t thought about it much before.” R2 (female)

“The programme has helped me critically think about my study skills because it was something I had never really put any effort into before.” R131 (female)

Graduate entry

Being a graduate student was associated negatively with ‘The AT has helped me learn from both my successes and failures’ and positively with ‘If I had an academic problem, I would feel able to discuss this with my tutor’ and ‘I have positive relationship with my tutor’ (r = 0.207, 0.1891, 0266 respectively, p > 0.05). Being a graduate student was also associated with higher self-efficacy score (r = − 0.17, p = 0.04).

There were no explanatory comments, however, a contextual analysis revealed all graduate students had the same highly experienced Academic Tutor, and as graduate entry, when offered, was so competitive at this institution (1:15 offer ratio), these students may have already developed self-efficacy and/or have relatively limited experience of academic failure.

Widening participation

Identifying as a student from a ‘widening participation’ (WP) background, relating to being from a disadvantaged and/or under-represented group was associated with a moderately higher mindset score (r = − 0.223, p = 0.08). Qualitative comments suggested that these students’ growth mindsets preceded the course:

“I already knew how to learn from my successes & failures” R60.

Some WP students expressed positive affirmations and statements of self-belief that read like personal mantras:

“Without believing I can do it I’ll never do it.” R60

Nationality and ethnicity

The eight experience and outcome measures were reported similarly by students that went to secondary school in the UK or abroad, and for students who identified as majority or minority ethnic. Mindset and self-efficacy scores were not significantly different across these groupings.

Exploration of mindset, self-efficacy, and experience of the programme

Descriptive data for mindset and self-efficacy are displayed in Fig. 3.

Boxplots showing spread of self-efficacy and Mindset responses

There was no correlation between mindset and self-efficacy (r = 0.12, p = 0.18) confirming they are separate constructs. Table 2 shows the relationships between self-efficacy/mindset and the Likert responses. The Likert scores relating to learning from both successes and failures and thinking how to achieve goals were weakly associated with mindset. All Likert scores relating to outcomes, and three out of four Likert scores relating to experiences (excluding having a positive relationship with their Academic Tutor) were moderately associated with self-efficacy.

Thematic analysis

Analysis of the student responses to the opened ended survey questions led to identification of a number of common themes which are summarised in broad groupings relating to immediate educational value (Table 3) and transformative educational value (Table 4).

In line with the Wenger-Trayner framework, we present the subthemes related to immediate and intentional educational value and will then discuss subthemes relating to applied, realised and transformative educational value.

Immediate educational value: how was the programme experienced?

Experiences related to coaching approaches

Participants appreciated being treated as autonomous individuals, with respect and curiosity, but without judgement, rebalancing the power dynamic and creating the conditions for honest conversations.

“My academic tutor is really caring and treats me like a peer, not a student, so I feel really comfortable discussing my work ethic/ethos and goals.” R100

Participants appreciated personalised approaches that related to the learner’s agenda:

“The sessions were tailored exactly to my needs and what I wanted to talk about, so I was able to make the most out of these. It helped to have a personal one-to-one session to really get to the roots of my problems and what I wanted to talk about.” R107

Participants appreciated having the opportunity to articulate and reflect on their own goals in order to identify solutions:

“You sometimes need to say things out loud to someone to put things in perspective and realise what you need.” R7

Participants valued a caring, relational approach to conversations, enabling identification of personal wellbeing goals:

“[My tutor] helped me realise that spending time taking care of myself is very important. [They] also checked back with me the next time we met which meant a lot to me. After the break I felt much better and have since then felt great about my mental health and balancing personal time with schoolwork.” R19

Participants appreciated a non-directive approach that moved away from advice giving to generating a space for the students to identify their own solutions:

“She didn’t tell me what she would do in my place, but kind of helped me put things in perspective to realise on my own.” R7

Experiences relating to study skills

Participants appreciated learning about evidence-based study strategies, but also being encouraged to try things out, self-monitor and see what worked for themselves:

“I knew that my methods of revision weren’t ideal, but I was struggling to figure out how I should change them. My tutor guided me to think about better study methods which worked best for me.” R133

“The time management exercise (keeping a diary of how many hours per week are spent doing different activities) was also really useful in identifying where I was wasting time and allowed me to improve my productivity.” R81

“More that it’s the process of discovering your ability and skills. The way you learn as opposed to shoehorn yourself into a specific archetype.” R17

“I definitely think I have started evaluating my own study techniques more as a result of the academic tutor programme. I spend time thinking about which way works best for me in terms of learning.” R42

Experiences relating to wellbeing

In addition to discussions relating to study skills, tutors encouraged personal development and provided practical and emotional support. Some participants appreciated a structured approach to ‘checking in’ across a range of domains (housing, finances, health, careers, friends & family, harassment) during one-to-one sessions. Where this was not present some had difficulty broaching personal topics.

“I personally feel the 1-to- 1 sessions could be improved by having a prior agenda sort of set to base the session around. While they were a good check-up it often resulted in”so is there anything else you wanted to say or add”.” R17

Others wanted less structure and more personalised approaches.

“It’s like they had a template to follow and nothing was PERSONAL. I wish that there was more emphasis on the personal side of the programme.” R134

Reactions to the different programmatic components

Participants expressed differing personal preferences for the three different components of the programme. Some preferred the study skills lectures which were described as more time efficient for knowledge transfer; some preferred the group sessions which were described as more engaging and helpful for sharing, comparing, and critiquing learning strategies; and others the one-to-one tutorials which were described as more tailored and personal. Some had already developed effective learning strategies and did not feel they needed the programme.

“Talking to other people in the group made me realise different things about the learning style, also reassured me about how to revise.” R29

“I already had a study technique that worked for me at the beginning of the year and… sessions about how to find your preferred working technique felt a bit useless. I understand that this is important for some people but it’s difficult to cater for the needs of everyone in a single group session… In the one-to-one sessions I felt much more comfortable to talk about the things that worried me and open up to my tutor about the things I needed help with.” R7

“The academic tutorials were good, but they weren’t as informative about study skills as the lectures were.” R23

Some articulated changing preferences over the course of the academic year, wanting an emphasis on study skills and relationship building at the start of the year, moving towards more flexible, personalised approaches during exam season.

Affective reaction

Some expressed surprise at not having thought about their study skills before and gratitude for dedicated time and space to contemplate this. The programme was described as meaningful and important and elicited expressions of appreciation, and feelings of reassurance and hope.

“[The] tips on repetitive active learning were great. Also, the use of a 2nd year who failed his mock but came top in actual exam using active learning gave hope to people who felt a bit overwhelmed without making people complacent.” R100

Intentional value: what did students learn but not use?

Some reflected on their learning strategies and recognised the value of trying new approaches but found change difficult to initiate or maintain. Some appeared stuck on the cusp of moving from passive to active learner:

“[I learned] about how to plan my time more efficiently, although I found it hard to implement… I didn’t [change] very much, although I tried to focus less on passive revision methods… I would prefer to have [the group tutorials] as information sessions rather than so interactive.” R2

Applied Educational Value: how did students apply their learning? Applied, Realised and Transformative Educational Value

One hundred twenty-four out of 141 participants described changes they had made to their study habits because of this programme. Changes included more self-testing and self-monitoring, stopping or reducing passive strategies such as underlining and copying out, spaced repetition and interleaving between topics, linking and integrating across topics, preparing before live teaching sessions, changing the way they took notes including mind mapping, changing their working environment or place of study, earlier revision planning, revising “on the go” through podcasts and flashcards, and strategies for maintaining attention and motivation such as timers, chunking, exercise breaks, and switching off social media. Participants described using a variety of digital and paper flashcards which they either created, bought or shared. Some had gone on to read the recommended text “Make It Stick” [4].

“My revision was very passive and during my A-Levels I revised by just reading over notes and directly attempting exam questions, however, because of the large amount of information that we have to learn as medical students, this simply wasn’t working anymore, especially when trying to recall very minute pieces of information. Now I have changed my revision technique to be more active by using flashcards, brainstorms and then supplementing with exam questions.” R67

Realised value: what were the benefits of these new ways of working?

Participants described improved learning, time-management, and wellbeing.

Improved learning

Many were effusive about the educational value of their new active study techniques. Some expressed dismay at the time they had wasted on ineffective learning and revising the wrong way. They expressed a new understanding and surprise at the range of methods available and their varying success. They noted a deeper understanding of the material, better retention of information, and improved memory in general. Flashcards were described as effective for topics requiring broad memorisation such as anatomy. One described feeling empowered to stop using flashcards for topics where they were less effective. Some described better self-regulation through comparing and discussing strategies with peers. Participants frequently reported struggling to change their technique, but once engaged, found it worth the effort. Overall, they expressed delight and some relief in having found a technique that works for them.

“Although I was resistant to try the techniques suggested at first, I feel as though actually I have found the academic support system to be very helpful in terms of my learning ability… I found that once I began to engage … I started to notice an improvement in my ability to retain information.” R8

“I was quite scared about changing my study method. I learned that my ability to learn is actually a lot more flexible than I thought. I also learned that the way I was studying previously was probably not very effective. I [recently] learned that my current study method was effective after discussing successful exam results as a direct consequence of my [new ways of] studying.” R52

Improved time management

Participants described improved time-management, with one surprising themselves by finishing their revision on time. Chunking strategies such as the Pomodoro technique [28] (where the learner works for a pre-set amount of time, breaks for a pre-set amount of time, and takes longer breaks after every 3rd round of work) were described as helpful for getting through the work. On-the-go revision helped some free up time for socialisation and wellbeing activities.

Improved wellbeing

Improved self-care was a recurring theme. Students reported improved awareness and prioritisation of their mental health. Some reported feeling happier with their work ethic. Students linked improvements to wellbeing with the coaching approaches used during their one-to-one meetings: having the space to reflect on their own goals gave clarity, reduced overwhelm, improved prioritising skills, supported personal growth, and gave insight into what they wanted to achieve.

“In our 1–2- 1 meeting… I realised that my technique of revision was not appropriate for medical school and that my day-to-day activities could impact my ability to learn like sleep schedule and eating. I… arranged myself to get more sleep to be able to attend lectures and focus more. My tutor helped me seek the counselling and guidance I needed to be able to focus… I’ve been able to think critically about my studies due to the introduction of the idea of active recall and spaced repetition… Academic ability is something that can be improved and sharpened with focus and time.” R38

“The academic support programme… has made the prospect of being faced with a lot of new information to learn less daunting.” R8.

Participants described positive impacts of evaluating their wellbeing and needs. Mental health improvements were mentioned by some.

Transformative value: in what ways were students’ perspectives reframed?

There were multiple examples of transformative learning, which had repercussions beyond the programme. Transformative perspective shifts included changes to self-confidence, self-awareness, help-seeking behaviours, critical reflection, motivation to succeed, self-efficacy/confidence problem-solving, mindset, engagement with feedback, self-discovery, willingness to try new things, self-regulation, and adaptability. Participants frequently commented on increased introspection, and drew attention to becoming more reflective, meta-cognitive learners, questioning themselves, their thinking, and the thinking of others.

“I learned that I am more adaptable, and I am more capable of taking on challenges than I realised.” R105

Students openly identified the issues they were experiencing and accepted that if things were not working for them, they could take steps to change things or explore solutions and seek support through discussions with their tutors and peers.

“Academic ability is not a constant, it is fluid. If I’m not happy about my academic ability, I will work my guts off to change it and become better than I am.” R23