|Year : 2014 | Volume
| Issue : 2 | Page : 92-96
Why do medical students under-perform? A cross-sectional study from Kempe Gowda Institute of Medical Sciences, Bangalore
Chitra Nagaraj1, BS Pradeep2
1 Department of Community Medicine, Kempegowda Institute of Medical Sciences, Bengaluru, Karnataka, India
2 Department of Epidemiology, NIMHANS, Bengaluru, Karnataka, India
|Date of Web Publication||20-Jun-2014|
#34, Sajjan Rao Road, V. V. Puram, Bengaluru - 560 004, Karnataka
Source of Support: None, Conflict of Interest: None
Context: Globally, it is an accepted fact that training to become a medical professional is rigorous and needs a lot of hard work. In Kempe Gowda Institute of Medical Sciences, Bangalore on an average 15-25% of each year's student intake have difficulty in completing the medical course in the prescribed duration of 4½ years. There are many factors which influence the academic performance of the students. Identification of these factors could help to establish a support system to help the students to improve their academic performance.
Objective: This study was designed with the objective of evaluating the factors affecting the academic performance of medical students.
Materials and Methods: This cross-sectional study included all currently enrolled and willing undergraduate students and interns. A general information questionnaire and the Denis Congo Study Skills Inventory were used to collect data. Secondary data on each student's/interns marks were collected using the University marks sheet. Statistical analysis was carried out using STATA- Intercooled version 10.1 for windows (Stata Corp, Texas, USA).
Results: A total of 205 girls and 162 boys provided complete information. Univariate (odds ratio = 1.06, 95% confidence interval [CI]: 1.00-1.13) and multivariate (adjusted odds ratio = 1.09, 95% CI: 1.02-1.16) analysis revealed that note taking skills was significantly associated with good performance. Every unit increase in note taking skills increased the odds of success by 9%.
Conclusion: This study has identified poor study skills, note taking in particular to be a statistically significant cause for poor academic performance.
Keywords: Dennis Congo Study Skills Inventory, medical students, note taking skills, reasons for under performance
|How to cite this article:|
Nagaraj C, Pradeep B S. Why do medical students under-perform? A cross-sectional study from Kempe Gowda Institute of Medical Sciences, Bangalore. J NTR Univ Health Sci 2014;3:92-6
|How to cite this URL:|
Nagaraj C, Pradeep B S. Why do medical students under-perform? A cross-sectional study from Kempe Gowda Institute of Medical Sciences, Bangalore. J NTR Univ Health Sci [serial online] 2014 [cited 2019 Aug 19];3:92-6. Available from: http://www.jdrntruhs.org/text.asp?2014/3/2/92/134841
| Introduction|| |
Globally, it is an accepted fact that training to become a medical professional is rigorous and needs a lot of hard work. Ferguson, James and Madeley in their systematic review of literature for factors associated with success in medical school summarize that previous academic performance is a good, but not perfect predictor of achievement in medical training and it accounts for 23% of the variance in performance in undergraduate medical training. 
In India, though all students admitted to medical school, start off on the same platform, after completing their pre-university course from a junior college or 12 th standard from schools, we find that some students are able to sail through the medical course while others, struggle to complete the course within the stipulated 4 years. Janet Yates and David James have reported that 10-15% of each year's student intake at Nottingham University Medical School were identified as strugglers in Medical School.  In Kempe Gowda Institute of Medical Sciences (KIMS) on an average 15-25% of each year's student intake have difficulty in completing the medical course in the prescribed duration of 4 years.
Once the student starts performing poorly, many times he/she is not able to get back on track with improved performance. There are many factors which influence the academic performance of the students. Identification of these factors would help establish a support system to help the students to improve their academic performance.
Choudhary and Garg studying academic performance of various categories of students at Lady Hardinge Medical College, New Delhi, retrospectively, found that out of three categories in which the students were divided into, based on the government guidelines and criteria of entrance into medical college, the results of the first category was remarkably better that than the other two categories, which they feel makes it necessary for planning remedial measures at the earliest.  This study was designed with the objective of evaluating the factors affecting the academic performance of medical students of KIMS, an urban private medical college in Bangalore, India.
| Materials and methods|| |
A cross-sectional study was conducted at KIMS, between October and December 2008. The study subjects included all currently enrolled undergraduate students of the college who had taken up at least one university examination and interns who had done their undergraduate study in this college. A written informed consent was obtained before the study.
For all eligible students and interns providing consent, a pre-tested self-administered questionnaire was administered. This questionnaire included general information about the student including their year of study and the Dennis Congo Study Skills Inventory (DCSSI).  The DCSSI is a validated study skills inventory questionnaire. It consists of six domains, namely textbook reading, note taking, memory, test preparation, concentration and time management. Each of these six domains had 5 to 13 components which were assessed using sentences to compositely indicate each component on a five point rating scale. Secondary data on each student's/interns marks were collected using the university marks sheet, which had been manually entered into a master register maintained by the college authorities. This master register is the official marks sheet for all students studying in the college. Data entry was done in a database prepared exclusively for the study, using the software Microsoft Office Excel 2003 software. Double entry was carried out on a 15% random sample of the data entered. Re-entry of data was planned if there was more than 5% data entry error. However, the errors were minimal and did not call for re-entry.
Statistical analysis was carried out using STATA- Intercooled version 10.1 for windows (Stata Corp, Texas, USA). Univariate analysis with performance as the outcome and components of the DCSSI as exposure was done. Students, who had passed all their university exams in the first attempt, were considered as good performance and those who did not were considered bad performance. Multivariate analysis was carried out using logistic regression for the same outcome and exposure. Age, type of seat and living away from home were considered as confounders' a priori. All other potential confounders such as general health of the student, distance from home, hours of study, number of revisions before exams etc., were checked for association between exposure and outcome and only those potential confounders which changed the crude odds ratio (OR) by 10% was planned to be retained in the model. The ethical committee approvals were obtained from the institutional ethical committee at KIMS Bangalore.
| Results|| |
A total of 413 students and interns, currently enrolled in the college participated in the study. Among them, only 367 (88.86%) provided complete information. Of these 367, there were 205 (55.85%) girls and 162 (44.1%) boys and only they were considered for data analysis.
The DCSSI has six domains. Univariate analysis [Table 1] revealed that note taking skills (OR = 1.06, 95% confidence interval [CI]: 1.00-1.13), was significantly associated with good performance.
|Table 1: Summary of results using univariate analysis of domains of DCSSI with performance of medical students|
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Upon multivariate analysis [Table 2], it was found that only note taking skills (adjusted odds ratio = 1.09, 95% CI: 1.02-1.16) was significantly associated with good performance even after controlling for age, type of seat and living away from home. Every unit increase in note taking skills increased the odds of success by 9%.
|Table 2: Multivariate analysis of the association of domains of DCSSI with performance of medical students|
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Multivariate analysis of components of the domains of DCSSI scale [Table 3] showed that taking notes while reading textbooks (OR = 1.36, 95% CI: 1.10-1.67) and rewriting lecture notes (OR = 1.46, 95% CI: 1.10-1.91) under note taking domain was significantly associated with success. Under the domain of memory the component of reviewing notes (OR = 1.23, 95% CI: 0.98-1.56) was associated with an increase in the odds of success. It was also seen under the domain of memory, the components of memorizing notes (OR = 0.65, 95% CI: 0.49-0.85) and not organizing main ideas and details (OR = 0.71, 95% CI: 0.53-0.93) decreased the odds of success for the student.
|Table 3: Multivariate analysis of the association of components of domains of DCSSI with performance of medical students|
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| Discussion|| |
Taking notes while reading, rewriting lecture notes and reviewing lecture notes were associated with good performance. Quantifying the odds of good performance, this study revealed that for every unit increase in note taking skills the odds of good performance increased by 9%, taking notes while reading textbooks and rewriting lecture notes increases the odds of good performance by 36% and 45% respectively. Memorizing notes and failure to organize main ideas and details were associated with bad performance. Memorizing notes and failure to organize main ideas and details into logical and meaningful order reduced the odds of success by 36% and 30% respectively. Note taking skills were significantly associated with good performance of medical students.
This type of study was taken up at KIMS Bangalore, with a view of putting in place a support system in the form of study skill classes for the 1 st year students to help them improve/maintain their academic performance. Use of DCSSI and the secondary data of the university marks gave complete and authentic data for assessing the performance of the students.
Nourian et al. evaluated the study habits and skills in medical students and interns using a general information questionnaire and a specific researcher developed validated questionnaire on study skills and found that medical students had a problem with time management, concentration, reading speed, note taking, study habits and comprehension. Our study also used a validated study skills questionnaire found note taking to be significantly associated with academic performance.  Nourian et al. studied skills of medical students, which we did not address in our study. Nourian et al. did not relate their results to the term end University examinations, whereas we correlated the study skills with the term end University examinations. Nourian et al. also suggest that training courses be established in study habits and skills at universities and we also suggest putting in place a support system in the form of study skills to help the students to improve their academic performance.
McManus et al., studied the clinical experience, performance in final examinations and the study habits and learning style in medical students using Biggs validated study skills questionnaires prospectively.  The Biggs questionnaire tests the learning process and considers the study habits to be a superficial or a deep approach to learning. Their important finding was a success in the final examination was related to a strategic or deep study habits in the final year, although not at the time of entry to medical school, thus highlighting that study habits are an important factor for predicting success. Our study found memorizing notes and failure to organize main ideas and details into logical and meaningful order reduced the odds of success by 36% and 30% respectively and note taking skills were significantly associated with good performance of medical students.
Nouhi et al. studying study habits and skills and academic achievement of students in Kerman University of Medical Sciences, used a researcher made questionnaire of study skills containing 18 items on note taking along with other parameters.  The mean scores of students for note taking was 46.43 ± 13.8 (range 18-90). The major defects in the study skills of the students were planning and time management followed by concentration and note taking skills. Study skills had a significant correlation with educational achievement (r = 0.101, P < 0.05). Nouhi et al. had studied students from different streams of health sciences such as dentists, medicine, pharmacy, health management etc., whereas in our study, it was only on medical students. Our study also found note taking skills to be significantly associated with good performance of medical students. Nouhi et al. also suggest an educational course or workshop about study skills for students.
Frellsen et al. in their study on medical school policies regarding struggling medical students during the internal medicine clerkships: Results of a national survey conclude that students struggle for a variety of reasons.  They conclude that it is important to accurately identify and remediate struggling students in medical school to fulfill our societal obligation for patient care. They say that it is important to share the limited information available about struggling students to enhance their educational experiences and potential for successful remediation and we also support the concept of medical education as a continuum. They also want institutions to develop policies on sharing information about struggling medical students. They feel that time has come for a national discussion and a research agenda to facilitate the development of effective, generalizable remediation plans for struggling medical students.
In this study, the performance of the students has been evaluated using the marks obtained by them in the university, which does not give scope for subjectivity and most of the other studies quoted here also refer to poor study skills being an important cause poor performance. ,,, It is difficult to have interventions for other social, financial factors which lead to poor performance. However a well-designed study skills program can help in improving academic performance.
Frank way back in 1977, studied the effects of four 2 hour study skills seminars for a treatment and control group at York College, Pennsylvania and showed that those who attended the study skills workshop, had significantly improved in all the three study skills areas or study techniques, study organization survey and study motivation survey and they made the recommendation of an ongoing campus wide developmental course in study skills be established and also continue further research on study skills.  The authors of this study also conclude that conducting study skill classes for the 1 st year medical students would help in improving the academic performance. However, since this study has been carried out in a private medical college, this might not be directly applicable to Government Medical College. However, considering the private medical college students are also selected through a competitive process conducted by the Government of Karnataka, it is unlikely that they could differ significantly from the students studied under this study.
| Conclusion|| |
Apart from study skills, there are many other factors, such as social, relationships economic, distance to be traveled etc., which can have a role to play in the academic performance of the students. These factors were studied to a minimal extent, using the DCSSI and no association was found with performance. These factors were not studied in detail because the investigators felt, developing intervention for these factors were not easy.
This study has identified poor study skills, note taking in particular to be a statistically significant cause for poor academic performance and interventions can be developed to address these issues.
| Recommendation|| |
Similar multicentric studies would help to generalize the results of the study; we welcome collaborators and ideas to be a part of this study. We need to develop a study skills intervention program for improving the performance of the students.
| Acknowledgement|| |
The authors would like to thank Dennis H Congos for giving permission to use the DCSSI inventory. The authors wish to express their gratitude to the participants of the study, the Medical Education Unit of Kempegowda Institute of Medical Sciences, Bangalore and PSG Faimer Institute, Coimbatore, for their support and encouragement during the conduct of the study.
| References|| |
|1.||Ferguson E, James D, Madeley L. Factors associated with success in medical school: Systematic review of the literature. BMJ 2002;324:952-7. |
|2.||Yates J, James D. Predicting the "strugglers": A case-control study of students at Nottingham University Medical School. BMJ 2006;332:1009-13. |
|3.||Choudhry R, Garg K, Gaur U, Anand C. Academic performance of various categories of students admitted to Lady Hardinge Medical College, New Delhi. J Indian Med Assoc 1997;95:45-7. |
|4.||11/91rev12/02, 9/08, 3/10 Developed by Dennis H Congos, Academic Advisor and Learning Skills Specialist, First Year Advising and Exploration, 116 Phillips Hall, University of Central Florida, Orlando FL, 32816 407 - 823-3789. Email: firstname.lastname@example.org. |
|5.||Nourian A, Mousavinasab SN, Fehri A, Mohammadzadeh A, Mohammadi J. Evaluation of study skills and habits in medical students. S East Asian J Med Educ 2008;2-1:61-4. |
|6.||McManus IC, Richards P, Winder BC, Sproston KA. Clinical experience, performance in final examinations, and learning style in medical students: Prospective study. BMJ 1998;316:345-50. |
|7.||Nouhi E, Shakoori A, Nakhei. Study habits and skills, and academic achievement of students in Kerman University of Medical Sciences. J Med Educ 2008;12-3:77-80. |
|8.||Frellsen SL, Baker EA, Papp KK, Durning SJ. Medical school policies regarding struggling medical students during the internal medicine clerkships: Results of a national survey. Acad Med 2008;83:876-81. |
|9.||Frank PM. The effects of a study skills workshop upon study techniques, study organization and study motivation for resident freshmen a practicum presented to Nova University in partial fulfillment of the requirements for Degree of Doctor of Education on October 25; 1977. |
[Table 1], [Table 2], [Table 3]