Students’ perspectives on their early dropout of medical school

Abstract

BACKGROUND:

Enrolling in medical school launches a more demanding and stressful way of life for newly admitted students. Some students will struggle academically and will ultimately drop out from medical school. The study aims to understand the perspectives that dropped-out students have and their opinion regarding possible preventative solutions.

MATERIALS AND METHODS:

This study uses a mixed-method approach. The results of students’ examinations in the first 2 years of admission (within four academic years from 2016 until 2020) were collected from the medical school records. A questionnaire was developed to investigate the causes of early attrition during the study period. All dropped-out students who were admitted were included in this study.

RESULTS:

The study included 479 admitted students, 349 (72.9%) were females; 152 (31.7%) students dropped out in the premedical program (first two years); 104 (68.4%) of the dropped-out students were females. Thirty-five (23%) students responded to the questionnaire. Twenty-eight (80%) respondents believed that their low academic performance and leaving medical school was primarily related to psychological problems, 19 (54%) of respondents reported leaving for social reasons, and lack of self-organization in 13 (37.1%) respondents. Human anatomy was recorded as the most difficult course in the first year by 21 (63.6%) students.

CONCLUSIONS:

The cause of attrition is often multifactorial and complex. Psychological problems are one of the important factors in students with low academic performance and dropping out of the students. Some difficult courses in the curriculum may affect the students’ academic performance leading to their attrition.

Introduction

Around the world, placement in a medical school is highly competitive. The number of candidates applying to medical schools is greater than the available positions. Only the most qualified students are admitted to medical schools.[1] Many factors can be attributed to a student’s motivation to enroll in medical schools, including the willingness to serve people with illness, fulfill family wishes, and earn a substantial income along with the acquisition of a higher social status and community respect.[2] However, enrolling in medical school also commences a more demanding and stressful way of life. Some students will struggle academically during medical school and will ultimately dropout.

Most students’ attrition occurs during the first 2 years of medical school. Students give many reasons to leave their projected career in medicine including academic failure, a perceived wrong career choice, individual perceived shortcomings (lack of dedication, flexibility, and motivation to study medicine), and physical or psychological illness.[3]

According to Arulampalam et al., the most important factors contributing to students’ attrition are medical school-related factors, including candidates’ entry qualifications, and curriculum design and delivery.[4] Students’ attrition has a significant effect on the reputation of the medical school, on society, and on the students themselves.[5]

A recent study at the country of Colombia demonstrated that changing in the curriculum design from the traditional curriculum (basic and clinical sciences taught separately) to an integrated curriculum (basic and clinical sciences taught simultaneously) led to a dramatic decrease in the attrition rate from 41.5 to 3.3%.[6]

The effects of curriculum-in-use on attrition in medical schools have not been well studied in the literature. The curriculum-in-use is the actual curriculum that is delivered to the students and taught by each teacher. Understanding the influence of the type of curriculum design on academic failure and dropout is an important step to take in order to actively decrease the attrition rate of students.[7]

Most of the studies on students’ attrition focus on the predictive value of various entry qualifications and related attributes of the students. These studies have been performed on different communities with different methods of students’ admission requirements.[8,9] In a systematic critical literature review on medical education, O’Neill et al. found that the average attrition rate globally was 9.1% (range: 2.7–20.1%).[10]

In a previous study at our institution, the attrition rate in the premedical program was 31.7%.[11] This attrition rate is very high compared to the average attrition.

The aim of this study is to understand the perspectives on factors contributing to their own early attrition that dropped-out students have and their opinion regarding possible solutions. This will help in developing institutional interventions in the first 2 years of medical school to improve student retention and prevent the consequences of students’ attrition on the medical school, students, and community.

Materials and Methods

Study design and setting

College of Medicine and Health Sciences (CMHS), United Arab Emirates University (UAEU), is the largest and the only public medical school in the UAE. The UAEU ranks 251^st among the best universities worldwide according to the Times Higher Education Ranking of Universities 2023.[12]

Only students of the UAE nationality (Arabic speaking) are admitted to CMHS where the medical curriculum is taught in English. Most of the students admitted to CMHS are recent high-school (secondary school) graduates, with a few students admitted at the postgraduate level.

The Bachelor of Medicine and Bachelor of Surgery at CMHS has a 6-year curriculum without a foundational year. It is called the MD (Doctor of Medicine) program. The MD program is divided into three progressive curricula, each composed of 2 years (premedical, preclinical, and clinical programs).

The first semester in the first year of the premedical program includes six courses that focus primarily on basic scientific knowledge and are considered preparatory courses for medical studies (language and literacy, numeracy and information technology, human biology, chemistry for medicine, human anatomy and professional practice and communication). The pass threshold in each course is 75%. Students who fail any course in the first year are given opportunities for remediation. Students who fail in remediation are expelled from the program on academic grounds without the option to repeat the first year. Students who fail any course in the second year are also given opportunities for remediation. Students who fail this remediation must repeat the entire second year.

This study used a mixed-method approach (both quantitative and qualitative data) to obtain in-depth view of students’ experience and perspective on their attrition during the first 2 years of medical program (MD) at CMHS. All students who were admitted to CMHS within four academic years (2016–2020) were included in the study.

Study participants and sampling

All (479) students who were admitted to CMHS during the study period were included in the quantitative research. In the qualitative part of the study, a self-administered questionnaire was sent for all (152) dropped-out students during the study period.

Data collection tool and technique

In the quantitative research, all the students’ examination results during the first 2 years of MD program were collected from the existing medical school records. The collected data included the students’ age and gender.

A self-administered questionnaire for all the dropped-out students was developed in the qualitative part of the study to investigate the causes of early attrition at our institution. All dropped-out students’ contact information were collected from the existing students’ records.

The questionnaire was prepared on Google Forms (free online software that allows users to create a questionnaire and collect data). All students (152) who dropped out from the premedical program during the study period received a link to the questionnaire by e-mail. Closed-end questions, partially closed-end, and open-end questions were used in the questionnaire to explore the reflections of the students about their experience at CMHS and possible ways to reduce the student attrition rate. Likert scales were used in some of the questions.

The questionnaire was reviewed by three students for face validity of the survey items and for the clarity and consistency of the questionnaire items before sending it to all dropout students in an effort to enhance the response rate.[13]

The former students were invited to participate in the research project after a brief explanation of the study. Participation was entirely voluntary, and the questionnaires explicitly stated that participants could refuse to participate or leave at any point without penalty.[14] A simple content analysis for the questionnaire was performed.

Triangulation by using different types of data was essential in gathering different views leading to proper answer to the research questions and providing possible solutions for the high students’ attrition at CMHS.[15]

Ethical consideration

All collected data were anonymized, handled, and stored in accordance with the tenets of the Declaration of Helsinki. Participants were invited to participate in the study after receiving a brief summary of the research project, which included an explanation of the study, the value of their input, where the information will be reported, and impact of the study to CMHS and the community. The ethical approval of this study was obtained from the CMHS Social Sciences Research Ethics Committee (SS-REC), Reference Number: ERS_2019_6027.

Results

During the study period, 479 students were admitted to CMHS, 349 (72.9%) were females; 152 (31.7%) students dropped out in the premedical program (first 2 years of MD program). The student’s ages at their time of entry to CMHS ranged from 17 to 19 years; 104 (68.4%) of the dropped-out students were females. On average, in each admission cohort, around 35 students dropped out in their first year compared with four students in the second year.

The results of the examinations in the premedical program showed that 131 students failed in one course or more in the first semester of the first year; 94 (71.8%) of those students who failed in the first semester failed to pass the human anatomy course [Table 1].

Table 1.

Failed courses in the first semester of the first year (failed students n=131) at CMHS (2016–2020)

First semester courses	Failed students in the courses n (%)*
Human anatomy	94 (71.8%)
Human biology	48 (36.6%)
Language and literacy	43 (32.8%)
Professional practice and communication	41 (31.3%)
Chemistry for medicine	41 (31.3%)
Information technology	12 (9.2%)

*The percentage is more than 100% because one student may fail in more than one course

It is to be noticed that 128 (97.7%) students of those who failed courses in the first semester of the first year dropped out from the program within the first year. Only three students passed the remediation examinations.

The questionnaire was sent to 152 students [(104 (68.4%) females and 48 (31.6%) males] who dropped out from the medical program during the first 2 years of enrolment into CMHS. Thirty-five (23%) students responded to the questionnaire [28 (80%) females and 7 males].

All respondents were single when they enrolled into CMHS. The 2016 cohort had 7 respondents, the 2017 cohort had 12, the 2018 cohort had 11, and the 2019 cohort had 5 respondents. A personal desire to learn more about the human body, health, and disease was the primary motivator for studying medicine in 30 respondents (85.7%) [Table 2].

Table 2.

Students’ motivations to study medicine (n=35)

Motivations to study medicine	n (%)*
Personal interest in knowing about the human body, health, and disease	30 (85.7%)
Very good high school grades	20 (57.1%)
Consider the medical profession as a noble profession	17 (48.6%)
Influence of parents and family	12 (34.3%)
Experience of ill health (personal or family)	5 (14.3%)
High school teachers advise	2 (5.7%)

*The percentage is more than 100% because some students have more than one motivation

Twenty-one of the respondents (71.9%) did not seek any assistance and relied completely on themselves to improve their academic performance, while six (18.8%) students asked for help from individual faculty. Increased studying hours with no other guidance was the primary strategy used by 12 (42.9%) students to enhance their performance.

Twenty-eight (80%) respondents believed that their low academic performance and leaving medical school were related to psychological problems and 19 (54%) of respondents believed that their performance was influenced by social factors (e.g., commitments outside the academic study).

The most common nonsocial contributing factors to the low academic performance were a lack of self-organization in 13 (37.1%) respondents and a lack of feedback on assessment performance in 12 (34.3%) followed by low English language level in 11 (31.4%) respondents.

Eight (22.9%) students thought that it was difficult to cope with the physical and mental load of studying medicine. Ten (28.6%) respondents declined any support for academic improvement from faculty members.

Human anatomy was voted as the most difficult course in the first year by 21 (63.6%) students, followed by professional practice and communication courses.

Thirteen (37.1%) students evaluated the overall CMHS learning environment as poor, 11 (31.4%) evaluated as fair, and 11 (31.4%) as good. Table 3 presents a summary of the students’ opinions about the main contributing factors to their low academic performance and dropping out from the medical school.

Table 3*.

Summary of students’ opinions about the main contributing factors to low academic performance and students’ dropout

Factors	Students opinion
Psychological and social	Psychological problems Social conditions Commitments outside of academic study
Non-social	Poor time management skills difficult to cope with the physical and mental load Weak English language Several resits
Curriculum and learning environment	Lack of timely and constructive feedback CMHS curriculum is overcrowded The examinations are not well aligned with the objectives The workload during medical school is unmanageable Poor overall learning environment Faculty members are not supportive of their students’ academic growth

*The table arranged to show the students opinions and not in order from most- to least-mentioned

On leaving CMHS, 20 (57.1%) respondents planned to apply for an undergraduate science degree at UAEU and 10 (28.5%) respondents planned to apply to a different medical school. Fifteen (42.9%) respondents would not recommend high school students to enroll in CMHS compared with nine (29.7%) respondents who would recommend enrolment in CMHS.

Table 4 shows a summary of suggestions from the students to reduce attrition and improve learning at CMHS.

Table 4*.

Summary of suggestions from the students to reduce attrition and improve learning at CMHS

Suggestions	Students opinion
Learning and guidelines tutorials	Inform the students about resit and dismissal regulations at CMHS in the beginning of the first semester Organizing workshops about time management and self-directed learning in the beginning of the first semester
Delivery and content of curriculum	Reduce teaching time for less important courses Encouraging constructive feedback and formative assessment Peer-assisted group learning under faculty supervision More clinically oriented classes with fewer students per session Very busy schedule needs spacing and organization of the assessments to avoid concurrent examinations Different forms of assessment and more frequent assessments and quizzes to reduce the impact of the end-of-course exam and add various types of questions so as not to depend solely on MCQ type of questions
Learning environment	Improve communication, mutual respect, mentorship, and constructive feedback between faculty and students
Psychological assessments	A counselor psychologist can check on a student’s mental health regularly as needed

*The table arranged to show students’ opinions and not in order from most- to least-mentioned

Discussion

This study reports that psychological factors were identified by the students as the main factors contributing to their low academic performance and subsequent attrition. Most of the students (80%) attributed their attrition to psychological factors in contrast with prior reports that psychological factors become more prevalent in the later years of medical education and may not be obvious in the early years.[3,16] It is also reported that the frequency of psychological problems is likely to be higher than what is documented because many students will not request help and are unwilling to reveal the status of their mental health even after enrolment.[16]

The transition from high school to medical school can be a very stressful period. Some students with less psychological resilience may struggle to adjust to the medical school’s self-directed learning environment and become more prone to various psychological illnesses (e.g., stress, anxiety, and depression).[17] Additionally, living away from home, possibly for the first time, may trigger anxiety and depression which are then aggravated by the heavy workload of studying medicine.[18] Including psychometric analysis in the noncognitive admission examinations may help to predict each student’s ability to overcome the early critical time of attending medical school.[19]

The relationship between the curriculum-in-use and early attrition among students has not been widely researched in the literature.[20]

In this study, the students provided several observations regarding the existing curriculum and its effects on the learning process. The students’ late clinical exposure, the need for more interactive teaching sessions, the congestion of the curriculum with less important courses, and overlapping of the assessment schedules and the weight of the end-of-course examinations were the key concerns.

It is essential to consider reorganization of the courses and the assessment schedule to help the students focus their efforts and minimize distraction by conflicting examinations.

The integrated curriculum is becoming increasingly popular in medical schools around the world. Its core idea is to integrate clinical exposure into medical education at an earlier stage and to combine basic knowledge with clinical experiences. Some students have suggested that early clinical exposure will promote retention of knowledge and improve clinical skills which may help to reduce the attrition rate.[21,22]

Most of the students reported that the human anatomy course was the most difficult course in the curriculum. Human anatomy is one of the most important courses needed for studying medicine during undergraduate and postgraduate studies. It’s worth noting that 91 (96.8%) of the 94 students who failed the human anatomy course in their first semester of the first year dropped out from the program [Table 1]. High fail rates can sometimes indicate that something is incorrect in the course or the teaching, rather than with the students. The students may lack the opportunities to learn in anatomy laboratories due to time constraints with busy schedules and examinations.[23] Also, the COVID-19 pandemic may have affected student learning of anatomy as access to laboratory facilities has been restricted. As suggested by the students who participated in this study, allocating more time for teaching anatomy could improve teaching in such an important course. Providing more time for clinical and interactive teaching sessions along with online teaching may help academic improvement of the students.[24]

The interpersonal relationship between teachers and students plays a vital role in medical education and contributes to obtaining optimal learning outcomes.[25] This study reports that most students did not seek assistance from their teachers to improve their low academic performance prior to dropping out. The students depended on themselves to improve academically by increasing their studying hours, without any guidance. Some of the respondents also believed that faculty members were not supportive of their academic growth. Effective communication between teachers and students with mutual respect is an important part of the hidden curriculum and building of future physicians.[25]

The obstacles in communication and interaction between the students and teachers are very likely related to the relatively increased number of students per teacher, who then becomes overwhelmed with his or her very busy schedule and increasing responsibilities. As suggested by the respondent students, peer-assisted group learning with faculty supervision will facilitate the development of optimal communication and construction of a student-friendly learning environment.[26]

Continuous expansion of knowledge and improved accessibility to information have contributed to making self-directed learning the cornerstone in modern medical education.[27] The study reported that most students have inadequate self-directed learning capabilities. Inadequate self-directed learning capabilities of students may be one of the primary reasons for students’ low academic performance and resultant dropout. Future physicians benefit from being self-directed learners in order to continue studying for the rest of their lives in the ever-changing medical industry and to acquire the necessary information for professional development.[27] Premkumar et al.’s study surmised that poor time management and lack of self-organization adversely affect students’ performance as self-directed learners. Organizing workshops on self-directed learning and time management in the early days of attending medical school will help students to organize their learning activities, leading to the improvement in students’ performance, and ultimately reduce the attrition rate.[27]

Unfortunately, most of the students who are at risk of attrition and need a mentor’s support do not ever request a mentor’s help. It is essential to have a mandatory mentorship program for all students with low academic performance starting from the first year in medical school. A recent systematic review concluded that group mentorship programs allow personal reflection to be conducted within supportive environment.[28]

Limitations and recommendation

We acknowledge the limitations to this study. Although the questionnaire was sent to all the students who dropped out from the premedical program, only 23% of the students responded to the survey. The response rate for the questionnaires was low even with the use of e-mail and other electronic data-gathering tools.[29] Interviewing the dropped-out students in person may give more information; however, it was very difficult to have interviews with former students due to COVID-19 pandemic and other logistical issues.

Some of the responses on the questionnaire were likely to be inaccurate because some participants may have been reluctant to disclose the full requested information. Questions about psychiatric conditions were unlikely to be answered honestly and the incidence of problematic mental health could be higher than that reported in the findings.[30]

This study was conducted at our institution and the data may not apply to other medical schools with different admission processes, students’ demography, or a different curriculum. However, similar factors for attrition have been found in many international studies on attrition which suggests that the results of this study may apply to other schools and could possibly be generalized.[31]

Future research should examine the use of psychometric tests in the admission process of students applying for medical schools. More studies are needed to investigate the effects of modern integrated curricula on the attrition rate and on the quality of future physicians.

Conclusions

The cause of attrition is often multifactorial and complex. Psychological problems are one of the important factors in students with low academic performance and often lead to the eventual dropping out of the students. Including psychometric tests in the admission examination may help to predict each student’s ability to cope with the mental demands of studying medicine, especially in the early period of attending medical school.

Organizing workshops on time management and on self-directed learning early in medical school could improve the ability of the students to study medicine. Courses with high failure rate need more space in the curriculum and to be taught in a more interactive way to improve the academic performance of the students and reduce the overall attrition.

List of abbreviations

CMHS = College of Medicine and Health Sciences

MD = Doctor of Medicine

MBBS = Bachelor of Medicine and Bachelor of Surgery

MCQ = Multiple choice questions

PBL = Problem-based learning

RERB = Research Ethics Review Board

SS-REC = Social Sciences Research Ethics Committee

UAEU = United Arab Emirates University.

Declarations

Ethics approval and consent to participate

Ethical approval for this study was obtained from CMHS Social Sciences Research Ethics Committee, Reference Number: ERS_2019_6027. Informed consent was obtained from all subjects and/or their legal guardian(s). The authors confirm that all methods were carried out in accordance with relevant guidelines and regulations. All collected data were anonymized, handled, and stored in accordance with the tenets of the Declaration of Helsinki.

Consent for publication

Not applicable.

Availability of data and material

All data generated or analyzed during this study are included in this published article.

Authors’ contributions

All authors have the idea of the research, editing, and approving the final manuscript. A.F.H. wrote the main manuscript text, data collection, data analyses, literature review, and wrote the main manuscript text; A.AB. reviewed and edited the manuscript; M.A.K. reviewed and edited the manuscript, M.A.F. reviewed and edited the manuscript; N.A.M. reviewed and edited the manuscript.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.