Medical Science Educator (2023) 33:1183–1190 https://doi.org/10.1007/s40670-023-01873-1 ORIGINAL RESEARCH Medical Students’ Opinion of Their Learning Process Eva Montané1,2 · Cristina Vilaplana3,4 · Joan Riera5 · Marina Pujol5 · Maria Méndez6,7 · Albert Mas5 · Angel Vara5 · David Parés8,9 Accepted: 18 August 2023 / Published online: 6 September 2023 © The Author(s) 2023 Abstract Introduction The opinion of students is of utmost importance to identify areas of improvement in undergraduate stud- ies. Medical schools would use this information to plan actions to ensure that the students achieve the necessary medical knowledge. The aim of this study was to analyse the opinion of medical students about their learning process and to analyse the influence of their experience according to their year of medical degree. Methods A questionnaire including 21 items, divided into four sections (motivation, theory lectures, hospital internships, and research) and two overall questions, was distributed among eligible 246 students. Each item was scored from 1 (strongly disagree) to 5 (strongly agree). The opinions of intermediate-year students of medical degree (3rd and 4th) were compared to late-year students (5th and 6th). Results A total of 148 students answered the questionnaire (60.2% response rate). The mean scores for overall student motivation and teaching quality were 6.15 and 7.10, respectively. The student–teacher interaction and new learning tech- nological tools were considered important for student motivation. The only differences found between the two groups of students were that late-year students wished to become part of a medical team and to learn writing scientific papers more than the intermediate-year students. Conclusions This questionnaire revealed that the year of career had little influence on the medical students’ opinion on their learning process during their undergraduate studies. Late-year students rated highest on being more interested in being part of a medical team and their knowledge on writing scientific articles. The use of new technologies and the student–teacher interaction is key to motivate students. Keywords Academic research · Education graduate students · Learning process · Opinion · School of medicine · Undergraduate medical curriculum · Web-based questionnaire 5 * Eva Montané Medical School at Hospital Universitari Germans Trias i emontane.germanstrias@gencat.cat Pujol, Badalona, Barcelona, Spain, Universitat Autònoma de Barcelona, Bellaterra, Spain 1 Department of Pharmacology, Therapeutics and Toxicology, 6 Department of Paediatrics, Hospital Universitari Germans Universitat Autònoma de Barcelona, Bellaterra, Spain Trias i Pujol, Badalona, Barcelona, Spain 2 Department of Clinical Pharmacology, Hospital 7 Department of Paediatrics, Obstetrics and Gynecology, Universitari Germans Trias i Pujol, Carretera de Canyet s/n, Preventive Medicine and Public Health, Universitat 08916 Badalona, Barcelona, Spain Autònoma de Barcelona, Bellaterra, Spain 3 Experimental TB Unit, Department of Microbiology, 8 Department of Surgery, Hospital Universitari Germans Trias Northern Metropolitan Clinical Laboratory, Hospital i Pujol, Badalona, Barcelona, Spain Universitari Germans Trias i Pujol, Badalona, Barcelona, 9 Spain Department of Surgery, Universitat Autònoma de Barcelona, 4 Bellaterra, Spain Infectious Diseases and International Health Clinical Division, Northern Metropolitan Management of the Catalan Institute of Health, Badalona, Spain 13 Vol.:(0123456789) 1184 Medical Science Educator (2023) 33:1183–1190 Introduction regarding their learning process. We conducted a question- naire specially designed for this study in Spanish. Medicine studies are from ancient times the paradigm of uni- versity, where teaching not only aims to acquire new theoreti- Setting cal knowledge, but also develop technical skills. Therefore, to design, to plan, and to develop an adapted learning environment The medical degree in Spain is a 6-year university course of engaged with medical curricula is of paramount importance [1]. study. This study was carried out at the Faculty of Medicine With recent world changes, university undergraduate teaching of the Germans Trias i Pujol University Hospital (Barcelona, programs have to be linked with new expectations. Therefore, Catalonia, Spain), which receives students from the third to new methods for knowledge transfer, new technology tools and the sixth year of medical school. In the clinical setting, the advances on design thinking, changed the classical structure of vast majority of teachers are physicians who perform clinical undergraduate studies, especially in medical studies [2–4]. activities in hospital or outpatient care. The main teaching Recently, a change of motivation pattern among youth modalities used in our School of Medicine are theoretical and, consequently, among university students has been dem- classes, clinical seminars, laboratory practices, hospital onstrated. Also, burnout and changes on how to engage with internships, and simulation practices. The initial years of students play a role in the landscape of undergraduate studies the degree, first and second, are considered foundational for redesign [5, 6]. the learning of basic medical sciences, and they are taken Motivation is essential for engaging students in their learn- in a different university campus with a majority of teachers ing process being a predictor of their academic performance who do not carry out clinical activities. [7–9]. This motivation could change depending on their year of medical degree, from the beginning to the end of the career, as many factors that are involved in motivation such as autonomy, Study Population competence, and the relationship changes during the degree [10]. Thus, the opinion of students is of utmost importance to All students of our School of Medicine were invited to fill in identify areas of improvement in undergraduate studies. Medi- the questionnaire. In the 2017–2018 academic years, a total cal schools would use students’ motivation information, to plan of 246 students were enrolled in the program. changes and to introduce an action plan to assure they achieve In order to analyse the influence of the experience as medical knowledge. In fact, motivation related to methods student based on their year of career, students who answered of learning is clearly linked to student’s perceptions and the the questionnaire were divided into two groups: medical stu- achievement of good learning outcomes [11]. dents in intermediate years (students who were in their third To date, several surveys have been conducted exploring or fourth year) and medical students in late years (for those the students’ opinion on specific tools or learning skills such that were in the fifth or sixth year). as problem-based learning [12] or assessing the opinion on specific learning subjects such as psychiatry [13] or statistics Outcome Measures [14], or focusing on specific implemented learning modules such as scientific terms in the Faculty of Medicine Charite The anonymous questionnaire was developed ad hoc by four [15]. To our knowledge, data on the influence depending on teachers (ME, VC, MM, PD) and four students (RJ, PM, the year of career in the medical students’ opinion about their AM, VA). When the preliminary version of the question- learning process is scarce. naire was written, it was first distributed to a workgroup of The aim of this study was to analyse the opinion of medical 54 teachers and students to discuss changes to improve it and students on the quality and characteristics of their learning pro- a final version of the questionnaire was created. cess, in order to introduce structured changes that could improve The questionnaire was performed using the Typeform® their learning process, focusing on whether there was any differ- software (Typeform SL, Barcelona, Spain) and complied ence according to the year of medical degree of each responder. with the European General Data Protection Regulation. At the beginning of the questionnaire, there was an introduction explaining its objectives, as well as encouraging responses. Materials and Methods It also mentioned that the responses would be anonymous and voluntary. The web-based questionnaire took approxi- Study Design mately 10 min to complete and it could be filled through a computer, a tablet, or a smartphone. This study analyses the opinions of medical students in their In July 2018, the questionnaire was shared through third to sixth year of the Bachelor of Medicine program the university alumni mailing list and the university 13 Medical Science Educator (2023) 33:1183–1190 1185 administrative staff sent two reminders, each one a week questions distributed as: two overall questions, five ques- apart, in order to increase the answer rate. tions on motivation, seven on theory lectures, three on hos- The questionnaire included 40 closed questions distrib- pital internship, and four on medical research (Table 1). The uted in four sections or fields: motivation, theory lectures, questions not included in this work were related to the notes hospital internships, and medical research. For most of the of the theoretical courses provided by teachers or elaborated questions, participants were asked to rank their agreement by the students; since in our university, medical students with the questions through a Likert scale from 1 to 5, where are organized to collect and summarize the content of the 1 meant to strongly disagree with the topic; 2 disagree; 3 nei- theoretical classes they attend to share with the rest of their ther agree nor disagree; 4 agree; and 5 strongly agree. There classmates. In addition, we have excluded questions related were also two overall questions about motivation and teaching to a competitive examination taken by doctors in Spain to quality, rating from 1 to 10, and two open questions per sec- access a specialty called “Médico Interno Residente” exam tion, designed to collect detailed information on the medical (or MIR exam). students’ views, worries, and improvement proposals. In this article, we have done a selection of the questions Statistical Analysis that we are presenting. We have excluded those that asked for local aspects that could not be of real interest to other A descriptive analysis was performed. The answer rate of universities, resulting in a questionnaire with 21 closed the questionnaire was calculated by dividing the number Table 1  Description of the questionnaire Fields of questions Questions Range score (points) Motivation (M) Please rate the level of agreement on the following actions for student motivation: M1 Assisting theory lectures 1–5 M2 Encouraging student–teacher interaction 1–5 M3 Offering complementary activities to improve grades 1–5 M4 Incorporating new technology tools during lectures 1–5 M5 Seeking feedback on subjects 1–5 Theory lectures (TL) Please rate the level of agreement on the importance of the following statements about theory lectures: TL1 They are useful for learning 1–5 TL2 They are useful for passing a subject 1–5 TL3 Encouraging students to read materials in advance 1–5 TL4 Facilitating active participation 1–5 TL5 Providing key highlights of important concepts 1–5 TL6 Utilizing case reports for better conceptual 1–5 understanding TL7 Limiting lesson duration to a maximum of 50 min 1–5 Hospital Please rate the level of agreement on the importance of the following statements about hospital internship: internships (HI) HI1 They areuseful for acquiring skills and knowledge 1–5 HI2 Integrating students into medical teams 1–5 HI3 Establishing clear objectives and activities for training 1–5 in advance Research (R) Please rate the level of agreement on the importance of the following statements about research: R1 Research is important in the academic development of 1–5 medical students R2 Courses should incorporate research components 1–5 R3 Offering optional participation in a research group is 1–5 beneficial R4 Teaching medical students how to write scientific 1–5 papers and abstracts for conferences Overall (O) Please rate the level of the following: O1 Overall students’ motivation 0–10 O2 Overall quality of teaching 0–10 13 1186 Medical Science Educator (2023) 33:1183–1190 of responses by the total number of students matriculated. Questions About Overall Motivation and Quality For each question of the questionnaire, the mean score of Teaching (O) (SD) and the score range were provided for the two scales used (5-points Likert scale or 10-points overall scale). The mean (SD) score of the overall students’ motivation For the comparison analysis between the year of career (item O1) was 6.15 (1.6) ranging from 1 to 9. The mean (SD) (intermediate vs. late years), the t Student test was used score of the overall perception of quality of teaching (item for every mean score question. A bilateral p-value < 0.05 O2) was 7.10 (1.4) ranging from 1 to 10 (Table 3). No sta- was used to determine statistical significance. tistical differences were found between the mean scores of Statistical analysis was performed using the SPSS statis- those answers comparing students of two groups (p = 0.399 tical software package for Windows, version 15.0 (SPSS™ and p = 0.886, respectively) (Table 4). Inc., Chicago, IL, USA). Questions About the Students’ Motivation (M) Ethical Considerations The mean scores of all questions related to motivation are Before starting the questionnaire, participants were informed detailed in Table 3. To assist theory lectures (item M1) did about the aim of the study and the compliance with their not motivate the student (mean 2.1); and contrarily, the stu- rights. By answering the questionnaire, the students agreed dent–teacher interaction (seminars) (item M2), new technol- on participating in the questionnaire. Data was collected and ogy tools used during courses (item M4), and giving feed- analysed anonymously. back about any medical topic (discussion lectures) (item M5) motivated the students (the mean of M2 question was 3.9 and the mean of M4 and M5 questions was 4.3). There Results were no statistical differences when comparing all motiva- tion questions among groups (Table 4). Sample Questions About Theory Lectures (TL) An overall of 148 answers have been obtained out of 246 matriculate students (60.2% response rate). The question- The mean scores of all questions related to theory lectures naire was answered from a smartphone in 88.5% of the are detailed in Table 3. The teacher’s emphasis on relevant answers (131), from a computer or laptop in 10.8% (16), concepts (item TL5) and the use of case reports to complete and from a tablet in 0.7% (1). The average response time of understandable concepts (item TL6) were both important for the questionnaire was 11 min and 8 s. students (mean 4.8 and 4.6, respectively). When comparing The year of medical degree with a higher response rate theory lectures questions among groups, no statistical dif- was the fifth year (52/61, 85.2%), and the one with the ferences were found (Table 4). lower response rate was the sixth year (20/47, 42.6%). The response rate was higher in the late-year students Questions About Hospital Internships (HI) compared to the intermediate-year students (66.7% vs. 55.1%) (Table 2). The mean scores of all questions related to hospital intern- All the questionnaire results are detailed in Table 3 and ships are detailed in Table 3. When we compared all ques- Table 4. Table 3 shows the mean (SD) scores and score tions between intermediate-year and late-year students, ranges of each question from the total responses, and Table 4 no statistical differences were found. The only difference shows the mean (SD) scores and score ranges of each ques- observed was in the question related to the importance to tion for each of the student group (intermediate year and late become part of the medical team (item HI2), where late-year year) and their statistical comparison. students had a higher score (4.3 vs. 4.6; p = 0.009) (Table 4). Table 2  Answer rates according Year career course of Third Fourth Fifth Sixth Total to the year career course of medical students N (%) medical students Intermediate-year Late-year N (%) N (%) Matriculate students 72 (29.3) 66 (26.8) 61 (24.8) 47 (19.1) 246 (100) N (%) 138 (56.1) 108 (43.9) Answers 33 (45.8) 43 (65.1) 52 (85.2) 20 (42.6) 148 (60.2) N (%) 76 (55.1) 72 (66.7) 13 Medical Science Educator (2023) 33:1183–1190 1187 Table 3  Mean scores (SD) and range for each question Question Mean (SD) score Range score Motivation (M): Please rate the level of agreement on the following actions for student motivation: M1 Assisting theory lectures 2.1 (0.84) 1–4 M2 Encouraging student–teacher interaction 3.9 (1.13) 1–5 M3 Offering complementary activities to improve grades 3.5 (1.12) 1–5 M4 Incorporating new technology tools during lectures 4.3 (0.85) 1–5 M5 Seeking feedback on subjects 4.3 (0.93) 1–5 Theory lectures (TL): Please rate the level of agreement on the importance of the following statements about theory lectures: TL1 They are useful for learning 3.53 (1.03) 1–5 TL2 They are useful for passing a subject 3.20 (1.18) 1–5 TL3 Encouraging students to read materials in advance 3.18 (1.09) 1–5 TL4 Facilitating active participation 4.15 (0.81) 1–5 TL5 Providing key highlights of important concepts 4.80 (0.45) 2–5 TL6 Utilizing case reports for better conceptual under- 4.60 (0.68) 2–5 standing TL7 Limiting lesson duration to a maximum of 50 min 4.50 (0.90) 1–5 Hospital internships (HI): Please rate the level of agreement on the importance of the following statements about hospital internships: HI1 They are useful for acquiring skills and knowledge 4.17 (1.03) 1–5 HI2 Integrating students into medical teams 4.50 (0.72) 2–5 HI3 Establishing clear objectives and activities for training 4.41 (0.83) 1–5 in advance Research (R): Please rate the level of agreement on the importance of the following statements about research: R1 Research is important in the academic development of 3.88 (0.92) 1–5 medical students R2 Courses should incorporate research components 3.63 (1.02) 1–5 R3 Offering optional participation in a research group is 4.20 (0.99) 1–5 beneficial R4 Teaching medical students how to write scientific 4.24 (0.92) 1–5 papers and abstracts for conferences Overall (O): Please rate the level of the following: O1 Overall students’ motivation 6.15 (1.6) 1–9 O2 Overall quality of teaching 7.10 (1.4) 1–10 Questions About Research (R) undergraduate studies. In the present study, we aimed to ana- lyse the opinion of medical students regarding quality and The mean scores of all questions related to medical research characteristics of their learning process in order to imple- and innovation are detailed in Table 3. There were no statis- ment structured changes that could improve the learning tical differences between both groups except for the question process. We found interesting results, particularly concern- about the wish to learn how to write medical scientific arti- ing various aspects of teaching, including lectures, hospital cles and abstracts for conferences (item R4), where late-year internships, and medical research. students had a higher score (4.1 vs. 4.4; p = 0.039) (Table 4). Results regarding questionnaire studies are more accu- rate depending on the response rate. A 60% of students answered the questionnaire in our study, and therefore it Discussion could be considered that is a high response rate. This can be attributed to the fact that when the topics of the question- Motivation is key for engaging students in the medical learn- naire are relevant and meaningful to the participants, it is ing process. This motivation could be different depending more likely to impact their response rates [16]. In our study, on the year of career of the student. Therefore, the opinion some students were very involved from the beginning, both of students is crucial to identify areas of improvement in in the design and performance of the project, and in the 13 1188 Medical Science Educator (2023) 33:1183–1190 Table 4  Comparison of mean scores of each question between groups of medical students Question Intermediate- Late-year p year students students (n = 76) (n = 72) Motivation (M): Please rate the level of agreement on the following actions for student motivation: M1 Assisting theory lectures 2.1 (0.8) 2.0 (0.8) 0.515 M2 Encouraging student–teacher interaction 3.7 (1.2) 4.1 (1.1) 0.073 M3 Offering complementary activities to improve 3.3 (1.1) 3.6 (1.1) 0.123 grades M4 Incorporating new technology tools during 4.3 (0.8) 4.2 (0.9) 0.707 lectures M5 Seeking feedback on subjects 4.1 (1.0) 4.4 (0.8) 0.110 Theory lectures (TL): Please rate the level of agreement on the importance of the following statements about theory lectures TL1 They are useful for learning 3.41 (1.05) 3.65 (0.99) 0.148 TL2 They are beneficial for passing a subject 3.10 (1.25) 3.30 (1.11) 0.339 TL3 Encouraging students to read materials in advance 3.16 (1.10) 3.20 (1.10) 0.840 TL4 Facilitating active participation 4.05 (0.92) 4.26 (0.67) 0.115 TL5 Providing key highlights of important concepts 4.83 (0.53) 4.86 (0.35) 0.664 TL6 Utilizing case reports for better conceptual 4.51 (0.77) 4.68 (0.65) 0.134 understanding TL7 Limiting lesson duration to a maximum of 50 min 4.49 (0.99) 4.56 (0.80) 0.644 Hospital internships (HI): Please rate the level of agreement on the importance of the following state- ments about hospital internships HI1 They are useful for acquiring skills and knowledge 4.04 (1.14) 4.31 (0.88) 0.115 HI2 Integrating students into medical teams 4.34 (0.81) 4.65 (0.58) 0.009 HI3 Establishing clear objectives and activities for 4.39 (0.80) 4.43 (0.87) 0.795 training in advance Research: Please rate the level of agreement on the importance of the following statements about research R1 Research is important in the academic 3.88 (0.98) 3.87 (0.85) 0.965 development of medical students R2 Courses should incorporate research components 3.54 (1.10) 3.74 (0.93) 0.245 R3 Offering optional participation in a research group 4.22 (0.92) 4.18 (1.07) 0.792 is beneficial R4 Teaching medical students how to write scientific 4.09 (0.99) 4.40 (0.80) 0.039 papers and abstracts for conferences Overall (O): Please rate the level of the following O1 Overall students’ motivation 6.26 (1.66) 6.04 (1.51) 0.399 O2 Overall quality of teaching 7.08 (1.32) 7.11 (1.41) 0.886 analysis of its results. Therefore, there is a relationship of class attendance. As it was expected, students expressed experience as a medical student and rate of response as late- the need for the introduction of new learning methods year students had a higher response rate. Overall, students (including simulation, flipped classes, additional seminars considered they had a medium–high motivation; and they for cooperative learning, discussion, and clinical cases), considered the quality of teaching received as a high; how- increasing the student participation in the learning process ever, as recent reports support this belief [2] and has been and with the use of new technologies. This is presented by perceived among university students, measures to enhance Pickering and Swinnerton and Ekstrand et al. as a good the quality of education should be considered to further attitude trigger [7, 17]. In addition, they wanted to be part improve the learning process. of medical teams during hospital internship and to be “Assisting theory lectures to motivate students” trained in medical research [18]. Probably, as it was stated, (item M1) was the item with which all students agreed this part of medical professionalism can be introduced with the least (lowest score), which explains the wide lack of a structured mentorship program [6]. 13 Medical Science Educator (2023) 33:1183–1190 1189 The information contained in our results pointed out the thank all the students who kindly responded to the questionnaire that importance of the benefits of introduction of innovation in made this research possible. learning processes in the next future as well as the effects Author Contribution E. Montané: contributed to the study design, con- of engaging in medical teams during hospital internships. ducted the literature search, analysis and interpretation of the data, and In addition, especially the late-year students expressed the writing the first draft of manuscript. C. Vilaplana: created the question- viewpoint that gaining practical knowledge in research activ- naire, contributed to the study design, analysis, and interpretation of the data, and writing the manuscript. M. Mendez, J. Riera, M. Pujol, A. Mas, ities, including scientific article writing and participation in and A. Vara: contributed to the study design, analysis, and interpretation medical conferences, is of great importance. In our opinion, of the data, and writing the manuscript. D. Parés: conceived the idea, this would be an endpoint for redesigning medical studies. contributed to the study design, conducted the literature search, analysis, The active participation, through co-creation, of medical and interpretation of the data, writing the first draft of manuscript. All the authors contributed to the final draft and approved its content. students in medical studies curricula is then warranted [18]. This study is based on answers from a questionnaire. Funding Open Access Funding provided by Universitat Autonoma Although the response rate was high, there are some limita- de Barcelona. This research did not receive any specific grant from tions. Firstly, there is a selection bias, since the most moti- funding agencies in the public, commercial, or not-for-profit sectors. vated students are generally who answer the questions. In Availability of Data and Materials The datasets used and/or analysed addition, late-year students have more experience and have during the current study are available from the corresponding author a broader opinion on how the career should be. Further- on reasonable request. more, it is important to acknowledge that this questionnaire was distributed to a single medical school, which may limit Declarations its representativeness for students from other universities. Informed Consent This study was approved by the Research Ethics Another potential limitation is that the questionnaire was Committee of the Hospital Germans Trias i Pujol. By answering the administered in 2018, before the emergence of the SARS- questionnaire, the students agreed on participating in the questionnaire. CoV-2 pandemic, which might have changed students’ opin- ions following changes made to teaching programs [19]. Conflict of Interest The authors declare no conflict of interests. The main strength of our study is that this is the first Open Access This article is licensed under a Creative Commons Attri- study exploring the opinions of medical students regarding bution 4.0 International License, which permits use, sharing, adapta- their learning process through years of graduation, providing tion, distribution and reproduction in any medium or format, as long relevant information that could be useful to other medical as you give appropriate credit to the original author(s) and the source, schools. In addition, more than fifty students and teachers provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are participated in the design of the questionnaire, which dem- included in the article's Creative Commons licence, unless indicated onstrates the high degree of involvement in this project. Our otherwise in a credit line to the material. If material is not included in results have been used in our centre as a basis for several the article's Creative Commons licence and your intended use is not actions taken to improve the teaching and learning process, permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a such as increasing simulation-based learning, changing the copy of this licence, visit http://​creat​iveco​mmons.​org/​licen​ses/​by/4.​0/. schedule of hospital internship to make it easier for students to be a part of medical team, as well as increasing the num- ber of flipped classes to promote teacher-student interaction. Moreover, a recent novelty is that certain students have the References opportunity to carry out medical research internships. In conclusion, the year of career had little influence on 1. Karani R. 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