The coding system including clustering of main- and sub-categories at first and second level can be found in Fig. 1. Additional quotes that are not cited in the text can be found in Additional file 3.
Students perceived an insufficient information flow from administration and teaching staff which was characterized by missing information, inadequate feedback of results, delayed provision and updating of schedules, a lack of contact persons and conflicting information depending on which staff were asked. Furthermore, students criticized that there was no single standardized source of information, but reported that information about courses and examinations is spread across various online portals and web pages. Furthermore, some students felt stressed by the varying types of teaching materials (e.g. books, scripts, PowerPoint presentations) and lack of information regarding which of those materials ought to be used to prepare best for exams. This insufficient information flow resulted in rumors and hearsay, uncertainty of what is expected and fear of missing out on important information. Furthermore, mandatory attendance and regulation of absenteeism were perceived as burdensome.
“I think […], that it’s always somewhat unclear what’s going on. One asks about something and gets 10,000 different answers. Everyone says something else, and when you google it or check it on the website you don’t find anything. For example, not being able to attend, there are different regulations for each subject. How many times are you allowed to be absent. OK, 15% is allowed in general, but there are subjects where they’re calculating 15% per module. Then there are subjects where they’re calculating 15% for all 12 modules. In this case one can check for oneself, how often do I have to attend here and there and how many times can I be absent. Of course, you don’t know exactly, because we don’t have the schedules for all 12 modules yet […]. ” (Focus group (FG) 4 - Study year (Y) 1).
The timetable was perceived as an additional stressor due to a large number of teaching events in short periods of time or even simultaneous events.
“Well my group had a module with an internship in a practice and my impression was that I miss out on a lot of things during that week. I was in the practice every day until 7 p.m. and […
I somehow felt that I don’t have enough time to work through everything during that week. I also had to do a sonography exam during that week. I think it’s totally crazy to organize it in a way that it’s scheduled for the middle of the semester.” (FG 5-Y2).
Study participants also highlighted issues regarding repeat exams, which were usually scheduled at inconvenient times during the academic year. Some students criticized that the schedule changes on a weekly basis. Particularly those students who commute between university and their home town felt stressed when only one event was scheduled on a day or when unnecessary and long breaks were scheduled between different events (Quote (Q) 1, see Additional file 3). Furthermore, students believed that subjects were unstructured in terms of content and time and perceived a gap between theory and practice.
“One thing that continues to annoy me […
is the separation of practice from theory within the modules. That they are not connected at all is something that I find irritating again and again, […
Then you have a module about the head and afterwards you practice in, I don’t know, nephrology, radiotherapy, orthopaedics, and psychiatry, yes psychiatry would also be useful. But that there are no connections, I always find that annoying, also because then you’re often in a situation where you have to say, sorry, I haven’t learned that yet, I can’t say anything about it. Personally, I always find this very inconvenient and it doesn’t help me at all for getting in-depth knowledge on something I studied for three weeks.” (FG2-Y5).
In addition, registration to events and cancellations of events, especially when students were not informed beforehand, were mentioned as further stressors. Some students believed that those organizational deficits were associated with the conversion of the standard curriculum to a new curriculum.
Difficult exams, the German first state examination (“Physikum”), feelings of being unprepared, errors in the phrasing of exam questions as well as a high quantity of exams emerged as further stressors. In addition, cumulative exams (i.e., a number of exams that add up to a final grade) seemed to increase pressure because students had to wait until the end of the study block to know whether they passed the exam (Q2). The feeling of an imbalance between one’s efforts and rewards was often expressed as large amounts of time spent learning did not necessarily correspond with equivalent grades or passing exams.
“Before each final exam of a module you’ll go to your limit. I have never attended a module without someone crying because they had a nervous breakdown. It becomes, I don’t know, quite emotional. […]
And compared to this I think the results aren’t great either. I mean people go to their limits and still there are so many who fail.” (FG4-Y1).
Furthermore, unfair grading systems - i.e. the grade being partly contingent upon the specific examiner - were perceived to increase stress.
“I mean, I have already begun to wonder who will be in charge of my oral equivalency exam next year. Because no one can tell me that there are equal opportunities. Well, it makes a big difference who sits in front of you and asks questions, and these are things that create more stress than the preparation itself.” (FG5-Y2).
A disproportion between subject matter and number of exam questions was also alluded to. Furthermore, study participants felt highly stressed due to repeat exams because a) they were scheduled at inconvenient times, b) one has to learn for them again simultaneously with other regular exams, which increases time pressure (Q3), and c) of the option to repeat exams only twice. After failing the same exam for the third time, students are excluded from medical studies at any medical school in Germany.
“This is simply the pressure one feels, that you know that if you fail three times, something that happens really, really quickly, then you will never be able to do it again. If I failed three times, I have no idea what I would do then.” (FG8-Y2).
Poor quality of teaching, including lectures, lecture slides and scripts, as well as lack of guidance and supervision was often perceived as demotivating (Q4). Furthermore, study participants felt that they were not well prepared for exams (Q5). Some educational content was experienced to be inadequate. Specifically, according to participants’ views, unimportant and easy topics are frequently and strongly emphasized whereas important and more complex issues remain unaddressed.
“Yes, and honestly, it’s unbelievably discouraging when you’re told that you don’t really need this for practicing, then I ask myself, why don’t we learn the things that are really important for practicing.” (FG6-Y1).
Due to the perceived frequent emphasis on supposedly unimportant topics a feeling of time waste was often mentioned, especially in association with mandatory attendance. Furthermore, some students expressed that they are bored and not intellectually challenged due to the requirement of learning a lot of content simply by heart (Q6). Many participants pointed to poor supervision during practical tasks.
“Well, I find it annoying that we have no supervision and that we have to take care of everything by ourselves, you have to realize, it’s not always their fault, perhaps they would like to help but they just don’t have enough time. That’s annoying.” (FG1-Y5).
Some students also expressed that some physicians are unfriendly, demotivating and that they give them a feeling of being bothersome during their practical tasks.
“When you’re looking for a physician for three weeks who just makes you feel that you’re a burden (,) I do find this extremely discouraging.” (FG1-Y5).
Furthermore, some students felt that the mandatory internship at the general practitioner is ineffective. They complained about a lack of responsibility and the inability to adequately perform their tasks for university. If they were allowed to perform some medical examinations, they felt uncomfortable due to a lack of experience and permission to discuss their diagnoses with the patient.
“Sometimes it was really inconvenient to go to a patient and say, OK, I’m a student and I will examine you. And then they ask me, what do you think. Well, I am not allowed to express an opinion. What. No. Well I sometimes found this very inconvenient to sit there with my partial knowledge and to pretend that I could do a perfect examination, but I am not allowed to diagnose them.” (FG5-Y2).
In addition, the nursing internship of three months was experienced as time-consuming and some students reported that responsibilities during the internship were not clearly communicated beforehand.
“For example, in my case I divided the [nursing] internship into three parts and in one case they wanted me to work thirty days in a row for eight hours per day without a break. Not even two days off in between, although as I know now I would have had a right to them. I basically had no idea what I was allowed to do and what I wasn’t allowed to do. In the end […
nurses sometimes forced me to do things I wasn’t allowed to do, e.g. giving injections to prevent thrombosis.” (FG8-Y2).
Time and performance pressure
The feeling of time pressure caused by competing events, own rescheduling of learning, elective courses and a heavy workload due to a high amount of subjects as well as very comprehensive single subjects was often expressed (Q7). This seemed to result in a lack of time for private life and to learn guided by one’s own interests (Q8), in a lack of motivation (Q9), and in learning on short-term memory.
“I think here we really bring ‘bulimic studying’ to perfection. During the three weeks before the written exam I stuff myself with everything. Study all night. I try to find time for everything. I can’t tell you anything anymore about locomotor system or TB1 or TB3. I can’t tell you what I learned last week because I’ve already forgotten it. We try to learn so much in such a short period of time. And we have to concentrate on a new subject immediately afterwards. That there’s no chance to remember what you learned in the last modules or to enhance it.” (FG4-Y1).
Many students also alluded to a lack of recreational time due to courses, internships and exams during non-lecture periods and emphasized that they feel exhausted at the end of the academic term. Furthermore, they expressed the feeling of performance pressure, which occurred due to the scheduling of repeat exams and simultaneous scheduling of lecture periods, exams and internships. They further expressed the thought that this performance pressure is deliberately built up by the medical school to test students’ stamina and to thereby initiate selection according to stamina.
“The impression is that there’s pressure to simply select and I really find this (,) to be quite honest I have come to find this a bit annoying.” (FG8-Y2).
Interactions with administrative staff were heavily criticized and unfriendliness as well as a lack of appreciation, respect and support was experienced.
“Well you’re not really appreciated here. They rush you through it and, uh, when you don’t function you’ll be punished.” (FG8-Y2).
Additionally, a bad atmosphere between teaching staff and between students and teaching staff was reported (Q10). Furthermore, fellow students were identified as additional stressors. First, stress seemed to develop due to one’s own comparison with fellow students in terms of time spent for learning and learning progress.
“In the week before the exam I have at least one nervous breakdown per day, because I sit there and start crying, because when I talk to friends who are more advanced I see that there are so many things I still have to do. You have no idea what they’re talking about […]” (FG4-Y1).
Second, most social contacts involve other medical students and therefore conversations always addressed medical studies even in private life.
Internal stressors seemed to involve a guilty conscience when taking a break from learning due to high performance pressure, high self-expectations regarding one’s performance during medical studies (Q11), inability to relax and fear of failure regarding exams (Q12) and as a physician in the future.
“You always think about it, OK, you didn’t study for two hours. Now you have a bad conscience and having a bad conscience when you spent ten hours studying and did something else for two hours, somehow that’s sick.” (FG7-Y5).
“When I meet with friends or do something with my family, then I always think in the back of my mind that I could just as well study. You can’t enjoy it.” (FG6-Y1).
Finally some additional stressors were highlighted including the financial situation (Q13), commuting between university and one’s home town, transition from high school to university, writing a doctoral thesis (Q14), which in Germany is often performed during medical studies, and feeling unprepared for future work life.
“Somehow, I think that (,) for me it’s really sad, because after a very short time I will be a physician and I think OK, concerning the eyes, for example, there’s a knowledge gap. I find it very embarrassing because if you ask me about it or I have to say something about it, then I don’t know anything about it and because of all the organizational stuff this went wrong a bit.” (FG3-Y5).
A well-structured curriculum, combining practical and theoretical training and having a block by block structure, was appreciated by study participants. They argued that this helped them to deepen their knowledge, to really concentrate on one subject and to feel certain on what to expect at exams.
“What you said is quite right, these eight-week modules, I found it so relaxing to study there […]. That’s great. That’s so nice because it’s a combination of both. There are good modules for practicing, because they do a great job organizing, and you have theory, but it’s not too much and you can repeat in between.” (FG3-Y5).
Flexibility regarding optional attendance of lectures (Q15), the possibility of repeat exams (Q16) and having a contact person for each subject were named as additional organizational resources.
“Yes. Basically, I have to say that I found it really great that in the beginning professor X stood there and said ‘I am in charge of this module and if you have any questions please contact me’. In the other modules, it was not clear (other participants: agreement – yes) who you could contact. But basically, you simply have someone of whom you knew you could contact them. And I must say this module was the first one where this happened. I found this extremely helpful.” (FG5-Y2).
Practical training and career prospects
Practical training and internships were viewed as opportunities to practice what has been learnt. It seemed to help to remember and to better understand content covered in teaching. Furthermore, practical training, internships and side jobs seemed to motivate study participants to proceed further with their education because it reinforced their career choice (Q17). Good career prospects in the medical field were also repeatedly named as important motivation to proceed further with studies despite increased stress and workload.
“I believe I simply know that it’s the right thing and that you look forward to it, and I think being a physician is stressful and perhaps frustrating and all kinds of things, but it’s a great job. I really look forward to it because it’s not a job that involves moving piles of pallets from A to B, or checking if some part for cars arrived, it’s a job where I will rush home at night and I will say you did not change the world but you made a certain difference for a patient and I think this is (,) this will be a great feeling. And we have this with small things, during part-time jobs all of us (,) or in a practical module, or during a clinical elective or something like this, but it’s very satisfying and this is what helps you to get through with your studies.” (FG2-Y5).
In addition, prospects on easier and more interesting parts of the curriculum seemed to help some participants to carry on (Q18).
Contact with relatives and friends seemed to help study participants to cope with increased stress due to their studies (Q19). Additionally, also social interactions with students from higher years and fellow students were named as important resources. They assured social contact and exchange of important information (Q20–21). Furthermore, students felt less lonely and were able to share their stress, anger and fears regarding medical studies with like-minded persons.
“What really helped me is that I wasn’t the only one who suffered. I always think that sharing suffering, that’s what (,) while studying medicine it becomes very obvious that it’s extremely helpful when others are in the same boat and also rant.” (FG3-Y5).
Conversely, some participants believed that distance from fellow students helped them to cope with and get away from stress due to medical studies.
“But it was the most important thing, I completely isolated myself from my fellow students, I really didn’t want to meet them because I knew they are also stressed out by studying and they are all afraid and I didn’t want to catch their panic. And this really worked out.” (FG7-Y5).
A relaxed attitude involving lower self-expectations, acceptance when things are not going so well (Q22) and less comparison with other students was believed to decrease stress. Also past experiences seemed to help students cope with high demands related to medical studies (Q23). Furthermore, a good knowledge base, interest in the medical field, partial control of learning content according to one’s own interests, ability to learn easily by heart and rewarding oneself were named as further resources.
Hobbies, physical activity, meeting friends, holidays, recreational time and breaks during learning phases were thought to be important by the majority of study participants.
Committed teaching staff and medical doctors who mentor during practical training seem to motivate study participants to carry on and help them with learning content (Q24).
“I always find when I meet a physician who is very motivated and who is able to explain things very well, then I really enjoy it and I think wow, that’s a great kind of studies. And I look forward to becoming a physician one day.” (FG7-Y5).
Personal feedback from teaching staff was also regarded to be helpful. Furthermore, preliminary tests (Q25) and mock exams were regarded as opportunities to practice and to prepare for major exams.
uploaded an exam for preparation, twenty questions were assigned by chance and you could answer them, and finally you could see the right and wrong answers and who failed. I think that prior to the locomotor system exam I did this 38 times. I felt so incredibly safe, I was not afraid of the exam at all.” (FG6-Y1).
Suggestions for improvement
The study participants made a broad range and to some extent also very specific suggestions for improvement. The reproduction of all suggestions would by far exceed the scope of this article and thus the presentation is limited to the most salient findings.
Regarding timetables, study participants wished for earlier announcement of examination dates, more flexibility (Q26) and less mandatory events (Q27). In addition, temporal equalization in placing subjects from time-consuming terms into more relaxed terms and increasing lecture periods and study blocks was suggested (Q28). However, some participants also wished that no further events should be scheduled for non-lecture periods (Q29). Furthermore, parallel scheduling of corresponding theoretical and practical training was requested. A group size of less than 15 students during bedside teaching was regarded to increase opportunities for learning (Q30). Furthermore, some participants wished to be taken on daily work routines of medical doctors and to have more guidance during practical tasks (Q31). They further wished that the teaching staff of different subjects would discuss and coordinate their content to ensure that topics between subjects are complementary and non-overlapping. Furthermore, to improve information flow students suggested that there should be i) one single online portal which comprises all important information (Q32) and ii) a single designated contact person for organizational issues.
Several suggestions were expressed regarding repeat exams including a larger number of attempts, prompt scheduling after the first exam and the possibility to unsubscribe from exams. Furthermore, a wish was stated that exams should assess understanding and more relevant topics rather than rote recall. Further suggestions included a smaller number or less importance of mid-term exams (Q33).
To increase the quality of teaching, better pedagogical education of teaching staff, inspection of teaching clinics, higher appreciation of teaching and exemption of medical doctors from day-to-day business for bedside teaching was proposed. Students also wished that their evaluations of study courses are incorporated in continuous development of the curriculum. Some students suggested to reduce the nursing internship to one month and to inform nurses about learning objectives and range of authority to decrease strain on medical students. Furthermore, some students wished for more consultation with teaching staff including opportunities to pose questions after lectures. In addition, suggestions pertaining to more basic teaching (Q34), soft skills and medical skills (e.g. thoracic drainage or sonography, Q35) as well as tutorials and practical training to deepen and discuss learning content were made.
“Could it perhaps be useful if there were regular seminars for the different subjects, by simply (.) […
I think oral presentations don’t make sense because no one listens, but mid-term tests, one prepares for them, one deals with them, then you do the test. Then we could simply discuss them afterwards or exchange ideas or talk about them, so that it’s sustainable. Step by step. Building in-depth knowledge by repetition throughout the curriculum. […
To be quite honest, when you discuss a subject with other people, then it consolidates.” (FG4-Y1).
Some students asked for information events, especially in the beginning of the academic term, to increase information flow about inter alia upcoming subjects, exams or elective courses.
“Just a simple suggestion (,) if one could simply say at the beginning of the semester perhaps the dean will attend in this case, will spend two hours of time and come to the lecture hall. He will give an introductory lecture, just like at the beginning of the first semester, but that we simply are told this semester encompasses these subjects, these are the dates of the written exams. Then you also have the chance to ask questions if anything is unclear.” (FG8-Y2).
Furthermore, students wished for guidelines about upcoming subjects and learning objectives, a tutorial for stress management, support for families, mentoring and student advisory services (Q36).
“OK, well, yes, that you receive a kind of schedule in the beginning, after each semester this is what you should be able to tick off and this is what you should have done.” (FG3-Y5).
“What I think another issue is, I don’t know if this could be put into practice because of the large number of students. It would be great if every student could have a physician as a mentor […
That would be awesome, then you would have access. Then you would have a person to provide stability and who says, this and that is what you need to know. Someone who looks over your shoulder. Who, I don’t know. Then it would be easier for us to transition between theory and practice. We could better fulfil the expectations.” (FG7-Y5).