Association of Perfectionism with the academic performance of medical students and its interaction with self-efficacy in an active learning curriculumABSTRACT
Introduction: Academic performance in medical education is influenced by psychological factors such as perfectionism and self-efficacy, yet their combined effect remains insufficiently explored, especially in hybrid problem-based learning curricula.
Objective: This study aimed to investigate the academic performance of medical students and its association with perfectionism, as well as to evaluate the interaction effect of self-efficacy on this association.
Method: A cross-sectional quantitative analysis was conducted between August and November 2022 at a private higher education institution in Fortaleza, Brazil. A total of 412 medical students enrolled in semesters one through eight completed online questionnaires assessing perfectionism using the Reduced Frost Multidimensional Perfectionism Scale-Brief and self-efficacy through a 34-item Higher Education Self-Efficacy Scale. Academic performance was measured via the institution’s Academic Performance Index (IRA), which calculates an average grade based on approved subjects.
Result: The sample was predominantly female (70.1%) with a mean age of 22.9 ± 5.8 years. The median score for Evaluative Concerns was 2.50 and for Striving was 3.50, while the median academic performance score was 7.99 out of 10. All self-efficacy domains demonstrated strong performance, with medians exceeding 8. Statistical analyses revealed a significant positive association between striving perfectionism and academic performance (p < 0.001), whereas evaluative concerns were not significantly correlated (p = 0.135). Moreover, regression models showed that high self-efficacy-in dimensions such as academic effectiveness, training regulation, proactive actions, social interaction, and academic management-enhanced the positive effect of striving perfectionism on academic performance. Notably, this association was not significant among students with low academic management self-efficacy.
Conclusion: Effort perfectionism is associated with better academic performance, but only in students who exhibit high self-efficacy. These findings suggest that interventions designed to boost self-efficacy could be key to optimizing academic success in medical education.
Keywords:
Students, Medical; Perfectionism; Self Efficacy; Problem-Based Learning; Learning
RESUMO
Introdução: O desempenho acadêmico na educação médica é influenciado por fatores psicológicos como perfeccionismo e autoeficácia, mas o efeito combinado desses construtos ainda é pouco explorado, especialmente em currículos híbridos baseados em problemas.
Objetivo: Este estudo teve como objetivo investigar o desempenho acadêmico de estudantes de medicina e sua associação com o perfeccionismo, bem como avaliar o efeito da interação da autoeficácia nessa associação.
Método: Uma análise quantitativa transversal foi realizada entre agosto e novembro de 2022 em uma instituição de ensino superior privada em Fortaleza, Brasil. Um total de 412 estudantes de medicina matriculados nos semestres de um a oito responderam a questionários online que avaliavam o perfeccionismo usando a Reduced Frost Multidimensional Perfectionism Scale-Brief e a autoeficácia por meio de uma Escala de Autoeficácia no Ensino Superior com 34 itens. O desempenho acadêmico foi medido por meio do Índice de Rendimento Acadêmico (IRA) da instituição, que calcula uma nota média com base nas disciplinas aprovadas.
Resultado: A amostra era predominantemente feminina (70,1%) com idade média de 22,9 ± 5,8 anos. A pontuação mediana para Preocupações Avaliativas foi de 2,50 e para Esforço foi de 3,50, enquanto a pontuação mediana de desempenho acadêmico foi de 7,99 em 10. Todos os domínios de autoeficácia demonstraram forte desempenho, com medianas superiores a 8. Análises estatísticas revelaram uma associação positiva significativa entre o perfeccionismo de esforço e o desempenho acadêmico (p < 0,001), enquanto as preocupações avaliativas não foram significativamente correlacionadas (p = 0,135). Além disso, modelos de regressão mostraram que a alta autoeficácia - em dimensões como eficácia acadêmica, regulação do treinamento, ações proativas, interação social e gestão acadêmica - aumentou o efeito positivo do perfeccionismo de esforço no desempenho acadêmico. Notavelmente, essa associação não foi significativa entre os alunos com baixa autoeficácia na gestão acadêmica.
Conclusão: Em conclusão, o perfeccionismo de esforço está associado a melhor desempenho acadêmico, mas apenas em alunos que exibem alta autoeficácia. Essas descobertas sugerem que intervenções destinadas a aumentar a autoeficácia podem ser fundamentais para otimizar o sucesso acadêmico na educação médica.
Palavras-chave:
Estudantes, Medicina; Perfeccionismo; Autoeficácia; Aprendizagem Baseada em Problemas; Aprendizagem
INTRODUCTION
Academic performance (AP) is defined as the way to measure learning throughout education and is determined by several factors, addressing aspects related to the student, such as personal factors, academic factors, and psychological characteristics. 1 However, it is worth mentioning that there is still a lack of consensus in the literature regarding the relevance of each factor in AP. 2 Far from invalidating the consistency of the studies, this fact reinforces its multidimensional aspect in the face of different factors that have a direct relationship with performance. In this perspective, it is important to always include in the AP evaluations, besides the students’ cognitive abilities, the other intervening variables in the academic learning process, such as self-efficacy and perfectionism 2.
Corroborating the importance of these psychological characteristics for academic success, J. Stoeber and K. Otto suggested in a narrative review that Perfectionism consists of two main dimensions: perfectionist efforts and perfectionist concerns. Perfectionist efforts are associated with positive aspects of Perfectionism; perfectionist concerns are associated with negative aspects. They claimed that people with high levels of perfectionist efforts and low levels of perfectionist concerns demonstrated more academic success 3. Perfectionism is a personality trait characterized by setting excessively high standards for oneself and experiencing negative consequences when those standards are not met. Recent scientific publications have identified Perfectionism as a prevalent trait among medical students, who are often under significant academic and clinical pressures. 4
A number of studies have examined the prevalence of Perfectionism among medical students, with varying results. For example, a study with 8,689 students in the U.S. found that nearly a quarter of medical students reported high levels of perfectionism 5. The occurrence of perfectionism among medical students is concerning, as it has been associated with negative outcomes such as burnout, anxiety, and depression, as well as with lower levels of self-efficacy 6. For example, a study by Yu et al. (2016) found that medical students with higher levels of self-efficacy had lower levels of socially-prescribed perfectionism, which is characterized by unrealistic and inflexible standards6. Moreover, Bandura, in his studies, emphasized that students’ beliefs in their ability to regulate their own learning (self-efficacy) can act as a positive predictor of AP. Self-efficacy is a psychological construct that refers to an individual’s belief in their ability to perform a specific task or achieve a desired outcome. It is a key component of social cognitive theory, which posits that individuals can shape their own behavior through their thoughts, beliefs, and actions. In the context of medical education, self-efficacy has been shown to be an important predictor of student performance and achievement. Higher levels of self-efficacy have been associated with better academic performance, greater persistence in the face of challenges, and increased motivation to learn 7)-(10.
Numerous studies have investigated medical students’ self-efficacy and perfectionism and their effects on academic performance in traditional and PBL curricula. However, our literature review revealed that very few studies assessed the interaction of perfectionism and self-efficacy on the association of perfectionism and AP, in medical courses that simultaneously include problem-based learning (PBL), traditional teaching and practical activities, i.e., hybrid PBL (Hpbl). Therefore, it becomes interesting to assess whether perfectionism would be associated with academic performance and interact with self-efficacy to develop strategies for better performance of students. With these considerations, we aimed to investigate the academic performance of medical students and its association with perfectionism and the interaction effect of self-efficacy in this association.
METHODS
This is a cross-sectional observational quantitative analytical study.
Setting and period of study
The study was carried out from August to November 2022 at the Centro Universitário Christus (Unichristus). This private higher education institution offers a variety of programs, including medicine, dentistry, nutrition, psychology, physiotherapy, and nursing. The medical program spans 12 semesters, with the first two focused on the clinical cycle using a traditional teaching approach, and subsequent semesters following a hybrid PBL model. Unichristus is located in Fortaleza, the capital city of Ceará in northeastern Brazil. Fortaleza lies approximately 2,285 km from Brasília, the nation’s capital. With an area of 314.93 km² and a population estimated at 2,643,247 in 2018, it has the highest population density among Brazilian capitals, at 8,390.76 inhabitants per km². Fortaleza is also the most populous city in Ceará and the fifth largest in Brazil.
Population and Sampling
The investigation encompassed medical students at Unichristus, spanning from the first to the eighth semesters.
Inclusion Criteria: Students qualified for participation if they were formally enrolled and had attended at least 75% of their classes.
Exclusion Criteria: Students were not considered if any physical, mental, or psychological impairments prevented them from completing the questionnaires.
Data Collection
Trained interviewers administered digital questionnaires, which were designed using Google Forms, in person. These questionnaires were distributed to the students, who completed them electronically on their own devices while under the supervision of the interviewers.
Participation was voluntary. Students were invited to complete the electronic questionnaire during in-person academic activities, after receiving information about the study and providing informed consent. The data collection procedure was organized at the classroom level, and individual nonparticipation or refusal was not systematically recorded by the research team. Therefore, the exact number of refusals and the overall refusal rate could not be calculated.
Variables
At the outset, participants responded to a questionnaire that gathered sociodemographic data and details regarding extracurricular engagements. The analyzed variables included gender, ethnicity, age, family income, marital status, employment status, weekly work hours, weekly study hours, and participation in extracurricular activities.
To assess the levels of perfectionism among the students, the Reduced Frost Multidimensional Perfectionism Scale (F-MPS-Brief) was utilized. This instrument evaluates the principal dimensions of perfectionism, namely Striving (S)-which involves setting high goals and pursuing them-and Evaluative Concerns (EC)-which pertains to self-criticism for failing to meet these goals and an increased focus on performance. The scale comprises eight self-report items, each rated on a 5-point Likert scale, offering an effective and reliable measure for assessing intrapersonal perfectionism 11. The scale was validated in Brazilian Portuguese, and the instrument demonstrated good internal consistency, with Cronbach`s alpha ranging from 0.80 to 0.89. 12.
Subsequently, the participants responded to the “Self-Efficacy Scale in Higher Education,” a validated instrument in Portuguese comprising 34 items evaluated on a 10-point Likert scale and structured into five distinct dimensions. Among these items, nine measure academic self-efficacy, reflecting confidence in one’s capacity to learn, demonstrate, and apply acquired knowledge; seven measure self-efficacy in training regulation, which pertains to confidence in setting goals, making decisions, planning, and self-regulating during training and career development; another seven assess self-efficacy in proactive actions, indicating confidence in taking advantage of training opportunities, updating knowledge, and contributing to institutional improvements; seven evaluate self-efficacy in social interaction, relating to confidence in engaging with peers and instructors for academic and social purposes; and the remaining four measure self-efficacy in academic management, reflecting confidence in organizing, planning, and meeting academic deadlines. As reported by Guerreiro-Casanova and Polydoro (2010), self-efficacy is classified as weak for scores up to 5.9, moderate for scores between 6 and 7.9, and strong for scores between 8 and 10. The scale exhibits excellent internal consistency, with an overall Cronbach’s alpha of 0.94-ranging from 0.80 to 0.81 across its dimensions-and an explained variance of 56.68%, thereby supporting its appropriateness as an evaluative tool 13.
Academic Performance (IRA)
The academic performance was obtained directly from the administration of the medical school. The IRA is the result of a complex mathematical operation that results in an average grade for the student in the semester and works as a reference index for pedagogical monitoring at Unichristus. It is a grade obtained by means of a calculation, representing the student’s average grade in the course up to that moment. The IRA is calculated using the following formula (Figure 1).
NC(D1S1) means the final mark (or final average) of the first subject/module obtained in the student’s first semester transcript, only for APPROVED subjects on the transcript, except for subjects named Complementary Activity. NC (D2S1) is the final mark (or final average) of the second subject/module obtained in the student’s first semester transcript, only for APPROVED subjects, except for subjects named Complementary Activity. So, it goes on successively until the last subject approved by the student in the first semester, which will be NF(DNS1), which means the final mark (or final average) of the Nth subject/module obtained in the student’s first semester transcript only for APPROVED subjects, except for the subjects named Complementary Activity. QDS1 means the number of subjects (only approved and failed, except for the subjects named “Complementary Activity”) taken in the first semester of the student’s transcript. The NC(D1S2) means final mark (or final average) of the first subject/module obtained in the student’s 2nd semester transcript only for the APPROVED subjects on the transcript, except for the subject called Complementary Activity.
NC(D2S2) means final mark (or final average) of the second subject/module obtained in the student’s second semester transcript only for the subjects approved in the transcript, except the subject called Complementary Activity. And so on, until the last subject approved by the student in the second semester that will be NF(DNS2), which means final mark (or final average) of the Nth subject/module obtained in the student’s second semester transcript only for the subjects approved in the transcript, except for the subject called Complementary Activity. QDS2 means the number of subjects (only approved and failed subjects, except the subjects named “Complementary Activity”) taken in the second semester of the student’s transcript.
NC(D1SN) means the final mark (or final average) of the first subject/module obtained in the student’s academic record for the 1st semester, only for approved subjects, except for the subject named Complementary Activity. The NC(D2SN) is the final mark of the second subject/module obtained in the student’s school transcript, only for approved subjects, except for the subjects named Complementary Activity. And so on, until the last subject approved by the student in the Nth semester that will be NF(DNSN) that means the final mark of the Nth subject/module obtained in the student’s record of the Nth semester only for the subjects approved in the record, except for the subject called Complementary Activity. QDSN means the number of subjects (only approved and failed subjects, except the subjects named “Complementary Activity”) taken in the student’s Nth semester on the student’s transcript. QSL means the number of academic semesters taken by the student.
Statistical analysis
Categorical quantitative data were presented as percentages and frequencies, while numerical data were summarized using measures of central tendency. The normality of the numerical variables was assessed through Kolmogorov-Smirnov tests. To examine the relationship between perfectionism factors and self-efficacy, simple and multiple linear regression models with robust standard errors were applied, treating each of the five domains as well as the overall self-efficacy score as dependent variables. The multiple regression models incorporated variables previously found to be associated with self-efficacy-namely, gender, employment status, and participation in extracurricular activities. A comprehensive model was developed that integrated all main effects along with all potential simple and multiple interaction terms. The data were organized into tables and analyzed using IBM SPSS Statistics for Windows, Version 23.0 (Armonk, NY: IBM Corp., 2015).
Ethical aspects
The project was submitted to the Research Ethics Committee (CEP) of Centro Universitário Christus (Unichristus), under registration number CAAE 58824522.7.0000.5049, and was approved in accordance with opinion number 5.516.860. Informed consents for both participation and publication were obtained from all participants, and all applicable Brazilian research laws were strictly observed.
RESULTS
A total of 412 students participated in the study, with a predominance of female participants (70.1%). The average age was 22.9 years (SD = 5.8), and the majority self-identified as white (71.4%). Over 80% of the students reported a family income exceeding five Brazilian minimum wages (with one minimum wage equivalent to US$231.96 at the time of data collection in 2022), whereas 8.4% reported a family income of up to three minimum wages, or less than 10 dollars per capita per day in a family of three individuals. More than 90% of the students were not employed, dedicating themselves fully to their academic pursuits; those who were employed worked an average of 1.6 hours per week. The mean weekly study time was 30.2 hours, and 11.7% of the students were married. Regarding academic progression, the majority of respondents were in the first semester (27.1%), followed by those in the second semester (19.6%) and the fourth semester (22%). Additionally, 70.5% of the students participated in extracurricular activities. It is important to note that the semester distribution shown in Table 1 refers to respondents included in the analytic sample, rather than to the total number of students enrolled in each semester at the institution. Participation varied substantially across semesters, with a higher proportion of respondents from the first, second, and fourth semesters and a very small number of respondents from the fifth semester. A detailed summary of the sample’s descriptive data is presented in Table 1.
The average results in each perfectionism and self-efficacy domain, and academic performance results, can be seen in Table 2. For perfectionism, two sub-scales are reported:
Evaluative Concerns: The median score is 2.50, indicating that the median participant reported experiencing some level of concern about being judged negatively. The 25th percentile score of 2.00 and 75th percentile score of 3.25 suggest that most participants reported experiencing some degree of evaluative concerns, but the degree of concern varied across the sample.
Striving: The median score is 3.50, indicating that the median participant reported striving for high standards and achievement. The minimum score of 1.00 and maximum score of 5.00 indicate that some participants reported very low or very high levels of striving.
For academic performance, the median score is 7.99, indicating that the median participant achieved a score close to 8 out of 10 on a measure of academic performance. The 25th percentile score of 7.65 and 75th percentile score of 8.30 suggest that most participants achieved scores within this range, with some variation across the sample. The minimum score of 0 and maximum score of 9.48 indicate that there was some variability in academic performance across the sample.
All self-efficacy domains exhibited median values exceeding 8, indicative of robust self-efficacy. Moreover, the 25th percentile for each domain surpassed 7.5, with the exception of the proactive actions domain. Notably, this domain also recorded the lowest minimum score among the students (Table 2).
In Figure 2, we can see the correlation of perfectionism and academic performance. There is a positive correlation with both striving and evaluative concerns domains and academic performance, but only the first was statistically significant (p < 0.001 and 0.135, respectively).
Scatterplot of the pairs striving and evaluative concerns perfectionism domains and academic performance. (B = beta for regressive equation).
In Table 3, the results of the statistical analysis examining the association between striving for perfectionism and academic performance, specifically looking at the interaction with different factors (self-efficacy, training regulation, proactive actions, social interaction, and academic management) are presented. It was identified that there is a significant positive association between striving for perfectionism and academic performance for individuals with high levels of self-efficacy, training regulation, proactive actions, social interaction, and academic management. However, there is no significant association between striving for perfectionism and academic performance for individuals with low levels of academic management. These results are detailed in Table 3.
DISCUSSION
In this study, we identified that striving for perfectionism is associated with better academic performance. In addition, we identified that the evaluative concerns perfectionism domain was not associated with academic performance and that low self-efficacy in the academic effectiveness and academic management domains may inhibit the positive effect of striving for perfectionism on student performance.
Problem-based learning (PBL) was initially implemented at McMaster University in the late 1960s and subsequently gained widespread adoption in medical schools worldwide. At the same time, several institutions introduced modifications to the traditional PBL model and endorsed alternative methods, resulting in the development of “hybrid” PBL (hPBL) 14. Harvard’s New Pathway curriculum changed the scope, frequency, and format of its dialogical lectures and hands-on lab classes and hybridized them with problem-based active discussion (PBL). This is our institution’s model curriculum15.
In this model, students are required to participate in lectures and practical sessions for approximately 10 hours per week in addition to the PBL activities. Consequently, they experience a higher cognitive load compared to the traditional “pure” PBL model, which contributes to an elevated level of resilience and self-efficacy relative to other educational approaches 14),(16.
Given this scenario, what would be the association of perfectionist behavior and self-efficacy with academic performance? There are several ways to evaluate it. The most commonly used in research and practice are individual test performance (e.g., end-of-term exams), class performance (e.g., grades), and performance across classes (e.g., grade point average, GPA) 17. In the present study, to evaluate the performance of students, the academic achievement index (IRA, in Portuguese) was chosen, the form that indicates whether the student has achieved the expected goals in our institution.
Researchers in educational psychology postulate that personality factors are also particularly important in performance. They point out that the additional personality factor that may predict variation in academic performance is perfectionism 18. In line with that, the result of our study, as already described, evidenced that, unlike concerns perfectionism, effort perfectionism is associated with better academic performance.
Perfectionism is generally conceptualized as a multidimensional personality disposition characterized by extremely high standards of performance and concerns about making mistakes 19. Although it is a multifaceted concept, it is often interpreted along two distinct dimensions: perfectionistic efforts and perfectionistic concerns 3. The former refers to the tendency to set very high standards and strive to achieve them, and the latter refers to the negative aspects of perfectionism, such as excessive worry about making mistakes, doubts about actions, perceived discrepancy between actual achievements, high expectations, and overly critical self-evaluations 20.
Corroborating our results, studies conducted in mostly traditional academic settings have found a positive association between perfectionist efforts and performance, and often an inverse association with perfectionist concerns. They also highlight that perfectionist efforts are primarily associated with positive outcomes indicative of academic success, such as goal mastery, low academic procrastination, academic efficacy, and academic achievement. In contrast, perfectionist concerns are primarily associated with negative outcomes indicative of low academic success, such as fear of failure, test anxiety, low academic efficacy, and low academic performance 21)-(23.
Regarding PBL, which belongs to our hybrid curriculum (hPBL), we can ask about the interference of perfectionism in academic performance in this teaching methodology. This information would be very important for facilitators of tutorial sessions since medical students need to be guided on balanced ways to strive for high standards, which can motivate them, while avoiding unrealistic performance expectations that may cause stress. We suppose that the personality factor, perfectionist concerns, also exerts negative interference in the teaching-learning process in this methodology.
However, due to the scarcity of studies to date that evaluate this association in Problem Based Learning (PBL) it was not even possible to discuss it based on the literature. However, we can assume that the shift from traditional teaching where dualism predominates and where the educator’s role is to ensure the right answer, to a learning scenario (PBL) where the acceptance of uncertainty is important, all opinions (right or wrong) have merit and where the main goal is the teaching and learning process rather than the outcome 24) will probably intervene even more than in traditional teaching on students with perfectionist concerns due to their excessive preoccupation with making mistakes; they do not accept the middle ground and are always stuck in black-and-white thinking, thus compromising the acquisition of skills, attitudes and knowledge.
Self-assessment is another factor that can compromise students in this methodology with perfectionist concerns. Self-assessment and tutor evaluation are integral parts of many PBL tutorial groups and aim to measure a range of skills such as self-learning, group cooperation with respect and responsibility, communication and critical analysis 25),(26. Through these assessments, students can reflect on their strengths and weaknesses, which promotes self-directed learning 27.
However, this process must take into account the subdimensions of perfectionism since students with more perfectionistic concerns are likely to develop distorted self-perceptions and find themselves unable to achieve their goals. This would increase the likelihood of engaging in inaccurate self-assessments. On the other hand, those with high perfectionistic efforts are likely to have accurate self-assessment to recognize their areas for improvement and therefore achieve their goals 28. Future studies are needed to confirm all these conjectures.
Another objective of the present study was to assess the mediating role of self-efficacy in the relationship between perfectionism and academic achievement.
It was observed that self-efficacy in the domains of academic self-efficacy and academic management plays a mediating role in the relationship between positive perfectionism and academic performance. The present findings support findings in the literature that perfectionist efforts as well as perceived self-efficacy have a significant association, like perfectionist efforts, with higher academic performance 29),(30.
Perceived self-efficacy is defined as the determination of the course of action necessary to accomplish a goal and beliefs about one’s ability to implement 31. University students with strong self-efficacy beliefs are better equipped to adapt to the behavioral changes and personal restructuring demanded by a new learning environment, particularly when engaging in group activities that incorporate innovative teaching methodologies and impose significant academic challenges. This adaptability can be partially explained by the fact that individuals with high self-efficacy are more inclined to actively engage in learning, exert greater effort, maintain focus on problem-solving, and persist longer when faced with complex academic tasks. In contrast, students with low self-efficacy are more susceptible to frustration and a higher likelihood of disengagement or withdrawal from challenging learning situations 29),(32),(33.
Furthermore, research has revealed that positive perfectionist students have more beliefs in their self-efficacy to achieve an extremely difficult goal in addition to higher levels of motivation 22),(34. Mor, Day, Flett, and Hewitt (1995), showed that self-efficacy plays a mediating function between perfectionism and performance-related concerns and an anxiety-reducing function in professional performers 35.
It was also observed that the mediation of self-efficacy in students with effort perfectionism in relation to good academic performance was significant only in the management and academic self-efficacy domain. We can assume, from the experience with our students, that this fact is due to the numerous simultaneous pedagogical tasks (PBL, dialogical exposition and practical activities) that make the “password of academic success” to achieve the goals in the hPBL curriculum be, the belief of effective learning (important to any curriculum model) and in particular the belief of good planning and accomplishment of their tasks. Otherwise, anxiety would overwhelm them, preventing the action of any other domain that favors the teaching and learning process.
Highlighting the importance of detecting low self-efficacy in our students for early intervention, low self-efficacy was found to abolish the association between Perfectionism and academic performance. Studies have evidenced that negative Perfectionism has a significant negative effect on perceived self-efficacy and academic performance and a significant positive effect on self-deficiency. It can be inferred from this result that students with a high sense of negative perfectionism, have low perceived self-efficacy and vice versa, and low academic performance and are highly self-insufficient. It is known that these students tend to set unrealistic goals beyond their abilities and constantly experience fear and anxiety about making mistakes. Having standards beyond their abilities and lacking the knowledge, skills, and abilities to meet those standards may negatively affect their beliefs in their academic abilities and achievements. In addition, they may exhibit more self-destructive behaviors to protect their self-esteem and not be perceived as untalented and inept 36.
The uneven distribution of respondents across semesters deserves consideration. First-semester students represented approximately one quarter of the sample, whereas some later semesters, especially the fifth semester, had very few respondents. This imbalance may reflect differences in class availability, fieldwork logistics, or willingness to participate during data collection. Because of this distribution, the study was not designed to compare semesters individually, and the findings should not be interpreted as evidence of semester-specific effects. Rather, the results describe the association between perfectionism, self-efficacy, and academic performance in the overall participating sample.
Also, the relatively high proportion of first-semester students also deserves consideration. These students had recently entered medical school after a competitive admission process and may have differed from more advanced students in motivation, academic expectations, self-perception, and adaptation to the medical curriculum. To evaluate whether this subgroup could have driven the findings, we reran the main analyses after excluding first-semester students and observed no substantial change in the direction or interpretation of the results. Nevertheless, because the distribution of respondents across semesters remained uneven, the findings should be interpreted as pooled associations for the participating sample rather than as semester-specific effects.
This study presents certain limitations. Firstly, due to its cross-sectional design, the identified associations cannot be interpreted as causal relationships. Additionally, while a validated self-efficacy scale was utilized, it does not comprehensively capture all aspects of perfectionism in each individual, despite demonstrating satisfactory accuracy in previous validation studies. Another limitation concerns the possibility of response bias. Although data were collected in person and the study included 412 medical students, participation was voluntary and individual refusals were not systematically recorded. Consequently, the refusal rate could not be estimated, and students who agreed to participate may have differed from nonparticipants in motivation, academic engagement, self-efficacy, perfectionism, or academic performance. Finally, the sample was unevenly distributed across semesters, with a high proportion of first-semester students and a very small number of participants from some later semesters. Although additional analyses excluding first-semester students did not indicate substantial changes in the main findings, the study was not designed or powered to evaluate semester-specific associations. Future studies with balanced recruitment across semesters should examine whether the relationship between perfectionism, self-efficacy, and academic performance varies across different stages of medical training.
CONCLUSIONS
In summary, this study identifies the association of effort perfectionism with better academic performance, but only in students with good levels of self-efficacy. The predictors of academic performance is of great importance, since in this way the interventionist process of the pedagogical support service can be effective and contribute to the academic success of our students.
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Source: prepared by the authors.
Source: prepared by the authors.