Success and failure in academic performance during surgical clerkship: causal attributions by medical studentsABSTRACT
Introduction: The medical internship is a phase of intensive clinical practice, during which students experience both successes and failures. The way students attribute causality to these outcomes influences their future coping strategies and performance. Understanding the causal attributions made by students can assist preceptors and program coordinators in planning improvement initiatives.
Objective: This study aimed to identify the causal attributions for successes and failures during the surgical clinical rotation and to outline the strategies adopted by residents to maximize success and minimize factors leading to failure.
Methods: This was a mixed-methods, quantitative-qualitative study conducted at a private higher education institution in São Paulo. Participants were students who completed their surgical internship at a high-complexity public hospital. In the first phase, 62 surgical internship students completed the Causal Attribution Assessment Scale. In the second phase, focus groups were conducted with 15 students selected based on the highest scores on the failure subscales. Quantitative data were analyzed using descriptive and inferential statistics, and qualitative data were analyzed using thematic analysis.
Results: The students attributed success to internal factors (effort, commitment) and external factors (program organization, faculty support). Failure was associated with both internal vulnerabilities (emotional instability and fragility) and external barriers (hostile environment, difficult interpersonal relationships, fewer practical opportunities). The proposed improvement strategies focused on personal initiatives (proactivity, emotional management) and institutional initiatives (faculty support, resilience training).
Conclusion: It was observed that the challenges faced by medical residents during their general surgery rotation are multifactorial, and both internal and external causes were attributed to failure. The students recognized the need to develop a prevention plan and identify strategies for improvement, with a particular emphasis on personal initiatives and educational interventions to strengthen emotional resilience.
Keywords:
Internship and Residency; Academic Performance; Causality; School Failure; Medical education
RESUMO
Introdução: O internato em Medicina é uma etapa de intensa prática assistencial, em que o estudante se depara com sucessos e fracassos. A forma como o aluno atribui a causalidade a esses resultados influencia seu enfrentamento e desempenho futuros. Compreender as causalidades atribuídas pelos estudantes pode auxiliar preceptores e coordenadores de curso no planejamento de ações de melhoria.
Objetivo: Este estudo teve como objetivos identificar as atribuições de causalidade para os sucessos e fracassos durante o estágio em clínica cirúrgica e delinear as estratégias adotadas pelos internos para potencializar o sucesso e minimizar os fatores que levam ao fracasso.
Método: Trata-se de um estudo misto, quantiqualitativo, realizado em uma instituição privada de ensino superior de São Paulo. Participaram estudantes que vivenciaram o internato em cirurgia em um hospital público de alta complexidade. Na primeira fase, 62 estudantes do internato em cirurgia responderam à Escala de Avaliação das Atribuições de Causalidade. Na segunda fase, realizaram-se grupos focais com 15 estudantes selecionados a partir dos maiores escores nas subescalas de fracasso. Os dados quantitativos foram analisados por estatística descritiva e inferencial, e os qualitativos, por análise temática.
Resultado: Os estudantes atribuíram o sucesso a fatores internos (esforço, empenho) e externos (organização do programa, apoio docente). O fracasso foi associado tanto a vulnerabilidades internas (instabilidade e fragilidade emocional) quanto a barreiras externas (ambiente hostil, relações interpessoais difíceis, menor oportunidade prática). As estratégias de melhoria propostas focaram iniciativas pessoais (proatividade, gestão emocional) e institucionais (apoio docente, preparo para resiliência).
Conclusão: Observou-se que os desafios enfrentados pelos internos de Medicina no estágio de cirurgia geral são multifatoriais, e atribuíram-se ao fracasso tanto causas internas como externas. Os estudantes perceberam a necessidade de desenvolver um planejamento de prevenção e apontar estratégias de melhorias, em que se destacaram iniciativas pessoais e intervenções educacionais para o fortalecimento da resiliência emocional.
Palavras-chave:
Internato e Residência; Desempenho Acadêmico; Causalidade; Fracasso Escolar; Educação Médica
INTRODUCTION
Medical Internship, a compulsory part of the curriculum, constitutes the practical stage of the course, giving students the opportunity to apply their theoretical knowledge in a clinical setting and develop psychomotor and interpersonal skills1. During the surgical rotation - an intense environment characterised by long working hours and a steep learning curve - the intern is exposed to a range of situations that test not only their theoretical knowledge, but also their practical skills, emotional resilience and ability to integrate into multidisciplinary teams 2),(3.
The educational setting in surgery, for both interns and residents, is generally considered to be demanding and associated with higher rates of burnout. These high burnout rates that have been demonstrated in general surgery training programmes highlight the need for actions to identify risk factors and implement protective measures 4. Perceived shortcomings in professionalism, a sense of not belonging, a hierarchical culture, inflexible working hours, conditions that affect well-being, such as inadequate rest or nutrition, an exhausting workload and conflicts with students’ prior expectations are some of the factors that cause stress and burnout5),(6.
In addition to stressors, as in any academic environment, students on the surgical clerkship may also underperform and, in a self-assessment, attribute their own failure to various causes. Success or failure in academic performance does not depend on a single factor alone, but rather on a combination of various elements, which may include, for example, personal factors (such as study habits, motivation and mental health), social factors (support from peers and family) and institutional factors (quality of teaching, curriculum and the university environment).
In light of the causal attribution theory regarding academic success and failure, Weiner classifies the causes into three loci: Causality (internal and external), Stability (stable and unstable) and Controllability (controllable and uncontrollable). However, it is worth noting that the attribution of the cause does not fully reflect objective reality. Individuals attribute causes to certain events subjectively, depending on their interpretation of their experiences and interactions; in other words, the determination of cause can be based on the individual’s perception of himself, others and the environment7)-(10.
Although there is Brazilian literature on medical internship, studies focus predominantly on the general structural and evaluative aspects of the programmes11),(12 , with limited exploration of the student’s experience in specific contexts, such as the surgical clerkship. Based on this, several questions arose:
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What factors do students attribute as causes of poor academic performance during their surgical internship?
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Are these factors related to aspects internal or external (beyond the student’s control) to the student?
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Can students develop a plan for improvement strategies based on identifying the causes of poor performance?
Identifying factors attributed to academic failure, specifically during the surgical clerkship, can help preceptors and course coordinators to make the learning experiences during this phase more successful, thereby improving students’ performance and well-being. There are direct implications for clinical supervisors and internship coordinators regarding the benefits of interventions designed to support students in assessing and modifying internal factors that interfere with their performance, particularly with a focus on mitigating the harm arising from this environment 13.
The aims of this study are to understand the causal factors behind successes and failures during the Surgical clerkship and to identify the strategies adopted by junior doctors to maximise success and minimise the factors that lead to failure.
METHODOLOGY
An exploratory study using a mixed-methods approach was designed in two phases: Quantitative and Qualitative14),(15. The survey was conducted in the first half of 2025 at a private university in the city of São Paulo, within the Medicine degree programme which was awarded the highest rating by the Ministry of Education and Culture (MEC) in 2023. The institution has partnerships with municipal Primary Health Care (PHC) services and specialist care services for medium- to high-complexity cases, where students gain practical experience at different stages of their undergraduate training. The surgical clerkship takes place during the tenth stage, in the fifth year of the course. The average number of students per semester on the General Surgery Clerkship is 64.
The convenience sample16, in accordance with the selection criteria, comprised 62 medical students from this institution who had completed their general surgery clerkship. The study was developed in two stages: the first was quantitative and the second qualitative. In the first stage, the students were invited to take part in the study via an individual invitation sent via WhatsApp®, which provided information such as the aims, benefits and research tools. Furthermore, mention was made of possible participation in the second phase, subject to the analysis of the quantitative data. The electronic ICF was sent exclusively by email after participants had expressed an interest in taking part in the study.
In the first phase, which involved quantitative research, demographic information and the participants’ backgrounds were collected, and subsequently, the Rating Scale of Causal Attributions for Academic Success and Failure for University Students, developed by Boruchovitch & Santos, was administered to select participants for the qualitative phase of the research. The scale was developed on the basis of Weiner’s Theory of Causal Attribution4),(9) , taking into account the dimensions of locus of causality, stability and controllability. Studies using the same scale have already been carried out in Education, Nursing, Medicine, Engineering and Psychology degree programmes, adapting it to suit the context17)-(21.
The scale consists of 44 items relating to causal attributions in situations of academic success and failure, on a four-point Likert scale, ranging from 1 (Does not apply to me at all) to 4 (Describes me very well). The total score for the answers can range from 44 to 176 points. The scale consists of four sub-scales: 1. Success/Internalisation, 2. Failure/Internalisation, 3. Success/Controllability, 4. Failure/Controllability.
Evidence of validity and reliability: The RSCA-U (Rating Scale of Causal Attributions for Academic Success and Failure for University Students, by Boruchovitch & Santos) has been used as a standardised instrument in various studies and research projects. In this study, internal consistency was measured using Cronbach’s alpha, which yielded a value of 0.70 for the total scale and the following values for the subscales: 0.86 for Failure/Controllability, 0.78 for Failure/Internalisation, 0.73 for Success/Controllability and 0.64 for Success/Internalisation.
Quantitative data were described using absolute frequencies and percentages for qualitative variables, and medians, quartiles, minimum and maximum values for quantitative variables. This choice was made due to the asymmetric distribution of the quantitative variables. The association between total and subscale scores and qualitative variables was investigated using Student’s t-tests or Mann-Whitney tests for two groups, and one-way ANOVA or Kruskal-Wallis 22 tests for three or more groups. The analyses were carried out using the software R23 and SPSS24, with a significance level of 5%.
For the second phase, involving qualitative research, data was collected by means of focus groups, conducted remotely and synchronously. This decision was based on the operational ease afforded by the use of a remote communication platform and its potential to facilitate data collection and recording. The selection of students for the second phase of the study was based on the highest scores on the ‘Failure/Internalisation’ and ‘Failure/Controllability’ subscales of the RSCA-U tool. We considered those individuals who were simultaneously among the top 75% on both scales, which resulted in 31 individuals being invited to take part in the qualitative phase. Of these, 15 voluntarily reaffirmed their wish to continue in the study by signing the Phase 2 informed consent form, and were split into two groups according to their availability for the online meeting.
To facilitate the focus groups, a questionnaire was used containing the following guiding questions:
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How did you rate your performance in the surgical clerkship?
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What factors influenced your performance in the surgical clerkship?
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In your opinion, what strategies - personal, educational or institutional - could help to improve students’ performance in the surgical clerkship?
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Is there anything else that hasn’t been covered that you’d like to talk about?
Two focus groups were held, comprising 6 and 9 students respectively, each lasting an average of one hour. The recordings of the meetings were transcribed and anonymised, then read through and reread. The thematic analysis sought to follow the principles set out by Braun & Clarke25, adopting the six stages of the proposed methodology.
The data collection and analysis were conducted concurrently. As the response patterns became repetitive and no new elements emerged, the researchers deliberately halted the data collection. In this context, given the density of the data, the authors understood the phenomenon, indicating that saturation had been reached 26.
The research project was submitted to the Ethics Committee of Einstein Hospital Israelita (Parecer N. 6.937.359) e do Centro Universitário das Américas - FAM (Parecer N. 7.642.796) and approved under reference number CAEE 7973652400000071. The Informed Consent Forms (ICFs) were duly signed by all research participants.
RESULTS
The results of this study are presented in line with the sequential exploratory mixed-methods design, integrating quantitative and qualitative data. First, the participants’ sociodemographic characteristics are described, with the aim of providing context for the sample. The results of the quantitative phase are then presented, integrated with the qualitative analysis developed on the basis of these findings, with a view to deepening our understanding of the phenomenon under investigation.
During the focus group sessions, the students’ perceptions of their overall internship experiences were identified, linking them to the factors that influenced their performance during the placement. It is worth noting that, although the analysis focused on failure, these pupils nevertheless generally performed well in their work.
A total of 62 students took part in the study, the majority of whom were women (58.1%). The age range was from 22 to 46 years old, with a median of 30. The majority are single (64.5%) and have no children. As regards the cost of the course, the majority (77.4%) receive financial support from their own family. (Table 1)
As for the students’ prior education, 46.8% had completed another undergraduate degree. The most frequently cited previous undergraduate qualifications were Business Administration and Law (14.6% each), Nursing (12.2%), Biomedicine and Psychology (7.3% each), Production Engineering, Veterinary Medicine and Dentistry (4.9% each). As regards postgraduate qualifications, four of the trainees hold a Master’s degree and one holds a doctorate.
Some students were employed: 24.5% worked in the informal sector, and 9.7% in the formal sector. A wide variety of professions was observed among the participants, such as nurse, dentist, and psychologist, which were grouped under the health care category. Professions related to administration and management were grouped under “administrative field,” and the rest under “other” (Table 2).
Of the total number of students, 53 (85.5%) intend to sit the residency exam, with the most frequently cited specialities being: general surgery (18.9%), followed by clinical specialities and paediatrics (11.3% each), and anaesthesiology, gynaecology and obstetrics, and psychiatry, at 9.4% each (Table 2). Clinical specialities include neurology, dermatology, infectious diseases and intensive care medicine, whilst ‘Others’ include ophthalmology, ENT and radiology. Students who were undecided between two or more specialisms were categorised as ‘undecided’.
The overall score on the Rating Scale of Causal Attributions returned a median of 122, which is a high score within a possible range of 44 to 176 points. The Success/Internalisation subscale, ranging from 14 to 56, had a median of 40, and the Success/Controllability subscale, with a range from 11 to 44, had a median of 38, meaning that the values on the success subscales are concentrated at higher levels.
As regards the failure scales, the Failure/Internalisation subscale, ranging from 11 to 44, had a median of 13, whereas the Failure/Controllability subscale, with a range from 8 to 32, had a median of 32. Maintaining the different variables, ‘Failure/Internalisation’ shows lower values, whilst ‘Failure/Controllability’ shows higher values (Table 3).
A comparison of the total scores and subscale scores across the different categories investigated reveals no significant associations for the total scale or for the Success/Controllability and Failure/Controllability subscales. The significant differences found were in the variable ‘exercising a professional activity’ on the Success/Internalisation and Failure/Internalisation subscales (p-value 0.016 and 0.020 respectively), which indicated that students not in paid employment had higher scores than those in paid employment on the Success/Internalisation subscale, and that students engaged in informal work had higher scores than those not in paid employment on the Failure/Internalisation subscale. These results suggest that students who are not in employment attributed their success more to internal factors than to external ones, compared with those who are in employment, whereas students who are in employment attributed their failure more to internal factors than to external ones, compared with students who are not in employment. These analyses indicate that the perception of controllability is similar across all groups, but the perception of internal causality in failure is more prevalent amongst students who are in employment (Table 4).
The highest scores on the Success/Internalisation and Success/Controllability subscales can be explained by the category “Internal and external factors that influence success in the surgical clerkship”, which comprises two subcategories. In this context, students perceive success as resulting from internal factors, expressed through a sense of confidence in attitudes that depend on themselves, such as commitment and study, as well as the need for emotional stability. On the other hand, other factors related to the institution or their colleagues also contributed to the positive results they achieved.
To select students for the second phase of the study, we assessed the participants with the highest scores on the failure subscales. To this end, we consider the value that identifies the individuals with the top 75% of marks (1st quartile). The scores were 11 for the ‘Failure/Internalisation’ scale and 30 for the ‘Failure/Controllability’ subscale, that is to say, 75% of participants scored 11 or higher on the ‘Failure/Internalisation’ subscale and 75% of participants scored 30 or higher on the ‘Failure/Controllability’ subscale. By evaluating the scales together, we identified 31 individuals who exhibited both characteristics simultaneously, and these were invited to take part in the second phase.
Student self-focus: personal commitment and engagement in practical training
The students’ perceptions of their performance at the boarding school were predominantly positive. The internal factors attributed to success are linked to personal commitment, such as hard work and the organisation of study methods. Furthermore, factors such as engagement and emotional regulation were also cited as reasons for success.
“I attribute success and failure primarily to myself [...] The learning depends 50% on the student and 50% on the preceptor; it’s up to the student to make the effort.” (G1P5)
“It was an internship in which I managed to excel in my marks and in the number of hours I spent studying; I worked really hard, and I put all of that down to my own efforts.” (G1P1)
The role of the training setting: the institution, supervisors and peers as mediators of success
The external factors attributed to good performance were linked to the organisation of the clerkship programme, such as the adoption of an appropriate methodology and clear objectives.
“The way the internship programme is organised - with the full schedule being sent out in advance [...] - when everything is organised, it makes it easier for me to learn.” [...] ‘I need organisation; I like having a routine.’ (G1P3)
Another important aspect was the support provided by teaching staff. During this particularly challenging phase of their surgical clerkship, the students highlighted the importance of the role of preceptors as facilitators in helping them navigate this stage of their training.
“When our preceptor is right there, it’s like having someone holding our hand and saying: ‘right here’ (when carrying out a procedure), you feel more confident about taking the risk of performing a procedure, because we’re there learning, aren’t we?” (G1P1)
At this stage in a student’s life, peers are seen as sources of support and help in overcoming obstacles.
“It was much easier to walk into the room where he was carrying out the procedure and ask him: ‘Hey, doctor, can we watch?’ Or through a ‘connection’ (a friend’s help), for example, I’d stay with (name of a student), because she’d speak more.” (G1P4)
The choice of sample, based on internal and controllable causes of failure, stemmed from the understanding in the literature that this student, by recognising that the problem originated within themselves, could take control and manage the cause, adopting an adaptive approach to the identified difficulty. Nevertheless, it is worth noting that the selected students achieved an average mark of 8.6 (8.3; 9.4) during their surgical clerkship. Average summative mark = 7.65 (5.0-9.5).
The students’ perceptions revealed that failure in the surgical clerkship was strongly associated with a combination of internal and external factors, as explained by the category “Determinants of failure in the surgical clerkship: emotional vulnerabilities and contextual barriers” and its constituent subcategories.
At the individual level, emotional and behavioural factors were highlighted as the main contributors to failure, particularly instability in emotional regulation. Causes linked to personal choices were also reported, as well as initial difficulties in adapting to the internship environment and gaps in theoretical knowledge. As for external factors, the students attributed their failure to the presence of hostile institutional environments and unfavourable interpersonal relationships.
Internal vulnerabilities: instability in emotional regulation and limitations in self-control.
Of the internal factors attributed to failure, the emotional and/or behavioural aspects classified as instability in emotional regulation (anxiety, shyness, insecurity and fear) were perceived by the students as the most significant contributing factors. The other causes were attributed to personal choices (such as competition between areas of focus or interest), as well as reflections on initial difficulties in adapting to the context or theoretical gaps.
“When I say I’m a bit more reserved, that’s exactly what I mean - I’m just a bit shyer. I know, I’m worried about asking to do a procedure and then getting it wrong.” (G1P1)
“During the operations, I felt nervous and afraid of making a mistake and being called out.” (G1P3)
External barriers: a hostile environment and the complexity of interpersonal relationships in the surgical setting
Among the external factors that contributed to the failure, the most prominent were environmental factors and less favourable relationships in the clerkship setting (a hostile institutional environment), as well as difficult interpersonal relationships with residents, hospital staff such as other doctors or nurses, etc.
“A tense atmosphere and some unwelcoming teams can inhibit the clerkship student.” (G2P4)
A lack of family support was identified as a factor that hampered the students’ performance:
“I can’t devote as much time to my studies because of family commitments; I have a young daughter, so she takes up a lot of my time, and I can’t study for as long as I’d like to” (G1P6)
Structural (institutional) constraints and disparities in performance or behaviour amongst peers gave rise to the perception of factors that had a negative impact on students’ performance.
“The passive attitude of some colleagues and a lack of theoretical understanding were what undermined the (collective) experience of some.” (G2P4)
Of the external factors, some were not interpreted as the cause of the failure, but rather as being dependent on personal interpretation and emotional response (hostile environment, interpersonal relationships); they did not lead to inhibition, but rather to proactivity.
“As I’m a bit brass-necked, that part was much easier for me. Of course I heard ‘no’ a few times, but the surgical unit was big enough to accommodate plenty of people (...) I made friends with the residents there, (...) and I carried out a lot of procedures there.” (G1P2)
By identifying the factors that influence success and the triggers of failure, the students described, in category 3, the “Strategies to maximise success and minimise the factors leading to failure in the surgical clerkship”.
Students most frequently cited personal factors (internal and controllable attributes) as drivers of improved performance. The personal strategies developed to overcome difficulties were: commitment (which they referred to as proactivity or engagement), emotional regulation, managing controllable factors (for example, study time) and support from friends.
“With an open heart, I want to experience this stage, tackle and take on board everything (I learn) that this placement has to offer, even if it isn’t the specialism I want to pursue, because I need this to become a doctor.” I’ll do my best.” (G2P6)
“Revising the theory before the practical and being proactive, without fear of the challenge” (G2P2)
A number of external and uncontrollable factors were listed as intervention measures to overcome the factors that led to failure. From an institutional perspective, a number of strategies were identified, such as ensuring that the tutor is a member of the care staff, which would facilitate access to procedures and enhance the students’ emotional security. Furthermore, the students felt that the institution needed to take action regarding education on emotional resilience and measures to promote behavioural adjustment and peer guidance.
“When the preceptor works there (at the hospital), they are part of the system, they are working there, and they know the place; this also makes it easier for the environment to be geared towards ‘pulling’ the trainee further in (to the practice).” (G1P6)
The students’ perceptions of their performance at the boarding school were predominantly positive. The internal factors attributed to success are linked to personal commitment, such as hard work and the organisation of study methods. Furthermore, factors such as engagement and emotional regulation were also cited as reasons for success.
DISCUSSION
The study showed that the students perceived their performance in the surgical clerkship to be primarily the result of internal factors such as effort, skills, emotional state and personal strategies 27),(28. Contrary to other studies, the participants in this study cited emotional factors linked to low resilience as the main internal causes of failure, rather than a lack of motivation 29.
Emotional regulation was frequently perceived as an unstable cause (variable depending on interpretation and the situation), yet with the potential to be controlled (subject to modification by the student themselves). According to another study, the analysis revealed a significant association between low emotional resilience and internal causal attributions and coping strategies30.
An analysis of the codes associated with controllable internal causes, such as personal effort, proactivity and emotional regulation, illustrates the complexity with which students internalise responsibility for their performance, shaping their coping strategies and their emotional reactions31),(32.
Students with higher levels of perseverance reported lower levels of emotional exhaustion and a greater sense of personal fulfilment, suggesting that personality traits play a decisive role in shaping the internship experience. In this context, the culture and professional identity within medicine - with its emphasis on and pressure for competence and resilience - ultimately promote adaptive resources specific to overcoming adversity33.
Factors such as structural constraints (heavy workload, teaching staff not being part of the support team) and a hostile environment were frequently perceived by students as stable causes (persistent and difficult to change in the short term) and beyond their control, leading to feelings of frustration and helplessness. On the other hand, the quality of teaching support and the organisation of the programme (methodology), although external factors, were sometimes seen as factors that the institution could control, which prompted the students to suggest changes and improvements.
The improvement strategies were categorised according to their locus of action, and Internal Strategies refer to initiatives that originate with the student themselves, perceived as being within the individual’s control (effort, commitment, dedication and emotional regulation) and can be seen as attempts to transform unstable causes into positive outcomes8. On the other hand, External Strategies encompass suggestions that depend on changes in the environment or institution. These proposals aim to address factors with an external locus of control, understood as being stable and beyond the student’s control, but potentially controllable by external agents (teachers, the educational institution).
The distinction between these strategies reinforces students’ understanding of where the power to bring about change lies and how they seek to make improvements in the face of academic challenges.
For external agents of change, there was a prevalence of institutional codes that promote emotional resilience with a view to strengthening resilience and the ability to cope with difficulties. It was then suggested that the teacher’s status be changed so they would work within the care system, offering the student more support in a setting of hierarchical relations/hostile environment.
Students may use coping strategies, seeking formal support through the university’s counselling or tutoring services, and informal support from family and friends. However, barriers such as stigma and a lack of awareness of available resources can make it difficult to access help34.
Identifying these factors and understanding how they affect performance and learning is essential, as an understanding of causality can help in the development of strategies to improve learning. Furthermore, they can influence teaching staff and educational institutions to develop educational support programmes 35.
Consequently, clinical supervisors and educational institutions, aware of the factors identified by students, may be challenged to identify best educational practices to develop a learning process tailored to the undergraduate study pathway36, whilst recognising and taking into account the challenging aspects of the degree programme and the career, such as cognitive overload, exposure to intimidating environments, and dealing with the suffering of others.
Given the complex perception of failure and the factors that influence it, as well as the internal and external pressures, it is important that institutions and teaching staff provide the necessary resources and ensure transparency to assess the situation and develop effective remedial strategies. As well as academic support, students will benefit from learning skills to identify and manage the factors that lead to failure, through personalised strategies
The results highlighted practical educational implications to be incorporated into the clerkship programme. There was a predominance of internal attributions of failure, such as anxiety and insecurity, which points to the need for interventions and strategies to develop skills in emotional regulation and study methods before the start of the placement. Strategies such as identifying maladaptive attributional patterns, applying coping guidelines and systematically evaluating the outcomes of improvement measures were implemented on the basis of the study’s findings.
As for factors external to their failure, the students cited as the main causes the hostile atmosphere in their relationships with the hospital’s specialist and resident staff, and the fact that the preceptor was not a member of the staff, which suggests the need for measures to foster a welcoming environment and clear communication regarding the student’s role within the SUS learning setting, where all healthcare undergraduates need to interact and gain practical experience.
Limitations, contributions and suggestions for future studies
The data were collected at a single centre from students from the same cohort, which limits the generalisability of the findings. There were a small number of participants in the qualitative phase, which may limit the diversity of perspectives.
Participation was voluntary, and the students who were most engaged with the clerkship were the most likely to agree to take part in the study. These students, who are possibly more committed, may represent a selection bias, whilst unmotivated students or those with very poor performance may have avoided taking part.
It should be emphasised that the students’ performance (summative assessment) was not evaluated, as this was not the objective; and although they performed well, the scope of the research was to reflect on the factors they themselves perceived as contributing to their failure.
As this was a study in which the students’ own interpretation of their performance served as the research instrument, and as the focus group session was led by the lecturer and took place amongst peers, there may have been a tendency to provide accounts that were more acceptable within the academic environment. In this regard, vulnerabilities, insecurities or shortcomings may have been under-reported. Accounts of the types of success most highly valued in an academic context - such as success resulting from effort, skills, emotional state and personal strategies - bear this out. Similarly, the causes of failure were attributed to external and less controllable factors, such as structural or organisational limitations (teaching staff, workload) and a hostile environment.
Self-assessment of performance during surgical clerkship is subject to limitations arising from social desirability bias and causal attribution bias. The dynamics of a focus group may even reinforce socially desirable responses. The lack of multiple data sources, such as formal performance appraisals or feedback from mentors, limits the scope for triangulation, making the study dependent solely on the participants’ perceptions.
Future studies involving larger samples and from different institutions are recommended to improve the consistency of the results. It is also suggested that longitudinal studies be carried out to follow the same pupils at different stages or in different phases.
The study made a significant contribution by presenting findings that shed light on the causal attributions made by general surgery trainees regarding the factors associated with success and failure during their clerkship. The perceptions and discourses identified can inform and enhance the planning of activities for this stage of the training programme, both before and during this cycle.
FINAL CONSIDERATIONS
The study sought to identify the causal factors behind academic success and failure amongst medical students in their General Surgery clerkship. It was observed that the challenges faced by medical students during their General Surgery placement are multifactorial, ranging from the ability to adapt to a complex environment to environmental and structural barriers, such as difficulties in building relationships and participating in the institution’s practical setting. Low resilience to pressures and uncertainty about their role manifested as an internal locus of control for failure, whilst environmental and structural barriers limited opportunities for active participation and were identified as the main external causal factors.
Students reported feeling insecure about their responsibilities in the face of a hostile environment, which led them to adopt a passive stance for fear of making mistakes or holding the team back, attributing failure to an external locus of control, which they perceived as uncontrollable. It was mentioned that the guidance and information provided by the clerkship programme were important as external factors contributing to success, which demonstrates the importance of external controllability from the student’s perspective.
The research identified ways in which these difficulties might be mitigated. In light of their observations, the students suggested strategies aimed at both personal development and institutional improvement. The students identified their own controllable initiatives - namely, effort, dedication and emotional regulation - as internal factors that drive change and lead to success.
Educational interventions such as guidance aimed at adaptive change and at creating opportunities for more active involvement in the care setting are promising strategies. Furthermore, recognising individual internal factors, such as perseverance and commitment, opens up new perspectives for the development of student support programmes aimed at strengthening resilience skills.
Ultimately, this study reinforces the importance of considering not only the development of technical skills, but also the strengthening of students’ emotional resilience. Overcoming these difficulties is essential to preparing them comprehensively for the challenges of the profession, so that they may become competent and resilient doctors.
References
- 1 Brasil. Resolução CNE/CES nº 3, de 20 de junho de 2014. Diário Oficial da União; 23 jun 2014 jun 23. Seção 1:811. Alterada pela Resolução CNE/CES nº 3, de 3 nov 2022.
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