Coping Strategies of Failing International Medical Students in Two Chinese Universities: A Qualitative Study

Jiang, Q., Yuen, M., & Horta, H. (2023). Coping Strategies of Failing International Medical Students in Two Chinese Universities: A Qualitative Study. Teaching and learning in medicine, 1–11. https://doi.org/10.1080/10401334.2023.2204077

Introduction

A large number of international medical students are enrolled in Bachelor of Medicine and Bachelor of Surgery (MBBS) programmes in China. The overwhelming majority of these students are from low-income countries in Asia and Africa and are self-supported. These students expend substantial personal and financial effort to come to China to become medical doctors and to contribute to the healthcare workforce in their home countries. However, little is known about their educational success as international students attending Chinese universities. Even less is known about how international medical students who initially fail courses in Chinese medical universities manage to subsequently achieve academic success. Therefore, we explored the coping strategies adopted by international medical students after they fail exams during MBBS training. 

Research methods

This qualitative study was set in two Chinese medical universities in Jiangsu province, China. We adopted a purposive sampling method and interviewed international medical students who had a record of failing courses but successfully passing make-up exams and re-sits. A total of 21 international students from developing countries in Asia and Africa were recruited. Semi-structured face-to-face and virtual (due to the COVID-19 pandemic) interviews were conducted with these students. During the interviews, we encouraged the participants to describe the difficulties they experienced in their courses, the academic challenges they faced, and how they coped with and then overcame the experience of failing initial exams. A thematic analysis approach was adopted to analyse the interview data. 

Findings 

After failing initial exams, the international medical students in the sample adopted seven coping strategies to help them pass future examinations and recover their academic success: (i) increased help-seeking behaviours; (ii) improved learning motivation and attitudes; (iii) improved learning strategies; (iv) improved exam preparation; (v) utilised library resources; (vi) enhanced time management; and (vii) enhanced English language skills. Of these seven strategies, seeking the help of friends, peers, seniors, and teachers was the strategy reported most frequently. 

Discussion

We found that failing international medical students are not necessarily passive or lazy learners (as they may commonly be perceived); in fact, they demonstrated resilience and agency to cope with failure. The coping strategies applied by the participants in our study were consistent with the findings of others studies: effective learning strategies and exam preparation (Bin Abdulrahman et al., 2021), social support (Todres et al., 2012), intrinsic learning motivation (Hayat et al., 2018; Wu et al., 2020), the utilisation of campus resources (Banjong, 2015), efficient time management (Foong et al., 2022), and adequate English skills (Su & Harrison, 2016). 

However, unlike other studies that found that failing medical students often fail to seek help from their institutions or peers, the participants in our study reported proactively initiating help-seeking behaviours after failing exams. There are several possible reasons for these different findings. First, the university staff in the establishments in this study may be approachable and willing to help the students. The participants did not mention institutional efforts to proactively support relationship formation and mentorship or institutional support to overcome exam failure, but some mentioned that a few teachers tried to help them as much as possible. Another explanation for the students’ proactive help-seeking behaviour may be the international students’ own cultures. Many South Asian, Southeast Asian, and African cultures are strongly rooted in close social mutual support and interaction (Rabbi & Canagorajah, 2021), and this may have played a positive role in promoting proactive help-seeking behaviours and positive responses from peers, teachers, and seniors. The help-seeking behaviours may also be due in part to the fact that in China, international students in MBBS programmes live and study together in collective learning communities for up to 6 years. Daily interactions with peers, seniors, teachers, and student administrators may foster trust and support among them, making students more willing to seek support and help from these sources. This setup may create a strong sense of community, where teachers, seniors, students perceived as academically successful, and others may serve as role models and mentors for international students, advising and actively supporting them in overcoming exam failure (Arthur, 2017). Another possible reason is that intense academic or career competition may not occur among these students, as they will ultimately leave China and return to their home countries to take local licensing exams or even migrate to a third country.

Social support, particularly seeking help from immediate friends, was stressed by the participants as an aspect of all seven of the coping strategies identified in this study. This highlights the vital role that social support plays in helping international medical students (and likely other international students) with their academic performance (Sandars et al., 2014). A supportive environment that fosters students’ relationships with their peers and teachers can be a positive ‘hidden curriculum’ that is conducive to learning (Sandars et al., 2014). An important finding is the medical students’ use of peer-assisted learning in the form of group study, along with occasional individual tutoring, which has been recognised in the literature as a useful method adopted by students to overcome academic problems (Brierley et al. 2022).

Conclusion

Chinese medical institutions may wish to recognise the resilience and agency of failing international medical students and make positive changes to help them achieve academic success. Institutional efforts could be made to develop contextualised intervention plans that stimulate students’ learning motivation and encourage them to adopt self-help strategies by making useful resources (e.g., help from peers, seniors, and teachers) available. To pre-empt the problem, enrolment could become more selective and could integrate specific English language proficiency criteria, interviews, and entrance exams. Although many international medical students demonstrate resilience and agency, some failing students may require academic remediation.

References

Arthur, N. (2017). Supporting international students through strengthening their social resources. Studies in Higher Education, 42(5), 887–894. https://doi.org/10.1080/03075079.2017.1293876

Banjong, D. N. (2015). International students’ enhanced academic performance: Effects of campus resources. Journal of International Students, 5(2), 132–142. https://doi.org/10.32674/jis.v5i2.430

Bin Abdulrahman, K. A., Khalaf, A. M., Bin Abbas, F. B., & Alanazi, O. T. (2021). Study habits of highly effective medical students. Advances in Medical Education and Practice, 12, 627–633. https://doi.org/10.2147/AMEP.S309535

Brierley, C., Ellis, L., & Reid, E. R. (2022). Peer-assisted learning in medical education: A systematic review and meta-analysis. Medical Education, 56(4), 365–373. https://doi.org/10.1111/medu.14672

Foong, C. C., Bashir Ghouse, N. L., Lye, A. J., Pallath, V., Hong, W.-H., & Vadivelu, J. (2022). Differences between high- and low-achieving pre-clinical medical students: a qualitative instrumental case study from a theory of action perspective. Annals of Medicine, 54(1), 195–210. https://doi.org/10.1080/07853890.2021.1967440

Hayat, A. A., Salehi, A., & Kojuri, J. (2018). Medical student’s academic performance: The role of academic emotions and motivation. Journal of Advances in Medical Education & Professionalism, 6(4), 168–175.

Rabbi, S., & Canagarajah, S. (2021). Cosmopolitanism and plurilingual traditions: Learning from South Asian and Southern African practices of intercultural communication. In The Routledge Handbook of Plurilingual Language Education (pp. 82-95). Taylor and Francis. https://doi.org/10.4324/9781351002783-6

Sandars, J., Patel, R., Steele, H., McAreavey, M., & Association for Medical Education Europe. (2014). Developmental student support in undergraduate medical education: AMEE Guide No. 92. Medical Teacher, 36(12), 1015–1026. https://doi.org/10.3109/0142159X.2014.917166

Su, M., & Harrison, L. M. (2016). Being wholesaled: An investigation of Chinese international students’ higher education experiences. Journal of International Students, 6(4), 905–919. https://doi.org/10.32674/jis.v6i4.325

Todres, M., Tsimtsiou, Z., Sidhu, K., Stephenson, A., & Jones, R. (2012). Medical students’ perceptions of the factors influencing their academic performance: an exploratory interview study with high-achieving and re-sitting medical students. Medical Teacher, 34(5), e325-31. https://doi.org/10.3109/0142159X.2012.668626

Wu, H., Li, S., Zheng, J., & Guo, J. (2020). Medical students’ motivation and academic performance: the mediating roles of self-efficacy and learning engagement. Medical Education Online, 25(1), 1742964. https://doi.org/10.1080/10872981.2020.1742964

Authors’ bio

Dr Qinxu Jiang holds a doctoral degree from the Faculty of Education, the University of Hong Kong. Her research focuses on academic success, life satisfaction, student mobility of international medical students, and medical faculty development. E-mail: jiangqx@hku.hk

Dr Hugo Horta is an Associate Professor, Director of the Consortium for Higher Education Research in Asia (CHERA), and Director of the MeD programme at the Faculty of Education of the University of Hong Kong. He is also the Chairperson of the Consortium of Higher Education Researchers (CHER) and Coordinating-editor of the journal Higher Education. His main topics of interest are academic research processes, outputs and outcomes (including strategic research agendas), academic mobility and academic inbreeding, and career trajectories of PhD holders. E-mail: horta@hku.hk

Managing editor: Lisa (Zhiyun Bian)