Abstract
To investigate the incidence and accountable factors for the potential dropout thoughts among Saudi medical students. A cross-sectional survey questionnaire based study was conducted among Saudi medical students enrolled at the College of Medicine, King Saud University. A total number of 587 (39.13%) medical students out of ∼1,500 filled the questionnaire. Among them 302 (51.4%) reported incidence(s) of dropout thoughts at least once. However, only 17 (5.6%) have thought of dropping out very seriously. The majority of the students (67.5%) thought for withdrawal only on stressful days. The first year of the medical school was the most common year for all the students (49.3%) for thinking of dropout and academic problems were the most common reasons behind dropout thoughts (37.8%). The students, whose decision for entering in the medical school was influenced by the surroundings were at higher risk of dropout thoughts than their peers (OR = 1.912, CI 1.33–2.75). A significant amount of dropout thoughts was prevalent among Saudi medical students, but serious thinker about dropout were less in numbers. A well-structured academic guidance program supported with psychological teaching method must be designed and offered to diagnose the symptomatic students before actually they get affected with dropout thought which might lead to actual dropout.
Introduction
Medical student dropout refers to a student who leaves a medical school or medicine degree before his/her graduation and this definition applies in different capacities to other schools/subject streams/degrees as well. Earlier studies from different parts of the world have reported this serious issue, hence medical student dropout can be considered as an international problem (Han et al., 2012; Lassibille & Navarro Gómez, 2008; Mørcke et al., 2012; Tumlinson et al., 2019). If this issue is not taken seriously or controlled effectively, it will impede the individual goals and leads to severe wastage of time and effort. Student dropout from medical school is a matter of grave concern as it may eventually lead to a reduction in the number of future medical practitioners, which will further the grim healthcare situation of any country. Moreover, dropout is found to be a source-wasting phenomena in our society because a handsome percentage of an economy is being spent on medical education and its facilities by a majority of the countries of the world, unfortunately which is met by a (Araújo et al., 2019; Arulampalam et al., 2004; Lazin & Neumann, 1991; Mørcke et al., 2012; Vos et al., 2019).
A very high dropout rate (∼40%) has been seen in Spain (Lassibille & Navarro Gómez, 2008); Likewise, few more studies have reported high the dropout incidence in Austria (39%) (Dyrbye et al., 2010) and Denmark (27%) (Han et al., 2012). Soothingly, a recent study has reported that dropout rate is slightly decreased in Denmark from 27% to 20% in the last few years (Mørcke et al., 2012). On the similar lines, a study from Korea reported a 17.4% dropout rate among the students from medical schools (Maher et al., 2013). The medical school of Beer Sheva University, Israel has also reported an average incompletion prevalence of 12% (Stetto et al., 2004). In contrast, a lesser dropout incidence rate (4%) has been reported from medical schools of the United Kingdom (Arulampalam et al., 2004, 2007). These figures denote the incidence rate of actual dropouts; however, when we talk about how prevalent the potential thoughts of dropout or withdrawal from the United States reported that 25.2% of American medical students had serious thoughts of leaving their schools (Dyrbye et al., 2010). The idea of investigation about dropout thought is significant as these thoughts sometimes get transform into reality and leads to actual dropout case. If the frequency, impulse, and intensity of these dropout thoughts are quite high, then the chances of the transformation of these deliberations into practicality are really high.
A study conducted at five different medical schools of the United States of America reported serious thoughts dropout of leaving medical school among 11% of the students (Dyrbye et al., 2010).
The accountable factors that precipitate dropout or putting medical students at a higher risk of cogitation about dropout are critical matters of concern, a substantial basis for the literature review and in-depth research. Earlier reports published from various medical schools investigated their medical students’ controlling variables and deciphered varying degrees of association with dropout thoughts. The factors associated with medical students’ dropout thought can be divided into two main categories, (i) academic (before and after the admission in a medical school), (ii) and non-academic (personal or societal); and these two categories have shown to play a significant role in galvanizing the decision of deserting a medical school. In general, the academic factors are the underlying cause for a majority of dropout cases among medical students. These accountable factors may range from barely burnout to poor academic performance and failure (Ahmady et al., 2019; Dyrbye et al., 2010; Maher et al., 2013; Weber et al., 2019). Interestingly, academic non-satisfaction usually experienced by dropped out medical students is generally considered as secondary in comparison with non-academic reasons like student’s psychology, family or health-related issues (Abdulghani et al., 2021; Stetto et al., 2004) A review article published by (O’Neill, Wallstedt et al., 2011) involving 13 studies summarized the potential factors associated with dropout from medical schools and concluded that a broad range of entry qualification seems to be associated with a lower risk of dropout especially those students who have earned a prior degree and high admission test score (Ahmady et al., 2019; Andriole & Jeffe, 2010; Fall & Roberts, 2012).
Till now, no dedicated study has been conducted to explore the reasons or investigate the accountable factors associated with actual dropout cases or dropout thoughts prevalent among Saudi medical students. In this is study the potential factors associated with the Saudi medical students’ dropout thoughts have been investigated at a government medical college by using a cross-sectional survey questionnaire. To understand this complex phenomenon, it is imperative to know the academic details of medicine degree course accredited in Saudi Arabia. In order to select suitable candidates for any government or private medical college in Saudi Arabia, the high school graduate must fulfill four components of the admission criteria that includes, (i) a high school passing grade greater than 90% (it weighs 30%), (ii) the “Aptitude Test,” that evaluates the level of understanding of the given reading materials Physics and chemistry and some mathematical problem-solving capabilities (this test accounts for the second 30% of the total 100%). The remaining 40% of the total weightage is attributed to (iii) the “Achievement Test,” which is based on the cumulative score of 3-year high school science stream subjects (i.e., biology, chemistry, physics, mathematics, and English). Finally, at the end, (iv) the applicant must face a well-structured interview process conducted by the university where the applicant has applied for the admission. This interview process excludes only about 10% to 15% of the applicants already shortlisted from the first three criteria mentioned above (Ahmady et al., 2019). Despite following this highly specific and efficient selection process of medical students in Saudi medical schools, the dropout cases are still prevalent in a significant number.
If the problem of dropout is not taken seriously and controlled meticulously, it will impede the goals of an individual and a society, which ultimately leads to the wastage of time and effort. Furthermore, it will eventually result in curtailing the number of future doctors and healthcare manpower. Medical student dropout is found to be a source-wasting element in the society as a hefty percentage of the economy is being spent on medical education and its facilities, which is generally suffered from high incidence of dropout and this situation is applicable to the majority of the countries of the world including Saudi Arabia. Only scanty studies have been conducted to measure the incidence rate and investigate about pertinent accountable factors linked with medical students’ dropout or dropout thoughts in many countries. To the best of our information, no published data are available that investigate actual dropout or dropout thoughts phenomenon prevalent among medical students from all the Arabian peninsular countries. Keeping the aforesaid background in view, the present study was conducted to measure the incidence of dropout thoughts prevalent among Saudi medical students and explore the liable factors associated with it.
Methods
Study Design
The present study is quantitative, observational, and cross-sectional type. The study was performed during the academic years 2018/2019 involving students (subjects) of all the levels (from the first to the fifth academic year) of the College of Medicine (CoM), King Saud University (KSU), Riyadh, Saudi Arabia.
Data Collection
A self-administered questionnaire was designed after an exhaustive literature review to achieve the objectives of the study. The survey questionnaire consisted of three sections, viz., (1) socio-demographic and psychological variables (including information regarding student’s gender, age, marital status, residency, family education and economic status, personal accomplishments, homesickness, social seclusion, chronic illnesses, and positive or negative life event(s) in the previous year). In section (2) academic variables or factors (including questions about the student’s scores in examinations before entering in the university such as aptitude test score, achievement test score and high school percentage, questions evaluating the academic performance of the student in the CoM-KSU, that is, Grade Point Average (GPA), withdrawal, resit (repetition or remedial) in the examination, repeated years, problems with the understanding of the English language, and students’ ways of studying and time management and the last section (3) comprised of questions related to dropout thoughts. We asked the students, if they had ever thought of dropping out of medical college and in case their answer was “Yes,” then we enquired, how often (means the frequency) and how serious, in which academic year, when, and the possible causes of it. If their answer was “No,” then no further questions were asked. Initially, the total number of questions included were 68 but reduced to 55 after multiple rounds of revision. A pilot study involving 15 subjects was performed to validate the survey questionnaire. Written consent was taken at the beginning of the survey questionnaire as the participation was completely voluntary and the objective of the study was clearly explained to the study subjects. A convenient purposive sampling method was used by conducting the survey electronically using the SurveyMonkey website and sent via email by the Student Council to all the medical students (all semesters/levels) of CoM, KSU. The students were asked to participate in the survey anonymously and voluntarily. There was low response rate from the fourth and fifth academic year students especially the male section, which was possibly due to heavy clinical training hours. Thus they were followed up manually and hard copies of the questionnaire were distributed in their classes, hospital wards, and clinics to maximize their participation and for more realistic data.
Statistical Analysis
Statistical analysis was performed by using Statistical Package for the Social Sciences (SPSS) software program (SPSS Inc., Chicago, IL, USA) Version 22. Frequencies and percentages were calculated for all the nominal variables, and means and standard deviations were calculated for all the numerical variables. Chi-square test was employed for comparing all the nominal variables between the students who thought of dropping out of medical school and those who didn’t. However, student t-test (for two independent groups) was used for comparing the two groups of the students with respect to their measurable variables (for e.g., GPA, percentage of high school etc.). The statistical significance level was followed as p-value less than .05 (p < .05).
Results
The validated survey was delivered to all the students (n = 1,357) of the CoM-KSU and 662 students participated in this study. A total of 75 survey questionnaires were uncompleted and therefore excluded during the analysis. In the end, 587 medical students who completed the survey were included in this study with a response rate of ∼40%.
Students’ socio-demographic and economic condition and dropout thought
Of the included participating students, 306 students were male and 281 were female. The majority (98.5%) of these students were single (means they were bachelor/non-married) and live with their family member (92.7%) students. Among 587 students, only eight students were married and only one of them has children. Regarding participants’ parental education, ∼75% of the students’ fathers and ∼62% of students’ mothers have a bachelor or higher degree. Around ∼14% of students informed that their one parent is a medical physician and ∼18% of students have physician siblings. Around 11% of students informed about their financial issues. Interestingly, none of the participating students’ sociodemographic or socio-economic variables suggest any significant relationship with dropout thoughts (Table 1).
Students Thoughts of Dropping Out from Medical School.
Table 2 shows that more than half (n = 302; 51.4%) of the subjects had thought of dropping out of medical school at least once during their medical studies. Out of these 302 students, only 25 students (∼8%) informed about continuous thinking of dropout of medical school. However, the majority (67.5%) of the medical students informed that they had thought of dropout only on stressful days. Soothingly, the percentage of the students who contemplated about dropout very seriously was only 5.6%. The first year of the medical school appeared to be one of the most difficult years of medical education as the majority (49.3%) of the students thought of withdrawal, it is followed by the third year in which ∼34% of students thought of dropping out. The survey questionnaire revealed that academic struggling is the most (37.8%) common reason behind dropout thought.
The Relation Between Socio-Demographic Variables and Dropout Thoughts.
Personal and Psychological Variables and Dropout Thought
Table 3 reflects the correlation of students’ personal and psychological variables and their dropout thoughts. According to the survey, the thoughts of dropping out were increased two times among students who suffered from any negative event in the past year (OR = 2.023; CI 1.424–2.87) and vice versa (OR = 0.621; CI 0.443–0.870). In addition, an experience of decreased sense of personal accomplishment and social isolation due to studying medicine were found associated with increased dropout thought and gave the odds ratios corresponding to 2.260 and 1.450 (all p-values < .02). Above all, the students having accommodation problems had eight times more chance to have dropout thought than students who didn’t (OR = 1.850; CI 1.046–3.271). The students who spent their time watching TV were more likely (∼68%) to think of dropout than the student who hadn’t (OR = 1.68; CI 1.161–2.439).
The Relation Between Personal and Psychological Variables and Dropout Thoughts.
Academic Variables and Dropout Thought
Various academic factors (variables) playing diverse roles in the life of a medical student and their correlation with dropout thought for all the participants are shown in Table 4. As mentioned earlier that a high school graduate must fulfill the CoM-KSU’s admission criteria, hence pre- and intra-medical variables were also analyzed from statistical point of view; and we found that the students graduated from a governmental high school protected against thinking of dropout from a medical school or we can say that dropout thoughts are less prevalent in students graduated from government schools (OR = 0.66; CI 0.476–0.913; p-value = .012). Nearly 93% (n = 265) of students who hadn’t faced dropout thought were unaware about the medical school environment, but still hadn’t thought of withdrawal. About 97% of students who didn’t report any attack of dropout thought were found well adherent of the curriculum with no prior withdrawal (withdrawn year, semester or at least a course) movements (p-value = .019). A total of only ∼8% of medical students who reappeared for at least one exam were found under the category of dropout thinkers. Whereas, only ∼3% from the non-dropout thinker students category reappeared for at least one exam and this association was statistically significant (p-value = .019). Likewise, ∼8% of students who contemplated for dropout had history of repeating an academic year at least once in their medical studies. However, no linguistic barrier was found associated with dropout thought as an accountable factor. In other words, no significant association was detected between facing the English language related problems in medical studies and thinking of discontinuation of medical studies (p-value = .676).
The Relation Between Academic Variables and Dropout Thoughts.
GPA Score and Dropout Thought
Table 5 evaluates the association of student’s individual GPA score and incidence of dropout thought(s). This table summarized the data by calculating the mean of the participants’ current GPA and their high school’s passing percentage, and then it was compared for their resultant effects in terms of risk for discontinuation of medical studies. The students with earlier thoughts of dropout (n = 301) had a low GPA score recorded (mean M = 4.41) and vice versa (Table 5). The students’ high school passing percentage appeared not to play a significant role in the incidence of dropout thought phenomenon or in other words, students’ high or low high school grades can’t predict their career either to complete or dropout the medical school (p-value = .570).
The Relation Between GPA and Dropout Thoughts.
Discussion
This study deciphers the accountable factors linked with dropout thought prevalent among Saudi medical students. The results of this study suggested a variety of personal, psychological and academic variables/factors linked with incidence of serious thoughts of dropout among medical students. Overall, this study speculates that these identified variables generally play a role of an accountable factor and predicts the incidence of dropout thoughts prevalent among medical students, and in severe cases it may lead to actual withdrawal.
The present study is important as the incidence of dropout thought among Saudi medical students was found as 51.4%, whereas previously published multi-institutional study reported a much lower rate (25.2%) of dropout thoughts (Dyrbye et al., 2010; Pham et al., 2019). However, the percentage of Saudi medical students who seriously considered withdrawal from the medical college was nearly half (5.6%) compared to the earlier report (the reported withdrawal rate was 11%) (Dyrbye et al., 2010). Earlier studies have already reported that the first year is the most common year for the incidence of potential dropout thoughts or real dropout among majority of the medical students (Aarkrog et al., 2018; Ahmady et al., 2019; Lazin & Neumann, 1991; Stetto et al., 2004), and we found the same in our study. In contrast, as an exception, one study published from Korea reported that the second year of medical degree is the most common year of dropout thought (Han et al., 2012). All socio-demographic variables considered in this study were not able to significantly differentiate between the students who seriously thought of dropping out and who didn’t. As an example, students’ gender, we found no association of medical students’ gender with dropout thought, which is similar to the finding reported earlier (Dyrbye et al., 2010). This is in contrast with two studies (Arulampalam et al., 2004; Maher et al., 2013), that reported more likelihood of dropout thought among male students and three other studies (Costa et al., 2018; Mørcke et al., 2012; Reibnegger et al., 2011) that mentioned greater probability of withdrawal among female students. In our study, only 2.8% of the students were married, so we failed to establish a statistically significant correlation of relationship status with the incidence of dropout thoughts. Interestingly, the association of students’ relationship status and the incidence of dropout thoughts is very dubious as one study has reported in the past that married students have a higher dropout rate (Costa et al., 2018; Rogers et al., 2016), whereas another study reported no effect of relationship status with the incidence of dropout thought (Dyrbye et al., 2010; Kehm et al., 2019). Although the Saudi Arabia is a multi-ethnicity society and people from different parts of the world are living, studying and working there, however in this study we did not measure ethnicity-based association of dropout thoughts among medical students, as the seats are only limited to Saudi high school graduates. Although, based upon the published literature there might be an effect of ethnicity on the person’s thought process, and many studies have established the correlation of ethnicity with the incidence of dropout thought prevalent among students (Dyrbye et al., 2010; Kehm et al., 2019; Maher et al., 2013; Reibnegger et al., 2011; Szlyk, 2020).
Surprisingly, the incidence of dropout thoughts was found more among the students of highly educated parents compared to the students of less educated parents, however these findings were statistically insignificant. Also, we found that having doctor/physician parent(s) or sibling(s) doesn’t provide any immunity or cushioning against dropout thought among Saudi medical students. These results suggest that students of less-educated parents have more persistence in order to complete their medicine degree and securing a good job for better income. This is in contrast with previously published three studies that reported students having doctor/physician parent(s) are less prone to dropout from the medical school (Arulampalam et al., 2004; O’Neill, Wallstedt et al., 2011; Vos et al., 2019). As expected, students’ family income, financial problems (including debt or bank loans) and chronic diseases were found statistically insignificant factors as probably the Saudi government heavily invests in education and healthcare and provides free education, free residence in the university campus, free transportation or transportation allowance, free healthcare, and above all, a monthly reward (stipend/studentship) for all the university students. Our above findings were mix of congruence or incongruence with other previously published reports. As two studies have reported in the past that financial problem has no significant role in the incidence of dropout thoughts among students (Arulampalam et al., 2004; Faizullina et al., 2013) in contrast the study of (Dyrbye et al., 2010) reported that debt is associated with future serious thoughts of dropping out. Having a chronic illness is not a significant factor in the study of (Faizullina et al., 2013), whereas opposite results were found in the studies of (Maher et al., 2013; Stetto et al., 2004). As stated above, student’s accommodation (either in the campus, with family or with friends) was not found as a significant factor. But, accommodation related problems appear to play a possible significant role in the incidence of dropout thoughts or dropout risk, as earlier studies have reported that dropout risk for the students residing in their homes is lesser than the students residing in a dormitory (McLuckie et al., 2018). Interestingly, the study of (Arulampalam et al., 2004) has reported that students living off campus increases the dropout probability (Arulampalam et al., 2004).
Four out of five psychological factors reviewed in this study have insignificant effect on withdrawal or dropout thought and this was also supported by other studies as well, for example, positive/negative life events have been evaluated in relation with the incidence of dropout thoughts in a study published from the USA. Positive life events have protective effect against withdrawal thoughts whereas negative experiences enhance the risk of dropout thinking (Dyrbye et al., 2010; Vos et al., 2019). Likewise, decreased sense of personal accomplishments has been evaluated in the study of (Araújo et al., 2019), the results showed that personal accomplishments decrease gradually as dropout thoughts increase (Dyrbye et al., 2010; Kehm et al., 2019). On the similar lines, social seclusion was found as a potential factor in ∼20% of the dropped-out students in a study published from Ireland, and this phenomenon was more prevalent in other international students (Maher et al., 2013). Also, watching TV as a free time activity is the only significant predictor of dropout thought as prolonged watching of TV has plethora of harmful effects which are not limited to health, time, and financial resources. This finding is in contrast with the study published from Korea, which reported that spare time activities are insignificantly associated with dropout thoughts (Han et al., 2012).
In Saudi Arabia, it is difficult to find a medical student with a previous degree in any other specialty as it is not mandatory like in other countries, such as USA and UK (Arulampalam et al., 2004). Our results agreed with other studies where they reported that high school type, that is, either government or privately operated, doesn’t signify any correlation with the probability of dropout thought (Fall & Roberts, 2012; McLuckie et al., 2018). As stated earlier, the first year of the medicine degree is the most common year for the students to have thought(s) of withdrawal (Arulampalam et al., 2007), and similar response was found in our study, which endorses the above finding (Vos et al., 2019). Literature review of the germane studies revealed that the selection of applicants in a medical school is solely depend upon the high school grade/percentage; and the study of (Kadmon et al., 2014) predicted the continuity of students in the medical schools on that basis (Kadmon et al., 2014). On the other hand, students got admitted on the basis of their high GPA score were at the higher risk of disenrollment in their medical studies compared with their peers who underwent pre-medical testing (Ahmady et al., 2019; O’Neill, Hartvigsen et al., 2011; Puryear & Lewis, 1981). However, in the present study, high school grade/passing percentage failed to establish any apposite association with dropout risk/thought. As a shortcoming of this study, we failed to test the statistical effect of the interview (conducted at the time of admission) with the incidence of dropout thought/risk.
Although, most of the published studies report academic struggling or poor academic performance as the prime cause of withdrawal/dropout. In contrast, another study reported that two-thirds of the dropped students (∼61%) withdraw from the medicine degree because of non-academic (family or health related issues) reasons. Apparently, ∼51% of those students were found to be in a decelerated curriculum. Thus, poor academic performance, either more or less, is the foremost reason behind a majority of dropout cases either academic or non-academic (Kötter et al., 2017; Maher et al., 2013; Stetto et al., 2004). We found a statistically significant association between the incidence of dropout thought and repetition of at least a year during medical studies and this finding was in congruence with the reports of (Kehm et al., 2019; Maher et al., 2013). Additionally, our study significantly related reappearance in exams with dropout thoughts, which is similar as reported by (Maher et al., 2013) and in contrast with the findings of (Mørcke et al., 2012). Also, we found that linguistic problems (issues related with the English language difficulties) didn’t play a significant role in the incidence of dropout thoughts, however, a previous study of (Maher et al., 2013; Nam et al., 2020) reported that ∼10% of the dropped-out students had English language fluency issues and supported its association with withdrawal thoughts. Regarding the role of GPA score in the incidence of dropout thoughts, as expected, we found that lower medical school-GPA score was significantly linked with higher likelihood of discontinuation of degree (OR = 0.45; p = .001) and this was supported by the study of (Mørcke et al., 2012), where they found similar results.
Limitations of the Study
Low response rate and inclusion of one medical college are one of the major limitations of our study, as multi-center study with higher response rate might give more generalized results applicable to other medical schools using diverse selection criteria and varying population. In this study, we have elucidated the potential factors associated with dropout thoughts, but the actual cause(s) of withdrawal is/are still unknown in most of the cases and possibly it could be multifactorial and even more complex.
Recommendations of the Study
In order to conclude the precise findings, conducting similar studies in the other Saudi medical schools (governmental as well as private) is highly recommended, then only we will be able to evaluate and compare the incidence of actual withdrawal and potential dropout thoughts and accountable factors linked with it. In order to get the actual picture, in depth interview of the already dropped-out students are highly recommended to decipher and evaluate the factors/causes responsible for their decision of discontinuation. Moreover, short-term academic guidance programs supported with psychological pedagogy must be offered to diagnose and enlighten the symptomatic students before actually they got affected with the incidence of dropout thought or actual withdrawal; this guidance will support such students in overcoming the potential causes/problems that may precipitate their thoughts of withdrawal.
Conclusion
In conclusion, the prevalence of dropout thoughts among Saudi medical students at CoM-KSU was significantly high. Among Saudi medical students, academic struggles are one of the major reasons for dropouts. However, serious thinking about withdrawal from the medical school was not considerably high. It was found that the incidence of dropout thoughts has been increased in the recent years, which might attribute to the updated medicine curriculum introduced in the year 2008. In order to curb the menace of actual withdrawal, which is gradually precipitated due to the continuous incidence of dropout thoughts, a fully structured academic guidance programs must be implemented to detect symptomatic students before they get affected with dropout thoughts which might lead to actual withdrawal.
Footnotes
Acknowledgements
This work was supported by the College of Medicine Research Center, Deanship of Scientific Research, King Saud University, Riyadh, Saudi Arabia.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Ethical Consideration
The study was approved by the Institutional Review Board (IRB) of the ethical committee of CoM, KSU, Riyadh, Saudi Arabia. Subjects participation was fully voluntarily without any reward. All the information related to the personal identification of the voluntary subjects collected during the research study was kept confidential.
