The evolution of an undergraduate medical student into a safe and competent physician is interminable, demanding, and stressful [1]. This journey involves combatting what Smith [2] defined as the “swampy lowlands where situations are confusing ‘messes’ incapable of technical solutions” coping with hidden insecurities of clinical practice. In fact, medical students have a higher predominance of mental health problems than other student groups of the same age [3]. This indicates that medical education itself contributes as a key stressor, an observation corroborated by other studies [4,5]. Academic stress is defined as the body’s response to academic-related strains and tensions that exceed adaptive potentials of students. Medical students experience high degrees of academic stress, where the most commonly reported stressors in the academic environment are related to oral presentations, academic overload, scarcity of time to meet commitments, and taking examinations. [6]. While some academic stress may boost academic performance [7], elevated stress levels in medical students may lead to detrimental consequences such as depression [8], burnout [9], somatic complaints [10], decrease in empathy [11], dismal thoughts about quitting medical school [12], suicidal ideation [5], and poor academic performance [13,14]. Therefore, it is imperative to determine the association between important psychoeducational variables and academic performance in the context of medical education to define the role of each psychoeducational variable in the response to academic stress.

The aim of this proof-of-concept study is to determine the relationship between meta-motivational skills for handling stress (resilience), meta-cognitive skills for study (learning approaches), and meta-emotional skills for managing stress (stress-coping strategies) and how they can collectively predict achievement in undergraduate medical students, founded on the competence of learning, studying, and performing under stress (CLSPS) model [15] (Textbox 1).

The following research questions will be addressed:

The research questions are founded on the following hypotheses regarding undergraduate medical students:

An initial cross-sectional study was pursued at MBRU. The ASSIST questionnaire [30] was circulated to 84 students in the college of medicine. Of the 84 students, 64 responded to the questionnaire. Of the 64 responses, 4 responses were excluded as they were either incomplete or ambiguous. Statistical analysis was conducted on the data obtained from 60 responses. Of these students, 57% (34/60) used a deep learning approach, 16% (10/60) used a strategic learning approach, and 27% (16/60) used a surface learning approach.

Next, we investigated the association of learning approaches with teaching approaches in the 60 responses using logistic regression. In this analysis, responses of 5 students were excluded, as they had equivalent scores in teaching approaches. Among the 55 included students, 71% (39/55) preferred the surface teaching approach and 29% (16/35) preferred the deep teaching approach. Furthermore, strategic learners had a significant positive correlation with perceived academic performance compared with other learners (Figure 2).

This initial study indicated that while the predominant learning approach was deep learning (seeking meaning and critical thinking), the preferred teaching approach was surface teaching. Also, strategic learners perceive themselves to perform better academically (Tables 1 and 2) [32].

However, what happens in a multidimensional milieu, when resilience and stress-coping strategies of students are also included, is currently unknown and will be investigated in this study.

In the demanding academic milieu of medical education, the psychoeducational variables resilience, learning approaches, and stress-coping strategies act in concert; it is imperative to investigate the relationships between these variables and their collective effect on the academic performance of undergraduate medical students. To our knowledge this has not been studied, and the proposed research would address this gap.

Mohammed Bin Rashid University of Medicine and Health Sciences (MBRU) is a new medical school located in Dubai Health Care City, the health care hub of United Arab Emirates, with a 6-year MBBS (Bachelor of Medicine, Bachelor of Surgery, or Medicinae Baccalaureus Baccalaureus Chirurgiae) undergraduate entry medical program where the curriculum is founded on a competency-based educational model. The MBRU curriculum is divided into 3 phases (Figure 3). Each phase of the curriculum includes integrated courses and builds on the preceding one such that the curriculum is a spiral: the students repeat the study of a subject, each time at a higher level of difficulty and in greater depth. The school has a diverse student population, drawing students from more than 19 countries across the globe. Approximately 75% of the students are women.

As indicated earlier, MBRU is a new medical school in its fourth year of operation. The study population will consist of 234 MBBS students (students in the dental program are not eligible) distributed over four cohorts. Purposive sampling will be used. Newly registered MBBS students will be excluded from the study because their brief period in the program is not adequate to evaluate their academic performance and psychoeducational variables.

Mapping of the correlation coefficient values (over a defined range from .20 to .80) for association of resilience to academic performance with a range of power values (0.60 to 0.90; Table 3) indicates that the number of participants will be suitable for the statistical correlations performed in the study. To detect a simple correlation between resilence and academic performance, where correlation coefficient r=.20 of N observations using a 2-sided test of 5% significance level (alpha=.05) with 80% power (β=0.20), the required sample size is approximately 194.

Our study will employ a modification of the Approaches and Study Skills Inventory for Students (ASSIST; Multimedia Appendix 1) questionnaire [33] to evaluate the predominant learning approaches of the students. This questionnaire was developed by Entwistle et al [30] to evaluate approaches to learning and has been refined and improved based on educational philosophies put forth by Martin and Saljo [34] and others [29].

The initially published ASSIST questionnaire consists of sections A, B, and C with questions rated on a Likert scale. As shown in Table 4, in the proposed research the 66 items have been reduced to 41 items (sections B and C). We modified the questionnaire to decrease the number of questions while maintaining an equal number of questions across the learning approaches. In the modified ASSIST, 4 items have been added to record the demographics of participants (age, gender, year of study in the MBBS program, and high school education). In modifying the ASSIST questionnaire, care has been taken such that overall validity of the tool is preserved. The original ASSIST questionnaire [30] has been amended instead of using an existing abridged version to make the tool as relevant as possible to the context of the proposed research. Modifications have been introduced to avoid survey fatigue among participants; specific items not relevant to the participants have been removed. Additionally, upon piloting the questionnaire we found that the language in a few items was ambiguous, and we amended these items.

The Connor-Davison [35] and Wagnild-Young [36] resilience scales were considered for our evaluation. We chose the Wagnild-Young scale (Multimedia Appendix 2) because it was developed using an oblimin rotation factor analysis (allowing correlatation) where the factor construction characterizes personal competence and acceptance of self and life [37]. The scale consists of 14 Likert-scale items grouped in five domains: self-reliance, meaning, equanimity, perseverance, and existential aloneness.

A 13-item coping strategies questionnaire has been designed (Multimedia Appendix 3) that will assess participant cognitive, emotional, and behavioral approaches for tackling difficulties and problems. The cognitive and emotional approaches (items 2, 3, and 4) have been adapted from the Coping Strategies Scale of Holahan and Moos [38]. Additional items focusing on emotional and cognitive approaches (items 1, 5, 6, and 8) have been adapted from Hamby et al [39]. Other items in the questionnaire are from Spitzberg et al [40].

Students participating in the proposed research will receive identical information, disseminated through Google Forms, similar to previous research studies conducted in medical education at MBRU [41-43]. Participants will respond to the questionnaires during the self-study time between 11 am and 1 pm (after the morning teaching sessions). Gathering and processing of the collected data will be pursued with the informed consent of the participating students, in line with the ethical and deontological principles of psychology. Collected data will be analyzed in an anonymous and group format, and the data will be stored in an encrypted database and on a password-protected solid-state drive with the research team.

We submitted the proposal to MBRU institutional review board (IRB) for which exemption has been awarded (application ID: MBRU-IRB-2019-013). Further clarification with regard to the policies and terms of reference can be obtained from the IRB.

The questionnaire response files from Google Forms will be converted to a spreadsheet, and the questions for each approach will be organized into adjacent columns with the value of each response in the respective row. All collected data will be cross-verified by two investigators from the research team. The average score for each questionnaire will be generated for each student. This will be done by taking the average of all responses recorded for a certain questionnaire for a particular student.

SPSS Statistics for Windows version 23.0 (IBM Corp) will be used for all statistical analyses. Cronbach alpha will be used to check internal consistency, and explanatory factor analysis will be used specifically for the questionnaire to confirm the evidence of its validity in the literature. Outliers will be identified by using a Bonferroni outlier test (P<.05). Scores of independent variables (resilience, stress-coping strategies, and learning approaches) will be calculated for independent variables. All scores will be tested for normality by using the Shapiro-Wilk test. An inter-item correlational matrix of the dependent and independent variables to test the pairwise correlation will be formed using Pearson bivariate correlation coefficients. Regression models will be used to answer questions with type II analyses of variance in tests involving multiple predictors. Regression analyses will be checked for homogeneity of variance (Levine test), normality of residuals, and multicollinearity (variance inflation factor). Statistical significance will be set at the conventional 5% threshold (alpha=.05). Effect sizes will be estimated with 95% CIs.

Ordered logistic regression will be used to analyze the effect of individual psychoacademic variables on academic performance controlling for age, gender, and cohort to which the student belongs.

We have presented the data from an initial study, where we have correlated student learning approach to academic performance. Data from this initial study further encouraged us to investigate academic performance of medical students in a multidimensional setting; when resilience and stress-coping strategies are also included, the study protocol for this investigation is presented in this article.

Findings from this investigation will elaborate on the need for further research regarding resilience in medical students and how resilience can be improved in this population and emphasize that the concepts of stress, burnout, resilience, and coping appear to be very much related in the context of undergraduate medical education.

The investigated variables, resilience, learning approaches, and stress-coping strategies, are individual traits; students’ learning history before they joined MBRU is unknown, so our research will not be able to address this specific aspect. Investigating this aspect would be difficult as the MBRU student pool draws from 19 different countries and 15 different high school curricula.

In addition, we cannot consider the gender variable in this study as more than 80% of our students are women, which has shown to have an effect on the investigated variables [50,51].

Results from the different psychoeducational instruments will institute the associative and extrapolative multidimensionality of the different variables in envisaging academic performance of medical students. To our knowledge, no study exploring the multidimensional association of learning approach, resilience, stress-coping strategies, and academic performance in undergraduate medical students has been pursued [52].

Additionally, this research will validate and expand on previous research on the importance of resilience and its association with academic stress and coping strategies in medical students [53,54]. Study results may initiate a framework for assessing psychoeducational variables while admitting students to medical school or during counseling as part of psychoeducational services.

Future studies from this research should investigate the associations of the studied psychoeducational variables with academic emotions or insufficient approaches of stress management, [55-57]. Study results can initiate strategies to integrate the studied variables in different models of medical curricula [58,59], adding to the understanding of the role of meta-motivational and meta-affective approaches during learning in medical school [60].