Our data show that above-average students had higher SR score while below-average presented higher SA, particularly SM, with no differences for the other dimensions of the questionnaires.
Intrinsic motivation affirmations such as a feeling of deep personal satisfaction through their study, a deep interest in understanding the content, and learning from mistakes, and strategies that were aligned with these motivations were more frequent in above-average students. In stark contrast, those below average didn’t find the content interesting, which led them to not being motivated to hard-work and prioritized rote learning.
Consistent with other measures in medical students , overall, DA score was significantly higher than the SA. It is important to bear in mind, though, that the differences were linked to the motivation, with students showing higher DM values than SM, while there were no differences in the overall process score (DS and SS scores), which may be linked to an aim on information reproduction linked to multiple choice question assessment of the university .
The learning approach reflects how students tackle a specific learning task . An intrinsic motivation and interest for understanding and integrating the to-be learnt material with previous experiences and knowledge is what characterizes a DA to learning. As such, the DA has been considered the desirable LA for meaningful learning .
In Hattie’s review a deep motivation traits are deemed to have potential to impact learning, while surface motivation and approach were likely to have a negative impact [8, 21].
When considering the academic results, previous studies performed in medical students show that those with better academic score [9,10,11]. In our sample, both above and below average students showed high DA score. Nevertheless, a higher proportion of above-average presented a DA > SA score. Concerning the absolute score, however, the main differences in the approach to learning were linked to the SA, instead of the DA, with below-average showed significantly higher SA, particularly SM.
Student engagement measures cognitive, behavioral, and emotional elements that impact learning outcomes . Higher SE levels are linked to higher academic courses  and better academic results . Although there is no prior available data for SE in medical students, students in our cohort present SE score similar to the results obtained in other degrees, with students showing high scores for cognitive and personal skills dimensions.
Problem Based Learning (PBL) represents one of the strategies developed in the paradigm-shift from passive students to actively-engaged students in order to enable students to become life-long learners , and is associated with higher SE levels. Interestingly, despite devoting an increasing percentage of the curricula to team-based learning and problem-based learning methodologies, still the cooperative scores are significantly low in our sample. Moreover, there were no significant differences between above and below-average students concerning the SE.
Additionally, students showing high levels of SR are able to appropriate allocate the use of resources to reach their learning objectives, which is paramount for self-directed and life-long learning [22, 23]. Intrinsic Value (IV) and SR, are among some of the student-dependent elements with potential to accelerate learning . Consistent with previous data, our population presented very high IV score and high SR score [12, 13]. Although the relationship with academic results shows conflicting results [12,13,14], in our cohort above-average students had statistically significant higher SR score.
To our knowledge, this is the first study to perform a multidimension assessment in a European sample of medical students considering the learning approach, student engagement and motivation, particularly intrinsic value, and self-regulation, and relating them with the academic results. The Cronbach’s alfas of our sample are comparable to those of the original studies, ensuring internal consistency. As expected, our data show a strong positive correlation between the DA of the R-SPQ-2F, the IV, and SR dimensions of the MSLQ questionnaire, and a strong negative correlation with the SA of the R-SPQ-2F.
With the aim of getting some insight regarding what attitudes and strategies medical students with better academic results have, in order to guide future recommendations for undergraduate students, we performed a comparative analysis per individual item. Our data show that above-average students are characterized by feeling a deep personal satisfaction through their study, and a deep interest in understanding the content, and learning from mistakes, aligning their strategies with these motivations, whereas, in stark contrast, those below average didn’t find interesting the topic, thus were not motivated to hard-work, and prioritized rote learning.
Another strength of our data is that the academic results of all the students in both courses (included and not included in the study) were available which allowed us to identify the traits of the "real" above-average students, and not only those with better results in our cohort. Since there were no significant differences in the distribution of above and below-average students per course, it is safe to assume the differences were based on individual traits, and not in course differences.
There are, however, some limitations to bear in mind. Firstly, the participants in our sample were recruited in a voluntary basis, so probably the inherently motivated students were the ones to sign-up. This may explain the high DA, cognitive and personal skills, IV, and SR values of our cohort, and may account to some of the discrepancies respective to prior data. Furthermore, students were from preclinical courses, so our results may not be representative of all the medical student’s population. Additionally, it could have limited our ability to find greater differences in students’ attitudes.
It should be taken into account that the academic results pertained to the prior course and were used as proxies for the baseline academic results of each of the participants. Since no known intervention occurred during the summer, and there were no differences for the prior courses receive between above and below-average students, it is safe to assume that there would be no significant differences.
Another limitation is that we highlight desirable traits under the assumption that good professional performance is associated to good academic results. Nevertheless, we “wrongly” assume that the content assessed with the university tests guarantee students will be able to retain this information in the long-term  and apply it. Medical graduates report feeling unprepared to face some of the challenges when they start working in the hospital, and their degree of confidence and preparedness is usually higher than those referred by the stakeholders or supervisors [25, 26]. Also, given the speed of new medical advancements, it is paramount that students develop the necessary habits for self-directed learning and life-long learning, since much of what is learnt may become obsolete in the coming years. That is why identifying how to best convey and instill these skills during medical school should be addressed.
Finally, our results are limited to the items assessed in the questionnaires. There are other elements in Hattie’s review such as self-efficacy, self-judgement and reflection meta-cognition strategies that rank higher in their potential to considerable accelerate learning review [8, 21], with promising results in medical students [23, 27, 28] and that should be the focus of future learning interventions.