Premkumar et al.

BMC Medical Education (2018) 18:134

https://doi.org/10.1186/s12909-018-1244-9

RESEARCH ARTICLE Open Access

Self-directed learning readiness of Indian

medical students: a mixed method study
Kalyani Premkumar1* , Elizabeth Vinod2, Solomon Sathishkumar2, Anna B. Pulimood2, Valerie Umaefulam1,
P. Prasanna Samuel2 and Tara A. John2

Abstract
Background: Self-directed learning (SDL) is defined as learning on one’s own initiative, with the learner having
primary responsibility for planning, implementing, and evaluating the effort. Medical education institutions promote
SDL, since physicians need to be self-directed learners to maintain lifelong learning in the ever-changing world of
medicine and to obtain essential knowledge for professional growth. The purpose of the study was to measure the
self-directed learning readiness of medical students across the training years, to determine the perceptions of
students and faculty on factors that promote and deter SDL and to identify the role of culture and curriculum on
SDL at the Christian Medical College, Vellore, India.
Methods: Guglielmino’s SDL Readiness Scale (SDLRS) was administered in 2015 to six student cohorts (452
students) at admission, end of 1st, 2nd, 3rd and 4th year of training, and at the beginning of internship in the
undergraduate medicine (MBBS) program. Analysis of variance (ANOVA) was used to compare SDL scores between
years of training. 5 student focus groups and 7 interviews with instructors captured perceptions of self-direction.
Transcripts were coded and analyzed thematically.
Results: The overall mean SDLRS score was 212.91. There was no significant effect of gender and age on SDLR scores.
There was a significant drop in SDLRS scores on comparing students at admission with students at subsequent years of
training. Qualitative analysis showed the prominent role of culture and curriculum on SDL readiness.
Conclusions: Given the importance of SDL in medicine, the current curriculum may require an increase in learning
activities that promote SDL. Strategies to change the learning environment that facilitates SDL have to be considered.
Keywords: Self-directed learning, Medical education, SDLRS score, Curriculum, Culture

Background medical students take the initiative, with or without the

Self-directed learning (SDL) is a vital educational principle help of others (e.g. instructors and colleagues), determine
in higher education that has been promoted by various in- their learning needs, set learning goals, identify resources
stitutions due to its value in developing professionals to for learning, choose and implement learning strategies to
become lifelong learners. Medical education systems acquire knowledge and finally evaluate learning outcomes
worldwide have embraced SDL so that medical students [2]. Hence, the medical student is responsible for his or
gain SDL skills to continuously equip themselves with her own learning. SDL readiness (SDLR) is the extent to
relevant knowledge and skills in the ever evolving world which the student has the ability, attitude and personal
of medicine. SDL is generally defined as learning on one’s characteristics appropriate for SDL [3].
own initiative, with the learner having primary responsibil- In a constantly changing environment, SDL is essential to
ity for planning, implementing, and evaluating the effort enable medical students to develop independent learning
[1]. In medical education, SDL is the process in which skills, increased responsibility, assertiveness and account-
ability which are key attributes to a medical professional’s
career. Medical educators similarly seek to adopt SDL with
* Correspondence: [email protected]; [email protected]
1
HSC E-wing 3226 Department of Community Health and Epidemiology,
the primary aim of producing learners who can manage
College of Medicine, University of Saskatchewan, Saskatoon, SK, Canada their own learning in their careers and have a continuous
Full list of author information is available at the end of the article

© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
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Premkumar et al. BMC Medical Education (2018) 18:134 Page 2 of 10

quest for knowledge through critical thinking that will en- culture and customs and these influence the way stu-
hance retention and recall of information to promote better dents learn. Thus, students share ideas and practice their
decision making [4]. cultural values even in an academic environment be-
Thus, health professionals need to be self-directed so cause it is a part of their life.
as to increase independence, self-confidence in practice, India is rich in culture and it plays a major role in the
motivation, self-discipline and goal orientation due to in- process of learning. The instructors also bring into class-
formation explosion and the continuously evolving med- rooms, beliefs based on their own experiences [13]. Par-
ical knowledge during their careers [5]. ents play a key role in their children’s education and the
social environment in which families live influences their
Medical education in India involvement [14].
The Medical Council of India (MCI) has set uniform Recent trends in medical education have shown an in-
standards for medical education in India. In 2011, the crease in the adoption of student-centred methods such as
MCI modified the curriculum and provided directions problem-based learning (PBL) that emphasize SDL. The
for teaching and learning methodology in medical edu- acceptability of such methods is not universal and shows
cation – Vision 2015, so that Indian medical graduates variation across different cultures and countries [15].
can be lifelong learners [6]. Thus, the curriculum Cultural factors that impede SDL in medical students
followed by medical institutions, seek the development across cultural groups differ. Frambach et al. [15] found
of SDL readiness in students [7] as promoted by MCI. that uncertainty and tradition were principle restraints in
However, monitoring changes and quality of education Middle Eastern students’ SDL, whereas a dependence on
is a huge challenge given that India has the largest num- hierarchical sources rather than oneself was challenging to
ber of medical colleges globally (n = 460). SDL in Asian students. The pressure of achievement was
high in non-Western students. These factors had minimal
Christian medical college, Vellore, curriculum and SDL influence on students in Western countries [15].
The Christian Medical College (CMC) is one of the lead- It was noted, however, that once introduced, students
ing medical institutions in India, committed to excel- grew accustomed to newer methods of education; and
lence in education, patient care and research. It provides acceptability as well as skills in SDL increased across dif-
quality primary, secondary, tertiary and quaternary pa- ferent cultures despite the various challenges in each set-
tient care services, with a special concern for the poor ting [15].The impact of culture is seen not only in
and the marginalized. Hence, yearly admission into this development of readiness to SDL but also in communi-
medical college is rigorous and highly competitive [8]. cation and learning strategies adopted [16].
The medical program at CMC, Vellore, is a four and a The curriculum at CMC has various components that
half years program followed by one year of internship. promote SDL such as the Integrated Learning Program.
The program is organized with a mix of subject-based, It has not been studied whether the students are indeed
community-based, competency-based and problem-based self-directed and whether the curriculum and culture
curricular components. There are several opportunities promote or deter self-direction. Given that SDL is an
for SDL within the curriculum which include the Inte- important skill required for lifelong learning, it is vital
grated Learning Programs [9], early clinical exposures for this question to be investigated in order to promote
[10], clerkship programs, laboratory practicals, chart dis- SDL among Indian medical students.
cussions, tutorials, student seminars, e-learning, projects
in the community, bedside clinics, research projects, prize Purpose of study
examinations and secondary hospital programs. The aims of the study were to:

Culture and education 1. Measure the SDLR of medical students at

Culture is the set of meanings that a group in a time admission and students at different stages of
and place come to adopt or develop, and culture can medical training.
also be regarded as how people think and address vari- 2. Determine the perceptions of students and faculty
ous situations/experiences which may be based on indi- regarding SDL and factors that promote and deter
vidualism, collectivism, or honor [11]. Culture is a SDL.
dominant controlling factor that impacts one’s way of 3. Identify the role of culture and curriculum on SDL.
learning and communication in an academic setting
[12]. In general, students learn attitudes, norms, prac- Method
tices, and beliefs even before being exposed to formal This is a cross-sectional study that investigated the readi-
education. Values such as unity, tolerance, obedience ness for SDL among undergraduate medical students at
and respectfulness are instilled from a young age via CMC, Vellore. Institutional Review Board approval was
Premkumar et al. BMC Medical Education (2018) 18:134 Page 3 of 10

obtained prior to the start of the study. As a result of the The researchers invited faculty in the medical school
importance of this study to the curricular mandate of CMC, to participate in semi- structured interviews. Seven
the researchers invited all students in the medical program members of the faculty took part in the interviews. In
to participate in the study and 453 students participated. addition, students from each year of training participated
Participating students and faculty gave informed consent. in focus group discussions. There were five focus group
discussions conducted with each cohort of students. The
Conceptual framework and the instrument focus group discussions and interviews were held to gain
The Guglielmino’s self-directed learning readiness scale a better understanding of the participants’ definition of
(SDLRS) is a self-scoring instrument designed to assess at- SDL, factors facilitating and deterring SDL as well as
tributes supportive of SDL based on individual personality perceptions on culture and curriculum affecting SDL.
characteristics, values, attitudes and skills [17]. The instru- All focus groups and interviews were recorded and tran-
ment consists of a self-report questionnaire of 58 questions scribed. The transcriptions were analyzed by two of the
and is a common instrument used for assessing SDL readi- researchers for common themes.
ness [18]. It measures eight factors including creativity, love
of learning, initiative and independence in learning, Data analysis
openness to learning opportunities, informed acceptance of SPSS (Statistical Package for Social Sciences–Version 19,
responsibility to one’s own learning, self-concept as an Chicago, Illinois) was used for analysis. Descriptive stat-
effective learner, ability to use basic study and istical methods were used to summarize all study vari-
problem-solving skills and positive orientation to the future. ables. Analysis of variance (ANOVA) was used to test
The SDLRS utilizes a five-point Likert scale (1 = Almost the difference in mean SDLRS scores between years of
never true of me; I hardly ever feel this way; 5 = Almost al- training. The dependent variable was SDLRS scores and
ways true of me; there are very few times when I don’t feel years of training (defined categorically as 0 = at admis-
this way). Examples of the Likert statements include ‘I’m sion, 1 = end of 1st year, 2 = end of 2nd year, 3 = end of
looking forward to learning as long as I’m living‘, ‘I know 3rd year,4 = end of 4th year of training, 5 = Beginning of
what I want to learn‘, ‘when I see something that I don’t Internship) was used as independent variable. Post-hoc
understand, I stay away from it‘, ‘if there is something I analysis was performed using Bonferroni correction. Re-
want to learn, I can figure out a way to learn it’. The sults were presented as means with 95% confidence in-
scores range from 58 to 290, with an average adult score tervals. All results were analyzed using α = 0.05.
of 214 (±25.59) [17]. The scores are interpreted as 58 to The recorded interviews and focus group discussions
201 (below-average SDL readiness), 202 to 226 (average were transcribed (Additional file 1). The primary re-
SDL readiness), and 227 to 290 (above-average readiness). searcher and a content and qualitative expert independ-
The scores show that individuals present SDL readiness ently examined transcripts for common themes. Data
state with the ability to improve with appropriate educa- was analyzed via thematic analysis and repeated discus-
tional interventions (Guglielmino and Associates). The in- sions were held until the coders reached a consensus.
strument has a test–retest reliability of 0.829 and 0.79, a
Pearson split-half reliability estimate of 0.94, and a Cron-
bach alpha reliability coefficient of 0.87 [1]. As a result of Results
the extensive study of this instrument and usage in mul- There were more female students as compared to males
tiple studies, it is considered to be accurate and useful for (Table 1).
measuring SDL readiness.
Measurement of SDL
Participants All students were admitted into the college at about the
Prior to administration of the SDLRS (described above), same age (17–18 years). The overall mean SDLR score for
the study’s objective was explained, and the researchers medical students at CMC was 212.91 (Fig. 1). Data showed
followed the protocol for administration, as provided by that there was a significant drop in SDLR scores (p < 0.01)
the SDLRS developers to the participants. The instru-
ment was administered to six cohorts of students Table 1 Distribution of Participants
enrolled in the MBBS program (at admission, at the end SEX Freq. Percent
of 1st, 2nd, 3rd and 4th year of training, and at the Male 174 38.63
beginning of internship) (Additinal file 1). A total of 453
Female 258 56.95
students participated in the study but one student data
had to be discarded because this participant left many Missing 20 4.42
questions unanswered. The SDL scores obtained for 452 Total 452
students were analyzed. Missing = Gender data not entered
Premkumar et al. BMC Medical Education (2018) 18:134 Page 4 of 10

‘Understanding your own skill and abilities and

learning in a specific pattern that adapts to that’
(Batch 2015, at admission).

Faculty expressed their understanding of SDL in

multiple perspectives. Some faculty were of the opin-
ion that SDL should be initiated by instructors while
others noted that the student takes sole ownership of
the learning process, as expressed in the different def-
initions given:

‘SDL,...have a small discussion at the start of the topic

and certain areas we can cover and then give certain
Fig. 1 Box plot showing the mean SDLR score of all the areas they can go and learn and then come back and
medical students
have a discussion rather than direct lectures, and if it
is done in small groups it will be a better way’ (F3).
on comparing students at admission with those in medical
training (Table 2; Figs. 2 and 3). ‘Usually I would like students in India to get into this
The speed of decline appeared to decrease at latter form of SDL which according to me is students are
time points (Figs. 2 and 3). able to gather, secure information on their own and
also internally motivate to learn on their own and
Qualitative analysis have a desire for learning on their own cause ….In my
Qualitative data captured perceptions on the role of cul- definition, what it would encompass would be internal
ture and the curriculum on SDL from 5 student focus motivation, looking for resources on their own and
groups and 7 faculty interviews. having a desire to learn not being pushed by anybody,
the teacher or the parents’ (F4).
Perceptions of SDL
Definitions
There was general working knowledge of SDL across the Activities in curriculum and other factors that promote SDL
cohorts. The definition was more specific with students in Students indicated that when faculty explained a topic
more advanced years of study highlighting the key elements very well and promoted interactive sessions in class by
of SDL in their definitions compared to earlier years: asking questions, this motivated SDL because the students
sought to read more in order to close the knowledge gap
‘SDL is something that you can learn from, something identified. Similarly, if the faculty presented a new clinical
that is different, you are usually motivated to go back case or situation that is different, the student is more
and read up more about the subject and is not limited self-directed in studying. The Integrated Learning Pro-
to what your teacher tells you in that half an hour, or gram (ILP) [9] was repeatedly noted by both students and
one hour’ (Batch 2011, end of final year). faculty to promote SDL. As indicated in this statement:

‘It should also include, understanding your own ‘ILP…. it was an integrated program for the three
potential, how much you can learn, you should learn, subjects. We had a lot of experience there and
basically it is like time management’ (Batch 2014, end gathered more knowledge and that is when we realized
of first year). that we should go and read other books’ (Batch 2014).

Table 2 Mean SDLRS scores of student cohorts

Cohort n Mean SD Lower 95%CL for Mean Upper 95%CL for Mean
At admission 95 228.81 21.88 224.35 233.27
End of 1st Year 95 215.87 25.89 210.60 221.15
End of 2nd Year 79 211.64 27.23 205.50 217.78
End of 3rd Year 75 205.08 23.10 199.77 210.40
End of 4th Year 53 203.45 28.11 195.71 211.20
Beginning of Internship 56 202.11 31.86 193.57 210.64
Interpretation of scores: Low (58–176); below average (177–201); average (202–226); above average (227–251); high (252–290)
Premkumar et al. BMC Medical Education (2018) 18:134 Page 5 of 10

Fig. 2 Mean SDLR scores with 95% confidence intervals at admission, end of 1st, 2nd, 3rd and 4th year of training, and at the beginning of
Internship (Batch of 2015, 2014, 2013, 2012, 2011 & 2010 respectively based on year of admission)

Students in the advanced years of study identified on cases and clinical training were some learning activ-
practical case discussions, observation of doctors in clin- ities in the curriculum that supported SDL. As some in-
ical settings and clerkship (where students are posted in structors stated:
the clinical wards and are involved in patient care and
management from admission to discharge) as key fea- ‘Chart discussion, we make some charts on cases and
tures of the curriculum that promotes SDL because of problems. They will be given time to read about it and
the different mode of learning: find the answer themselves. Some mode of self-learning
happens there. But again, ultimately, we discuss in de-
‘SDL affects us more during clerkship - the clinical tail. But at least, it encourages them to read by them-
posting. We are fully involved in how the patient is selves’ (F1).
managed which is different from how we get to know
in lectures, reading topics than the usual exam Faculty also believed that interactive classes via stu-
oriented clinics’ (Batch 2011). dent led seminars, topic specific presentations by stu-
dents, tutorials and providing students with lecture
Faculty indicated that clerkship in clinical years (2nd to topics ahead of class promoted SDL. In addition, faculty
4th year), secondary hospital program, health education perceived that pre-tests and post-tests, assessments
message development, eLearning modules, discussions given at the end of class and Objective Structured

Fig. 3 Fit Plot from regression model showing mean SDLR score at admission, end of 1st, 2nd, 3rd and 4th year of training, and at the beginning
of Internship (Batch of 2015, 2014, 2013, 2012, 2011 & 2010 respectively based on year of admission)
Premkumar et al. BMC Medical Education (2018) 18:134 Page 6 of 10

Clinical Examinations motivated students to be ‘… we must also look at our culture, traditionally, if
self-directed. Awards for excellence in studies were also you see, you know when our students come into the
a motivating factor for SDL. college, they are a little more like kids, they are just
adolescents. Our students are still young, because they
Factors that deter SDL come in here 18, 17 years of age, so SDL to a large
Assessment was a key factor that both facilitated and de- extent should have to be pushed by us, though it is
terred SDL. Some students perceived that assessment can called SDL.’ (F4).
drive SDL only if it means something to the final exams.
However, others perceived assessments as a hindering factor Both faculty and students identified that the type of
to SDL. The curriculum is loaded with various activities tar- schooling/coaching before admission to medical college,
geted towards the various assessments which occur at fre- learning background and environment of the student in-
quent intervals of learning. Students are assessment-oriented fluences their way of studying. The way of learning
and as such, all learning is focused on acquiring skills and which students are used to is based on the traditional
knowledge that will enable them to excel in assessments. curriculum of direct learning. Hence, the students ex-
There is limited time set aside for SDL. Students considered pect to be ‘spoon–fed’, deterring SDL. Instructors also
that the frequency of tests was an SDL deterrent. In addition, stated that distractions due to modern technology and
faculty indicated that the current form of teaching is some- excess socializing are SDL deterrents.
times exam-oriented due to the rigid curriculum. This like-
wise influences instructors’ form of teaching in trying to Culture and SDL
achieve the required standard. There were mixed perceptions on the impact of parents,
culture and environment on education and SDL. Some
‘Because the curriculum demands, I mean for all of students indicated that their parents motivated them to
us, we just want to get through the exams, so if you study by being supportive and continuously checking on
are studying something else, then you might be their performance. Others were of the opinion that their
missing something that is important for your exams’ parents were more interested if they pass their exams and
(Batch 2012). not keen on their daily educational activities and gave the
students freedom to make their own studying choices:
Each week there is an exam…so it is also a
problem’ (F1). ‘Parents…..In school, they were like pushing us to
study. Now that we are in college we tend to call them
‘Regulations….They say that these are the topics that once or twice and then they tell us to study. But then I
have to be covered, these are the exams, these are the say, mamma I have things to do, they think we are
marks, we are told very clearly this is the case, these under too much pressure, so they don’t stress us too
are the exercises that we have to do, we have to much’ (Batch 2014).
concentrate to make sure that the students pass.’ (F3).
On the other hand, the faculty play the role of parents
Other factors that deterred SDL at times included not in prompting students to study. Faculty emphasized the
being adequately questioned during clerkship or class, influence of culture and family on SDL. Faculty indicated
hence reducing motivation for SDL. Too much of extra- that society and parents have a lot of influence on stu-
curricular activities for some students takes up time that dents’ learning. Parents motivate students to study in
could be used for SDL. Faculty similarly noted that as a various ways including waking the students up in the
result of the curriculum demands and extracurricular ac- morning to prepare for classes:
tivities, some students have insufficient time for SDL.
Also, faculty considered the age and state of maturity ‘I think the parents again have a lot of input into the
of students at admission to the college as a deterrent. Indian children’s life. I think we cannot get away from
Students are admitted into the college at a young age that and you know that is again part of our culture, so
and so some students are not mature to adequately mo- you see even to the extent of your mum still calling
tivate themselves to be self-directed in their study: you up in the first year, waking you up for the eight
o’clock class’ (F4).
‘They get in at 17, and are out by 22 as doctors. Many
of them are straight from high school. And therefore ‘So all parents want children to excel in their studies
the expectation from us also is sometimes too much. so actually, it is like, you go study in the morning, they
We expect them to be,... they are playful, they are pack their lunch, even the pencils in the box, sort of
children, they want to have their fun also.’ (F2). study, study, study’ (F6).
Premkumar et al. BMC Medical Education (2018) 18:134 Page 7 of 10

Students attended special coaching classes to train for The medical students’ SDLR score indicate average
the entrance exams into medical college. Faculty and self-direction. This study’s score was slightly lower than
students both indicated that the preparation for the en- similar studies carried out in Hawaii, USA (Mean SDLR =
trance exams is intensive and most students start attend- 235.68) and Saskatchewan, Canada (Mean SDLR = 230.6)
ing coaching classes as early as in their 9th grade. A few [1]. Nevertheless, the findings align with a similar longitu-
participants perceived that as a result of the intense dinal study [1] that found the students become less
studying for admission exams, few first year students are self-directed with medical training. Our findings were also
‘burnt-out’ and tired of studying on admission. similar to a study on SDLR of dental students which used
the same SDLRS instrument [19].This indicates that there
Suggestions to improve SDL is a decrease in SDLR of medical students during training
This study showed that students understand the import- irrespective of the type of curriculum. For instance, the
ance of being self-directed, however constraining factors curriculum in Hawaii is problem-based while that of
mentioned above limits them. Hence, key recommenda- Sasktchewan is more traditional. The curriculum in the
tions were primarily focused on self-management in re- Indian medical school is different from both the others.
spect to creating a balance of time and course workload,
as well as guidance on SDL. Students indicated that fac- SDLR and culture
ulty should make classes more engaging and interactive. Data shows the prominent role of culture and the learning
They also required direction in readings and orientation environment on SDL readiness. Students and faculty iden-
on what to expect and how to learn: tified similar curricular and cultural factors affecting SDL.
Students are influenced by their culture and learning en-
‘Personally I think in medicine, no one can teach vironment which subsequently sculpts their ability for
you everything, you have to learn on your own but SDL [20]. Differences in SDL readiness are strongly re-
the difficulty comes in the fact that... we have been lated to certain features of the country’s learning culture
conditioned in a way since childhood, we were [17]. Medical students may either adopt deep learning,
taught everything, and then suddenly, that is not wherein they are motivated to study due to the interest in
what you need and we don’t know what to do, so if the subject or its professional application, or students may
you need to make a change, actually that thing adopt surface learning, which associates with motivation
should happen then, because after 14 years and to study as a result of the desire to complete a course or
plus one year of this, it is kind of hard to change’ fear of failure [21]. The type of learning approach adopted,
(Batch 2013). impacts the SDLR of medical students. The learning cul-
ture in India shows that some students do not actively
In addition, students saw the value of using videos to seek information for themselves rather, they focus on
teach and more practical sessions and earlier contact learning with the goal to pass exams and achieve high
with patients. grades (collectivism) [22]. Shah et al. [21] showed that at
Faculty concurred that curriculum should provide stu- the completion of the first academic year, there is a pro-
dents with enough time to study. In addition, students gressive shift from deep to surface learning approach.
need to be orientated on SDL and SDL should be tried In India, students are also influenced to a greater ex-
in small groups first for better impact. They stated that tent by the power position of instructors. Thus, author-
peer learning and change in the assessments would also ity to impart information lies with the instructor who is
promote SDL. considered to have superior knowledge and students are
conditioned from childhood to accept what the in-
‘That is where the curriculum has to come in and you structor says rather than think for themselves [22]. The
have to give enough time’ (F2). perception of power is a key obstacle in most Asian stu-
dents which influences not only SDL readiness but also
communication and learning strategies adopted [15].
Discussion Nevertheless, contextual factors such as a traditional,
Measurement of SDL teacher-centred secondary education, and examination
The study showed that there was a reduction in the content not covered during learning sessions can inhibit
SDLR in students across different curriculum years from or enhance medical students’ SDL [15].
admission year to the final year of studies. Again, the Our results provide yet another perspective on SDL,
definition of SDL differed across the years with medical particularly the impact of culture and the type of prior
students in advanced years providing the key elements schooling students had before entering medical college
of SDL than in junior students thereby, showing varying in determining SDL readiness. The study by Choi and
understanding of SDL. colleagues [23] shows that due to the transition from
Premkumar et al. BMC Medical Education (2018) 18:134 Page 8 of 10

traditional high school education to PBL instruction, the SDLR and curriculum
students felt uncertain about their learning. Relation- In line with previous work, our study showed that cur-
ships between learning styles and student demographics riculum plays a major role in SDL and aligns with Towle
exist [24] but, El-Gilany and Abusaad [2] noted that al- and Cottrell [30] who indicated that SDL can be en-
though most students had high levels of SDLR, there hanced by providing students with explicit advance in-
was no significant difference with socio-demographics of formation about tasks, specific performance goals for
the students as well as their learning style. assignments, rewards for task completion, flexible time
that allows sufficient time for task completion, support
SDLR and gender for student learning such as personal tutors, feedback
Studies on the relationship between SDLR and gender are and appropriate summative assessment. Kohli and Dhali-
variable. Our study findings align with another study with wal [31] noted that mentoring of students by faculty and
first year MBBS students in India which showed that there peers, might improve the learning environment for stu-
was no significant difference among male and female stu- dents. Inability of students to cope with academic work-
dents [4]. Yuan et al. [25] also stated no difference in SDL load deters SDL suggesting that the curriculum needs a
readiness between male and female students. re-look in respect to course content and delivery.
Findings from a study of fifth year MBBS medical stu- Our study indicates that students require support for
dents in India showed that although there was a general SDL. Students need assistance to improve their
low SDLR among the MBBS students, male students self-management skills [32, 33] so as to take control over
had higher scores than females [7]. In contrast, Cadorin his or her own learning especially in respect to time, re-
et al. [26] found that females had higher SDLR scores. sources and learning strategies due to the packed curricu-
lum. Various strategies for SDL can be strengthened so that
SDLR and age students can improve on their SDL skills [34]. Saurabh and
Contrary to some western medical education such as in Agrawal [35] similarly stated that students require more
United States and Canada, obtaining a prior degree before case or problem-based studies, clinical orientations, innova-
admission into medical college is not a requirement in tive teaching programs group discussions and tutorials in
India. The age of admittance into the medical program in regular teaching so as to improve their performance in
Indian colleges is 17–20 years. Students are young and exams and to make them more self-directed.
with no prior higher education or work experience. The
SDLR scores of the Indian medical students were slightly Limitations of the study
lower than that of students in western medical schools. A few participants seem to have misinterpreted some
Similar to medical students in the west, the SDLR scores questions in the SDLR assessment tool, as revealed dur-
dropped as they got older and advanced in years at the ing the focus group discussions. Hence, although the in-
college. This was contrary to the findings of Klunklin et al. strument has been tested, validated and found reliable in
[27] where SDL readiness on nursing students, increased other countries, the SDLR score of these students may
with age, maturity, and as students progressed across a not reflect the true score. In addition, data used are
course. Similarly, a SDLR study with Chinese nursing stu- based on self-reports and students’ perceptions.
dents showed that students in higher years of study had
higher scores for SDLR than students in lower study years Conclusion
and postulates that maturity promotes developing Given the decline in SDLR between batches of students
self-directedness [25]. from admission year to the final year of studies and the
The students in this study are similar to the partici- importance of SDL in medicine, the current curriculum
pants in a study conducted by Shankar et al. [28] in may require an increase in learning activities that pro-
Nepal, wherein students were younger i.e. between 18 mote SDL. This study points out the need to address
and 19 years as compared to medical students in the medical students’ SDL skills and ways to build these
West; less independent, more dependent on family and skills. It also shows that curriculum, assessments and
teachers and less trained for SDL during their prior culture does impact SDL readiness.
medical college school years. The study showed that Didactic lectures, tutorials, and practical classes are
scores improved at the end of first year of learning but the common methods of teaching in most medical col-
significant improvement was seen only in leges of India [35]. In order to promote SDL, current
self-management scores. On the other hand, another teaching and learning strategies may need to be
study revealed no significant influence of age but first re-examined and modified. Faculty development plays
year students demonstrated lower levels of SDLR [29]. an important role in implementing such changes.
These findings suggest that age and maturity is a deter- The results of this study indicate that multiple factors
mining factor of SDL. play a role in SDLR of medical students. Further studies
Premkumar et al. BMC Medical Education (2018) 18:134 Page 9 of 10

that monitor SDLR in postgraduate medical education Received: 23 June 2017 Accepted: 30 May 2018
can provide insight into how medical training transforms
health professionals into lifelong learners.
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