title: The impact of students and curriculum on self-study during clinical training in medical school: a multilevel approach.
abstract: BACKGROUND
  In higher education, the focus has shifted from the acquisition of knowledge to learning objectives and skills. This means that, the majority of student learning time is spent independently working outside the classroom. Students take an active role in setting goals, deciding how to achieve them, and planning individual study time. Although extensive research has recognized the importance of curriculum and students' characteristics in time devoted to self-study, it is still unclear to what extent these variables affect time to study. Due to the growing reliance on self-directed learning in medical education, and in an attempt to elucidate this issue, this research aims to evaluate self-study time during clinical training and assess whether this is more influenced by the student or the curriculum.
  
  
  METHODS
  A questionnaire was given to 1220 medical students (43.3% of the enrolled students). The students were asked to indicate the average number of study hours per week beyond the time allocated to classes for each clerkship (rotation) attended. Variation and generalizability of students' self-study were estimated using linear mixed models.
  
  
  RESULTS
  Findings showed that the intrinsic differences within students were a greater source of variation in self-study time than differences within clerkships (56.0% vs. 6.9%). If the amount of self-study dedicated to an individual clerkship is to be determined, at least 32 students are needed to achieve acceptable reliability. However, this data with two clerkships per student can used to retrospectively measure the self-study reported by students in clinical training.
  
  
  CONCLUSIONS
  The findings suggest that, both, curriculum and student characteristics influence self-study in undergraduate clinical training. Indeed, students' characteristics play a significant role in time devoted to study. Further research should be undertaken to investigate students' characteristics that may predict self-study during undergraduate medical training.
authors.affiliation: Department of Simulation and Medical Education, Faculty of Medicine of the University of Porto, Al. Prof. Hernâni Monteiro, 4200-319, Porto, Portugal. joselina@med.up.pt.
authors.forename: J
authors.identifier: http://orcid.org/0000-0002-1854-1572
authors.initials: J
authors.lastname: Barbosa
authors.affiliation: Undergraduate Education Department, Institute of Biomedical Sciences Abel Salazar of the University of Porto, Porto, Portugal.
authors.forename: A
authors.initials: A
authors.lastname: Silva
authors.affiliation: Department of Simulation and Medical Education, Faculty of Medicine of the University of Porto, Porto, Portugal.
authors.forename: M A
authors.initials: MA
authors.lastname: Ferreira
authors.affiliation: Department of Simulation and Medical Education, Faculty of Medicine of the University of Porto, Porto, Portugal.
authors.forename: M
authors.initials: M
authors.lastname: Severo
mesh_terms: D001291:Attitude of Health Personnel; D002982:Clinical Clerkship / Q000379:methods* / Q000592:standards; D002983:Clinical Competence / Q000592:standards; D003479:Curriculum; D004501:Education, Medical / Q000379:methods* / Q000592:standards; D005180:Faculty, Medical; D005260:Female; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D007858:Learning; D008297:Male; D011174:Portugal; D013337:Students, Medical / Q000523:psychology* / Q000706:statistics & numerical data; D011795:Surveys and Questionnaires; D013663:Teaching; D013997:Time Factors; D016526:Workload
keywords: Clinical training; Curriculum design; Medical students; Self-directed learning; Self-study