Sample size
The sample size (N = 81) was calculated by considering the following assumptions: total student number (N = 103), the 95% confidence level, margin of error (d = 5%).
Ethical standards
We conducted this study under the condition that the information obtained would be used solely for this study, following the ICMJE requirements on privacy and informed consent from study participants and the Personal Information Protection Law in Japan. It is completely anonymized and cannot be used to identify individuals. Therefore, after consulting with the IRB in Shimane University Hospital, we omitted approval from the Ethical board. We also explained they were free to refuse to participate, their participation or refusal would be unknown to their instructors, and there would be no negative consequences to their standing in the program or university if they failed to participate.
Measures
In the questionnaire, we investigated respondents’ background factors and motivation. The background factors included age, gender, the experience of failing or waiting for the entrance examination, hometown, whether they gained entrance as part of a regional quota, whether they have parents who are medical professionals, scholarship and its classification on their entrance permission, extracurricular activities, smoking habits, average hours of sleep, breakfast habits, time spent working part-time during the week, what matters in daily life, concerns, and whether they have someone to talk to about their problems (Appendix 1).
We used the Academic Motivation Scale (AMS) to evaluate motivation, quantifying the extensively studied self-determination theory (SDT).5,8 The AMS is an SDT-based questionnaire developed in France to measure motivation. It was translated into English in 1992 and has been shown to be valid and appropriate.9 The AMS classifies motivation into three categories: Intrinsic Motivation (IM), Extrinsic Motivation (EM), and Amotivation.
IM refers to the pleasure or satisfaction one derives from working on an object for its own sake. IM can be further divided into three categories: IM-to know, IM-to accomplish, and IM-experience. IM-to know refers to the pleasure one feels in learning, exploring, or trying to understand something new. IM-to accomplish refers to the satisfaction one feels in trying to accomplish or create something. IM-experience describes the state of participating in an activity to experience the stimulating sensations that result from that activity.
EM is further divided into three categories: EM-identified, EM-introjected, and EM-externally regulated. EM-identified refers to the state in which people judge the value and importance of an object and choose it for themselves. In contrast, EM-introjected refers to the state in which people begin to internalize the object based on past experiences, and EM-externally regulated refers to the state in which the reason for doing something is externally controlled.
Unlike the above two types of motivation, amotivation is a state of not finding a connection between the target and one’s own behavior. The higher the value of amotivation, the less motivation one has for the issue at hand. These motivation elements are hierarchical in SDT, with amotivation being the most non-self-determined state, followed by EM-externally regulated, EM-introjected, EM-identified, and IM (Fig. 1).10 SDT states that IM and EM-identified positively affect academic performance and well-being, while high non-self-determined motivations, such as amotivation, have a negative impact.3
The AMS is divided into seven subscales (three IM, three EM, and one amotivation) as described above, which are evaluated with 28 question items. Four questions are assigned to each subscale in a random order, and each question is answered on a seven-point scale. The questions in the AMS translated into Japanese were used in this study. The translated Japanese questions were back-translated using Google Translate to ensure that the content was completely understandable (March 7, 2021). A reliability test of the AMS used in this study showed that it had a Cronbach’s alpha of 0.84, indicating that the results of this questionnaire were highly reliable.
Procedure
On May 8, 2019, the survey was administered before the liberal arts class on ethics and professionalism. The questionnaire was distributed to the class, and the students were informed that submitting the questionnaire was not mandatory and that the submission and their answers would have no effect on their grades. In addition, we explained that this was an anonymous survey and how to handle personal information.
We used response sheet card for the questionnaire and collected them after the class. The faculty of the academic affairs division used a read-only machine to scan the mark sheets. They sent personal information in the format of a .csv file without being linked to the analyst, and we analyzed the data. As described above, we were allowed to omit the Ethics Committee review because only participants whose consent could be obtained were included, anonymity was ensured, there were no particular harmful effects, and the content was within the scope of our daily educational work to improve medical education.
Data analysis
Chi-square tests or Fisher’s exact tests were used to compare nominal variables. For continuous variables, t-tests or Wilcoxon rank-sum tests were used as appropriate with Cohen’s d being used to estimate the effect size of score differences.11 For multiple logistic analysis, we incorporated several important factors that were likely to be significant (p < .10), and several items suggested to be important by previous studies, avoiding multicollinearity: gender, age, recommended admission, receiving a scholarship, parents are medical professionals, an absence of concerns, not having someone to talk to about one’s problems, and belonging to an athletic club. None of the variance inflation factor values exceeded 10, and the mean VIF of the model was less than 1.27. All analyses were performed using the Stata statistical software, version 14.0 (Stata Corp. 2015, Stata 14 Base Reference Manual). All tests were two-sided, with p < .05 being considered statistically significant.