The role of emotions in academic performance of undergraduate medical students: a systematic review

doi:10.21203/rs.3.rs-4047564/v1

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The role of emotions in academic performance of undergraduate medical students: a systematic review

https://doi.org/10.21203/rs.3.rs-4047564/v1

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published 23 Aug, 2024

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Background

This paper is devoted to a systematic review of the literature on emotions' role in academic performance in medicine. The review aims to examine the role emotions play in the academic performance of undergraduate medical students.

Methods

Eight electronic databases were used to search the literature from 2013 to 2023, including Academic Search Ultimate, British Education Index, CINAHL, Education Abstract, ERIC, Medline, APA Psych Articles and APA Psych Info. Using specific keywords and terms in the databases, 3,285,208 articles were found. After applying the predefined exclusion and inclusion criteria to include only medical students and academic performance as an outcome, 45 articles remained, and the quality of the retrieved literature was assessed by three reviewers, then Seventeen articles were selected for the narrative synthesis.

Result

The findings indicate that depression and anxiety are the most frequently reported variables in the reviewed literature, and they have negative and positive impacts on the academic performance of medical students. The included literature also reported that a high number of medical students experienced test anxiety during their study which affected their academic performance. Positive emotions lead to positive academic outcomes and vice versa. However, Feelings of shame did not have any effect on the academic performance of medical students.

Discussion

The review suggests a significant relationship between emotions and academic performance among undergraduate medical students. While the evidence may not establish causation, it underscores the importance of considering emotional factors in understanding student performance. However, reliance on cross-sectional studies and self-reported data may introduce recall bias. Future research should concentrate on developing anxiety reduction strategies and enhance mental wellbeing to improve academic performance

emotions

medical students

academic performance

Studying medicine is a multi-dimensional process; it involves acquiring medical knowledge, clinical skills and attitudes. Previous research has found that emotions play a significant role in this process (1). Different types of emotions are important in an academic context, and these emotions are linked to performance on assessments and evaluations, receiving feedback and exam scores and whether a student is satisfied with their learning experience. In particular, medical students experience a wide range of emotions compared to other students (2), due to many emotionally challenging situations such as experiencing a heavy academic workload, being in the highly competitive field of medicine, retaining a large amount of information, keeping track of a busy schedule, taking difficult exams and dealing with a fear of failure (3, 4). Especially during their clinical years, medical students may experience stress when they interact with patients who are suffering, ill or dying, and they must work with other healthcare professionals. Therefore, it is necessary to understand the impact of emotions on medical students to improve their academic outcomes (5).

According to the literature, 11–40% of medical students suffer from stress, depression and anxiety due to the intensity of medical school, and these negative emotions impact their academic achievement (6, 7). Severe anxiety may impair memory function, decrease concentration, lead to a state of hypervigilance, and interfere with judgment and cognitive function, further affecting academic performance (8). However, some studies have suggested that experiencing some level of anxiety has a positive effect and serves as motivation that can improve academic performance (8, 9).

Despite the importance of medical students’ emotions and their relation to academic performance, few studies have been conducted in this area, and most of them discussed the prevalence of specific emotions but did not mention solutions to improve medical students’ academic performance. There is no existing systematic review addressing the role of emotions in academic performance among undergraduate medical students.

Aim of the study

This review aims to examine the role emotions play in the academic performance of undergraduate medical students.

Research Question

This systematic review uses a population, intervention (or exposure), comparison and outcome (PICO) format to explore the research question, which is to determine the impact of negative and positive emotions, including anxiety, test anxiety, depression, hope, joy, and pride (Exposure), on academic performance, academic achievement, success or failure, test results, exam results, exam performances, or GPA among undergraduate medical students worldwide, within the timeframe of 2013–2023, as outlined by in the international standards for medical schools and institutions by the World Health Organization guidelines (2013) for health profession education. This review followed the PRISMA 2020 reporting guidelines.

Eligibility criteria

Inclusion Criteria

The study's scope was confined to the period from January 2013 to December 2023, focusing exclusively on undergraduate medical students. The research encompassed articles originating within medical schools worldwide, accepting content from all countries. The criteria included only full-text articles in English-language, published in peer-reviewed journals. All forms of primary research, irrespective of study type, were considered, embracing both quantitative and qualitative methodologies. To address the research question, the selected studies had to explicitly reference academic performance, test results, or GPA as key outcomes.

Exclusion Criteria

The study excluded individuals beyond the undergraduate medical student demographic, such as students in other health fields and junior doctors. There was no imposed age limit for the student participants. The research specifically focused on articles within medical schools, excluding those from alternative settings. It solely considered full-text articles in English-language peer-reviewed journals. Letters or commentary articles were excluded, and the study did not limit itself to a particular type of research and exclusion criteria involved articles related to factors impacting academic performance, as well as those analysing nursing students and gender differences. The reasons and numbers for excluding articles are shown in Table 1.

Information sources

Eight electronic databases were used to search the literature. These were the following: Academic Search Ultimate, British Education Index, CINAHL, Education Abstract, ERIC, Medline, APA Psych Articles and APA Psych Info. The databases were chosen from several fields and according to relevant topics including education, academic evaluation and assessment, medical education, psychology, mental health and medical research. Initially, with the help of a subject librarian, the researcher used all the above databases; the databases were searched with specific keywords and terms, and the terms were divided into the three following concepts emotions, academic performance and medical students. also, Google Scholar, EBSCOhost and the reference list of the retrieved articles were used to identify other relevant articles.

Search Strategy

This systematic review started with a search of the databases. Eight electronic databases were used to search the literature from 2013 to 2023. Specific keywords and terms were used to search the databases, resulting in 3,285,208 articles. After removing duplicates, letters and commentary, this number was reduced to 1,637 articles. Exclusion and inclusion criteria were then applied, resulting in 45 articles. After the literature was assessed by three assessors, 17 articles were selected for the systematic review. This review could not be registered in PROSPERO as there is no clinical intervention used.

Selection process

This systematic literature review attempts to gather only peer-reviewed journal articles published in English on undergraduate medical students’ negative and positive emotions, and academic performance from January 2013 to December 2023. Their emotions, including depression, anxiety, physiological distress, shame, test anxiety, happiness, joy and other emotions were searched in the quantitative research. This research also attempted to use qualitative methods to review studies on undergraduate medical students’ emotions and academic performance; however, only one such study was identified, and it used mixed methods.

Keywords: Emotion, Anxiety, Stress, empathy, academic emotion, test anxiety, exam anxiety, test stress, exam stress, depression, emotional Regulation, test scores, academic performance, grades, GPA, academic achievement, academic success, test result, assessment, undergraduate medical students and undergraduate medical education.

Emotions: TI (Emotion* OR Anxiety OR Stress OR empathy ) OR academic emotion* OR ( test anxiety or exam anxiety or test stress or exam stress )OR (depression ) OR AB ( ( Emotion* OR Anxiety OR Stress OR empathy ) OR academic emotion* OR ( test anxiety or exam anxiety or test stress or exam stress ) ) (MH "Emotions") OR (MH "Emotional Regulation") DE "EMOTIONS"

Academic performance: TI (test scores or academic performance or grades or GPA) OR (academic achievement or academic performance or academic success ) OR test result* OR assessment* ) OR AB ( test scores or academic performance or grades or GPA ) OR ( academic achievement or academic performance or academic success ) OR test result* OR assessment*

Medical Students: TI (undergraduate medical students OR undergraduate medical education) OR AB (undergraduate medical students OR undergraduate medical education), TI "medical students" OR AB "medical students" DE "Medical Students"

Moreover, to focus the search, the author specified and defined each keyword by using advanced search tools, such as subject headings in the case of the Medline database. The author used ‘MeSH 2023’ as the subject heading, then entered the term ‘Emotion’ and chose all the relevant meanings. This method was applied to most of the keywords.

Studies were included based on predefined criteria related to study design, participants, exposure, outcomes, and study types. Two independent reviewers screened each record and the report was retrieved. In the screening process, reviewers independently assessed each article against the inclusion criteria and discrepancies were resolved through consensus during regular team meetings. In cases of persistent disagreement, a third reviewer was consulted. Endnote library program was used for the initial screening phase. This tool was used to identify duplicates, facilitated the independent screening of titles and abstracts and helped to retrieve the full-text articles. The reasons for excluding the articles are presented in Table 1.

Data collection process

Two independent reviewers extracted data from the eligible studies, with any discrepancies resolved through discussion and consensus. If the two primary reviewers could not reach an agreement, a third reviewer served as an arbitrator. For each included study, the following information was extracted and recorded in a standardized database: first author name, publication year, study design, sample characteristics, details of the emotions exposed, outcome measures, and results.

Data items

Academic performance as an outcome for medical students was defined to include the following: Exam scores (e.g., midterm, final exams), Clinical assessments (e.g., practical exams, clinical rotations), Overall grade point average (GPA) or any other relevant indicators of academic achievement.

Data were sought for all outcomes, including all measures, time points, and analyses within each outcome domain. In cases where studies reported multiple measures or time points, all relevant data were extracted to provide a comprehensive overview of academic performance. If a study reported outcomes beyond the predefined domains, inclusion criteria were established to determine whether these additional outcomes would be included in the systematic review. This involved assessing relevance to the primary research question and alignment with the predefined outcome domains.

Quality Assessment

The quality and risk of bias in included studies were assessed using the National Institute of Health’s (NIH) critical appraisal tool. The tool evaluates studies based on the following domains: selection bias, performance bias, detection bias, attrition bias, reporting bias, and other biases. Two independent reviewers assessed the risk of bias in each included study. Reviewers worked collaboratively to reach a consensus on assessments. Discrepancies were resolved through discussion and consensus. In cases of persistent disagreement, a third reviewer was consulted.

To determine the validity of eligible articles, all the included articles were critically appraised, and bias was assessed by all reviewers. The validity and reliability of the results were assessed by using objective measurement. Each article was then given a score out of 14, with 14 indicating high-quality research and 1 indicating low-quality research. High-quality research, according to the NIH (2013), includes a clear and focused research question, defines the study population, features a high participation rate, mentions inclusion and exclusion criteria, uses clear and specific measurements, reports results in detail, lists the confounding factors and lists the implications for the local community. Therefore, an article was scored 14 if it met all criteria of the critical appraisal tool. Based on scoring, each study was classified into one of three quality categories: good, fair or poor. The poorly rated articles mean their findings were not reliable and they will not be taken into consideration. Quality assessment of the papers included in the systematic review is in the appendix. After critical appraisal using the NIH appraisal tool, 17 articles were chosen, as shown in Table 2.

Effect measures

For each outcome examined in the included studies, various effect measures were utilized to quantify the relationship between emotions and academic performance among undergraduate medical students. The effect measures commonly reported across the studies included prevalence ratios, correlation coefficients, and mean differences. And the studies that did not report the effect, the reviewer calculated the effect size. The choice of effect measure depended on the nature of the outcome variable and the statistical analysis conducted in each study. These measures were used to assess the strength and direction of the association between emotional factors and academic performance.

The synthesis method

The findings of individual studies were summarised to highlight crucial characteristics. Due to the predicted heterogeneity, the synthesis involved pooling effect estimates and using a narrative method. A narrative synthesis approach was employed in the synthesis of this systematic review to qualitatively assess and interpret the findings from the included studies. The narrative synthesis involved a qualitative examination of the content of each study, focusing on identifying common themes. This synthesis was employed to categorize and interpret data, allowing for a nuanced understanding of the synthesis. Themes related to emotions were identified and extracted for synthesis. Control-value theory was used as an overarching theory, providing a qualitative synthesis of the evidence and contributing to a deeper understanding of the research question. If the retrieved articles include other populations than medical such as dental students or non-medical students, the synthesis will distinguish between them and summarize the findings of the medical students only, highlighting any differences or similarities.

To consider if depression, anxiety and test anxiety are significantly harmful to medical students, The cut-off scores for depression, anxiety, and test anxiety can vary depending on the specific assessment tool used. Below are examples of commonly used scales and their cut-off scores.

Depression

The Beck Depression Inventory (BDI) typically categorizes scores more than 20 to 28 as moderate depression and more than 29 as severe depression.

Anxiety

Beck Anxiety Inventory (BAI) more than 16 to 25 is moderate Anxiety and more than 26 is severe Anxiety. While in Anxiety Sensitivity Index a score of 54 or above is considered high anxiety sensitivity.

Test Anxiety

Higher scores indicate higher levels of test anxiety. In Westside test anxiety, a score of more than 3.5 is considered high.

Data Extraction

For this step, a data extraction sheet was developed by using the data extraction template provided by the Cochrane Handbook. To ensure the review is evidence-based and bias-free, the Cochrane Handbook strongly suggests that more than one reviewer review the data. Therefore, one review author extracted the data from the included studies, and two additional reviewers checked the included, excluded and extracted data. Any disagreements were resolved via discussion among the three review authors. The data extraction table (Table 2) identified, all study features, including the author’s name, the year of publication of the study, the method used, the aim of the study, number and description of participants, data collection tools and study findings.

Table 1

The reasons and numbers for excluding articles
Main reason	No. of articles
Excluding any duplicates and letters and commentary	1592
Other Factors Affecting Academic Performance
Mentoring Emotional intelligence Studying habits Testing scales Conference papers Gender discrimination Environment Physiological factors (menses, sleep) Motivation Perfectionism Computer use Grading system Socioeconomic factors Only exam anxiety Math course Smoking Depression Patient safety Stress management Counselling Clerkship Quality of life Only Empathy OSCE/ Assessment tools Mindfulness Medication Mental health Communication skills Academic Engagement Compassion EEG Neuroimage Music Nursing students Junior doctors Not Medical Primary health care	3 20 10 19 3 5 13 22 5 3 5 4 6 1 1 9 7 1 5 1 1 12 7 6 11 3 7 3 5 1 1 2 3 20 1 3 1

Finalization of references and study characteristics

PRISMA sheet and the summary of final studies that have been used for the review

When the keywords and search terms related to emotions, as mentioned above, in the eight databases listed, 3,285,208 articles were retrieved. After using advanced search and subject headings, the number of articles increased to 3,352,371. Similarly, a search for the second keyword, ‘academic performance’ using all the advanced search tools, yielded 8,119,908 articles. Searching for the third keyword, ‘medical students’, yielded 145,757 articles. All terms were searched in article titles and abstracts. After that, the author combined all search terms by using ‘AND’ and applied the time limit from 2013 to 2022; the search narrowed to 2,570 articles. After duplicates, letters and commentary were excluded, the number was reduced to 1,637 articles. After reading the title and abstract to determine relevance to the topic and applying the exclusion and inclusion criteria mentioned above, 45 articles remained; after the quality of the retrieved literature was assessed by more than 3 examiners, 17 articles were selected for the systematic review. The PRISMA flow diagram summarizing the same is presented below. One article by Ansari et al, (2018) was selected for the review but it met most of the inclusion and exclusion criteria except that the outcome measure is cognitive function and not academic performance, therefore, It was excluded from the review. Figure 1 shows the Prisma flow diagram (2020) of studies identified from the databases.

Study characteristics

Table 2 summarizing the characteristics of the included studies is presented below.

Table 2

Study Characteristics Table
N	Author/ year	Country	Methodology	Aim	Population	Tools	Findings	Quality scoring
1	Aboalshamat (2015)	Saudi Arabia	Cross-section Study	To evaluate the psychological health of medical students and the relationship between psychological health and their academic success.	(n = 422) preclinical medical and dental students (2nd and 3rd year).	1. Depression Anxiety Stress Scale. 2. General Self-Efficacy Scale 3-Satisfaction with Life Scale. 3. Students’ academic weighted grades.	1-Depression is the only psychological predictor of academic performance. 2- η2 for the effect of depression on academic performance is 0.018 This value indicates that depression explains 1.8% of the variance in academic performance (Small effect size).	9/14 Good
2	Behrens (2019)	Chile/ South America	Mixed-method study.	1. Investigate achievement emotions and simulation-based learning. 2. Relationship between achievement emotions and medical students’ performance. 3. The effect of emotions on learning.	(n = 55) 6th-year medical students	1. Achievement Emotion Questionnaire 2. Observational ward round assessment tool. 3. Focus groups. 4. Simulation	1- Challenging simulations increase learning, motivation and success in medical students. 2-In the simulation, some students encountered shame, which appeared to be a potent external motivator for learning. However, the study found non-significant correlations between achievement emotions and performance.	13/14 Good
3	Ben-Loubir (2014)	Morocco	Cross-section	To investigate the association between test anxiety and academic skills.	(n = 275) Medical Students	1. Sociodemographic scale. 2. Test anxiety scale 3. Academic Skills Questionnaire.	Test anxiety is negatively correlated with academic abilities (r=-0.39) (Large effect size). .	8/14 Fair
4	Burr and Dallaghan (2019)	Nebraska/USA	Cross-section study	The relationship between achievement emotions, burnout, and academic performance?	(n = 264) 1st and 2nd-year medical students	1. Achievement Emotions. 2. The Maslach Burnout Inventory. 3. General Survey. 4-Academic performance (final overall percentage for the semester).	Correlation to academic performance: Professional efficacy(r = .57), Hope(r = .50), pride (r = .41), anxiety (r = .30) and shame (r =. 40) Professional efficacy was the most significant predictor of academic performance explaining 31.3% of the variance in academic performance.	8/14 Fair
5	Del-ben (2013)	Brazil	Cross-section	1. To assess academic motivation, anxiety, depression and social adjustment among first-year medical students 2. Determine the influence on their academic performance.	(n = 85) 1st-year medical students	1. Beck’s Anxiety and Beck’s Depression, 2. Social Adjustment Scale 3. The Academic Motivation Scale 4- GPA	There was no correlation between academic motivation, anxiety and depressive and social adjustment with academic achievement.	8/14 Fair
6	Dendle (2018)	Australia	one-year prospective cohort study	Examine the impacts of workplace and study-related stress factors on student’s psychological distress and their academic performance during their first clinical year.	(n = 126) 1st year medical students	1. Kessler psychological distress scale. 2. The General Health Questionnaire. 3. Sources of workplace stress. 4. Academic scores.	There was no correlation between the anxiety and academic performance.	9/14 Good
7	Green (2016)	Connecticut/ USA	Cross-section & RCT	1) Determine the relationship between test anxiety and performance on the (USMLE) exam. 2)Determine the impact of a test-taking strategies course on test anxiety and USMLE scores.	(n = 25) 2nd-year medical students before USLME step- 1.	1. Westside test anxiety 2. USMLE score. 3. Medical college admission test.	Test anxiety negatively correlated with USMLE step 1 (r= − 0.24). -A test-taking strategy course relatively reduced anxiety but did not increase test scores. - Anxiety may impair performance by interfering with attention to task-relevant information, accordingly, decreasing the cognitive resources available for task-processing.	10/14 Good
8	Hahn (2017)	Germany	Quantitative Explorative study.	To investigate the relationship between anxiety, depression and academic performance among medical students	(n = 200) Second-year medical students	1-Multiple Choice Vocabulary Intelligence Test. 2-State-Trait-Anxiety Inventory 3-Beck’s Depression Inventory II	1- Anxiety did not correlate with depressive symptoms or past or future academic achievement. 2- Depression did not correlate with academic performance.	5/10 Poor
9	Hautz (2017)	Swiss	RCT (Shame)	To further enhance the understanding of state shame and its influence on learning	(n = 49) 4th and 3rd medical students	Experimental shame scale. outcome assessed: number of lumps correctly documented during final performance assessment, time on task and OSCE score.	Students training with a standardised patient experienced more shame during training. Shame doesn’t have any effect on OSCE scores.	9/14 Good
10	Hayat (2018)	Iran	descriptive-correlative study	The role of medical students’ emotions and motivation in their academic achievement.	(n = 370) medical students.	1-Academic emotions Questionnaire. 2-Work preference inventory 3-Academic score.	1-Motivation (β = 0.56) and positive emotions (β = 0.11) increase medical students’ academic performance, explaining 40% of academic performance variance. 2-Negative emotions: anger, anxiety, hopelessness, shame, and boredom, were found to have a negative and significant correlation with the academic achievement of learners (r=-0.15, r = 0.24, r = 0.23, r=-0.215, and r=-0.21) (small effect).	9/14 Good
11	Kausar (2018)	Pakistan	Cross-section	To explore the effect of pre-exam stress levels of final-year medical students on their academic performance.	(n = 79) Students of final medical year.	Medical Student Stressors Questionnaire.	-Academic performance among medical students is enhanced by pre-exam stress x² = 23.52 (p = .00). (W = .78 large effect)	9/14 Good
12	Kim (2016)	Korea	Cross-section	Investigate the effect of test anxiety on OSCE among Medical students.	(n = 101) 3rd and 4th year medical students.	1-Korean Achievement Emotions Questionnaire.	- Test anxiety is moderately associated with achievement emotions in the class, which are: anxiety and boredom (r = 0.46 and 0.32, p < 0.00). Test anxiety is not significantly correlated with the OSCE scores (r = 0.09, p = 0.40), or with the GPAs (r = 0.09, p = 0.41). .	7/14 Fair
13	Junaid (2020)	Saudi Arabia	Analytical Cross section	Prevalence of anxiety and its effect on the academic performance among medical students.	(n = 247) medical students.	1-Beck Anxiety Inventory 2-GPA	Anxiety was high and negatively correlated with academic performance mean CGPA = 3.93, SD = 0.88, p = .00. Cohen's d = 1.1 (large effect size)	5/14 Poor
14	Mihailescu (2016)	Romania	Quantitative Cross-section	-Association between anxiety and depression and academic performance.	(n = 254) 1st and 2nd-year medical students	1-Zung Self-rating Anxiety scale. 2- Zung Self-rating Depression Scale. 3-GPA.	Depression and anxiety are negatively correlated with academic performance in medical students. (rho=-.14, p < 0.05), (rho=-.19, p < 0.05).	9/14 Good
15	Moreira (2018)	Portugal	Cross-section	Prevalence of anxiety and depression in Portuguese medical students compared to non-medical students.	Total (n = 750) students (n = 512) medical students and (n = 238) nonmedical students.	1-Socio-demographic survey. 2-Hospital Anxiety and Depression Scale (HADS).	-Depression is associated with poor academic performance but not statistically significant. Anxiety negatively significantly associated with the average curricular grade χ2 = 4.49; p < 0.00 (W = .76 large effect size)	7/14 Fair
16	Nazir et al (2021)	Pakistan	Cross-section	Assess test anxiety and its influencing factors on medical students.	(n = 680) medical students.	1-Test anxiety inventory.	There is a significant association between test anxiety and academic performance with excellent students exhibiting lower levels of test anxiety compared to those with lower academic grades. OR = 1.47 (95% CI:1.05, 2.06), P = .02.	5/14 Poor
17	Zalihic (2017)	Bosna and Hercegovina	Cross section	Examine the impact of anxiety sensitivity on the success of medical students	(n = 100) 1stand 5th-year medical students.	1-Anxiety Sensitivity Index.	Anxiety has a positive statistically significant on academic performance OR = 1.28 (95% CI: 1.16–1.51), p = .00	8/14 Fair

Findings of the study

Country of the study

Many of the studies were conducted in developing countries, with the majority being conducted in Europe (n = 4), followed by Pakistan (n = 2), then Saudi Arabia (n = 2), and the United States (n = 2). The rest of the studies were conducted in South America (n = 1), Morocco (n = 1), Brazil (n = 1), Australia (n = 1), Iran (n = 1), South Korea (n = 1) and Bosnia and Herzegovina (n = 1). No included studies were conducted in the United Kingdom.

Study design

In terms of study design, most of the included papers used a quantitative methodology, including 12 cross-sectional studies. Two randomised controlled trials, one descriptive correlation study and one cohort study, but only one study used mixed methodology.

Population and Study Setting

Regarding population and setting, most of the studies focused on all medical students studying in a medical school setting, from first-year medical students to those in their final year. One study compared medical students with non-medical students, and one study combined medical students with dental students.

Study aims

The study aims varied across the included studies. Seven studies examined the prevalence of depression and anxiety among medical students and their relation to academic performance. Four studies examined the relationship between test anxiety and academic performance in medical education. Four studies examined the relationship between medical students’ academic emotions and academic achievements. One study explored the influence of shame on medical students’ learning.

Study quality

The studies were assessed for quality using tools created by the NIH (2013) and then were divided into good, fair and poor based on these results. Nine of the studies had a high-quality methodology, seven studies achieved fair ratings and only three studies achieved poor ratings. The studies that were assigned the poor rating were mostly cross-sectional studies, and the areas of weakness were due to the study design, low response rate, inadequate reporting of the methodology and statistics, invalid tools, and unclear research goals.

Outcome measures

Most of the outcome measures were heterogenous and self-administered questionnaires, one study used focus groups and observation ward assessment (10). All the studies used the medical students’ academic grades.

Results of the study

The prevalence rate of psychological distress in the retrieved articles

Depression and anxiety are the most common forms of psychological distress examined concerning academic outcomes among medical students. Studies consistently show concerningly high rates, with prevalence estimates ranging from 7.3–66.4% for anxiety and 3.7–69% for depression. These findings indicate psychological distress levels characterised as moderate to high based on common cut-off thresholds have a clear detrimental impact on academic achievement (2, 8, 11, 12).

The studies collectively examine the impact of psychological factors on academic performance in medical education contexts, using a range of effect sizes to quantify their findings. Aboalshamat et al. identified a small effect size (η2 = 0.018) for depression's impact on academic performance, suggesting a modest influence. Mihailescu (2016) found a significant negative correlation between levels of anxiety/depression and academic performance and GPA among medical students. Burr and Beck Dallaghan reported professional efficacy explaining 31.3% of the variance in academic performance, indicating a significant effect size. However, Del-Ben et al. did not provide the significant impact of affective changes on academic achievement, suggesting trivial effect sizes for these factors.

In conclusion, anxiety and depression, both indicators of psychological discomfort, are common among medical students. Strong evidence links distress to poor academic performance results, implying that this relationship merits consideration. Table 3 below shows the specific value of depression and anxiety in retrieved articles.

Table 3: The score of depression and anxiety in the retrieved articles
Author	Scale used	Depression	Anxiety
Abolashamat et al. (2015)	Depression Anxiety Stress	69% (high)	66.4% (high)
Burr and Dallaghan (2019)	Beck anxiety	-	30%
Del-ben et al. (2013)	Beck's anxiety & depression	6.8 (low)	7.3 (mild)
Junaid et al., (2020)	Beck anxiety	-	49.4% (high)
Moreira et al. (2018)	Hospital Anxiety & depression Scale	3.7% (low)	21.5% (high)
Mihailescu et al. (2016)	Zung anxiety & depression	29% (low)	41% (low)
Zalihić et al. (2017)	Anxiety sensitivity index	-	30% (moderate)

Test anxiety

In this review, four studies examined the relationship between test anxiety and academic performance in medical education. The studies found high rates of test anxiety among medical students, ranging from 52% (13) to as high as 81.1% (14) Final year students tend to experience the highest test anxiety (14).

Test anxiety has a significant negative correlation with academic performance measures and grade point average (GPA) (13–15). Green et al., (2016) found that test anxiety was moderately negatively correlated with USMLE score (r= − 0.24, p = .00); high test anxiety was associated with low USMLE scores in the control group. further suggesting that anxiety can adversely affect performance. The findings that a test-taking strategy course reduced anxiety without improving test scores highlight the complex nature of anxiety's impact on performance.

Nazir et al., (2021) found that excellent students reported significantly lower test anxiety than those with low academic grades, with an odds ratio of 1.47, indicating that students with higher test anxiety are more likely to have lower academic grades. Kim's (2016) research shows moderate correlations between test anxiety and negative achievement emotions such as anxiety and boredom, but interestingly, this anxiety does not significantly affect practical exam scores (OSCE) or GPAs. However, one study by Kausar (2018) found that examination stress enhanced academic performance with a large effect size (W = 0.78), with stress levels at 47.4% among their sample, suggesting that a certain level of stress before exams may be beneficial.

Shame

Three papers explored the effect of shame on the academic achievement of medical students. Hayat et. al, (2018) reported that academic feelings like shame, significantly depend on the academic year. shame was found to have a small negative and significant correlation with the academic achievement of learners (r=-0.15). One study found that some medical students felt shame during simulations-based education examinations because they had made incorrect decisions, which decreased their self-esteem and motivation to learn. However, others who felt shame were motivated to study harder to avoid repeating the same mistakes (10).

Hauts (2017) study was conducted to examine how shame affects medical student’s learning using a randomised controlled trial where researchers divided the students into two groups: one group performed a breast examination on mannequins and the other group, on real patients. The results showed that students who performed the clinical examination on real patients experienced significantly higher levels of shame but performed better in examinations than in the mannequin group. In the final assessments on standardised patients, both groups performed equally well. Therefore, shame decreased with more clinical practice, but shame did not have significant statistics related to learning or performance. Similarly, Burr and Dallaghan (2019) reported that the shame level of medical students was (40%) but had no association with academic performance.

Academic emotions and medical students.

Three articles discussed the academic emotions and academic performance of medical students (2, 10, 16). Burr and Dallaghan (2019) examine the relationship between academic success and emotions in medical students such as pride, hope, worry, and shame. It emphasises the links between academic accomplishment and professional efficacy, as well as hope, pride, worry, and shame. Professional efficacy was the most significant predictor of academic performance explaining 31.3% of the variance in academic performance. The importance of emotions on understanding, processing of data, recall of memories, and cognitive burden is emphasised throughout the research. To improve academic achievement, efforts should be made to increase student self-efficacy.

Hayat (2018) found that positive emotions and intrinsic motivation are highly connected with academic achievement, although academic emotions fluctuate between educational levels but not between genders. The correlations between negative emotions and academic achievement, ranging from − 0.15 to -0.24 for different emotions, suggest small but statistically significant negative effects.

Beheren et. al, (2019) discovered that students felt a variety of emotions during the simulation, with a focus on positive emotions and moderate amounts of anxiety. However, no significant relationships were found between positive emotions and the student's performance during the simulation.

This systematic review aims to investigate the role of emotions in the academic performance of undergraduate medical students. Because of the heterogeneity of the data collection tools and different research designs, meta-analysis cannot be used (17). Therefore, narrative synthesis was adopted in this chapter. The studies are grouped into four categories as follows: 1) The effect of depression and anxiety on academic performance, 2) Test anxiety and academic achievement, 3) Shame and academic performance, and 4) Academic emotions and medical students. The control-value theory (18) will be used to interpret the findings.

The effect of depression and anxiety on academic performance

According to the retrieved research, depression and anxiety can have both a negative and a positive impact on the academic performance of medical students. Severe anxiety may impair memory function, decrease concentration, lead to a state of hypervigilance, interfere with judgment and cognitive function, and further affect academic performance (3). Most of the retrieved articles found that anxiety and depression were associated with low academic performance (2, 8, 11, 12). Moreira (2018) and Mihailescu (2016) found that higher depression levels were associated with more failed courses and a lower GPA, but they did not find any association between anxiety level and academic performance.

By contrast, some studies have suggested that experiencing some level of anxiety reinforces students’ motivation to improve their academic performance (8, 19). Zalihic et al. (2017) conducted a study to investigate anxiety sensitivity about academic success and noticed a positive relationship between anxiety level and high academic scores; they justified this because, when medical students feel anxious, they tend to prepare and study more, and they desire to achieve better scores and fulfil social expectations. Similarly, Jamil et al study (2022) found anxiety has a negative impact on academic performance when excessive and a positive effect when manageable, in which case it encourages medical students and motivates them to achieve higher scores.

In the wider literature, the impact of anxiety on academic performance has contradictory research findings. While some studies suggest that having some level of anxiety can boost students' motivation to improve their academic performance, other research has shown that anxiety has a negative impact on their academic success (20, 21).

Test Anxiety and Academic Achievement

The majority of the studies reviewed confirm that test anxiety negatively affects academic performance (13–15). Several research have found a significant correlation between test anxiety and academic achievement, indicating that higher levels of test anxiety are associated with lower exam scores and lower academic performance (22, 23). For example, Green et al. (2016) RCT study found that test anxiety has a moderately significant negative correlation with USMLE score. They found that medical students who took the test-taking strategy course had lower levels of test anxiety than the control group, and their test anxiety scores after the exam had improved from the baseline. Although their test anxiety improved after taking the course, there was no significant difference in the exam scores between students who had and had not taken the course. Therefore, the intervention they used was not effective. According to the control-value theory, this intervention can be improved if they design an emotionally effective learning environment, clear instructional design, foster self-regulation of negative emotions, and teach students emotion-oriented regulation (18).

Additionally, according to this theory, students who perceive exams as difficult are more likely to experience test anxiety because test anxiety results from a student’s negative appraisal of the task and outcome values, leading to a reduction in their performance. This aligns with Kim’s (2016) study, which found that students who believed that the OSCE was a difficult exam experienced test anxiety more than other students (18, 24).

In the wider literature, the British Psychology Society (2022) reported that higher test anxiety was associated with poorer performance on a final exam. They conducted a longitudinal study on students' knowledge levels during a semester before the exam and discovered that test anxiety was associated with lower performance on mock exams. Moreover, Song et al. (2021) experimental study examined the effects of test anxiety on working memory capacity and found that test anxiety negatively predicts academic performance. Therefore, the evidence from Song’s study suggests that there is a small but significant size effect of anxiety on working memory capacity. However, another cross-sectional study revealed that test anxiety in medical students had no significant effect on exam performance (25). The complexities of this relationship necessitate additional investigation. Since the retrieved articles are from different countries, it is critical to recognise the possible impact of cultural differences on the impact of test anxiety. Cultural factors such as different educational systems, assessment tools and societal expectations may lead to variances in test anxiety experience and expression across diverse communities (26, 27).

Shame and academic performance

The systematic review examined three studies that discuss the impact of feelings of shame on academic performance (2, 9, 10). Generally, shame is considered a negative emotion which involves self-reflection and self-evaluation, and it leads to rumination and self-condemnation (28). Intimate examinations conducted by medical students can induce feelings of shame, affecting their ability to communicate with patients and their clinical decisions. Shame can increase the avoidance of intimate physical examinations and also encourage clinical practice (2, 9, 10).

One study found that some medical students felt shame during simulations-based education examinations because they had made incorrect decisions, which decreased their self-esteem and motivation to learn. However, others who felt shame were motivated to study harder to avoid repeating the same mistakes (10). Shame was decreased with more clinical practice, but shame did not affect their learning or performance (9). The existing literature regarding how shame affects medical students’ learning is inconclusive (29).

In the wider literature, shame is considered maladaptive, leading to dysfunctional behaviour, encouraging withdrawal and avoidance of events and inhibiting social interaction, but few studies have been conducted on shame in the medical field. Therefore, more research is needed to investigate the role of shame in medical students’ academic performance (28).

Academic emotions and medical students.

The literature review focused on three studies that examined the relationship between academic emotions and the academic achievements of medical students (2, 10, 16). Academic emotions refer to the emotions that are associated with academic outcomes(16).

Behren's (2019) mixed-method study on the achievement emotions of medical students during simulations, found that placing students in challenging clinical cases that they can handle raises positive emotions. These emotions were perceived by students as a positive drive for learning, while mild anxiety was considered beneficial for learning. However, the study also found non-significant correlations between emotions and performance during the simulation, indicating a complex relationship between emotions and academic performance. The results revealed that feelings of frustration were perceived to reduce students' interest and motivation for studying, hampered their decision-making process, and negatively affected their self-esteem, which is consistent with the academic achievement emotions literature where negative emotions are associated with poor intrinsic motivation and reduced the ability to learn (30).

The reviewed research reveals a positive correlation between positive emotions and academic performance and a negative correlation between negative emotions and academic performance. These findings align with the control–value theory (18), which suggests that positive emotions facilitate learning through mediating factors including cognitive learning strategies such as strategic thinking, critical thinking and problem-solving and metacognitive learning strategies such as monitoring, regulating, and planning and students’ intrinsic and extrinsic motivation. Additionally, several studies found that extrinsic motivation from the educational environment and the application of cognitive and emotional strategies improve students’ ability to learn and consequently their academic performance (2, 10, 16). By contrast, negative emotions negatively affect academic performance. This is because negative emotions reduce students’ motivation, ability to focus, and ability to process information (2, 10, 16).

Limitations of the study

This systematic review aims to thoroughly investigate the relationship between emotions and academic performance in undergraduate medical students, but it has inherent limitations. Overall, the methodological quality of the retrieved studies is mostly good and fair. They demonstrated strengths in sampling techniques and data collection. However, other drawbacks were discovered, most notably the need for a more causal relationship, which is inherent in the design of cross-sectional studies. Furthermore, given the reliance on self-reported data, there were concerns about potential recall bias. These methodological difficulties were noted in all of the examined research. When contemplating the implications for practice and future study, the impact of these limitations on the validity of the data should be acknowledged.

The limitation of the review process and the inclusion criteria restricted the study to articles published from January 2013 to December 2023, potentially overlooking relevant research conducted beyond this timeframe. Additionally, the exclusive focus on undergraduate medical students may constrain the applicability of findings to other health fields or educational levels.

Moreover, the exclusion of non-English language articles and those not published in peer-reviewed journals introduces potential language and publication biases. The reliance on electronic databases and specific keywords may inadvertently omit studies using different terms or indexing. While the search strategy is meticulous, it might not cover every relevant study due to variations in indexing and database coverage. However, the involvement of three assessors for study screening, selection, data extraction and quality assessment improved the robustness of the review and ensured that the review included all the relevant research.

In conclusion, these limitations highlight the need for careful interpretation of the study's findings and stress the importance of future research addressing these constraints to offer a more comprehensive understanding of the nuanced relationship between emotions and academic performance in undergraduate medical education.

The systematic review exposes the widespread prevalence of depression, anxiety and test anxiety within the medical student population. The impact on academic performance is intricate, showcasing evidence of both adverse and favourable correlations. Addressing the mental health challenges of medical students necessitates tailored interventions for enhancing mental well-being in medical education. Also, effective interventions targeting these multifaceted factors are essential to address test anxiety. Future research should concentrate on developing anxiety reduction strategies to improve academic performance, aligning with the control-value theory's emphasis on fostering an emotionally supportive learning environment and there is a need to investigate cultural variations to better inform solutions and support systems that are suited to specific cultural situations.

The impact of shame on academic performance in medical students was inconclusive. Shame, characterized as a negative emotion and its influence on learning outcomes is intricate. The inadequacy of current literature emphasizes the imperative for additional research to unravel the nuanced role of shame in the academic journeys of medical students.

Overall, academic emotions play a crucial role in shaping students’ academic performance and research has attempted to find solutions to improve medical students’ learning experiences; thus, it is recommended that medical schools revise their curricula and consider using simulation-based learning in their instructional designs to enhance learning and improve students’ emotions. Also, studies have suggested the use of academic coaching to help students achieve their goals, change their learning styles, and apply self-testing and simple rehearsal of the material. Moreover, the findings suggested improving medical students’ critical thinking, and autonomy and changing teaching styles to better support students.

Ethics Approval

Not applicable.

Consent to Participate

Not applicable.

Data Availability

Data sharing does not apply to this paper as no datasets were generated or analysed during the current study. all included articles in the systematic review are mentioned in the manuscript, the quality assessment of included articles is located in the supplementary materials file no.1.

Competing Interests

The authors declare that they have no competing interests.

Funding

This research received no specific grant from any funding agency in the public or commercial.

Authors' Contributions

NA made substantial contributions throughout the systematic review process and was actively involved in writing and revising the manuscript. NA's responsible for the design of the study, through the acquisition, analysis, and interpretation of data, to the drafting and substantive revision of the manuscript. NA has approved the submitted version and is personally accountable for her contributions, ensuring the accuracy and integrity of the work.

IF was instrumental in screening the literature, extracting data, and conducting the quality assessment of the included studies. Additionally, IF played a crucial role in revising the results and discussion sections of the manuscript, ensuring that the interpretation of data was both accurate and insightful. IF has approved the submitted version and has agreed to be personally accountable for his contributions, particularly in terms of the accuracy and integrity of the parts of the work he was directly involved in.

SG contributed significantly to the selection of papers and data extraction, demonstrating critical expertise in resolving disagreements among authors. SG's involvement was crucial in revising the entire content of the manuscript, enhancing its coherence and alignment with the study's objectives. SG has also approved the submitted version and is personally accountable for his contributions, committed to upholding the integrity of the entire work.

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No competing interests reported.

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The role of emotions in academic performance of undergraduate medical students: a systematic review

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