The perspectives of undergraduate medical students in mainland China towards adaptive learning within exam-oriented medical education: a phenomenological analysis

The perspectives of undergraduate medical students in mainland China towards adaptive learning within exam-oriented medical education: a phenomenological analysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The perspectives of undergraduate medical students in mainland China towards adaptive learning within exam-oriented medical education: a phenomenological analysis Hanying Liu, Guiyang Chen, Jie Peng, Xing Liu, Ge Lan, Huiyin Deng, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7361555/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Backgrounds: Rapid development in technology led to the growing prevalence of adaptive learning in mainland China. The role of adaptive learning in university settings became more pronounced as a result of the pandemic. Aims: Undergraduate medical education in Chinese universities is characterized by exam-oriented approaches. Perspectives towards adaptive learning within this setting remain underexplored. The insights would better inform the direction of contemporary reforms in Chinese medical education. Sample: 7 fourth-year undergraduate students from a mix of rural and urban backgrounds participated. Methods: An interpretative phenomenological analysis (IPA) was conducted in the mainland Chinese University of Guangzhou. After gaining ethics approval, individual semi-structured interviews were conducted with each student, and the interview transcripts were analyzed. Through structural analysis, an analytic account that synthesizes their lived experiences into group experiential themes was produced and integrated into discussion. Results: Most participants responded positively to the role of adaptive learning in their education, although some expressed concerns over its misuse and effects on learning habits. Participants viewed adaptive learning as an effective modern aid to improved learning outcomes. Conclusions: Adaptive learning is the favored learning approach by undergraduate medical students to address pressures within exam-oriented settings. Multiple factors play into the effectiveness of adaptive learning. Whereas industrious learners combine adaptive learning with conventional learning practices, the presence of adaptive learning technology leads to metacognitive laziness and academic procrastination for less intrinsically motivated students. Adaptive learning Medical education Phenomenology IPA Figures Figure 1 Figure 2 Introduction The advent of adaptive learning in medical and health sciences education has fostered heightened interest in personalizing learning experiences and redirecting focuses onto learner-aware learning for medical students[ 1 ]. This popularization of technology-enhanced learning is inseparable from the rapid development of technological infrastructure in recent decades in the form of ease of internet access and prevalence of digital devices[ 2 , 3 ]. Specifically, the expanding role of China as a forerunner in digital technology indicates the continued relevance of the country in the research of adaptive learning, contributing more than 40% of concurrent literature in this field [ 4 ]. Moreover, the country harbors the largest medical education system in the world, which includes 192 listed higher education institutions providing clinical medicine education and over 1.7 million medical students enrolled in 2021[ 5 ]. At the same time, theoretical and technological advancements have yet to fully translate into a consistently high-quality medical education for Chinese medical students[ 6 ]. While recent research highlighted the positive effect that Covid-19 had had on the public attention towards adaptive learning in China, these studies seldom address and contextualize challenges within indigenous perspectives using the phenomenological lens. In an age of digital learning, both the standards by which academic performance is measured and the approaches that students take to meet these criteria are in need of reform[ 7 ] These reforms have in mind the goal of producing medical personnel with socio-emotional competency and professional skills needed to accommodate growing medical demands[ 8 ]. Talent cultivation forms a crux of the “Healthy China 2030” scheme that is currently viewed as the most important national health policy in mainland China[ 9 ]. Academic progression in the medical field of China consists of several different programs with distinct paths during postgraduate education[ 10 ]. At the same time, undergraduate medical education remains homogeneous and fundamental to professional medical careers. The emphasis on academic performance has been the cornerstone tenet for Chinese medical education in its goal of cultivating physicians consistent with the developing nation’s rising healthcare demands[ 11 ]. Moreover, the mainland Chinese undergraduate medical education is characterized by an exam-oriented teaching design that emphasizes on summative assessments to evaluate academic achievements [ 12 , 13 ]. The dominance of instructional design that focuses exclusively on examinations creates a particular paradigm for students to interact with adaptive learning. Adaptive learning has been shown to have a positive impact on the performance of mainland Chinese students in standardized competence examinations. Meanwhile, the learner-focused approach upheld by adaptive learning may bring into discussion the prospect of formative assessment to supplant the existing measures[ 14 ]. Medical students’ own perspectives towards curricula standards play a defining role in navigating both the effectiveness of adaptive learning in the current educational climate and the conditions for change. The outbreak of Covid-19 has assisted experimentations into adaptive learning experiences amongst mainland Chinese university students[ 15 ]. E-learning and remote teaching became the educational norms as a result of the pandemic and mainland China’s lockdown policies[ 16 , 17 ]. The development of tools for distance education, in turn, contributed to the propagation of adaptive learning approaches. This transformation is mirrored globally as the pedagogy and students come to accustom themselves to the new normal of learning management[ 18 ]. Exploring student experiences of adaptive learning has value beyond this particular context, as the maturing of generative artificial intelligence ushered in more accessible technologies for widespread implementation of adaptive learning. Better understanding of the perspectives that Chinese undergraduate medical students have towards the current exam-oriented medical education in light of adaptive learning opportunities may inform benefits and challenges on the side of the learners. This knowledge may in turn contribute to a more effective reform at personalizing learning experiences in Chinese medical educational institutes and ultimately improve the quality of clinical services to meet the rising expectations of the Chinese population. Study aim This constructivist study aims to explore Chinese undergraduate medical students’ experiences and perspectives of adaptive learning vis-à-vis standardized exam environments in contemporary Chinese medical education. Methodology Ethics Interviews were anonymized prior to analysis, and the study used pseudonyms to report its results. All participants provided written consent for data collection, data analysis, and the publication of said anonymized results. Participants were guaranteed protection of their privacy and retraction of their information from the research at any time without needing justification. Study design Embracing a constructivist view of the medical pedagogy and learning process, the study employs interpretative phenomenological analysis (IPA) as its methodological approach to develop understandings of learners’ perspectives with an idiographic focus[19]. The phenomenological aspects of IPA find their roots in Husserl and Heidegger’s thinking, which separately afforded the emphasis on lived experience through Husserlian transcendentalism and the hermeneutic approach rooted in Heideggerian philosophy[20]. The approach carries out an inquiry into the formative processes of learners’ experiences while positing these processes within the particular context to establish an exhaustive and systematic analysis. IPA is a widely adopted qualitative method to explore under-researched topics that involves themes of the self and meaning-making activities of the participants[21]. The subjective epistemological implications of IPA encourage a spiraling approach that engages the researcher in a back-and-forth interaction with the subject and their own preconceptions. IPA usually predicates that these subjective preconditions cannot be completely filtered via bracketing measures[22,23]. A reflexive approach is therefore suggested to add weight and credibility to the interpretations[24]. This study thus calls for a double hermeneutic approach that retains the agency of the researcher by enabling them to interpret their own interpretations. In this study, the author is a Chinese national who has prior experiences with adaptive learning under the same environment of medical education as the participants of this study in a mainland Chinese higher education institute in the past. Reflexive notes were made available after each interview, and the study assesses its data from different levels that acknowledge and honor the role of the researcher. Throughout the hermeneutic cycle, the study prioritizes the goal of making sense of the participants’ psychological reality. Context This study is conducted in the context of the aforementioned 5-year bachelor’s degree at the University of Guangzhou in the Guangdong province of mainland China. During their academic years, medical students spend between eleven to fourteen days receiving twelve examinations on a broad range of topics that cover most clinical areas, including pediatrics and obstetrics. Given that semester schedules do not leave extended vacancy between class teaching and end-of-year examinations, medical students frequently employ adaptive learning approaches such as apps and AI models to detect and fill in missing gaps of knowledge. Recruitment IPA prescribes a small sample size with participants with reasonably homogeneous qualities constrained by inclusion criteria. This demands a purposive sampling strategy with which the study recruited seven fourth-year University of Guangzhou medical students between July and September 2024. This timeframe was chosen because it was between the end of the final examinations and the beginning of the new semester. The sampling occurred by means of information about a screening meeting distributed with help from the university administration office via email and group chat to all medical students who have studied for and attended their required examinations with plans to proceed with a career in medical fields or related areas. The author provided the cohort of attendees to the screening meeting with more detailed, written information on the research. A brief Q&A session was hosted to answer any further questions. Students who have expressed explicit interests were then screened through a brief survey to confirm their applicability to this study. Data Collection Following successful screening, the author conducted a series of separate interviews with each individual participant apropos of their experiences of adaptive learning in their current academic environment and perspectives towards adaptive learning at large. Three of the interviews were conducted in person, and the other four were conducted via video due to participant preferences. Interviews are semi-structured, and a pre-written interview guide was set up to provide some open-ended, topic-related questions to help the conversation flow. During the interviews, the author encouraged individual participants to voice their thoughts openly and steer the conversation to areas that concern them the most personally. The more flexible design of interview schedules in semi-structured interviews allowed participants to traverse topics of their interest at greater depths. The author only intervenes to keep the dialogue loosely within the scope of the research questions and relevant literature. The first part of the interviews focused on Chinese medical students’ experiences with adaptive learning, in particular with respect to the final examinations that they had recently completed at the time of the interview. The second part delved into their perspectives towards the role of adaptive learning in mainland Chinese medical education. The author personally supervised all interviews. Interviews lasted between an hour and an hour and a half. These were digitally recorded, anonymized, and subsequently transcribed verbatim. Data was stored confidentially. Participants received transcripts of their own interviews to check for accuracy. The author also enclosed with the transcripts an email explaining the data privacy policy and contact addresses for any follow-up questions or comments. The author also guarantees access to resources if welfare support is needed. Data Analysis The study utilized a four-phase program of interpretative phenomenological analysis on the transcribed data described by Smith et al. and widely endorsed by peer research (Fig. 1). Completing this program for all interviews yielded a set of Group Experiential Themes (GETs), which were then fleshed out into an analytic summary supported by quotes from individual participants[21,22]. Whereas the program was conducted on the original transcripts in Chinese, the quotes were translated into English for the sake of clarity. The process of translation and a full account of the research steps taken were recorded and stored for future replication of this study. To strengthen the credibility of the analytical approach, the research steps and the summary of themes were submitted to an unaffiliated researcher with no vested interest for review and audit. This was also done with several academic medical peers to ensure accuracy of representation and sufficient basis for grounding the themes in the transcripts. Enactment of Epoche and Bracketing The initiation of epoche in this study involved a structured and sustained effort by the primary researchers to identify preconceptions concerning adaptive learning and the pressures of Chinese medical education[25]. This was treated as an ongoing iterative process. Initial Phase of Preconception Logging Prior to participant interaction, the researchers undertook autobiographical exercises. This involved documenting specific personal experiences within the Chinese medical education system and explicitly noting prior encounters with exam-oriented pedagogy. For instance, specific anxieties remembered from personal examination periods and assumptions about student motivations were cataloged. This inventory of preconceptions was formally recorded and served as a reference document for the reflexive process throughout the research. Bracketing during Data Collection and Analysis: Entries were made in the reflexive journal following each of the seven interviews and during each phase of data analysis for each transcript. These entries were structured to capture: 1. Observational Notes: Details of the interview setting, participant demeanor, and non-verbal cues. 2. Methodological Notes: Effectiveness of specific prompts or moments where the researchers consciously rephrased questions 3. Emotional Reactions: The researchers documented any feelings evoked by the participant's narrative. 4. Preliminary Interpretive Thoughts: Initial patterns were noted with a key addendum: these were flagged as requiring grounding in further data. These tentative notes were regularly reviewed and compared against the initial preconception log to identify any consistent biases shaping early interpretations. Operationalizing the Double Hermeneutic for Bracketing: The researchers consciously engaged in the double hermeneutic by understanding the participant's sense-making of their experience. During the transcription and initial coding phases, the focus was on the participants’ dialogues and their immediate context. The researchers made deliberate efforts to use the latter’s own language in initial codes and thematic descriptions as much as possible before moving to more abstract analytical labels. Peer Debriefing and External Audit of Reflexivity: The impromptu session with unaffiliated researchers served as an external bracketing mechanism. In this session, the researchers presented anonymized excerpts of their reflexive journal and preliminary interpretations. Colleagues were asked to challenge the researchers on how their stated background and beliefs might be influencing the framing of emergent themes. This dialogue provided an external perspective that helped to uncover subtle biases and reinforce the commitment to representing the participants' experiences authentically. Process of Phenomenological Reduction The phenomenological reduction process in this study involved a systematic engagement with the interview data operationalized through the four-phase program of IPA. Phase 1: Deep Immersion and Initial Engagement with Transcripts: Each of the seven interview transcripts was first read multiple times in its original language to gain a sense of the participant's unique account. Simultaneously, the audio recordings were listened to repeatedly alongside the transcript. This dual engagement helped capture nuances of tone, emotional expression, hesitations, and emphasis that text alone might not fully convey. During this phase, the researchers made open-ended memos for each transcript that noted overall impressions and the perceived emotional arc of the interview. This phase involved familiarization before any formal coding commenced. Phase 2: Exploratory Noting, Deconstruction, and Construction of Experiential Statements This phase involved a line-by-line analysis of each transcript: ·Deconstruction: The researchers segmented the text into manageable meaning units: phrases or sentences that conveyed a distinct aspect of participant experiences. · Exploratory Noting: For each meaning unit, exploratory comments were made in the margins. o Descriptive comments focused on summarizing the overt content (e.g., "Participant describes using app X to review for Y exam"). o Linguistic comments noted particular uses of language, metaphors, or repetition (e.g., "Participant repeatedly uses 'battle' metaphor for exams"). The description of final examinations as "life or death sentences" by multiple participants is an example of such a linguistic point. o Conceptual comments involved making preliminary interpretations of the psychological significance of the statement (e.g., "This suggests a feeling of being overwhelmed, seeking control through technology"). · Horizontalization and Initial Abstraction: Initially, all meaning units relevant to the research questions were treated with equal potential significance. The researchers then began to abstract these initial notes and meaning units into more concise "experiential statements" that captured the essence of what was being expressed, staying close to the participant's own language and perspective. For example, multiple similar statements about stress before exams and anxiety over the volume of material were condensed into experiential statements reflecting "exam-induced pressure" or "information overload." Phase 3: Developing Experiential Statements into Emergent (Individual-Level) Themes: This phase focused on participant accounts individually before any cross-case analysis: · Clustering and Thematizing: The experiential statements derived from the previous phase for a single participant were then examined for connections and interrelationships. The researchers looked for patterns, repetitions, and clusters of meaning. This involved a process of grouping related experiential statements together. For instance, statements about "the app helping me find my weak spots," "the AI tailoring questions to my level," and "feeling the learning was more focused" were clustered under a preliminary theme like "Personalized Learning Pathway." · Structuring Themes: For each participant, a list of discrete emergent themes was developed, each with a descriptive label that aimed to capture the essence of the clustered experiential statements. These themes were then organized hierarchically where appropriate (e.g., a main theme with sub-components). Each theme was explicitly defined. The specific meaning units and experiential statements supporting it were cataloged. This maintained a clear audit trail from raw data to the individual-level theme. This was an iterative process involving re-reading transcripts and earlier notes to ensure the themes accurately represented individual experiences. The goal was to create an idiographic portrayal of each participant's unique engagement with the phenomenon. The reflexivity journal was consulted here to ensure the clustering was driven by the participants’ narrative logic instead of the researchers' pre-existing theoretical frameworks. Application of Imaginative Variation Following the aforementioned phenomenological reduction, imaginative variation was employed to move emergent themes from individual experiential accounts to Group Experiential Themes (GETs)[26]. 1. Probing the Boundaries and Invariance of Individual Themes: For each significant theme identified within an individual participant's account (e.g., "adaptive learning as a stress mitigator" for Participant A, or "fear of missing out on effective adaptive learning (AL) tools" for Participant B), the researchers engaged in a series of imaginative exercises. This involved asking specific "what if" questions documented in the analytical memos: o "If this participant had not had access to feature X of the adaptive learning tool, would this experience of 'stress mitigation' still be present in the same way? What aspects would change? What would remain?" o "Consider the opposite: what if this participant described adaptive learning as increasing their stress? What conditions described in their narrative would need to be different for that to be the case?" This helped to clarify the specific conditions under which adaptive learning was experienced positively or negatively. o For a theme like "technological dependence," the researchers would vary contextual elements in their reflection: "Is this dependence primarily linked to the high-stakes nature of exams, or is it a broader characteristic of their learning style? How might this dependence manifest if exams were less critical for progression"? Such questioning helped to distinguish the core of the dependence from its situational triggers. 2. Exploring Textural and Structural Dimensions: Imaginative variation was used to move between the what (texture) and the how (structure) of the experiences. o Textural Exploration : The researchers would focus on a theme (e.g., "improved perceived performance") and immerse themselves in verbatim statements from a participant, trying to grasp the full range of feelings and thoughts associated with it. "What does it feel like for this student to perceive their performance as improved through adaptive learning?" o Structural Exploration : The researchers then shifted to understanding the underlying conditions that gave rise to this feeling. "What specific aspects of the adaptive learning interaction (e.g., instant feedback, progress tracking, targeted questions) contribute to this 'improved perceived performance'? How do these elements interrelate to produce the overall experience?" This involved imaginatively altering these components to see their impact on the experienced theme. 3. Cross-Contextual Imaginings for Essential Meanings: When comparing similar themes across participants (e.g., several participants mentioning "effort minimization"), imaginative variation was used to identify the shared essence. The researchers asked, "Despite differences in their backgrounds (e.g., rural vs. urban, high vs. lower intrinsic motivation as described by Liu Shuai vs. Huang Jian ), what is the invariant core of this experience of 'effort minimization' as it relates to using adaptive learning tools for exam preparation? Is it about strategic time-saving, a circumvention of deeper learning, or a pragmatic response to overwhelming workloads?" This involved considering the theme across participant narratives and imaginatively stripping away idiosyncratic details to arrive at the structural core. Synthesis of Meanings into GETs The synthesis of meanings represented the interpretive act of the analytical process where idiographically derived understandings were woven into a coherent structure of Group Experiential Themes (GETs) that represented the lived experience for the participant cohort. Systematic Cross-Case Thematic Comparison: After the aforementioned analysis of each of the seven participants, the synthesis began with a formal cross-case comparison. An analytical matrix was developed that listed each participant and their derived themes. This matrix allowed the researchers to visually map convergences, divergences, and interconnections. For example, themes from Participant A related to "feeling less anxious with mock exams on the app" were compared with themes from Participant B concerning "using AL to reduce study load before finals," looking for underlying commonalities that could point towards broader experiences of distress reduction. Iterative Development and Refinement of GETs: The identification of patterns in the matrix led to the iterative formulation of candidate GETs: o Initial Grouping: Similar individual themes were clustered under tentative GET labels. For example, various individual expressions of reduced anxiety and managed stress were initially grouped under a code of "Emotional Impact of AL." o Conceptual Abstraction and Labeling: The researchers then worked to refine these broad codes into more precise GET labels that captured the essence of the shared experience. "Emotional Impact of AL" was refined to "Decreased distress." Sub-themes like "academic burnout" and "exam stress" were identified as distinct but related facets of this GET. o Defining and Substantiating GETs: Each GET was then defined within its scope. The researchers returned to the individual participant data to select the most compelling verbatim quotes that exemplified each GET and its sub-themes . Structuring the Overall Experiential Account: The identified GETs were then organized into a coherent narrative structure that aimed to tell the collective story of the participants' engagement with adaptive learning. The relationships between these GETs were explored. For example, "improved learning proficiency" might contribute to "decreased distress," or "liabilities after extended use" might emerge over time despite initial benefits. Peer Auditing for Credibility: As mentioned before, the summary of themes was subjected to review by an unaffiliated researcher and academic medical peers. Specifically, these auditors were asked to evaluate the coherence of the thematic structure, the clarity of the GET definitions, and the convincingness of the link between the GETs and the supporting participant quotes. Feedback from this process was used to refine the wording of themes and ensure the analytical narrative was compelling. Justification of Sample Size (N=7) within an IPA Framework The decision to include seven participants in this study was a methodological choice rooted in the principles of IPA and consistent with contemporary evidence for data saturation in qualitative studies at relatively small sample sizes [27,28]. Homogeneous studies have also prioritized depth and richness of lived experience over numerical representativeness in similar sample sizes[29,30]. Deliberate Pursuit of Idiographic Depth: IPA’s primary commitment is to an idiographic understanding that thoroughly examines individual cases before attempting to identify shared patterns. A sample of this size allowed the researchers the necessary scope to engage deeply with each individual transcript that IPA demands. This ensured that the unique voice and perspective of each of the seven medical students were fully explored and honored before any cross-case synthesis was undertaken. A larger sample would have pragmatically constrained the ability to achieve this level of individual analytical depth. Ensuring Data Richness for Phenomenological Insight: The seven selected fourth-year medical students provided data of substantial richness and texture in their shared context of an exam-oriented curriculum and recent engagement with adaptive learning tools. The data obtained from these seven individuals were not superficial: participants offered elaborate accounts of their study practices, emotional responses to academic pressures, perceptions of adaptive learning technologies, and the specific ways these tools integrated into their exam preparation strategies. Achieving Thematic Sufficiency for the Specific Phenomenon: While IPA does not typically use the term "saturation" in the same way as some other qualitative methodologies, a key consideration was whether the sample size allowed for a robust and sufficiently complex understanding of the phenomenon. With seven participants, recurring patterns of experience began to emerge with consistency across different accounts while also highlighting unique individual variations. The three major GETS and their associated sub-themes were well-supported by data from multiple participants. Further interviews were deemed unlikely to significantly alter the core thematic structure that emerged from these accounts, indicating a level of thematic sufficiency. Analytical Manageability and Rigor: The process of IPA, from transcription and repeated immersions to detailed coding, theme development, and cross-case synthesis, is labor-intensive. This sample size allowed the research team to maintain a high level of analytical quality and detail throughout the process. It ensured that each transcript could be afforded the necessary focused attention without compromising the depth of interpretation, which aligns with recommendations by Smith et al.[19] for IPA studies aiming for sufficient details in publishable accounts. Personal reflexivity Reflecting on the potential effects that pre-existing beliefs may have had on the outcomes of the interpretation is constitutive of the aforementioned double hermeneutic of this study. The author took part in reflexivity using the reflexive notes compiled from each interview. Moreover, the author had an impromptu session involving unaffiliated researchers questioning the author on their worldview and its potential influences this may have on the research. The result is a reflexivity statement that helps understand the beliefs underlying this work. The author is a researcher and educator affiliated with medical institutions. They completed their qualifications in a mainland Chinese university and underwent similar regimes as the participants of the study. The author personally believes in the practical benefits of competency-based education. They also believe in the advantages afforded by learner-focused and learner-directed medical training to produce more suitable candidates for modern healthcare. Summative assessment, as the kind experienced by participants in the study, is a flawed system in the author’s view, as it creates overly high stakes and negatively impacts the well-being of students. Overall, the author believes in a need for medical educational reform in mainland China that steers towards more holistic education rather than a narrow-scoped focus on textbook materials and didactic teaching methods. Results Participants For the remainder of the article, pseudonyms will be used to protect the anonymity of participants. Table 1 provides the list of pseudonyms and corresponding details of the participants’ backgrounds. This informs the interpretation and helps contextualize their responses during the interviews. Table 1 Participants’ pseudonyms and backgrounds Participant pseudonyms Participant backgrounds Li Qiang −22 years old - Male, ethnic Han Chinese - Student council representative - Urban middle class background (self-described) from the city where the university is located at (Guangzhou) Liu Shuai −21 years old - Male, ethnic Han Chinese - Awarded distinction in several provincial level chemistry competitions during secondary education - Currently aiming to change schools for postgraduate studies - Rural working class background (self-described) from a socio-economically deprived area of the province where the university is located at (Guangdong) Wang Jun −22 years old - Male, ethnic Zhuang Chinese (a Tai-speaking ethnic group in South China) - Originally planned for engineering major, transferred to studying in the medical field due to personal and familial reasons - Rural working class background (self-described) from a socio-economically deprived area out of the province Chen Gang −23 years old - Male, ethnic Han Chinese - Took a mental health leave during third year and an in-semester leave this year - Urban upper middle class background (self-described) from Shanghai Huang Jian −22 years old - Male, ethnic Han Chinese - Parents both work in the medical field - Urban upper middle class background (self-described) from Guangzhou Zhang Min −21 years old - Female, ethnic Han Chinese - Urban upper classmiddle background (self-described) from Guangzhou Lin Na −22 years old - Female, ethnic Yao Chinese (a Mien-speaking ethnic group in Southwest China) - Rural working class background (self-described) from a socio-economically deprived area out of the province Structural Analysis Structural analysis reveals three major group experiential themes and their associated sub-themes across student perspective towards adaptive learning in their studies (Fig. 2; Table 2). Table 2 Results of structural analysis identifying major and sub-themes Major themes Sub themes Decreased distresses Academic burnout Exam stress Improved learning proficiency Perceived performance Tailored learning experiences Liabilities after extended use Effort minimization Technological dependence Decreased distresses Adopting adaptive learning methods have reduced learning-related distresses found within medical students. This allowed participants to approach learning with a more active and motivated mindset. Two main forms of distresses were promptly addressed through the introduction of adaptive learning tools: academic burnout and exam stress. Academic burnout Participants reported multiple cases of feelings of burnout prior to examinations and sporadically during their school year. There was a prevalent feeling that “studying becomes a chore and an unbearable thing to think about” (Zhang Min) when faced with prolonged periods of non-stop instructions and large quantities of instructional materials. Participants also exhibited signs reminiscent of academic procrastination: “Sometimes, I know I should be reading up on [class notes], but I just don’t want to. It is strange because there was one me that knew I must do it, and there was another me that just did not want to do anything… It becomes very tiresome at that point.” (Chen Gang) Access to adaptive learning platforms restores some motivations for students and contributes to them regaining self-determination in learning by mitigating feelings of apprehension and frustration usually associated with academic burnout. “It is reassuring to know that… there is this tried and tested tool [adaptive learning app] that I can pull up and use to make good progress… It is good; it makes me think less about what would happen if I did not make good progress and learn enough today.” (Li Qiang) Even in cases where motivations are not improved after the introduction of adaptive learning alternatives, participants still reported a general decrease in feelings of burnout. Students felt less exhausted and reacted less negatively to long periods of studying. “I don’t think it made me more motivated... I mean, but [I agree] that I am definitely less stressed about exams and learning stuff. Less tired,… that is how I would [put] it; studying usually makes me want to fall asleep, but [adaptive learning tools] make it more tolerable.” (Huang Jian) Adaptive learning also enabled students to become more willing to participate in classes and attend lectures more regularly. This is a consequence of improved sense of ability derived from adaptive learning experiences. “If the class I am going to is not listed on the [adaptive learning] app, I am not going to sit in the front row… Imagine getting called to answer questions… With the app, I can at least get a general gist of what the lecture involves before going there.” (Li Qiang) Consulting adaptive learning tools has decreased frustration by providing a sense of initiative and agency towards improving one’s learning progress. “The best thing [about adaptive learning] is, I think, I start to see where I need help. With [traditional] instruction, I go to class, and the professor goes through a list of key points before showing a few exam questions. That is it. But if something different comes up in the exam or as a mock question, I am completely unprepared. and it is frustrating to go wrong but not know where you went wrong or how you can come about fixing it.” (Liu Shuai) Exam stress Exam stress is another form of distress that adaptive learning has significantly helped to mitigate during the participants’ experiences before final examinations. The summative assessment format that mainland Chinese undergraduates adopt makes final examinations extremely high-stake and generates a high level of stress shared by all participants in the study. Several of the participants called final examinations a series of “life or death sentences” (Liu Shuai, Wang Jun, and Lin Na). Lin Na viewed the level of exam stress as negatively impacting her performance, something that adaptive learning can help to address: “I personally feel a lot of stress before exams... and that makes me double-guess a lot of my answers during exams and just waste too much time overthinking about things. The mock paper part of the [adaptive learning] platforms is quite good because I can at least enter into the exam knowing that I am predicted a 90% or higher mock-wise.” (Lin Na) The participant group attributed exam stress to the overburdensome amount of knowledge that undergraduate medical examinations cover. Adaptive learning plays an active role in tailoring learning to cut down on unnecessary work and focus on areas that participants most urgently need to focus on: “I have to do like 15 exams this year, and it is all within a two-week period too. There are approximately 500 pages of reading notes for just one of the exams. I also have to learn Marxism and political studies as part of the school requirements. Realistically, I am not going to be able to cover all of that. So the [adaptive learning] software keeps the learning materials to a reasonable level, and I can actually study without having to be stressed over a mountain pile of papers.” (Li Qiang) The lack of exam-related discussions from the end of the educators also engendered stress and created ambiguity regarding examinations that adaptive learning alleviates by encouraging more self-regulated learning. “Professors do not talk about examinations because they do not want to leak anything by mistake. But sometimes you give them an answer and ask, ‘Is that how I am supposed to answer this type of question?’ and they just tell you to figure it out by yourself and that ‘the answers are all in the textbooks.’ That is just not really true, so I use adaptive learning tools to locate standard answers and sample questions.” (Zhang Min) Improved learning proficiency Perceived performance Continued employment of adaptive learning led to increased academic proficiency as reflected in their perceived performance. Adaptive learning tools were described as “a lifesaver for passing exams and achieving good grades” (Lin Na). Responses towards the use of adaptive learning are unanimously positive, and participants viewed adaptive learning as an integral part of their revision process for final examinations. “Most of the end-of-year revision that I did was done through Yikaobang (an adaptive learning platform developed for mainland Chinese students). It is useful for brushing up on questions that I usually struggle with and identifying weak spots to learn more about.” (Li Qiang) The effectiveness of adaptive learning on academic performance is widely recognized amongst medical students. Some participants transitioned into adaptive learning as a result of positive experiences from seniors and classmates: “[Adapting learning tools], everyone uses them... It is frequently advised, especially towards exam season. I was told [by others] that attending classes is not enough and textbooks provide limited information compared to the content that will actually appear on exams.” (Wang Jun) Participants attributed improvements in their grades to the amount of time spent on adaptive learning platforms, rather than how much time they devoted to other instructional materials. “I spent roughly the same time on contents handed out during class. Adaptive learning is where the real differences are made, in my opinion. It is also because there is only so much to look at with lecture notes and recordings, whereas adaptive learning platforms regularly update you with new questions, examples, and exam-related tips.” (Li Qiang) Some participants, when discussing the aforementioned effects of adaptive learning on academic distress, also noted that adaptive learning indirectly improved their performance by decreasing the amount of negative emotions associated with learning. “Adaptive learning made content more digestible and easier to comprehend... It would be frustrating to spend hours remembering Latin names by rote. But the game feature [on this adaptive learning app] definitely made the process less tedious.” (Lin Na) Tailored learning experiences Another salient area of adaptive learning where participants articulated overwhelming approval for is the provision of personalized learning experiences. Participants recognized that adaptive learning more promptly addresses unique needs than conventional, non-adaptive methods. Tailoring the education experience through differentiated instructions enhanced the quality of learning by emphasizing personalized learning frameworks. “Professors just teach. They are often quite busy, and our classes are large, 60–100 people. And there is just no time to really answer any questions or discuss any of the specifics. These [adaptive learning] platforms give a feeling of, sort of, personal tutelage.” (Zhang Min) Participants appreciated the interactive aspects of adaptive learning that allow for learners to gradually customize difficulty and processes to suit their own needs. These are aspects that would not be as accessible in conventional teaching environments: “The customization features are very cool. I took a year and some time off, so I am quite behind on several classes. And I always feel a bit apprehensive asking basic questions in class, especially if the lecture is already way past basic knowledge. So, having a tool that can answer basic questions and explain it to me patiently is a great help.” (Chen Gang) Temporal constraints and teacher-student relationships also play a part in adaptive learning, enabling students to learn more proficiently. The hierarchical relationship between professors and students in mainland China makes tailored learning inaccessible otherwise. “Even when I do get a chance at scheduling a meeting with my professor, I usually have to prepare ahead of time the questions I want to ask, and I cannot take up too much time if he has other affairs to attend to that day. So, I only really do that once or twice a month. For the most part, adaptive learning tools are just far more convenient for answering questions that I sporadically encounter during my time studying.” (Wang Jun) Participants also repeatedly referred to the concept of “discovering knowledge gaps and filling them up” (Li Qiang). This is viewed as the most urgent need of undergraduate medical students during their academic careers. Students noted that the personalization in adaptive learning permits a learner-focused education that targets gaps in knowledge. “Most of us know the content. We go to classes, and we study daily. The issue is, amongst 10 or 15 classes and hundreds of textbooks, you are bound to have some lapses—areas where you just forgot or missed some key information. This is the most important problem that we must tackle to achieve good grades. Adaptive learning speeds up that process so we do not have to reread the entire mountain of books every time we study.” (Liu Shuai) Liabilities after extended use Effort minimization Participants recognized that the use of adaptive learning technology bifurcates depending on the level of motivation of the user. If the user is highly motivated to succeed academically, adaptive learning alone is insufficient for reaching that goal. This leads to a strange case where the most frequent users of adaptive learning tend to be the least motivated: “I personally do not just rely on adaptive learning… I am currently aiming for Tongji University for my postgraduate studies, so I need excellent grades in my finals. My own experiences are that adaptive learning is good, but you cannot just rely on them. I also do my own graphs, use 3D anatomy apps to learn, make my own mindmaps... all that.” (Liu Shuai) Current adaptive learning technologies available to mainland Chinese students focus heavily on exam-style questions and sample answers with less emphasis on textbook knowledge. “[Adaptive learning] apps are great for checking my answers for mock exam papers and seeing how I should be answering these questions. But the amount of technical details is amiss in a lot of the services that they provide. I use them for practicing questions more than anything else... I think they can be improved otherwise.” (Zhang Min) Students with less motivation and lower goals rely more heavily on adaptive learning tools to boost their performance in the short run without investing much effort. “I do not really have any serious academic pressures. I need to pass, sure, but I already have a job lined up locally. So, adaptive learning platforms are a lifesaver for getting by exams without much studying. For some of my classes, I spent about 40 hours on the applications and just memorized a lot of the common questions. I think it is an extremely convenient alternative to actually going through all the materials.” (Huang Jian) Others have reported that adaptive learning tools may be used to deal with less important classes and allow them more time to focus on professional knowledge. “I think there is nothing wrong with using adaptive learning tools to study politics/English. Those were sort of forced on us always. I just skip those classes and materials and use adaptive learning apps to practice until I am confident that I can pass those classes.” (Chen Gang) Participants also identified some level of mentality shift involved in long-term use of adaptive learning tools that bring about more slothful learning approaches and greater technological dependence. This part of the conversation stimulated some individual reflections: “Now that you mention it, I definitely feel like getting lazier with learning, especially if the class that I am studying for has really good adaptive learning modules online. In those cases, I tend to just leave it up to the artificial intelligence or algorithm or something to do the job. I do think that, now that you said that, when there was not much adaptive learning stuff around... pre-Covid? I was more actively engaging with the content.” (Li Qiang) Technological dependence Central to the long-term effects felt by student participants was the feeling of increased reliance on adaptive learning tools to assist with their studies. This was experienced by most interviewees as a gradual buildup of “a habit to pick up the phone as opposed to the textbook when an exam is coming up.” (Lin Na) Respondents also noted that this feeling of reliance led to more efforts in searching for relevant adaptive learning materials. This led to more academic discussions revolving around the medium of adaptive learning as opposed to the learned content. Not all the content that we get tested on is listed on these sites… I mean, most of them are created by students and companies, not schools, yes. So we have this group chat where we ask around on what is the newest, best platform to use to study for an exam… “Finding the right website is more important than reading the books over and over again…that is my motto anyway.” (Chen Gang) Dependence on adaptive learning tools meant that students developed feelings of trepidation or anxiety when their familiar tools became unavailable or did not contain the content that they needed. This translates to academic stress similar to exam-related stress. “Sometimes, the [adaptive learning] websites do not update to the latest edition of our textbooks or just happen to not cover the content that we know will get tested on…I get so scared when that happens; I am always like, “Please, please let [the exam materials] be there.” (Zhang Min) This stress has been reported as a worse experience than the usual stress that they felt before studying with adaptive learning tools or during their high school days when adaptive learning was unavailable. The increased stress is likely due to difficulties with returning back to non-adaptive formats of learning and the lack of related preparations. “I just feel cold sweat down on my spine when I see a course being ‘unavailable at the moment’ or ‘waiting for update’… It feels so bad having to return to reading the books bit by bit and borrowing people’s notes. I am constantly feeling like I was doing well before because of the internet tools and not because I know everything well.” (Li Qiang) “Studying felt awful when there was nothing available online for you. My notes in class have been quite poor since they are not that important to my revision anyway nowadays. But sometimes I do wish I was a bit more industrious in class about them.” (Chen Gang) Sometimes, this stress will cause students to pay money for premium services hosted by privatized adaptive learning platforms. “I have spent more money on subscriptions than textbooks this year.” (Huang Jian) Other times, this will cause students to find alternative means of accessing their desired mode of adaptive learning: “I am actually programming my own AI-powered adaptive learning tool this year in my free time. It is convenient to piggyback on good domestic language models.” (Liu Shuai) Students generally displayed disinclination to return to more conventional learning formats, citing their dependence on adaptive learning technology as “keeping up with the trends of learning.” (Wang Jun) Participants responded negatively to the dependence on adaptive learning technology being interpreted as a phenomenon of concern. “I think [teachers and schools] are making a big deal out of something trivial. Yes, we use online platforms to study…yes, these platforms use advanced algorithms and large language models to predict questions or layer our studying to be more effective. But [adaptive learning] is efficient, and we did not cheat. To me, this is no different from upgrading from going to the library to browsing through e-books. Saying that we are dependent on adaptive learning is like saying we are dependent on computers…of course we are! It is the modern form of learning, and I think it will be the future for the foreseeable time to come.” (Liu Shuai) Discussion This study investigated the perspectives of Chinese undergraduate medical students towards their current experiences with adaptive learning and situated these experiences within the exam-oriented environment of Chinese medical education. Participant responses confirmed some of the existing theories of adaptive learning as a salient tool in addressing the individual learning needs of students. While minimal effects on learning motivation are observed, the participants identify personalization as a key theme in adaptive learning’s advantage over traditional instructions. At the same time, cultural and contextual elements of Chinese education played a nontrivial part in shaping student perception of adaptive learning. From these viewpoints, adaptive learning is sometimes perceived as a technological shortcut for individuals to meet the baseline requirements of academic progression rather than an efficacious tool for enabling academic excellence amongst all medical students. Load management Medical students have long reported symptoms of exam-related distress, including academic burnout and exam stress prior to this study[ 31 ]. Emphasis on academic achievement and fear of failure associated with examinations lead to degraded medical school learning environments[ 32 , 33 ]. These aspects increase the cognitive load and stress levels of students, which in turn lead to worsening mental welfare and learning efficacy[ 34 ]. The mediating role that technology has in the interplay of cognitive load management and self-regulated learning has been viewed as one upside of adaptive learning tools[ 35 ]. Participants used adaptive learning tools, most often applications, to manage their workload before final examinations and also minimize their cognitive load. The latter is consistent with the theory of cognitive load and the load management idea frequently seen in medical education[ 36 ]. The theory advocates for an optimization of learning through the reduction of extraneous cognitive loads by adjusting processes by which instructional information is presented to the learner[ 37 ]. In the context of Chinese medical education at the undergraduate level, these cognitive loads consist of the clarity of instructional materials provided and the translation of these instructions into examination-style questions and answers[ 9 ]. Employment of adaptive learning encourages parallel processing and improved automaticity, thereby lowering cognitive load amongst students[ 38 ]. Aside from cognitive load, participants also sought to reduce workload by targeting areas where the algorithms have deemed them the weakest at or most likely tested for. Participants conventionally expect this improvement in both cognitive load and workload to occur by means of additional instructions and instructors charting out a narrower scope of the content for students to revise. Participants identified these as customary teaching practices in Chinese medical education. The introduction of adaptive learning has alleviated exam-related distresses by permitting load management before examinations[ 39 ]. In the case of China, this introduction has not established a new learning practice but rather transferred the role of load management from instructors into the hands of learners, thereby enabling a greater degree of agency and equality amongst medical students. On the flip side, this could indicate that the significance of adaptive learning to medical education is limited by the effectiveness of conventional measures to monitor the workload and cognitive load of students. Personalization The advantage of personalization through adaptive learning environments over non-adaptive approaches is not a novel discovery[ 40 ]. The real-time feedback and minimization of bias play important roles in raising user satisfaction and improving learners’ engagement. Embedded within these technological upsides are the benefits of self-regulated learning by medical students in comprehending content and applying it in exam settings[ 41 ]. Participants find themselves more at ease with personalized interfaces that allow them to set their own schedules and study at an individualized pace. This is in congruence with instructional scaffolding, which posits that efficient learning is facilitated through a learner-centered, collaborative interaction that takes place in the learner’s zone of proximal development[ 42 ]. The eventual removal of scaffolds occurred algorithmically as participants moved from content comprehension to practice questions, then towards tailored exam questions. The participants were generally more content with their increased agency in determining and regulating the type and difficulty of the tasks as well as the feedback received. More hierarchical teacher-student relationships and larger class sizes in Chinese universities could account for the sustained preference of Chinese medical students for personalized learning[ 43 ]. Whereas personalization improved overall satisfaction and expectation of performance, the effects of adaptive learning on medical students’ intrinsic motivation remain indistinct. Contrary to some prior studies[ 44 ], participants did not report significant improvements to their motivation. Students with low intrinsic motivation for academic distinction prior to their exposure to adaptive learning did not develop more incentive to pursue higher academic goals. It is unclear whether intrinsic motivation served as a mediating factor linking the effect of adaptive learning on the academic performance of medical students. Fear of not passing and the aforementioned exam-related distresses could indicate that the extraneous motivators play a larger part in the exam-oriented environment of Chinese medical education[ 45 ]. Students exhibit more preoccupation with test score performance than task mastery. Differences in personal backgrounds could also account for different levels of goal-setting and, therefore, different levels of intrinsic motivation to learn. This is a case for broadening the scope of competency-based approaches in Chinese medical education to enable the personalizational aspects of adaptive learning to play a greater role in improving motivation. Complacent mindsets The study pinpoints a unique issue of medical students using adaptive learning tools as a shortcut to achieving basic requirements in standardized examinations needed for academic progression[ 46 ]. This behavior resonates with behaviors of academic procrastination and can further deteriorate performance and intrinsic motivation[ 47 ]. It involves the purposeful postponement or avoidance of completing academic tasks, usually associated with self-doubt, lack of self-regulation, and other behavioral impediments. Some studies have identified the usefulness of using adaptive learning to address academic procrastination[ 48 ]. While some participants confirmed this relationship for more intrinsically motivated medical students, students with pre-existing tendencies to procrastinate or lower expectations tend to operate in the converse. Students with high intrinsic motivation tend to seek approaches beyond adaptive learning, often in combination with adaptive methods. On the other hand, students with low intrinsic motivation and symptoms of academic procrastination rely solely on technology to achieve their desired academic outcomes. Tools designed for adaptive learning are viewed as convenient alternatives for efficient learning only to the level of meeting minimum requirements. In spite of short-term improvements in task performance, the provision of adaptive learning opportunities does not lead to an accretive performance boost and positive goal orientation in the long run[ 49 ]. Low intrinsic motivation leads to maladaptive behaviors of academic procrastination and loss of self-regulation. The self-determination theory suggests that autonomy, competence, and social relatedness are necessary psychological needs for higher motivation and adaptive patterns of learning behaviors[ 50 ]. Dissatisfaction in those areas indicates likelihoods for academic burnout and a shift away from goal-oriented learning into indications of performance-oriented behaviors. This motivational makeup indicates a lack of self-regulation and a focus on maximizing academic performance with minimal input. The critical concept of “metacognitive laziness” introduced by Fan et al. identifies patterns of learning that offload metacognitive load onto adaptive learning tools, thereby encouraging technological dependence that hinders self-regulation and deeper engagement with instructions. It applies to the themes observed in this study as a consequence of habitual employment of adaptive learning tools as a method of cognitive load management per the aforementioned discussion. Moreover, the concept applies to both students and teachers, where metacognitive activities and autonomy give way to increased convenience of automation. Poorer self-regulation and loss of autonomy ascribed to these concerns may lead back to the aforementioned symptoms of academic procrastination, which could warrant a vicious cycle of deteriorating intrinsic motivation and technological dependence. Strengths and limitations Interpretative phenomenological analysis offers a chance at examining in-depth the psychological reality of how medical students in China perceive the role of adaptive learning against an exam-intensive backdrop. An effective methodology for exploring the nuanced aspects of lived experiences, this approach is suitable for understanding how these perceptions reveal underlying themes and overall perspectives towards adaptive learning[ 24 ]. There are undoubtedly some limitations at work. As with any constructivist methodology, IPA develops transferrable yet not fully generalizable, idiographic findings. The participants were recruited from the same class through university administration. This may have encouraged the students to speak less critically of the current medical education system and the instructions they receive, as they may presume some level of responsibility for the information that they disclose. This underestimates the positive facets of adaptive learning as a potential reform measure in Chinese medical education and overestimates the effectiveness of the current instructional approach. Moreover, the status of the author as a former medical student with prior experiences of the area of inquiry could have caused some premises to be taken for granted and result in participants’ experiences being underexplored. While reflective journals were beneficial to amend this drawback, it still warrants the possibility of insufficient scrutiny into some areas of interest. Implications for practice and further research Notwithstanding the lack of generalizability, the findings still affirm some of the key conclusions reached in extant literature on adaptive learning. Despite concerns about adaptive teaching and learning becoming the predominant mode of instruction, the study demonstrates the preference for adaptive learning at an individual level found amongst Chinese undergraduate medical students. Personalized learning and load management continue to be major selling points of adaptive learning with noticeable positive effects on learning proficiency in exam-oriented settings. Moving forward, adaptive learning proponents will need to address the persistent issue of inequality between technologically inclined and better-equipped students relative to their less advantageous peers. The general provision of technological education and equipment may be necessary for the benefits of adaptive learning to be distributed evenly. This resonates with studies that warn against the erosion of traditional teaching methods in pedagogical contexts where technological inequality is still widely present. It is also worth noting the role that some participants relegate adaptive learning tools to the status of achieving the bare minimum to pass. This has not been discussed widely in other studies but should be a focal concern for the widespread application of adaptive learning. The potential for metacognitive laziness as encouraged by generative artificial intelligence could see a similar phenomenon in adaptive learning where less motivated learners become more dependent on technology. Steps ought to be taken to prevent loss of self-regulating agency and promote sustainable student engagement with adaptive learning. This also calls into question the usefulness of intensive examination for cultivating qualified medical professionals and brings into discussion the notion of competency-based education and its prospect in Chinese medical education reforms. The current study leaves room for several future research directions. Understanding whether the conclusions reached in this study are transferrable to other provinces of mainland China may shed light on the potentially differing perspectives towards adaptive learning owing to differences in culture and pedagogical contexts. Furthermore, it would be enlightening to test whether the conclusions hold in the subsequent three-year residency training that constitutes part of the medical students’ path to professional qualification. The author would be interested in directing further research towards additional insights into incorporating adaptive learning as instrumental for motivating academic success and not just achieving the threshold of academic qualification. This requires understanding how adaptive learning could cultivate intrinsic motivation on a more extensive and sustained level via personalized learning frameworks and self-regulated learning. Reproducing this study under different contexts could yield more fruitful results that pave the way for adaptive learning to become a mainspring of the Chinese medical education reform. Conclusion This study has examined the perspectives towards adaptive learning in the exam-oriented educational environment of undergraduate medical students at the Guangdong University of mainland China. Exploration of student experiences through a phenomenological lens affirms some of the established conclusions on adaptive learning, namely its advantages in load management and personalized learning experiences that contribute to more proficient learning. This study also underscores the persistent concern of technological inequalities that undermine adaptive learning in its wider applications. A two-fold, diverging approach to utilizing adaptive learning is observed. Whereas more intrinsically motivated students use it for improving performance, less motivated students employ adaptive learning technology to shorten the time frame needed for meeting the minimum requirements of academic qualifications. The study thus lends support to the view that adaptive learning at its current stage does not boost intrinsic motivation. Mainland Chinese reformers of medical education must take into account the threat of adaptive learning enabling technological dependency and metacognitive laziness amongst undergraduate medical students. Further insights are needed before determining whether adaptive learning would be suitable for the current exam-based learning environment of Chinese undergraduate medical education. Declarations Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding statement This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Authors' contributions Lei Zhou: Writing – original draft, Methodology, Investigation, Funding acquisition, Formal analysis, Conceptualization. Hanying Liu: Writing-review & editing, Supervision, Methodology, Conceptualization. Guiyang Chen: Writing-review & editing, Supervision, Methodology, Investigation, Formal analysis, Conceptualization. Jie Peng: Writing-review & editing, Supervision, Methodology, Investigation, Formal analysis, Conceptualization. Xing Liu: Writing-review & editing, Supervision, Methodology, Investigation, Formal analysis, Conceptualization. Ge Lan: Writing-review & editing, Supervision, Methodology, Investigation, Formal analysis, Conceptualization. Huiying Deng: Writing-review & editing, Supervision, Methodology, Investigation, Formal analysis, Conceptualization. Acknowledgements Thanks to the other doctors within Xiangya Hospital who provided assistance with the writing and grammar correction of this article. Ethics approval and consent to participate Ethics This research conforms to the guidelines established by the Ethics Review Committee at Central South University and the guidelines of the Declaration of Helsinki (including its later amendments). All individual interviewees gave informed consent in writing and signature before starting interviews. Consent to Participate Participants has been given a clear and comprehensive information sheet detailing the research aims, the voluntary nature of participation, what involvement entails, how data will be used and stored, confidentiality measures, and their right to withdraw at any time without penalty. Written informed consent has been obtained prior to each interview. All identifiable information will be anonymised using pseudonyms in all research outputs. Data will be stored securely. Care will be taken when presenting findings to ensure that no specific local entities can be inadvertently identified. 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Br J Educ Technol. 2024;56(2). doi:10.1111/bjet.13544 Pelikan ER, Korlat S, Reiter J, Holzer J, Mayerhofer M, Schober B, et al. Distance learning in higher education during COVID-19: The role of basic psychological needs and intrinsic motivation for persistence and procrastination–a multi-country study. PLoS One. 2021;16(10):e0257346. doi:10.1371/journal.pone.0257346 Additional Declarations No competing interests reported. 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15:06:40","extension":"xml","order_by":7,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":161777,"visible":true,"origin":"","legend":"","description":"","filename":"e791a9918cb74c88a20e39a38ec2ff8d1structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7361555/v1/905ad3fbb3ba9f307db4a92a.xml"},{"id":93698165,"identity":"3899b7cd-1048-4993-8463-dd30236882e3","added_by":"auto","created_at":"2025-10-16 15:06:40","extension":"html","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":177508,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7361555/v1/0847ea2567f65921a49b7974.html"},{"id":93698156,"identity":"b1dbdd31-e50d-4655-9321-b6f2b955578f","added_by":"auto","created_at":"2025-10-16 15:06:39","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":79931,"visible":true,"origin":"","legend":"\u003cp\u003eA four-phase approach to interpretative phenomenological analysis utilizing the framework and processes\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7361555/v1/3b0595bd02dd555994e5173d.png"},{"id":93698158,"identity":"da4378e3-0463-4fb9-a5f4-d8564f858430","added_by":"auto","created_at":"2025-10-16 15:06:39","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":83015,"visible":true,"origin":"","legend":"\u003cp\u003eGroup experiential themes and sub-themes\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7361555/v1/f59efac01e7eea8053080749.png"},{"id":93699561,"identity":"1a9f3a03-56c1-44f7-92ad-5fd231000c38","added_by":"auto","created_at":"2025-10-16 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analysis","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe advent of adaptive learning in medical and health sciences education has fostered heightened interest in personalizing learning experiences and redirecting focuses onto learner-aware learning for medical students[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. This popularization of technology-enhanced learning is inseparable from the rapid development of technological infrastructure in recent decades in the form of ease of internet access and prevalence of digital devices[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Specifically, the expanding role of China as a forerunner in digital technology indicates the continued relevance of the country in the research of adaptive learning, contributing more than 40% of concurrent literature in this field [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Moreover, the country harbors the largest medical education system in the world, which includes 192 listed higher education institutions providing clinical medicine education and over 1.7\u0026nbsp;million medical students enrolled in 2021[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. At the same time, theoretical and technological advancements have yet to fully translate into a consistently high-quality medical education for Chinese medical students[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. While recent research highlighted the positive effect that Covid-19 had had on the public attention towards adaptive learning in China, these studies seldom address and contextualize challenges within indigenous perspectives using the phenomenological lens. In an age of digital learning, both the standards by which academic performance is measured and the approaches that students take to meet these criteria are in need of reform[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] These reforms have in mind the goal of producing medical personnel with socio-emotional competency and professional skills needed to accommodate growing medical demands[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Talent cultivation forms a crux of the \u0026ldquo;Healthy China 2030\u0026rdquo; scheme that is currently viewed as the most important national health policy in mainland China[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAcademic progression in the medical field of China consists of several different programs with distinct paths during postgraduate education[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. At the same time, undergraduate medical education remains homogeneous and fundamental to professional medical careers. The emphasis on academic performance has been the cornerstone tenet for Chinese medical education in its goal of cultivating physicians consistent with the developing nation\u0026rsquo;s rising healthcare demands[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Moreover, the mainland Chinese undergraduate medical education is characterized by an exam-oriented teaching design that emphasizes on summative assessments to evaluate academic achievements [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. The dominance of instructional design that focuses exclusively on examinations creates a particular paradigm for students to interact with adaptive learning. Adaptive learning has been shown to have a positive impact on the performance of mainland Chinese students in standardized competence examinations. Meanwhile, the learner-focused approach upheld by adaptive learning may bring into discussion the prospect of formative assessment to supplant the existing measures[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Medical students\u0026rsquo; own perspectives towards curricula standards play a defining role in navigating both the effectiveness of adaptive learning in the current educational climate and the conditions for change.\u003c/p\u003e\u003cp\u003eThe outbreak of Covid-19 has assisted experimentations into adaptive learning experiences amongst mainland Chinese university students[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. E-learning and remote teaching became the educational norms as a result of the pandemic and mainland China\u0026rsquo;s lockdown policies[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. The development of tools for distance education, in turn, contributed to the propagation of adaptive learning approaches. This transformation is mirrored globally as the pedagogy and students come to accustom themselves to the new normal of learning management[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Exploring student experiences of adaptive learning has value beyond this particular context, as the maturing of generative artificial intelligence ushered in more accessible technologies for widespread implementation of adaptive learning. Better understanding of the perspectives that Chinese undergraduate medical students have towards the current exam-oriented medical education in light of adaptive learning opportunities may inform benefits and challenges on the side of the learners. This knowledge may in turn contribute to a more effective reform at personalizing learning experiences in Chinese medical educational institutes and ultimately improve the quality of clinical services to meet the rising expectations of the Chinese population.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003e\u003cem\u003eStudy aim\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis constructivist study aims to explore Chinese undergraduate medical students\u0026rsquo; experiences and perspectives of adaptive learning vis-\u0026agrave;-vis standardized exam environments in contemporary Chinese medical education.\u003c/p\u003e"},{"header":"Methodology ","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthics\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInterviews were anonymized prior to analysis, and the study used pseudonyms to report its results. All participants provided written consent for data collection, data analysis, and the publication of said anonymized results. Participants were guaranteed protection of their privacy and retraction of their information from the research at any time without needing justification.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eStudy design\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEmbracing a constructivist view of the medical pedagogy and learning process, the study employs interpretative phenomenological analysis (IPA) as its methodological approach to develop understandings of learners\u0026rsquo; perspectives with an idiographic focus[19]. The phenomenological aspects of IPA find their roots in Husserl and Heidegger\u0026rsquo;s thinking, which separately afforded the emphasis on lived experience through Husserlian transcendentalism and the hermeneutic approach rooted in Heideggerian philosophy[20]. The approach carries out an inquiry into the formative processes of learners\u0026rsquo; experiences while positing these processes within the particular context to establish an exhaustive and systematic analysis. IPA is a widely adopted qualitative method to explore under-researched topics that involves themes of the self and meaning-making activities of the participants[21].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe subjective epistemological implications of IPA encourage a spiraling approach that engages the researcher in a back-and-forth interaction with the subject and their own preconceptions. IPA usually predicates that these subjective preconditions cannot be completely filtered via bracketing measures[22,23]. A reflexive approach is therefore suggested to add weight and credibility to the interpretations[24]. This study thus calls for a double hermeneutic approach that retains the agency of the researcher by enabling them to interpret their own interpretations. In this study, the author is a Chinese national who has prior experiences with adaptive learning under the same environment of medical education as the participants of this study in a mainland Chinese higher education institute in the past. Reflexive notes were made available after each interview, and the study assesses its data from different levels that acknowledge and honor the role of the researcher. Throughout the hermeneutic cycle, the study prioritizes the goal of making sense of the participants\u0026rsquo; psychological reality.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eContext\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study is conducted in the context of the aforementioned 5-year bachelor\u0026rsquo;s degree at the University of Guangzhou in the Guangdong province of mainland China. During their academic years, medical students spend between eleven to fourteen days receiving twelve examinations on a broad range of topics that cover most clinical areas, including pediatrics and obstetrics. Given that semester schedules do not leave extended vacancy between class teaching and end-of-year examinations, medical students frequently employ adaptive learning approaches such as apps and AI models to detect and fill in missing gaps of knowledge.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eRecruitment\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIPA prescribes a small sample size with participants with reasonably homogeneous qualities constrained by inclusion criteria. This demands a purposive sampling strategy with which the study recruited seven fourth-year University of Guangzhou medical students between July and September 2024. This timeframe was chosen because it was between the end of the final examinations and the beginning of the new semester. The sampling occurred by means of information about a screening meeting distributed with help from the university administration office via email and group chat to all medical students who have studied for and attended their required examinations with plans to proceed with a career in medical fields or related areas. The author provided the cohort of attendees to the screening meeting with more detailed, written information on the research. A brief Q\u0026amp;A session was hosted to answer any further questions. Students who have expressed explicit interests were then screened through a brief survey to confirm their applicability to this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eData Collection\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFollowing successful screening, the author conducted a series of separate interviews with each individual participant apropos of their experiences of adaptive learning in their current academic environment and perspectives towards adaptive learning at large. Three of the interviews were conducted in person, and the other four were conducted via video due to participant preferences. Interviews are semi-structured, and a pre-written interview guide was set up to provide some open-ended, topic-related questions to help the conversation flow. During the interviews, the author encouraged individual participants to voice their thoughts openly and steer the conversation to areas that concern them the most personally. The more flexible design of interview schedules in semi-structured interviews allowed participants to traverse topics of their interest at greater depths. The author only intervenes to keep the dialogue loosely within the scope of the research questions and relevant literature. The first part of the interviews focused on Chinese medical students\u0026rsquo; experiences with adaptive learning, in particular with respect to the final examinations that they had recently completed at the time of the interview. The second part delved into their perspectives towards the role of adaptive learning in mainland Chinese medical education.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe author personally supervised all interviews. Interviews lasted between an hour and an hour and a half. These were digitally recorded, anonymized, and subsequently transcribed verbatim. Data was stored confidentially. Participants received transcripts of their own interviews to check for accuracy. The author also enclosed with the transcripts an email explaining the data privacy policy and contact addresses for any follow-up questions or comments. The author also guarantees access to resources if welfare support is needed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eData Analysis\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study utilized a four-phase program of interpretative phenomenological analysis on the transcribed data described by Smith et al. and widely endorsed by peer research (Fig. 1). Completing this program for all interviews yielded a set of Group Experiential Themes (GETs), which were then fleshed out into an analytic summary supported by quotes from individual participants[21,22]. Whereas the program was conducted on the original transcripts in Chinese, the quotes were translated into English for the sake of clarity. The process of translation and a full account of the research steps taken were recorded and stored for future replication of this study. To strengthen the credibility of the analytical approach, the research steps and the summary of themes were submitted to an unaffiliated researcher with no vested interest for review and audit. This was also done with several academic medical peers to ensure accuracy of representation and sufficient basis for grounding the themes in the transcripts.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEnactment of Epoche and Bracketing\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe initiation of epoche in this study involved a structured and sustained effort by the primary researchers\u0026nbsp;to identify preconceptions\u0026nbsp;concerning adaptive learning\u0026nbsp;and\u0026nbsp;the pressures of Chinese medical education[25]. This was treated as an ongoing iterative process.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInitial Phase of Preconception Logging\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Prior to participant interaction, the researchers undertook autobiographical exercises. This involved documenting specific personal experiences within the Chinese medical education system and explicitly noting prior encounters with exam-oriented pedagogy. For instance, specific anxieties remembered from personal examination periods and assumptions about student motivations were cataloged. This inventory of preconceptions was formally recorded and served as a reference document for the reflexive process throughout the research.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBracketing during Data Collection and Analysis:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Entries were made in the reflexive journal following each of the seven interviews and during each phase of data analysis for each transcript. These entries were structured to capture:\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1.\u0026nbsp;Observational Notes:\u003c/strong\u003e Details of the interview setting, participant demeanor, and non-verbal cues.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.\u0026nbsp;Methodological Notes:\u003c/strong\u003e Effectiveness of specific prompts or moments where the researchers consciously rephrased questions\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.\u0026nbsp;Emotional Reactions:\u003c/strong\u003e The researchers documented any feelings evoked by the participant\u0026apos;s narrative.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4.\u0026nbsp;Preliminary Interpretive Thoughts:\u003c/strong\u003e Initial patterns were noted with a key addendum: these were flagged as requiring grounding in further data. These tentative notes were regularly reviewed and compared against the initial preconception log to identify any consistent biases shaping early interpretations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOperationalizing the Double Hermeneutic for Bracketing:\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe researchers consciously engaged in the double hermeneutic by understanding\u0026nbsp;the participant\u0026apos;s sense-making of their experience. During the transcription and initial coding phases, the focus was on the participants\u0026rsquo;\u0026nbsp;dialogues\u0026nbsp;and their immediate context. The researchers\u0026nbsp;made deliberate efforts to use the\u0026nbsp;latter\u0026rsquo;s\u0026nbsp;own language in initial codes and thematic descriptions as much as possible before moving to more abstract analytical labels.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePeer Debriefing and External Audit of Reflexivity:\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe impromptu session with unaffiliated researchers served as an\u0026nbsp;external bracketing mechanism. In this session, the researchers presented anonymized excerpts of their reflexive journal and preliminary interpretations. Colleagues were asked to challenge the researchers\u0026nbsp;on how their stated background and beliefs might be influencing the framing of emergent themes. This dialogue provided an external perspective that helped to uncover subtle biases and reinforce the commitment to representing the participants\u0026apos; experiences authentically.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eProcess of Phenomenological Reduction\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe phenomenological reduction process in this study involved a systematic engagement with the interview data operationalized through the four-phase program of IPA.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePhase 1: Deep Immersion and Initial Engagement with Transcripts:\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Each of the seven interview transcripts was first read multiple times in its original language to gain a sense of the participant\u0026apos;s unique account. Simultaneously, the audio recordings were listened to repeatedly alongside the transcript. This dual engagement helped capture nuances of tone, emotional expression, hesitations, and emphasis that text alone might not fully convey. During this phase, the researchers made open-ended memos for each transcript that noted overall impressions and the perceived emotional arc of the interview. This phase involved familiarization before any formal coding commenced.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePhase 2: Exploratory Noting, Deconstruction, and Construction of Experiential Statements\u003c/strong\u003e \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis phase involved a line-by-line analysis of each transcript:\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026middot;Deconstruction:\u003c/strong\u003e The researchers segmented the text into manageable meaning units: phrases or sentences that conveyed a distinct aspect of participant experiences.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026middot;\u0026nbsp;Exploratory Noting:\u003c/strong\u003e For each meaning unit, exploratory comments were made in the margins.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eo\u0026nbsp;Descriptive comments\u003c/em\u003e focused on summarizing the overt content (e.g., \u0026quot;Participant describes using app X to review for Y exam\u0026quot;).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eo\u0026nbsp;Linguistic comments\u003c/em\u003e noted particular uses of language, metaphors, or repetition (e.g., \u0026quot;Participant repeatedly uses \u0026apos;battle\u0026apos; metaphor for exams\u0026quot;). The description of final examinations as \u0026quot;life or death sentences\u0026quot; by multiple participants is an example of such a linguistic point.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eo\u0026nbsp;Conceptual comments\u003c/em\u003e involved making preliminary interpretations of the psychological significance of the statement (e.g., \u0026quot;This suggests a feeling of being overwhelmed, seeking control through technology\u0026quot;).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026middot;\u0026nbsp;Horizontalization and Initial Abstraction:\u003c/strong\u003e Initially, all meaning units relevant to the research questions were treated with equal potential significance. The researchers then began to abstract these initial notes and meaning units into more concise \u0026quot;experiential statements\u0026quot; that captured the essence of what was being expressed, staying close to the participant\u0026apos;s own language and perspective. For example, multiple similar statements about stress before exams and anxiety over the volume of material were condensed into experiential statements reflecting \u0026quot;exam-induced pressure\u0026quot; or \u0026quot;information overload.\u0026quot;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePhase 3: Developing Experiential Statements into Emergent (Individual-Level) Themes:\u003c/strong\u003e \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis phase focused on participant\u0026nbsp;accounts\u0026nbsp;individually before any cross-case analysis:\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026middot;\u0026nbsp;Clustering and Thematizing:\u003c/strong\u003e The experiential statements derived from the previous phase for a single participant were then examined for connections and interrelationships. The researchers looked for patterns, repetitions, and clusters of meaning. This involved a process of grouping related experiential statements together. For instance, statements about \u0026quot;the app helping me find my weak spots,\u0026quot; \u0026quot;the AI tailoring questions to my level,\u0026quot; and \u0026quot;feeling the learning was more focused\u0026quot; were clustered under a preliminary theme like \u0026quot;Personalized Learning Pathway.\u0026quot;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026middot;\u0026nbsp;Structuring Themes:\u003c/strong\u003e For each participant, a list of discrete emergent themes was developed, each with a descriptive label that aimed to capture the essence of the clustered experiential statements. These themes were then organized hierarchically where appropriate (e.g., a main theme with sub-components). Each theme was explicitly defined. The specific meaning units and experiential statements supporting it were cataloged. This maintained a clear audit trail from raw data to the individual-level theme. This was an iterative process involving re-reading transcripts and earlier notes to ensure the themes accurately represented individual experiences. The goal was to create an idiographic portrayal of each participant\u0026apos;s unique engagement with the phenomenon. The reflexivity journal was consulted here to ensure the clustering was driven by the participants\u0026rsquo; narrative logic instead of the researchers\u0026apos; pre-existing theoretical frameworks.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eApplication of Imaginative Variation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFollowing the\u0026nbsp;aforementioned\u0026nbsp;phenomenological reduction, imaginative variation was employed to move\u0026nbsp;emergent themes from individual experiential accounts to Group Experiential Themes (GETs)[26].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1.\u0026nbsp;Probing the Boundaries and Invariance of Individual Themes:\u003c/strong\u003e For each significant theme identified within an individual participant\u0026apos;s account (e.g., \u0026quot;adaptive learning as a stress mitigator\u0026quot; for Participant A, or \u0026quot;fear of missing out on effective adaptive learning (AL) tools\u0026quot; for Participant B), the researchers engaged in a series of imaginative exercises. This involved asking specific \u0026quot;what if\u0026quot; questions documented in the analytical memos:\u003c/p\u003e\n\u003cp\u003eo \u0026quot;If this participant had \u003cem\u003enot\u003c/em\u003e had access to feature X of the adaptive learning tool, would this experience of \u0026apos;stress mitigation\u0026apos; still be present in the same way? What aspects would change? What would remain?\u0026quot;\u003c/p\u003e\n\u003cp\u003eo \u0026quot;Consider the opposite: what if this participant described adaptive learning as \u003cem\u003eincreasing\u003c/em\u003e their stress? What conditions described in their narrative would need to be different for that to be the case?\u0026quot; This helped to clarify the specific conditions under which adaptive learning was experienced positively or negatively.\u003c/p\u003e\n\u003cp\u003eo\u0026nbsp;For a theme like \u0026quot;technological dependence,\u0026quot; the researchers\u0026nbsp;would vary contextual elements in their reflection: \u0026quot;Is this dependence primarily linked to the high-stakes nature of exams, or is it a broader characteristic of their learning style? How might this dependence manifest if exams were less critical for progression\u0026quot;? Such questioning helped to distinguish the core of the dependence from its situational triggers.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.\u0026nbsp;Exploring Textural and Structural Dimensions:\u003c/strong\u003e Imaginative variation was used to move between the \u003cem\u003ewhat\u003c/em\u003e (texture) and the \u003cem\u003ehow\u003c/em\u003e (structure) of the experiences.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eo\u0026nbsp;Textural Exploration\u003c/em\u003e: The researchers would focus on a theme (e.g., \u0026quot;improved perceived performance\u0026quot;) and immerse themselves in verbatim statements from a participant, trying to grasp the full range of feelings and thoughts associated with it. \u0026quot;What does it \u003cem\u003efeel\u003c/em\u003e like for this student to perceive their performance as improved through adaptive learning?\u0026quot;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eo\u0026nbsp;Structural Exploration\u003c/em\u003e: The researchers\u0026nbsp;then shifted to understanding the underlying conditions that gave rise to this feeling. \u0026quot;What specific aspects of the adaptive learning interaction (e.g., instant feedback, progress tracking, targeted questions) contribute to this \u0026apos;improved perceived performance\u0026apos;? How do these elements interrelate to produce the overall experience?\u0026quot; This involved imaginatively altering these components to see their impact on the experienced theme.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3. Cross-Contextual Imaginings for Essential Meanings:\u003c/strong\u003e\u0026nbsp; When comparing similar themes across participants (e.g., several participants mentioning \u0026quot;effort minimization\u0026quot;), imaginative variation was used to identify the shared essence. The researchers asked, \u0026quot;Despite differences in their backgrounds (e.g., rural vs. urban, high vs. lower intrinsic motivation as described by Liu Shuai vs. Huang Jian ), what is the invariant core of this experience of \u0026apos;effort minimization\u0026apos; as it relates to using adaptive learning tools for exam preparation? Is it about strategic time-saving, a circumvention of deeper learning, or a pragmatic response to overwhelming workloads?\u0026quot; This involved considering the theme across participant narratives and imaginatively stripping away idiosyncratic details to arrive at the structural core.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSynthesis of Meanings into GETs\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe synthesis of meanings represented the interpretive act\u0026nbsp;of the analytical process\u0026nbsp;where idiographically derived understandings were woven into a coherent structure of Group Experiential Themes (GETs) that represented the lived experience for the participant cohort.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSystematic Cross-Case Thematic Comparison:\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAfter the\u0026nbsp;aforementioned\u0026nbsp;analysis of each of the seven participants, the synthesis began with a formal cross-case comparison. An analytical matrix was developed\u0026nbsp;that\u0026nbsp;listed\u0026nbsp;each participant and their\u0026nbsp;derived themes. This matrix allowed the researchers\u0026nbsp;to visually map convergences, divergences, and interconnections. For example, themes from Participant A related to \u0026quot;feeling less anxious with mock exams on the app\u0026quot; were compared with themes from Participant B concerning \u0026quot;using AL to reduce study load before finals,\u0026quot; looking for underlying commonalities that could point towards broader experiences\u0026nbsp;of distress reduction.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIterative Development and Refinement of GETs:\u003c/strong\u003e The identification of patterns in the matrix led to the iterative formulation of candidate GETs:\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eo\u0026nbsp;Initial Grouping:\u003c/strong\u003e Similar individual themes were clustered under tentative GET labels. For example, various individual expressions of reduced anxiety and managed stress were initially grouped under a code of \u0026quot;Emotional Impact of AL.\u0026quot;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eo\u0026nbsp;Conceptual Abstraction and Labeling:\u003c/strong\u003e The researchers then worked to refine these broad codes into more precise GET labels that captured the essence of the shared experience. \u0026quot;Emotional Impact of AL\u0026quot; was refined to \u0026quot;Decreased distress.\u0026quot; Sub-themes like \u0026quot;academic burnout\u0026quot; and \u0026quot;exam stress\u0026quot; were identified as distinct but related facets of this GET.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eo\u0026nbsp;Defining and Substantiating GETs:\u003c/strong\u003e Each GET was then defined within its scope. The researchers returned to the individual participant data to select the most compelling verbatim quotes that exemplified each GET and its sub-themes .\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStructuring the Overall Experiential Account:\u003c/strong\u003e The identified GETs were then organized into a coherent narrative structure that aimed to tell the collective story of the participants\u0026apos; engagement with adaptive learning. The relationships between these GETs were explored. For example, \u0026quot;improved learning proficiency\u0026quot; might contribute to \u0026quot;decreased distress,\u0026quot; or \u0026quot;liabilities after extended use\u0026quot; might emerge over time despite initial benefits.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePeer Auditing for Credibility:\u003c/strong\u003e As mentioned before, the summary of themes was subjected to review by an unaffiliated researcher and academic medical peers. Specifically, these auditors were asked to evaluate the coherence of the thematic structure, the clarity of the GET definitions, and the convincingness of the link between the GETs and the supporting participant quotes. Feedback from this process was used to refine the wording of themes and ensure the analytical narrative was compelling.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eJustification of Sample Size (N=7) within an IPA Framework\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe decision to include seven participants in this study was a methodological choice\u0026nbsp;rooted in the principles of IPA\u0026nbsp;and\u0026nbsp;consistent with contemporary evidence for data saturation in qualitative studies at relatively small sample sizes [27,28]. Homogeneous studies\u0026nbsp;have also prioritized depth\u0026nbsp;and richness\u0026nbsp;of lived experience over numerical representativeness in similar sample sizes[29,30].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeliberate Pursuit of Idiographic Depth:\u003c/strong\u003e IPA\u0026rsquo;s primary commitment is to an idiographic understanding that thoroughly examines individual cases before attempting to identify shared patterns. A sample of this size allowed the researchers the necessary scope to engage deeply with each individual transcript that IPA demands. This ensured that the unique voice and perspective of each of the seven medical students were fully explored and honored before any cross-case synthesis was undertaken. A larger sample would have pragmatically constrained the ability to achieve this level of individual analytical depth.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEnsuring Data Richness for Phenomenological Insight:\u003c/strong\u003e The seven selected fourth-year medical students provided data of substantial richness and texture in their shared context of an exam-oriented curriculum and recent engagement with adaptive learning tools. The data obtained from these seven individuals were not superficial: participants offered elaborate accounts of their study practices, emotional responses to academic pressures, perceptions of adaptive learning technologies, and the specific ways these tools integrated into their exam preparation strategies.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAchieving Thematic Sufficiency for the Specific Phenomenon:\u003c/strong\u003e While IPA does not typically use the term \u0026quot;saturation\u0026quot; in the same way as some other qualitative methodologies, a key consideration was whether the sample size allowed for a robust and sufficiently complex understanding of the phenomenon. With seven participants, recurring patterns of experience began to emerge with consistency across different accounts while also highlighting unique individual variations. The three major GETS and their associated sub-themes were well-supported by data from multiple participants. Further interviews were deemed unlikely to significantly alter the core thematic structure that emerged from these accounts, indicating a level of thematic sufficiency.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAnalytical Manageability and Rigor:\u003c/strong\u003e The process of IPA, from transcription and repeated immersions to detailed coding, theme development, and cross-case synthesis, is labor-intensive. This sample size allowed the research team to maintain a high level of analytical quality and detail throughout the process. It ensured that each transcript could be afforded the necessary focused attention without compromising the depth of interpretation, which aligns with recommendations by Smith et al.[19] for IPA studies aiming for sufficient details in publishable accounts.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003ePersonal reflexivity\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eReflecting on the potential effects that pre-existing beliefs may have had on the outcomes of the interpretation is constitutive of the aforementioned double hermeneutic of this study. The author took part in reflexivity using the reflexive notes compiled from each interview. Moreover, the author had an impromptu session involving unaffiliated researchers questioning the author on their worldview and its potential influences this may have on the research. The result is a reflexivity statement that helps understand the beliefs underlying this work. The author is a researcher and educator affiliated with medical institutions. They completed their qualifications in a mainland Chinese university and underwent similar regimes as the participants of the study. The author personally believes in the practical benefits of competency-based education. They also believe in the advantages afforded by learner-focused and learner-directed medical training to produce more suitable candidates for modern healthcare. Summative assessment, as the kind experienced by participants in the study, is a flawed system in the author\u0026rsquo;s view, as it creates overly high stakes and negatively impacts the well-being of students. Overall, the author believes in a need for medical educational reform in mainland China that steers towards more holistic education rather than a narrow-scoped focus on textbook materials and didactic teaching methods.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec25\" class=\"Section2\"\u003e\u003ch2\u003eParticipants\u003c/h2\u003e\u003cp\u003eFor the remainder of the article, pseudonyms will be used to protect the anonymity of participants. Table\u0026nbsp;1 provides the list of pseudonyms and corresponding details of the participants\u0026rsquo; backgrounds. This informs the interpretation and helps contextualize their responses during the interviews.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eParticipants\u0026rsquo; pseudonyms and backgrounds\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eParticipant pseudonyms\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eParticipant backgrounds\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLi Qiang\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026minus;22 years old\u003c/p\u003e\u003cp\u003e- Male, ethnic Han Chinese\u003c/p\u003e\u003cp\u003e- Student council representative\u003c/p\u003e\u003cp\u003e- Urban middle class background (self-described) from the city where the university is located at (Guangzhou)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLiu Shuai\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026minus;21 years old\u003c/p\u003e\u003cp\u003e- Male, ethnic Han Chinese\u003c/p\u003e\u003cp\u003e- Awarded distinction in several provincial level chemistry competitions during secondary education\u003c/p\u003e\u003cp\u003e- Currently aiming to change schools for postgraduate studies\u003c/p\u003e\u003cp\u003e- Rural working class background (self-described) from a socio-economically deprived area of the province where the university is located at (Guangdong)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWang Jun\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026minus;22 years old\u003c/p\u003e\u003cp\u003e- Male, ethnic Zhuang Chinese (a Tai-speaking ethnic group in South China)\u003c/p\u003e\u003cp\u003e- Originally planned for engineering major, transferred to studying in the medical field due to personal and familial reasons\u003c/p\u003e\u003cp\u003e- Rural working class background (self-described) from a socio-economically deprived area out of the province\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eChen Gang\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026minus;23 years old\u003c/p\u003e\u003cp\u003e- Male, ethnic Han Chinese\u003c/p\u003e\u003cp\u003e- Took a mental health leave during third year and an in-semester leave this year\u003c/p\u003e\u003cp\u003e- Urban upper middle class background (self-described) from Shanghai\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHuang Jian\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026minus;22 years old\u003c/p\u003e\u003cp\u003e- Male, ethnic Han Chinese\u003c/p\u003e\u003cp\u003e- Parents both work in the medical field\u003c/p\u003e\u003cp\u003e- Urban upper middle class background (self-described) from Guangzhou\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eZhang Min\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026minus;21 years old\u003c/p\u003e\u003cp\u003e- Female, ethnic Han Chinese\u003c/p\u003e\u003cp\u003e- Urban upper classmiddle background (self-described) from Guangzhou\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLin Na\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026minus;22 years old\u003c/p\u003e\u003cp\u003e- Female, ethnic Yao Chinese (a Mien-speaking ethnic group in Southwest China)\u003c/p\u003e\u003cp\u003e- Rural working class background (self-described) from a socio-economically deprived area out of the province\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cdiv id=\"Sec26\" class=\"Section3\"\u003e\u003ch2\u003eStructural Analysis\u003c/h2\u003e\u003cp\u003eStructural analysis reveals three major group experiential themes and their associated sub-themes across student perspective towards adaptive learning in their studies (Fig.\u0026nbsp;2; Table\u0026nbsp;2).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eResults of structural analysis identifying major and sub-themes\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMajor themes\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSub themes\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDecreased distresses\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAcademic burnout\u003c/p\u003e\u003cp\u003eExam stress\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eImproved learning proficiency\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePerceived performance\u003c/p\u003e\u003cp\u003eTailored learning experiences\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLiabilities after extended use\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEffort minimization\u003c/p\u003e\u003cp\u003eTechnological dependence\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec27\" class=\"Section3\"\u003e\u003ch2\u003eDecreased distresses\u003c/h2\u003e\u003cp\u003eAdopting adaptive learning methods have reduced learning-related distresses found within medical students. This allowed participants to approach learning with a more active and motivated mindset. Two main forms of distresses were promptly addressed through the introduction of adaptive learning tools: academic burnout and exam stress.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec28\" class=\"Section2\"\u003e\u003ch2\u003eAcademic burnout\u003c/h2\u003e\u003cp\u003eParticipants reported multiple cases of feelings of burnout prior to examinations and sporadically during their school year. There was a prevalent feeling that \u0026ldquo;studying becomes a chore and an unbearable thing to think about\u0026rdquo; (Zhang Min) when faced with prolonged periods of non-stop instructions and large quantities of instructional materials. Participants also exhibited signs reminiscent of academic procrastination:\u003c/p\u003e\u003cp\u003e\u0026ldquo;Sometimes, I know I should be reading up on [class notes], but I just don\u0026rsquo;t want to. It is strange because there was one me that knew I must do it, and there was another me that just did not want to do anything\u0026hellip; It becomes very tiresome at that point.\u0026rdquo; (Chen Gang)\u003c/p\u003e\u003cp\u003eAccess to adaptive learning platforms restores some motivations for students and contributes to them regaining self-determination in learning by mitigating feelings of apprehension and frustration usually associated with academic burnout.\u003c/p\u003e\u003cp\u003e\u0026ldquo;It is reassuring to know that\u0026hellip; there is this tried and tested tool [adaptive learning app] that I can pull up and use to make good progress\u0026hellip; It is good; it makes me think less about what would happen if I did not make good progress and learn enough today.\u0026rdquo; (Li Qiang)\u003c/p\u003e\u003cp\u003eEven in cases where motivations are not improved after the introduction of adaptive learning alternatives, participants still reported a general decrease in feelings of burnout. Students felt less exhausted and reacted less negatively to long periods of studying.\u003c/p\u003e\u003cp\u003e\u0026ldquo;I don\u0026rsquo;t think it made me more motivated... I mean, but [I agree] that I am definitely less stressed about exams and learning stuff. Less tired,\u0026hellip; that is how I would [put] it; studying usually makes me want to fall asleep, but [adaptive learning tools] make it more tolerable.\u0026rdquo; (Huang Jian)\u003c/p\u003e\u003cp\u003eAdaptive learning also enabled students to become more willing to participate in classes and attend lectures more regularly. This is a consequence of improved sense of ability derived from adaptive learning experiences.\u003c/p\u003e\u003cp\u003e\u0026ldquo;If the class I am going to is not listed on the [adaptive learning] app, I am not going to sit in the front row\u0026hellip; Imagine getting called to answer questions\u0026hellip; With the app, I can at least get a general gist of what the lecture involves before going there.\u0026rdquo; (Li Qiang)\u003c/p\u003e\u003cp\u003eConsulting adaptive learning tools has decreased frustration by providing a sense of initiative and agency towards improving one\u0026rsquo;s learning progress.\u003c/p\u003e\u003cp\u003e\u0026ldquo;The best thing [about adaptive learning] is, I think, I start to see where I need help. With [traditional] instruction, I go to class, and the professor goes through a list of key points before showing a few exam questions. That is it. But if something different comes up in the exam or as a mock question, I am completely unprepared. and it is frustrating to go wrong but not know where you went wrong or how you can come about fixing it.\u0026rdquo; (Liu Shuai)\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec29\" class=\"Section2\"\u003e\u003ch2\u003eExam stress\u003c/h2\u003e\u003cp\u003eExam stress is another form of distress that adaptive learning has significantly helped to mitigate during the participants\u0026rsquo; experiences before final examinations. The summative assessment format that mainland Chinese undergraduates adopt makes final examinations extremely high-stake and generates a high level of stress shared by all participants in the study. Several of the participants called final examinations a series of \u0026ldquo;life or death sentences\u0026rdquo; (Liu Shuai, Wang Jun, and Lin Na). Lin Na viewed the level of exam stress as negatively impacting her performance, something that adaptive learning can help to address:\u003c/p\u003e\u003cp\u003e\u0026ldquo;I personally feel a lot of stress before exams... and that makes me double-guess a lot of my answers during exams and just waste too much time overthinking about things. The mock paper part of the [adaptive learning] platforms is quite good because I can at least enter into the exam knowing that I am predicted a 90% or higher mock-wise.\u0026rdquo; (Lin Na)\u003c/p\u003e\u003cp\u003eThe participant group attributed exam stress to the overburdensome amount of knowledge that undergraduate medical examinations cover. Adaptive learning plays an active role in tailoring learning to cut down on unnecessary work and focus on areas that participants most urgently need to focus on:\u003c/p\u003e\u003cp\u003e\u0026ldquo;I have to do like 15 exams this year, and it is all within a two-week period too. There are approximately 500 pages of reading notes for just one of the exams. I also have to learn Marxism and political studies as part of the school requirements. Realistically, I am not going to be able to cover all of that. So the [adaptive learning] software keeps the learning materials to a reasonable level, and I can actually study without having to be stressed over a mountain pile of papers.\u0026rdquo; (Li Qiang)\u003c/p\u003e\u003cp\u003eThe lack of exam-related discussions from the end of the educators also engendered stress and created ambiguity regarding examinations that adaptive learning alleviates by encouraging more self-regulated learning.\u003c/p\u003e\u003cp\u003e\u0026ldquo;Professors do not talk about examinations because they do not want to leak anything by mistake. But sometimes you give them an answer and ask, \u0026lsquo;Is that how I am supposed to answer this type of question?\u0026rsquo; and they just tell you to figure it out by yourself and that \u0026lsquo;the answers are all in the textbooks.\u0026rsquo; That is just not really true, so I use adaptive learning tools to locate standard answers and sample questions.\u0026rdquo; (Zhang Min)\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eImproved learning proficiency\u003c/h3\u003e\n\u003cdiv id=\"Sec31\" class=\"Section2\"\u003e\u003ch2\u003ePerceived performance\u003c/h2\u003e\u003cp\u003eContinued employment of adaptive learning led to increased academic proficiency as reflected in their perceived performance. Adaptive learning tools were described as \u0026ldquo;a lifesaver for passing exams and achieving good grades\u0026rdquo; (Lin Na). Responses towards the use of adaptive learning are unanimously positive, and participants viewed adaptive learning as an integral part of their revision process for final examinations.\u003c/p\u003e\u003cp\u003e\u0026ldquo;Most of the end-of-year revision that I did was done through Yikaobang (an adaptive learning platform developed for mainland Chinese students). It is useful for brushing up on questions that I usually struggle with and identifying weak spots to learn more about.\u0026rdquo; (Li Qiang)\u003c/p\u003e\u003cp\u003eThe effectiveness of adaptive learning on academic performance is widely recognized amongst medical students. Some participants transitioned into adaptive learning as a result of positive experiences from seniors and classmates:\u003c/p\u003e\u003cp\u003e\u0026ldquo;[Adapting learning tools], everyone uses them... It is frequently advised, especially towards exam season. I was told [by others] that attending classes is not enough and textbooks provide limited information compared to the content that will actually appear on exams.\u0026rdquo; (Wang Jun)\u003c/p\u003e\u003cp\u003eParticipants attributed improvements in their grades to the amount of time spent on adaptive learning platforms, rather than how much time they devoted to other instructional materials.\u003c/p\u003e\u003cp\u003e\u0026ldquo;I spent roughly the same time on contents handed out during class. Adaptive learning is where the real differences are made, in my opinion. It is also because there is only so much to look at with lecture notes and recordings, whereas adaptive learning platforms regularly update you with new questions, examples, and exam-related tips.\u0026rdquo; (Li Qiang)\u003c/p\u003e\u003cp\u003eSome participants, when discussing the aforementioned effects of adaptive learning on academic distress, also noted that adaptive learning indirectly improved their performance by decreasing the amount of negative emotions associated with learning.\u003c/p\u003e\u003cp\u003e\u0026ldquo;Adaptive learning made content more digestible and easier to comprehend... It would be frustrating to spend hours remembering Latin names by rote. But the game feature [on this adaptive learning app] definitely made the process less tedious.\u0026rdquo; (Lin Na)\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec32\" class=\"Section2\"\u003e\u003ch2\u003eTailored learning experiences\u003c/h2\u003e\u003cp\u003eAnother salient area of adaptive learning where participants articulated overwhelming approval for is the provision of personalized learning experiences. Participants recognized that adaptive learning more promptly addresses unique needs than conventional, non-adaptive methods. Tailoring the education experience through differentiated instructions enhanced the quality of learning by emphasizing personalized learning frameworks.\u003c/p\u003e\u003cp\u003e\u0026ldquo;Professors just teach. They are often quite busy, and our classes are large, 60\u0026ndash;100 people. And there is just no time to really answer any questions or discuss any of the specifics. These [adaptive learning] platforms give a feeling of, sort of, personal tutelage.\u0026rdquo; (Zhang Min)\u003c/p\u003e\u003cp\u003eParticipants appreciated the interactive aspects of adaptive learning that allow for learners to gradually customize difficulty and processes to suit their own needs. These are aspects that would not be as accessible in conventional teaching environments:\u003c/p\u003e\u003cp\u003e\u0026ldquo;The customization features are very cool. I took a year and some time off, so I am quite behind on several classes. And I always feel a bit apprehensive asking basic questions in class, especially if the lecture is already way past basic knowledge. So, having a tool that can answer basic questions and explain it to me patiently is a great help.\u0026rdquo; (Chen Gang)\u003c/p\u003e\u003cp\u003eTemporal constraints and teacher-student relationships also play a part in adaptive learning, enabling students to learn more proficiently. The hierarchical relationship between professors and students in mainland China makes tailored learning inaccessible otherwise.\u003c/p\u003e\u003cp\u003e\u0026ldquo;Even when I do get a chance at scheduling a meeting with my professor, I usually have to prepare ahead of time the questions I want to ask, and I cannot take up too much time if he has other affairs to attend to that day. So, I only really do that once or twice a month. For the most part, adaptive learning tools are just far more convenient for answering questions that I sporadically encounter during my time studying.\u0026rdquo; (Wang Jun)\u003c/p\u003e\u003cp\u003eParticipants also repeatedly referred to the concept of \u0026ldquo;discovering knowledge gaps and filling them up\u0026rdquo; (Li Qiang). This is viewed as the most urgent need of undergraduate medical students during their academic careers. Students noted that the personalization in adaptive learning permits a learner-focused education that targets gaps in knowledge.\u003c/p\u003e\u003cp\u003e\u0026ldquo;Most of us know the content. We go to classes, and we study daily. The issue is, amongst 10 or 15 classes and hundreds of textbooks, you are bound to have some lapses\u0026mdash;areas where you just forgot or missed some key information. This is the most important problem that we must tackle to achieve good grades. Adaptive learning speeds up that process so we do not have to reread the entire mountain of books every time we study.\u0026rdquo; (Liu Shuai)\u003c/p\u003e\u003cdiv id=\"Sec33\" class=\"Section3\"\u003e\u003ch2\u003eLiabilities after extended use\u003c/h2\u003e\u003c/div\u003e\u003cdiv id=\"Sec34\" class=\"Section3\"\u003e\u003ch2\u003eEffort minimization\u003c/h2\u003e\u003cp\u003eParticipants recognized that the use of adaptive learning technology bifurcates depending on the level of motivation of the user. If the user is highly motivated to succeed academically, adaptive learning alone is insufficient for reaching that goal. This leads to a strange case where the most frequent users of adaptive learning tend to be the least motivated:\u003c/p\u003e\u003cp\u003e\u0026ldquo;I personally do not just rely on adaptive learning\u0026hellip; I am currently aiming for Tongji University for my postgraduate studies, so I need excellent grades in my finals. My own experiences are that adaptive learning is good, but you cannot just rely on them. I also do my own graphs, use 3D anatomy apps to learn, make my own mindmaps... all that.\u0026rdquo; (Liu Shuai)\u003c/p\u003e\u003cp\u003eCurrent adaptive learning technologies available to mainland Chinese students focus heavily on exam-style questions and sample answers with less emphasis on textbook knowledge.\u003c/p\u003e\u003cp\u003e\u0026ldquo;[Adaptive learning] apps are great for checking my answers for mock exam papers and seeing how I should be answering these questions. But the amount of technical details is amiss in a lot of the services that they provide. I use them for practicing questions more than anything else... I think they can be improved otherwise.\u0026rdquo; (Zhang Min)\u003c/p\u003e\u003cp\u003eStudents with less motivation and lower goals rely more heavily on adaptive learning tools to boost their performance in the short run without investing much effort.\u003c/p\u003e\u003cp\u003e\u0026ldquo;I do not really have any serious academic pressures. I need to pass, sure, but I already have a job lined up locally. So, adaptive learning platforms are a lifesaver for getting by exams without much studying. For some of my classes, I spent about 40 hours on the applications and just memorized a lot of the common questions. I think it is an extremely convenient alternative to actually going through all the materials.\u0026rdquo; (Huang Jian)\u003c/p\u003e\u003cp\u003eOthers have reported that adaptive learning tools may be used to deal with less important classes and allow them more time to focus on professional knowledge.\u003c/p\u003e\u003cp\u003e\u0026ldquo;I think there is nothing wrong with using adaptive learning tools to study politics/English. Those were sort of forced on us always. I just skip those classes and materials and use adaptive learning apps to practice until I am confident that I can pass those classes.\u0026rdquo; (Chen Gang)\u003c/p\u003e\u003cp\u003eParticipants also identified some level of mentality shift involved in long-term use of adaptive learning tools that bring about more slothful learning approaches and greater technological dependence. This part of the conversation stimulated some individual reflections:\u003c/p\u003e\u003cp\u003e\u0026ldquo;Now that you mention it, I definitely feel like getting lazier with learning, especially if the class that I am studying for has really good adaptive learning modules online. In those cases, I tend to just leave it up to the artificial intelligence or algorithm or something to do the job. I do think that, now that you said that, when there was not much adaptive learning stuff around... pre-Covid? I was more actively engaging with the content.\u0026rdquo; (Li Qiang)\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\n\u003ch3\u003eTechnological dependence\u003c/h3\u003e\n\u003cp\u003eCentral to the long-term effects felt by student participants was the feeling of increased reliance on adaptive learning tools to assist with their studies. This was experienced by most interviewees as a gradual buildup of \u0026ldquo;a habit to pick up the phone as opposed to the textbook when an exam is coming up.\u0026rdquo; (Lin Na) Respondents also noted that this feeling of reliance led to more efforts in searching for relevant adaptive learning materials. This led to more academic discussions revolving around the medium of adaptive learning as opposed to the learned content.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eNot all the content that we get tested on is listed on these sites\u0026hellip; I mean, most of them are created by students and companies, not schools, yes. So we have this group chat where we ask around on what is the newest, best platform to use to study for an exam\u0026hellip;\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u0026ldquo;Finding the right website is more important than reading the books over and over again\u0026hellip;that is my motto anyway.\u0026rdquo; (Chen Gang)\u003c/p\u003e\u003cp\u003eDependence on adaptive learning tools meant that students developed feelings of trepidation or anxiety when their familiar tools became unavailable or did not contain the content that they needed. This translates to academic stress similar to exam-related stress.\u003c/p\u003e\u003cp\u003e\u0026ldquo;Sometimes, the [adaptive learning] websites do not update to the latest edition of our textbooks or just happen to not cover the content that we know will get tested on\u0026hellip;I get so scared when that happens; I am always like, \u0026ldquo;Please, please let [the exam materials] be there.\u0026rdquo; (Zhang Min)\u003c/p\u003e\u003cp\u003eThis stress has been reported as a worse experience than the usual stress that they felt before studying with adaptive learning tools or during their high school days when adaptive learning was unavailable. The increased stress is likely due to difficulties with returning back to non-adaptive formats of learning and the lack of related preparations.\u003c/p\u003e\u003cp\u003e\u0026ldquo;I just feel cold sweat down on my spine when I see a course being \u0026lsquo;unavailable at the moment\u0026rsquo; or \u0026lsquo;waiting for update\u0026rsquo;\u0026hellip; It feels so bad having to return to reading the books bit by bit and borrowing people\u0026rsquo;s notes. I am constantly feeling like I was doing well before because of the internet tools and not because I know everything well.\u0026rdquo; (Li Qiang)\u003c/p\u003e\u003cp\u003e\u0026ldquo;Studying felt awful when there was nothing available online for you. My notes in class have been quite poor since they are not that important to my revision anyway nowadays. But sometimes I do wish I was a bit more industrious in class about them.\u0026rdquo; (Chen Gang)\u003c/p\u003e\u003cp\u003eSometimes, this stress will cause students to pay money for premium services hosted by privatized adaptive learning platforms. \u0026ldquo;I have spent more money on subscriptions than textbooks this year.\u0026rdquo; (Huang Jian) Other times, this will cause students to find alternative means of accessing their desired mode of adaptive learning:\u003c/p\u003e\u003cp\u003e\u0026ldquo;I am actually programming my own AI-powered adaptive learning tool this year in my free time. It is convenient to piggyback on good domestic language models.\u0026rdquo; (Liu Shuai)\u003c/p\u003e\u003cp\u003eStudents generally displayed disinclination to return to more conventional learning formats, citing their dependence on adaptive learning technology as \u0026ldquo;keeping up with the trends of learning.\u0026rdquo; (Wang Jun) Participants responded negatively to the dependence on adaptive learning technology being interpreted as a phenomenon of concern.\u003c/p\u003e\u003cp\u003e\u0026ldquo;I think [teachers and schools] are making a big deal out of something trivial. Yes, we use online platforms to study\u0026hellip;yes, these platforms use advanced algorithms and large language models to predict questions or layer our studying to be more effective. But [adaptive learning] is efficient, and we did not cheat. To me, this is no different from upgrading from going to the library to browsing through e-books. Saying that we are dependent on adaptive learning is like saying we are dependent on computers\u0026hellip;of course we are! It is the modern form of learning, and I think it will be the future for the foreseeable time to come.\u0026rdquo; (Liu Shuai)\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study investigated the perspectives of Chinese undergraduate medical students towards their current experiences with adaptive learning and situated these experiences within the exam-oriented environment of Chinese medical education. Participant responses confirmed some of the existing theories of adaptive learning as a salient tool in addressing the individual learning needs of students. While minimal effects on learning motivation are observed, the participants identify personalization as a key theme in adaptive learning\u0026rsquo;s advantage over traditional instructions. At the same time, cultural and contextual elements of Chinese education played a nontrivial part in shaping student perception of adaptive learning. From these viewpoints, adaptive learning is sometimes perceived as a technological shortcut for individuals to meet the baseline requirements of academic progression rather than an efficacious tool for enabling academic excellence amongst all medical students.\u003c/p\u003e\u003cdiv id=\"Sec37\" class=\"Section2\"\u003e\u003ch2\u003eLoad management\u003c/h2\u003e\u003cp\u003eMedical students have long reported symptoms of exam-related distress, including academic burnout and exam stress prior to this study[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Emphasis on academic achievement and fear of failure associated with examinations lead to degraded medical school learning environments[\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. These aspects increase the cognitive load and stress levels of students, which in turn lead to worsening mental welfare and learning efficacy[\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. The mediating role that technology has in the interplay of cognitive load management and self-regulated learning has been viewed as one upside of adaptive learning tools[\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eParticipants used adaptive learning tools, most often applications, to manage their workload before final examinations and also minimize their cognitive load. The latter is consistent with the theory of cognitive load and the load management idea frequently seen in medical education[\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. The theory advocates for an optimization of learning through the reduction of extraneous cognitive loads by adjusting processes by which instructional information is presented to the learner[\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. In the context of Chinese medical education at the undergraduate level, these cognitive loads consist of the clarity of instructional materials provided and the translation of these instructions into examination-style questions and answers[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Employment of adaptive learning encourages parallel processing and improved automaticity, thereby lowering cognitive load amongst students[\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Aside from cognitive load, participants also sought to reduce workload by targeting areas where the algorithms have deemed them the weakest at or most likely tested for.\u003c/p\u003e\u003cp\u003eParticipants conventionally expect this improvement in both cognitive load and workload to occur by means of additional instructions and instructors charting out a narrower scope of the content for students to revise. Participants identified these as customary teaching practices in Chinese medical education. The introduction of adaptive learning has alleviated exam-related distresses by permitting load management before examinations[\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. In the case of China, this introduction has not established a new learning practice but rather transferred the role of load management from instructors into the hands of learners, thereby enabling a greater degree of agency and equality amongst medical students. On the flip side, this could indicate that the significance of adaptive learning to medical education is limited by the effectiveness of conventional measures to monitor the workload and cognitive load of students.\u003c/p\u003e\u003cdiv id=\"Sec38\" class=\"Section3\"\u003e\u003ch2\u003ePersonalization\u003c/h2\u003e\u003cp\u003eThe advantage of personalization through adaptive learning environments over non-adaptive approaches is not a novel discovery[\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. The real-time feedback and minimization of bias play important roles in raising user satisfaction and improving learners\u0026rsquo; engagement. Embedded within these technological upsides are the benefits of self-regulated learning by medical students in comprehending content and applying it in exam settings[\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Participants find themselves more at ease with personalized interfaces that allow them to set their own schedules and study at an individualized pace. This is in congruence with instructional scaffolding, which posits that efficient learning is facilitated through a learner-centered, collaborative interaction that takes place in the learner\u0026rsquo;s zone of proximal development[\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. The eventual removal of scaffolds occurred algorithmically as participants moved from content comprehension to practice questions, then towards tailored exam questions. The participants were generally more content with their increased agency in determining and regulating the type and difficulty of the tasks as well as the feedback received. More hierarchical teacher-student relationships and larger class sizes in Chinese universities could account for the sustained preference of Chinese medical students for personalized learning[\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eWhereas personalization improved overall satisfaction and expectation of performance, the effects of adaptive learning on medical students\u0026rsquo; intrinsic motivation remain indistinct. Contrary to some prior studies[\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e], participants did not report significant improvements to their motivation. Students with low intrinsic motivation for academic distinction prior to their exposure to adaptive learning did not develop more incentive to pursue higher academic goals. It is unclear whether intrinsic motivation served as a mediating factor linking the effect of adaptive learning on the academic performance of medical students. Fear of not passing and the aforementioned exam-related distresses could indicate that the extraneous motivators play a larger part in the exam-oriented environment of Chinese medical education[\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. Students exhibit more preoccupation with test score performance than task mastery. Differences in personal backgrounds could also account for different levels of goal-setting and, therefore, different levels of intrinsic motivation to learn. This is a case for broadening the scope of competency-based approaches in Chinese medical education to enable the personalizational aspects of adaptive learning to play a greater role in improving motivation.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec39\" class=\"Section2\"\u003e\u003ch2\u003eComplacent mindsets\u003c/h2\u003e\u003cp\u003eThe study pinpoints a unique issue of medical students using adaptive learning tools as a shortcut to achieving basic requirements in standardized examinations needed for academic progression[\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. This behavior resonates with behaviors of academic procrastination and can further deteriorate performance and intrinsic motivation[\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. It involves the purposeful postponement or avoidance of completing academic tasks, usually associated with self-doubt, lack of self-regulation, and other behavioral impediments. Some studies have identified the usefulness of using adaptive learning to address academic procrastination[\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. While some participants confirmed this relationship for more intrinsically motivated medical students, students with pre-existing tendencies to procrastinate or lower expectations tend to operate in the converse. Students with high intrinsic motivation tend to seek approaches beyond adaptive learning, often in combination with adaptive methods.\u003c/p\u003e\u003cp\u003eOn the other hand, students with low intrinsic motivation and symptoms of academic procrastination rely solely on technology to achieve their desired academic outcomes. Tools designed for adaptive learning are viewed as convenient alternatives for efficient learning only to the level of meeting minimum requirements. In spite of short-term improvements in task performance, the provision of adaptive learning opportunities does not lead to an accretive performance boost and positive goal orientation in the long run[\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. Low intrinsic motivation leads to maladaptive behaviors of academic procrastination and loss of self-regulation. The self-determination theory suggests that autonomy, competence, and social relatedness are necessary psychological needs for higher motivation and adaptive patterns of learning behaviors[\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. Dissatisfaction in those areas indicates likelihoods for academic burnout and a shift away from goal-oriented learning into indications of performance-oriented behaviors. This motivational makeup indicates a lack of self-regulation and a focus on maximizing academic performance with minimal input.\u003c/p\u003e\u003cp\u003eThe critical concept of \u0026ldquo;metacognitive laziness\u0026rdquo; introduced by Fan et al. identifies patterns of learning that offload metacognitive load onto adaptive learning tools, thereby encouraging technological dependence that hinders self-regulation and deeper engagement with instructions. It applies to the themes observed in this study as a consequence of habitual employment of adaptive learning tools as a method of cognitive load management per the aforementioned discussion. Moreover, the concept applies to both students and teachers, where metacognitive activities and autonomy give way to increased convenience of automation. Poorer self-regulation and loss of autonomy ascribed to these concerns may lead back to the aforementioned symptoms of academic procrastination, which could warrant a vicious cycle of deteriorating intrinsic motivation and technological dependence.\u003c/p\u003e\u003cdiv id=\"Sec40\" class=\"Section3\"\u003e\u003ch2\u003eStrengths and limitations\u003c/h2\u003e\u003cp\u003eInterpretative phenomenological analysis offers a chance at examining in-depth the psychological reality of how medical students in China perceive the role of adaptive learning against an exam-intensive backdrop. An effective methodology for exploring the nuanced aspects of lived experiences, this approach is suitable for understanding how these perceptions reveal underlying themes and overall perspectives towards adaptive learning[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThere are undoubtedly some limitations at work. As with any constructivist methodology, IPA develops transferrable yet not fully generalizable, idiographic findings. The participants were recruited from the same class through university administration. This may have encouraged the students to speak less critically of the current medical education system and the instructions they receive, as they may presume some level of responsibility for the information that they disclose. This underestimates the positive facets of adaptive learning as a potential reform measure in Chinese medical education and overestimates the effectiveness of the current instructional approach. Moreover, the status of the author as a former medical student with prior experiences of the area of inquiry could have caused some premises to be taken for granted and result in participants\u0026rsquo; experiences being underexplored. While reflective journals were beneficial to amend this drawback, it still warrants the possibility of insufficient scrutiny into some areas of interest.\u003c/p\u003e\u003cp\u003e\u003cb\u003eImplications for practice and further research\u003c/b\u003e\u003c/p\u003e\u003cp\u003eNotwithstanding the lack of generalizability, the findings still affirm some of the key conclusions reached in extant literature on adaptive learning. Despite concerns about adaptive teaching and learning becoming the predominant mode of instruction, the study demonstrates the preference for adaptive learning at an individual level found amongst Chinese undergraduate medical students. Personalized learning and load management continue to be major selling points of adaptive learning with noticeable positive effects on learning proficiency in exam-oriented settings.\u003c/p\u003e\u003cp\u003eMoving forward, adaptive learning proponents will need to address the persistent issue of inequality between technologically inclined and better-equipped students relative to their less advantageous peers. The general provision of technological education and equipment may be necessary for the benefits of adaptive learning to be distributed evenly. This resonates with studies that warn against the erosion of traditional teaching methods in pedagogical contexts where technological inequality is still widely present. It is also worth noting the role that some participants relegate adaptive learning tools to the status of achieving the bare minimum to pass. This has not been discussed widely in other studies but should be a focal concern for the widespread application of adaptive learning. The potential for metacognitive laziness as encouraged by generative artificial intelligence could see a similar phenomenon in adaptive learning where less motivated learners become more dependent on technology. Steps ought to be taken to prevent loss of self-regulating agency and promote sustainable student engagement with adaptive learning. This also calls into question the usefulness of intensive examination for cultivating qualified medical professionals and brings into discussion the notion of competency-based education and its prospect in Chinese medical education reforms.\u003c/p\u003e\u003cp\u003eThe current study leaves room for several future research directions. Understanding whether the conclusions reached in this study are transferrable to other provinces of mainland China may shed light on the potentially differing perspectives towards adaptive learning owing to differences in culture and pedagogical contexts. Furthermore, it would be enlightening to test whether the conclusions hold in the subsequent three-year residency training that constitutes part of the medical students\u0026rsquo; path to professional qualification. The author would be interested in directing further research towards additional insights into incorporating adaptive learning as instrumental for motivating academic success and not just achieving the threshold of academic qualification. This requires understanding how adaptive learning could cultivate intrinsic motivation on a more extensive and sustained level via personalized learning frameworks and self-regulated learning. Reproducing this study under different contexts could yield more fruitful results that pave the way for adaptive learning to become a mainspring of the Chinese medical education reform.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study has examined the perspectives towards adaptive learning in the exam-oriented educational environment of undergraduate medical students at the Guangdong University of mainland China. Exploration of student experiences through a phenomenological lens affirms some of the established conclusions on adaptive learning, namely its advantages in load management and personalized learning experiences that contribute to more proficient learning. This study also underscores the persistent concern of technological inequalities that undermine adaptive learning in its wider applications. A two-fold, diverging approach to utilizing adaptive learning is observed. Whereas more intrinsically motivated students use it for improving performance, less motivated students employ adaptive learning technology to shorten the time frame needed for meeting the minimum requirements of academic qualifications. The study thus lends support to the view that adaptive learning at its current stage does not boost intrinsic motivation. Mainland Chinese reformers of medical education must take into account the threat of adaptive learning enabling technological dependency and metacognitive laziness amongst undergraduate medical students. Further insights are needed before determining whether adaptive learning would be suitable for the current exam-based learning environment of Chinese undergraduate medical education.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLei Zhou: Writing – original draft, Methodology, Investigation, Funding acquisition, Formal analysis, Conceptualization. Hanying Liu: Writing-review \u0026amp; editing, Supervision, Methodology, Conceptualization. Guiyang Chen: Writing-review \u0026amp; editing, Supervision, Methodology, Investigation, Formal analysis, Conceptualization. Jie Peng: Writing-review \u0026amp; editing, Supervision, Methodology, Investigation, Formal analysis, Conceptualization. Xing Liu: Writing-review \u0026amp; editing, Supervision, Methodology, Investigation, Formal analysis, Conceptualization. Ge Lan: Writing-review \u0026amp; editing, Supervision, Methodology, Investigation, Formal analysis, Conceptualization. Huiying Deng: Writing-review \u0026amp; editing, Supervision, Methodology, Investigation, Formal analysis, Conceptualization.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThanks to the other doctors within Xiangya Hospital who provided assistance with the writing and grammar correction of this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eEthics\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis research conforms to the guidelines established by the Ethics Review Committee at Central South University and the guidelines of the Declaration of Helsinki (including its later amendments). All individual interviewees gave informed consent in writing and signature before starting interviews.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConsent to Participate\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eParticipants has been given a clear and comprehensive information sheet detailing the research aims, the voluntary nature of participation, what involvement entails, how data will be used and stored, confidentiality measures, and their right to withdraw at any time without penalty. Written informed consent has been obtained prior to each interview.\u003c/p\u003e\n\u003cp\u003eAll identifiable information will be anonymised using pseudonyms in all research outputs. Data will be stored securely. Care will be taken when presenting findings to ensure that no specific local entities can be inadvertently identified.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eDeclaration of Helsinki\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eEthics approval and informed consent to participate has been obtained prior to conducting the interviews. All procedures of this research are consistent with the Declaration of Helsinki (including its later amendments) and the guidelines established by the Ethics Review Committee at Central South University.\u003c/p\u003e\n\u003cp\u003eThe interview guide used in this study was developed for this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eDev P, Schleyer T. Digital Technology in Health Science Education. In: Springer EBooks. Springer; 2021:841\u0026ndash;65. doi:10.1007/978-3-030-58721-5_25\u003c/li\u003e\n\u003cli\u003eSharma N, Doherty I, Dong C. 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Qual Health Res. 2025;35(1):118\u0026ndash;31. doi:10.1177/10497323241260738\u003c/li\u003e\n\u003cli\u003eWang J, Liu M, Bai J, Chen Y, Xia J, Liang B, et al. Prevalence of common mental disorders among medical students in China: a systematic review and meta-analysis. Front Public Health. 2023;11. doi:10.3389/fpubh.2023.1116616\u003c/li\u003e\n\u003cli\u003eChoi B. I\u0026rsquo;m Afraid of not succeeding in learning: introducing an instrument to measure higher education students\u0026rsquo; fear of failure in learning. Stud High Educ. 2020;46(11):1\u0026ndash;15. doi:10.1080/03075079.2020.1712691\u003c/li\u003e\n\u003cli\u003eGhasempour S, Esmaeeli M, Abbasi A, Hosseinzadeh A, Ebrahimi H. Relationship between academic success, distance education learning environments, and its related factors among medical sciences students: a cross-sectional study. BMC Med Educ. 2023;23(1). doi:10.1186/s12909-023-04856-3\u003c/li\u003e\n\u003cli\u003eTzafilkou K, Perifanou M, Economides AA. 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PLoS One. 2021;16(10):e0257346. doi:10.1371/journal.pone.0257346\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Adaptive learning, Medical education, Phenomenology, IPA","lastPublishedDoi":"10.21203/rs.3.rs-7361555/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7361555/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cem\u003eBackgrounds:\u003c/em\u003e Rapid development in technology led to the growing prevalence of adaptive learning in mainland China. The role of adaptive learning in university settings became more pronounced as a result of the pandemic.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAims: \u003c/em\u003eUndergraduate medical education in Chinese universities is characterized by exam-oriented approaches. Perspectives towards adaptive learning within this setting remain underexplored. The insights would better inform the direction of contemporary reforms in Chinese medical education.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSample: \u003c/em\u003e7 fourth-year undergraduate students from a mix of rural and urban backgrounds participated.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eMethods:\u003c/em\u003e An interpretative phenomenological analysis (IPA) was conducted in the mainland Chinese University of Guangzhou. After gaining ethics approval, individual semi-structured interviews were conducted with each student, and the interview transcripts were analyzed. Through structural analysis, an analytic account that synthesizes their lived experiences into group experiential themes was produced and integrated into discussion.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eResults: \u003c/em\u003eMost participants responded positively to the role of adaptive learning in their education, although some expressed concerns over its misuse and effects on learning habits. Participants viewed adaptive learning as an effective modern aid to improved learning outcomes.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConclusions: \u003c/em\u003eAdaptive learning is the favored learning approach by undergraduate medical students to address pressures within exam-oriented settings. Multiple factors play into the effectiveness of adaptive learning. Whereas industrious learners combine adaptive learning with conventional learning practices, the presence of adaptive learning technology leads to metacognitive laziness and academic procrastination for less intrinsically motivated students.\u003c/p\u003e","manuscriptTitle":"The perspectives of undergraduate medical students in mainland China towards adaptive learning within exam-oriented medical education: a phenomenological analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-16 15:06:35","doi":"10.21203/rs.3.rs-7361555/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-10-15T21:17:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"219165023292403059063322377208280959057","date":"2025-10-08T14:07:38+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"338201892049674380337527404773267311151","date":"2025-10-06T12:08:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"204419403375521504811774345630222018701","date":"2025-10-06T06:49:28+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-06T05:29:56+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-09-12T10:52:42+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-03T10:10:56+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-03T09:52:22+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2025-09-03T09:48:07+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"dad5ee00-253a-4848-adea-394ccccbc5f3","owner":[],"postedDate":"October 16th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-10-16T15:06:35+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-16 15:06:35","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7361555","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7361555","identity":"rs-7361555","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}