Curricular Clocks and Cognitive Costs: A Multi-Institutional Study of Perceived Academic and Emotional Benefits of Flexibility in Undergraduate Medical Curricula

Curricular Clocks and Cognitive Costs: A Multi-Institutional Study of Perceived Academic and Emotional Benefits of Flexibility in Undergraduate Medical Curricula | 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 Curricular Clocks and Cognitive Costs: A Multi-Institutional Study of Perceived Academic and Emotional Benefits of Flexibility in Undergraduate Medical Curricula Nashwah Waheed, Furqan Shahid, Rabia Anis, Fatima Sial, Daniah Rizwan This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7654000/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 15 You are reading this latest preprint version Abstract Background Amidst global calls for curricular flexibility in medical education, the undergraduate medical programs in Pakistan remain tightly structured and time-restricted. This multi-institutional study aims to explore medical students' perceptions of curricular flexibility and its perceived effects on their well-being and academic performance, and investigate the need for and methods of incorporating flexibility in the current curriculum. Methods A sequential explanatory mixed-methods design was used, with a cross-sectional quantitative survey followed by qualitative interviews. A total of 372 medical students from five different colleges in Pakistan participated in the survey from April 2025 to June 2025. For the quantitative strand, a convenience sample of undergraduate medical students spread across all academic years was selected. Data was collected using a contextually adapted, pilot-tested questionnaire based on validated instruments, with items rated on a five-point Likert scale. Quantitative findings were analyzed using descriptive statistics, t-tests, ANOVA, Pearson correlations, and multiple linear regression analyses. For the qualitative strand, 15 volunteer students were purposively selected to ensure variation in year of study and gender, and interviews were conducted until thematic saturation was reached. Data were analyzed using Braun and Clarke’s six-step thematic analysis. Results A total of 372 students participated (mean age 22.1 years, SD = 2.16; 54.5% female, 45.5% male. Perceived curricular flexibility showed significant positive correlations with emotional well-being (r = 0.537, p < 0.001) and academic achievement (r = 0.587, p < 0.001). Regression analysis indicated that curricular flexibility explains more variance in perceived academic performance (r2 = 0.344) compared to well-being (r2 = 0.288), although both are meaningful. Females' scores on well-being showed more burnout with rigid curricula. than males (p < 0.01), and perceptions varied significantly across academic years (p < 0.001). Thematic analysis revealed challenges, including rigid schedules, mandatory attendance, and clustered exams; calls for recorded or asynchronous lectures, modular assessments, and greater learner autonomy; and perceived benefits of flexibility, such as reduced burnout, deeper learning, and enhanced motivation. Conclusion Students strongly linked curricular flexibility with academic gains and emotional well-being. Therefore, we propose that flexibility should be intentionally embedded in curricula, particularly in LMIC contexts, as a deliberate pedagogical strategy rather than a compromise. Curriculum flexibility medical education academic performance emotional well-being student perceptions Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Introduction Undergraduate medical education in Pakistan follows a nationally standardized five-year Bachelor of Medicine and Bachelor of Surgery (MBBS) model, with two pre-clinical/basic sciences foundation years and three years of clinical rotations. The Pakistan Medical and Dental Council (PMDC) encourages innovation in the curriculum, but traditional discipline-based models continue to be used by a majority of institutions [1]. Increasing numbers of medical schools have embraced integrated curricula with vertical and horizontal connections [2], but the temporal structure of medical education nationwide remains remarkably consistent [3]. Students are required to advance through the curriculum in strict time frames, adhering to rigid academic calendars that do not account for individual variation in learning pace, maturity, or personal circumstances [4]. Many Medical Schools in North America, Australia, and Europe have adopted competency-based models of medical education that allow progression based on the attainment of mastery, rather than the passage of time [5]. Central to these reforms is the notion of curriculum flexibility, which entails a structural reorientation that provides for the diverse needs, tempos, and directions of students, without sacrificing high levels of proficiency [6]. In this study, we define curriculum flexibility as a framework that enables medical students to progress at their own pace, with reduced reliance on fixed timelines or synchronized cohorts [6]. Curriculum 'rigidity' refers to students being required to learn the identical material at the same pace in a fixed learning environment with limited or absent individualized learning options. Flexibility may manifest as asynchronous delivery of material, self-paced progression through modules, flexible assessment timelines, or individualized remediation systems [6]. This approach maintains academic rigor while redefining when and how students demonstrate proficiency. This strategy has particular significance in medicine, a field characterized by substantial cognitive, emotional, and clinical demands [7], and where rigid curricula can potentially undermine both educational efficacy and student well-being [8]. An increasing body of literature links rigid academic structures with student stress, burnout, and academic disengagement [9]. These effects are particularly concerning in medical students, who already experience elevated baseline stress levels [10]. Despite global momentum for flexible, learner-centered curricula, Pakistan's medical education system is still largely time-bound [3]. Although burnout and educationally related stressor issues have been extensively documented in local studies [11], the structural role of curricular rigidity remains under-theorized and empirically underexplored, particularly in the South Asian context. To fill this important gap, we conducted a multi-institutional, cross-sectional study among students at five of Pakistan's most reputable medical colleges, spanning varied geographic and institutional settings. The purpose of our study was to assess students’ perceptions of the flexibility of their current curricular structures, and to determine if these findings are linked to two vital aspects of their learning experience: emotional well-being (with measures of stress, burnout, and emotional exhaustion) and academic performance (as perceived and reported by the students themselves). This study adds empirical evidence to ongoing discussions on medical curriculum reform in South Asia. We suggest that rethinking flexibility is not a pedagogical luxury, but an important step aligned with global trends, equity in education, and the preparation of adaptable future physicians. Methodology Research Design and Setting The study employed a sequential explanatory mixed-methods design to examine undergraduate medical students' views about curriculum flexibility and its relation to emotional well-being and academic performance. The five-year MBBS curriculum in Pakistan, which comprises two pre-clinical and three clinical years, is a national blueprint but is differently executed by the institutions adopting traditional and integrated curricula. To ensure contextual and institutional diversity, data were collected from five PMDC-approved medical colleges that represented a broad geographic and pedagogical spectrum. Colleges were selected based on their academic reputation, curricular model, and logistical feasibility for coordinated data collection. Quantitative survey data were complemented with qualitative interviews to deepen understanding. Participants, Instruments, and Data Collection A total of 450 MBBS students were invited to participate in the survey, of whom 372 completed it, resulting in a response rate of 82.6%. A convenience sampling technique was used, whereby all accessible students from the selected institutions who met the inclusion criteria were invited to participate. Active attendance in any year of the MBBS course and passing at least one academic semester were the inclusion criteria. Students self-reporting a diagnosed psychiatric condition under treatment were excluded, as this could confound well-being outcomes. Also, students preparing for licensing or board examinations were excluded, as their academic stress may not reflect regular curriculum exposure. The questionnaire used in this study was developed by adapting items from two validated instruments: the Medical Student Well-Being Index (MSWBI) [12] and the Academic Self-Perception subscale of the Dundee Ready Education Environment Measure (DREEM) [13]. Items from these scales were rephrased to fit the contextual focus on curricular flexibility, academic self-efficacy, and emotional well-being. Additional items were created to specifically capture perceptions of scheduling rigidity, flexible learning pathways, and assessment autonomy, which are not covered in the original tools. The adapted questionnaire was pilot tested on 30 medical students for clarity and contextual relevance. Internal consistency was high across the three constructs (Cronbach’s α = 0.77–0.81). An exploratory factor analysis confirmed a stable three-factor solution explaining 49.2% of the variance. The full English-language questionnaire is available as Supplementary File 1. The survey was administered online for six weeks via institutional networks, and all participants provided informed digital consent. In the second phase, students who volunteered for qualitative interviews were purposively selected to ensure variation in year of study and gender. A sample of 15 students was interviewed as saturation in themes was achieved at this point. Data Analysis Quantitative data were analyzed using IBM SPSS 20. Descriptive statistics (means, standard deviations, frequencies, percentages) were used to report demographic and construct-level responses. Independent samples t-tests assessed gender and institutional differences, and one-way ANOVA examined variation by academic year. Pearson's correlation coefficients were used to explore the inter-relationships between flexibility and the other two constructs. To determine the predictive capacity of curriculum flexibility on emotional well-being and academic performance, a multiple linear regression model was developed using flexibility as the independent variable and well-being and academic performance as the dependent variables. A statistical significance was established at p < 0.05. The qualitative data were interpreted using an inductive thematic analysis, adhering to the six-step process described by Braun and Clarke. Two researchers independently coded all transcripts, then compared and discussed their coding until full consensus was reached. To enhance trustworthiness, we maintained an audit trail and conducted peer debriefing. Codes were then grouped into themes through iterative comparison, consensus, and abstraction. Findings from both strands were integrated during analysis to enhance the depth of interpretation. Results A sample of 372 undergraduate medical students from five prestigious PMDC-accredited medical schools in Pakistan was surveyed. The average age was calculated to be 22.1 years (SD = 2.16), with 54.5% female respondents (202/372) and 45.5% males (170/372) (Table 1 ). The sample was homogenously distributed across all five years of study, thereby providing a balanced view from both pre-clinical (Years 1–2) and clinical (Years 3–5) phases of undergraduate medical education, as well as from institutions adopting traditional and integrated curriculum systems. Table 1 Demographic Characteristics of Participants Variable Value Total Participants 372 Mean Age (SD) 22.1 (2.16) Female 54.5% (202) Male 45.5% (170) Instrument Reliability and Descriptive Statistics Internal consistency reliability was evaluated with Cronbach's alpha for each respective construct. The findings were acceptable for all constructs, at 0.78 for curriculum flexibility, 0.81 for emotional well-being, and 0.77 for academic achievement (Fig. 1 , Table 2 ), thus exceeding the generally recognized threshold of 0.70 for reliability. Furthermore, exploratory factor analysis confirmed the construct validity of the instrument, demonstrating a stable three-factor solution with eigenvalues at 2.76, 1.54, and 1.11, justifying a cumulative variance of 49.2%, consistent with the hypothesized theoretical model. Table 2 Reliability and Descriptive Statistics of Constructs Construct Cronbach’s Alpha Mean (SD) Curriculum Flexibility 0.78 3.91 (0.53) Emotional Well-being 0.81 3.76 (0.78) Academic Performance 0.77 3.90 (0.53) All average scores were calculated on a five-point Likert scale. The mean scores on the three constructs were: flexibility 3.91 (SD = 0.53), well-being 3.76 (SD = 0.78), and academic performance 3.90 (SD = 0.53). Independent samples t-tests indicated that there was a statistically significant gender difference in emotional well-being (Fig. 2 ), with female students having higher average scores as compared to their male counterparts (4.02 vs. 3.51; p < 0.01). Gender differences in perceptions of curriculum flexibility (p = 0.14) or academic performance (p = 0.08) were not significant (Table 3 ). A one-way analysis of variance (ANOVA) was used to compare variations between different academic years. ANOVA indicated significant variation across academic years (F(4,367) = 6.45, p < 0.001) (Fig. 3 ). Mean scores suggested that first-year students reported higher perceived academic performance than senior cohorts. Table 3 Gender Differences in Constructs Construct Female Mean Male Mean p-value Curriculum Flexibility 3.95 3.86 0.14 Emotional Well-being 4.02 3.51 < 0.01* Academic Performance 3.93 3.87 0.08 Correlational and Regression Analyses Pearson's analysis of correlation coefficients revealed strong and statistically significant intercorrelations among the compared constructs. Curriculum flexibility had a significant positive intercorrelation with emotional well-being (r = 0.537, p < 0.001) and academic performance (r = 0.587, p < 0.001) (Table 4 , Fig. 4 ). To determine the predictive potential of these correlations, multiple linear regression analysis was carried out with well-being and academic performance as the dependent variables and curriculum flexibility as the independent variable Table 4 Correlation Matrix Curriculum Flexibility Emotional Well-being Academic Performance Curriculum Flexibility 1 0.537** 0.587** Emotional Well-being 0.537** 1 — Academic Performance 0.587** — 1 Note : **p < 0.001 for all correlations. Perceived curricular flexibility was highly correlated with emotional well-being (r = 0.537, p < 0.001) and academic achievement (r = 0.587, p < 0.001). Flexibility explained more variance in academic performance (r2 = 0.344) than in well-being (r2 = 0.288), although both are meaningful (Table 5 ). Table 5 Regression Results Dependent Variable Predictor R² p-value Emotional Well-being Curriculum Flexibility 0.288 < 0.001 Academic Performance Curriculum Flexibility 0.344 < 0.001 Collectively, the quantitative results demonstrate a consistent and statistically significant connection between flexibility in the curriculum and the overall emotional well-being of students and their academic performance. Therefore, provide empirical validation for the pedagogical worth of flexibility within medical curricula. Thematic analysis We conducted a thematic analysis of the open-ended survey questions, followed by an analysis of the interviews. Our analysis revealed three major themes: Challenges in the current curriculum, like fast-paced teaching, rigid schedules, and fixed assessments with no space for individualization; Suggestions for more practical and personalized learning with flexible assessments; Perceived benefits of curricular flexibility, like reduced burnout, improved learning with better engagement and motivation (Fig. 5 ). 1. Challenges in the Current Curriculum The main challenges faced by students with the current curriculum were the rigid academic schedules, strict attendance policies, fast-paced curriculum, and clustering of exams (Fig. 6 ). Several students reported mandatory attendance as a huge challenge, as a student quoted, “Rigid schedule of classes and entirely rigid schedule of assessments with zero flexibility is the major challenge.” The attendance criteria have come across as a major challenge for some students, as a student commented: “The constant hassle to complete attendance, although we are just physically present, our minds are not there, which is just useless”. Participants also reported that they get insufficient prep time compared to the bulk of the syllabus. A participant mentioned: “In our college, we get very little time to complete the syllabus as compared to other universities. We see that while other colleges provide 8 weeks for a module, ours allocates only 5 weeks for the same module.” Exams of all subjects together were also a serious concern: “Exam of all subjects together in one day is a difficult challenge for a medical student.” Another participant shared the same sentiment: “Broad and more subjects in a single assessment.” 2. Suggested Changes for Curriculum Flexibility When asked to share their suggestions regarding changes to the current curriculum, several recurring themes were identified, including flexible scheduling and attendance options, assessment restructuring, and learner autonomy with integration of modern tools (Fig. 7 ). The most common suggestion was making attendance non-mandatory. A participant shared: “Attendance should not be compulsory, but the lecture should be interesting enough so that the whole class should be present.” Several participants also showed a desire for the option of online lectures for asynchronous learning. “Introduce recorded lectures or asynchronous content.” Some students also shared that they would prefer a flexible exam schedule: “I would introduce flexible exam scheduling to allow students to take major assessments when they feel most prepared within a given window,” a participant suggested. “Exam should be structured similarly to international exams like USMLE, where you can give the exam whenever you are ready”. A student suggested that they should have more autonomy in their scheduling: “more authority over my time and what to study”. Also, it will enable students to study according to their own pattern and give more time to what suits them. A participant also suggested the use of modern tools to revolutionize education to meet the needs of personalized learning: "I'd like to have more active learning tools incorporated into our curriculum”. 3. Perceived Effects of Suggested Changes Many students felt that having more flexibility in their schedule would reduce burnout, improve learning, and lead to greater engagement and motivation (Fig. 8 ). A participant put it simply: “Better academic performance, less mental pressure.” A student noted, “This change would reduce stress, promote deeper understanding, and improve performance by allowing students to study at their own pace and focus on true learning rather than cramming.” A flexible schedule can give students more time to spend on their weak areas: “It will allow students to take time for self-study and focus on their weak areas more efficiently instead of listening to the same lecture in the lecture hall with only 10 to percent of retention after leaving the classroom”. When students control their pace, they can choose the period of maximum alertness to study important things, as noted by one participant: “I would like to do academic activities whenever I feel I can be more productive.” A participant shared that a more flexible schedule would increase the motivation to learn: “Would make me more eager to learn”. Discussion This study employs a mixed-methods approach across multiple institutions to investigate the attitudes of medical students towards curricular flexibility and its relationship with emotional well-being and academic achievement in the Pakistani undergraduate medical education system. Situated within a predominantly inflexible, teacher-centered model of learning, our findings offer important insights into structural determinants of student achievement, well-being, and engagement with learning. Drawing on data from 372 medical students, this study adds perspectives from a lower-middle-income country, where evaluations of curricular flexibility remain limited. The descriptive findings offer an important context. The relatively high mean for the flexibility dimension (M = 3.91) indicates that students highly aspire for a flexible curriculum. Likewise, the mean for emotional well-being (M = 3.76) indicates that inflexible curricular frameworks are viewed as detrimental to the psychological well-being of students. The academic performance score (M = 3.90) also reflects the students' belief that a flexible curriculum will enhance their learning and performance. Building on this, the inferential analysis revealed a statistically significant and conceptually consistent association between perceived curricular flexibility and significant learner outcomes. The observed predictive associations of flexibility with both emotional well-being and academic achievement support what has long been voiced anecdotally: rigid curricula can undermine not only academic success but also students’ emotional health [7]. The findings reported herein align with the growing corpus of interdisciplinary evidence backing curricular decompression principles, learner autonomy, and individualized pacing axioms upon which contemporary education models such as Competency-Based Medical Education (CBME) and self-determination theory (SDT) are founded [14]. The empirically substantiated predictive power of curriculum flexibility in our study underscores the fact that curriculum design cannot be considered as an inactive scaffold; rather, it is an active factor shaping student capability and accomplishment [15]. The fact that flexibility explained more variance in academic achievement than emotional well-being suggests that agency in the learning process functions not just as a buffer against stress but also plays a key part in facilitating cognitive and metacognitive activity [16]. Our research revealed gender differences in emotional well-being, with females being more affected by a rigid curriculum. This finding aligns with research from China, which also reports high psychological distress among female medical students associated with various societal, familial, and institutional pressures [17]. Nevertheless, flexibility and academic success perceptions were not gender-differentiated, indicating that consensus on structural curricular matters existed across demographic groups. Between-year comparisons revealed junior students reported higher perceived performance with a more flexible curriculum than senior cohorts. While previous research has demonstrated a decline in student satisfaction and self-efficacy during the clinical phases [18], our findings highlight a different challenge. Our study suggests that initial-year medical students face significant pressure while adapting to the rigid environment of their early curriculum and that they perceive flexible learning as a vital tool for improving their performance. The value in presenting qualitative findings lies not only in triangulation but in a sense of lived experiences, something not quantifiable. Students unanimously described a systemic sense of powerlessness to deal with on-campus schedules, attendance expectations, and content presentation that was packed to the point of bursting. The "burnout" theme, constructed emergently in dozens of comments, suggests an out-of-balance system in conflict with adult learning theory principles and psychological safety principles. Above all, students criticized long hours of lectures, packed exams, and rigid class timetables, which they frequently perceived as draining and counterproductive. This mirrors findings from US-based research demonstrating how misaligned academic structures can foster burnout and disengagement among medical students [19]. Even more importantly, students did not merely complain; they talked of possible, context-specific reforms aligned with international pedagogical trends. Suggestions like modular exams, asynchronous learning, flexible attendance, and adaptive scheduling have echoed in the contemporary global CBME innovations like the USMLE Step examination model, flipped classrooms, and learner-directed learning pathways.[20] Students demanded the addition of artificial intelligence platforms and optional subjects, which reflects a degree of curricular literacy and foresight not found in most South Asian students. This pattern is consistent with the contemporary trend in medical education, in which curriculum innovation is prioritized using a participatory approach, putting learners in the driver's seat rather than as passive responders to pedagogical change [21]. Interestingly, the suggestions offered were grounded in pragmatism rather than idealistic aspirations. The students elaborated clearly on links between suggested reforms and anticipated improvements in cognitive competence, emotional regulation, and motivation for learning. Their experiences demonstrated an awareness of their individual learning styles, limits of cognitive load, and motivational cues. This highlights the theoretical importance of learner-centered approaches that accommodate variations in learning rate, allow flexibility in preference, and cater to variations in readiness central tenets of mastery learning and adaptive expertise [22]. The synthesis of our qualitative and quantitative results paints a clear picture of how the concealed costs of curricular inflexibility manifest themselves not just in undermined academic performance but also in the realms of student morale, identity construction, and long-term career advancement. Although medical education worldwide has progressed toward more integrated, flexible, and student-centered approaches, our study demonstrates that many medical institutions in Pakistan continue to rely on rigid structures that may undermine their intended educational outcomes. This research contributes to the global call for action aimed at curricular reforms in medical education, not through the imposition of complete systems from the Global West, but through genuinely incorporating the voices of students from local contexts. All future attempts at curriculum reform should be evidence-driven, inclusive, and responsive to the various needs of the student bodies that they aim to serve. Recommendations From the findings emerging from this large-scale multi-institutional study, a set of requisite recommendations could be delineated for medical educators, curriculum planners, and medical education leadership. One thing is certain: there is a dire need to move away from didactic, time-restricted pedagogies to more student-centered, flexible curricular models. Medical schools in LMIC settings should be encouraged to implement modular course designs and student-directed learning spaces in which students can advance based on mastery rather than time. This change would take into account the various cognitive pacing and individual situations of the students, ease unnecessary academic pressures, and foster deep learning. Apart from this, current attendance policies that emphasize physical presence over engaged participation also require reevaluation. Use of recorded lectures and asynchronous learning content can indeed enable students to plan their learning schedules effectively, without any compromise on the quality of instruction. Moreover, the assessment environment must adapt itself; rigid and bunched assessments conventionally employed must give way to spaced, formative assessments where students can exhibit their competencies in a more personalized and less stress-inducing way. Such academic changes demand faculty preparedness. Therefore, sustained investment in faculty development initiatives is crucial to generate instructional flexibility, compassion, and incorporation of digital tools that complement pedagogy centered on flexibility. Finally, student wellness must be overtly recognized as an inherent education priority. Curriculum planning must integrate adequate rest periods, manageable workloads, and mental health provisions that foster holistic development. Medical education is not just designed to yield clinically proficient graduates but also emotionally resilient and intrinsically motivated professionals, a characteristic that is now linked more with curricular flexibility. Limitations Although this study provides valuable insights into the perceived effects of curriculum flexibility on medical students, several methodological limitations should be noted. The use of convenience sampling across five institutions restricts generalizability and may underrepresent some subgroups. Also, dependence on self-report measures raises issues about potential response bias. Excluding students with diagnosed psychiatric conditions may also have led to an underestimation of the true emotional impact of curricular rigidity. Students may have exaggerated or downplayed their ratings of well-being and academic success based on temporary mood states, personal expectations, or social acceptability. Another critical limitation is imposed by the cross-sectional design, which does not allow for causal inferences to be made. Despite the existence of strong correlations and predictive formulas, it cannot be assumed with absolute certainty that curriculum flexibility will lead to better academic performance or emotional well-being. It is equally possible that more academically efficacious or resilient individuals, by nature, may perceive the curriculum more favorably regardless of its structure. These limitations highlight the need for future studies using longitudinal and experimental designs, with broader institutional and demographic representation. Future Directions Extending the conceptual and empirical work of this study, subsequent research should pursue longitudinal research following the impact of curricular flexibility at various points throughout a student's academic career. This would allow for comprehension of how views of flexibility evolve and how they intersect with academic transitions, clinical experience, and identity formation. Furthermore, controlled trials and experimental research must be conducted to evaluate the concrete results of individual reforms aimed at flexibility, like asynchronous modules, adaptive evaluation timetables, or elective learning pathways. It is also important to broaden the analytical focus beyond the voices of students. Institutional ethnographies and qualitative investigations facilitated by faculty members may yield key insights about the structural, cultural, and administrative challenges implicated in the provision of flexibility in medical education. Furthermore, an equity-focused methodology is important when examining how flexibility, or its absence, disproportionately impacts students from underrepresented groups, including students with caregiving responsibilities, mental illness, or socioeconomic constraints. Conclusion This research provides evidence that curriculum flexibility is not an extraneous luxury but an essential component of modern medical education. Drawing on the perspectives of 372 students at five prominent Pakistani medical schools, we demonstrate how rigid academic structures impact emotional well-being and academic performance while flexible, student-centered approaches are associated with more positive outcomes. In the LMIC context, where a combination of traditional and integrated curricula still coexist, these findings suggest that curriculum flexibility should be intentionally embedded as a conscious pedagogical decision, not as a compromise. Abbreviations MBBS – Bachelor of Medicine, Bachelor of Surgery PMDC – Pakistan Medical and Dental Council LMIC – Low- and Middle-Income Countries CBME – Competency-Based Medical Education SDT – Self-Determination Theory MSWBI – Medical Student Well-Being Index DREEM – Dundee Ready Education Environment Measure EFA – Exploratory Factor Analysis SD – Standard Deviation SPSS – Statistical Package for the Social Sciences ANOVA – Analysis of Variance Declarations Ethics approval and consent to participate The study was approved by the Research Ethics Committee of Liaquat University of Medical & Health Sciences (Approval No. LUMHS/REC/-713, dated 29 April 2025). Participation was entirely voluntary, and informed consent was obtained electronically from all respondents prior to completing the online questionnaire. All responses were anonymous, and no personal identifying information was collected to ensure confidentiality. The study was conducted in full accordance with the ethical principles of the Declaration of Helsinki. Consent for publication Not Applicable. Competing Interests The authors declare that they have no competing interests Funding The author(s) reported that there is no funding associated with the work featured in this article. Author Contribution NW conceived the study, developed the research protocol, drafted the manuscript, and supervised all stages of the project. FS contributed to the study design, reviewed, and edited the final draft of the manuscript. RA facilitated ethics approval, coordinated institutional access, and contributed to data acquisition and manuscript revision. FSial assisted in data management, statistical and qualitative analysis. DR contributed to the literature review, data interpretation, and critical manuscript editing. All authors reviewed and approved the final version of the manuscript and agreed to be accountable for its content. 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BMC Medical Education. 2024 Jul 29;24(1):810. DOI: https://doi.org/10.1186/s12909-024-05781-9 Finn A, Fitzgibbon C, Fonda N, Gosling CM. Self-directed learning and the student learning experience in undergraduate clinical science programs: a scoping review. Advances in Health Sciences Education. 2024 Oct 23:1–32. DOI: https://doi.org/10.1007/s10459-024-10383-7 Dyrbye LN, Satele D, West CP. Association of characteristics of the learning environment and US medical student burnout, empathy, and career regret. JAMA Network Open. 2021 Aug 2;4(8):e2119110-. DOI: https://doi.org/10.1001/jamanetworkopen.2021.19110 Enyoojo, S.F., Ijah, C.E., Etukudo, E.M. et al. Satisfaction and learning experience of students using online learning platforms for medical education. BMC Med Educ 24 , 1398 (2024). https://doi.org/10.1186/s12909-024-06411-0 Ambrosetti É, Gaudin C, Flandin S, Poizat G. Students as co-designers in health professional education: a scoping review. BMC Medical Education. 2025 May 3;25(1):645. DOI : https://doi.org/10.1186/s12909-025-07110-0 Kua J, Lim WS, Teo W, Edwards RA. A scoping review of adaptive expertise in education. Medical Teacher. 2021 Mar 4;43(3):347 − 55. DOI : https://doi.org/10.1080/0142159X.2020.1851020 Additional Declarations No competing interests reported. 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The Pakistan Medical and Dental Council (PMDC) encourages innovation in the curriculum, but traditional discipline-based models continue to be used by a majority of institutions [1]. Increasing numbers of medical schools have embraced integrated curricula with vertical and horizontal connections [2], but the temporal structure of medical education nationwide remains remarkably consistent [3]. Students are required to advance through the curriculum in strict time frames, adhering to rigid academic calendars that do not account for individual variation in learning pace, maturity, or personal circumstances [4]. Many Medical Schools in North America, Australia, and Europe have adopted competency-based models of medical education that allow progression based on the attainment of mastery, rather than the passage of time [5]. Central to these reforms is the notion of curriculum flexibility, which entails a structural reorientation that provides for the diverse needs, tempos, and directions of students, without sacrificing high levels of proficiency [6].\u003c/p\u003e\u003cp\u003eIn this study, we define curriculum flexibility as a framework that enables medical students to progress at their own pace, with reduced reliance on fixed timelines or synchronized cohorts [6]. Curriculum 'rigidity' refers to students being required to learn the identical material at the same pace in a fixed learning environment with limited or absent individualized learning options. Flexibility may manifest as asynchronous delivery of material, self-paced progression through modules, flexible assessment timelines, or individualized remediation systems [6]. This approach maintains academic rigor while redefining when and how students demonstrate proficiency.\u003c/p\u003e\u003cp\u003eThis strategy has particular significance in medicine, a field characterized by substantial cognitive, emotional, and clinical demands [7], and where rigid curricula can potentially undermine both educational efficacy and student well-being [8]. An increasing body of literature links rigid academic structures with student stress, burnout, and academic disengagement [9]. These effects are particularly concerning in medical students, who already experience elevated baseline stress levels [10]. Despite global momentum for flexible, learner-centered curricula, Pakistan's medical education system is still largely time-bound [3]. Although burnout and educationally related stressor issues have been extensively documented in local studies [11], the structural role of curricular rigidity remains under-theorized and empirically underexplored, particularly in the South Asian context.\u003c/p\u003e\u003cp\u003eTo fill this important gap, we conducted a multi-institutional, cross-sectional study among students at five of Pakistan's most reputable medical colleges, spanning varied geographic and institutional settings. The purpose of our study was to assess students\u0026rsquo; perceptions of the flexibility of their current curricular structures, and to determine if these findings are linked to two vital aspects of their learning experience: emotional well-being (with measures of stress, burnout, and emotional exhaustion) and academic performance (as perceived and reported by the students themselves). This study adds empirical evidence to ongoing discussions on medical curriculum reform in South Asia. We suggest that rethinking flexibility is not a pedagogical luxury, but an important step aligned with global trends, equity in education, and the preparation of adaptable future physicians.\u003c/p\u003e"},{"header":"Methodology","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eResearch Design and Setting\u003c/h2\u003e\u003cp\u003eThe study employed a sequential explanatory mixed-methods design to examine undergraduate medical students' views about curriculum flexibility and its relation to emotional well-being and academic performance. The five-year MBBS curriculum in Pakistan, which comprises two pre-clinical and three clinical years, is a national blueprint but is differently executed by the institutions adopting traditional and integrated curricula. To ensure contextual and institutional diversity, data were collected from five PMDC-approved medical colleges that represented a broad geographic and pedagogical spectrum. Colleges were selected based on their academic reputation, curricular model, and logistical feasibility for coordinated data collection. Quantitative survey data were complemented with qualitative interviews to deepen understanding.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eParticipants, Instruments, and Data Collection\u003c/h3\u003e\n\u003cp\u003eA total of 450 MBBS students were invited to participate in the survey, of whom 372 completed it, resulting in a response rate of 82.6%. A convenience sampling technique was used, whereby all accessible students from the selected institutions who met the inclusion criteria were invited to participate. Active attendance in any year of the MBBS course and passing at least one academic semester were the inclusion criteria. Students self-reporting a diagnosed psychiatric condition under treatment were excluded, as this could confound well-being outcomes. Also, students preparing for licensing or board examinations were excluded, as their academic stress may not reflect regular curriculum exposure.\u003c/p\u003e\u003cp\u003eThe questionnaire used in this study was developed by adapting items from two validated instruments: the Medical Student Well-Being Index (MSWBI) [12] and the Academic Self-Perception subscale of the Dundee Ready Education Environment Measure (DREEM) [13]. Items from these scales were rephrased to fit the contextual focus on curricular flexibility, academic self-efficacy, and emotional well-being. Additional items were created to specifically capture perceptions of scheduling rigidity, flexible learning pathways, and assessment autonomy, which are not covered in the original tools. The adapted questionnaire was pilot tested on 30 medical students for clarity and contextual relevance. Internal consistency was high across the three constructs (Cronbach\u0026rsquo;s α\u0026thinsp;=\u0026thinsp;0.77\u0026ndash;0.81). An exploratory factor analysis confirmed a stable three-factor solution explaining 49.2% of the variance. The full English-language questionnaire is available as Supplementary File 1.\u003c/p\u003e\u003cp\u003eThe survey was administered online for six weeks via institutional networks, and all participants provided informed digital consent. In the second phase, students who volunteered for qualitative interviews were purposively selected to ensure variation in year of study and gender. A sample of 15 students was interviewed as saturation in themes was achieved at this point.\u003c/p\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003eData Analysis\u003c/h2\u003e\u003cp\u003eQuantitative data were analyzed using IBM SPSS 20. Descriptive statistics (means, standard deviations, frequencies, percentages) were used to report demographic and construct-level responses. Independent samples t-tests assessed gender and institutional differences, and one-way ANOVA examined variation by academic year. Pearson's correlation coefficients were used to explore the inter-relationships between flexibility and the other two constructs. To determine the predictive capacity of curriculum flexibility on emotional well-being and academic performance, a multiple linear regression model was developed using flexibility as the independent variable and well-being and academic performance as the dependent variables. A statistical significance was established at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e\u003cp\u003eThe qualitative data were interpreted using an inductive thematic analysis, adhering to the six-step process described by Braun and Clarke. Two researchers independently coded all transcripts, then compared and discussed their coding until full consensus was reached. To enhance trustworthiness, we maintained an audit trail and conducted peer debriefing. Codes were then grouped into themes through iterative comparison, consensus, and abstraction. Findings from both strands were integrated during analysis to enhance the depth of interpretation.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA sample of 372 undergraduate medical students from five prestigious PMDC-accredited medical schools in Pakistan was surveyed. The average age was calculated to be 22.1 years (SD\u0026thinsp;=\u0026thinsp;2.16), with 54.5% female respondents (202/372) and 45.5% males (170/372) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The sample was homogenously distributed across all five years of study, thereby providing a balanced view from both pre-clinical (Years 1\u0026ndash;2) and clinical (Years 3\u0026ndash;5) phases of undergraduate medical education, as well as from institutions adopting traditional and integrated curriculum systems.\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\u003eDemographic Characteristics of Participants\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\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eValue\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal Participants\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e372\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMean Age (SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e22.1 (2.16)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e54.5% (202)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e45.5% (170)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\n\u003ch3\u003eInstrument Reliability and Descriptive Statistics\u003c/h3\u003e\n\u003cp\u003eInternal consistency reliability was evaluated with Cronbach's alpha for each respective construct. The findings were acceptable for all constructs, at 0.78 for curriculum flexibility, 0.81 for emotional well-being, and 0.77 for academic achievement (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e), thus exceeding the generally recognized threshold of 0.70 for reliability. Furthermore, exploratory factor analysis confirmed the construct validity of the instrument, demonstrating a stable three-factor solution with eigenvalues at 2.76, 1.54, and 1.11, justifying a cumulative variance of 49.2%, consistent with the hypothesized theoretical model.\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\u003eReliability and Descriptive Statistics of Constructs\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eConstruct\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCronbach\u0026rsquo;s Alpha\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMean (SD)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCurriculum Flexibility\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.78\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3.91 (0.53)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEmotional Well-being\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.81\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3.76 (0.78)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAcademic Performance\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.77\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3.90 (0.53)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eAll average scores were calculated on a five-point Likert scale. The mean scores on the three constructs were: flexibility 3.91 (SD\u0026thinsp;=\u0026thinsp;0.53), well-being 3.76 (SD\u0026thinsp;=\u0026thinsp;0.78), and academic performance 3.90 (SD\u0026thinsp;=\u0026thinsp;0.53). Independent samples t-tests indicated that there was a statistically significant gender difference in emotional well-being (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e), with female students having higher average scores as compared to their male counterparts (4.02 vs. 3.51; p\u0026thinsp;\u0026lt;\u0026thinsp;0.01).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eGender differences in perceptions of curriculum flexibility (p\u0026thinsp;=\u0026thinsp;0.14) or academic performance (p\u0026thinsp;=\u0026thinsp;0.08) were not significant (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). A one-way analysis of variance (ANOVA) was used to compare variations between different academic years. ANOVA indicated significant variation across academic years (F(4,367)\u0026thinsp;=\u0026thinsp;6.45, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Mean scores suggested that first-year students reported higher perceived academic performance than senior cohorts.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eGender Differences in Constructs\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eConstruct\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale Mean\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMale Mean\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCurriculum Flexibility\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3.95\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3.86\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.14\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEmotional Well-being\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e4.02\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3.51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.01*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAcademic Performance\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3.93\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3.87\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.08\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eCorrelational and Regression Analyses\u003c/h2\u003e\u003cp\u003ePearson's analysis of correlation coefficients revealed strong and statistically significant intercorrelations among the compared constructs. Curriculum flexibility had a significant positive intercorrelation with emotional well-being (r\u0026thinsp;=\u0026thinsp;0.537, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and academic performance (r\u0026thinsp;=\u0026thinsp;0.587, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e, Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). To determine the predictive potential of these correlations, multiple linear regression analysis was carried out with well-being and academic performance as the dependent variables and curriculum flexibility as the independent variable\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eCorrelation Matrix\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\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\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCurriculum Flexibility\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eEmotional Well-being\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eAcademic Performance\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCurriculum Flexibility\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.537**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.587**\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEmotional Well-being\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.537**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAcademic Performance\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.587**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eNote\u003c/b\u003e: **p\u0026thinsp;\u0026lt;\u0026thinsp;0.001 for all correlations.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003ePerceived curricular flexibility was highly correlated with emotional well-being (r\u0026thinsp;=\u0026thinsp;0.537, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and academic achievement (r\u0026thinsp;=\u0026thinsp;0.587, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Flexibility explained more variance in academic performance (r2\u0026thinsp;=\u0026thinsp;0.344) than in well-being (r2\u0026thinsp;=\u0026thinsp;0.288), although both are meaningful (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eRegression Results\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\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\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDependent Variable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePredictor\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eR\u0026sup2;\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEmotional Well-being\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCurriculum Flexibility\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.288\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAcademic Performance\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCurriculum Flexibility\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.344\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eCollectively, the quantitative results demonstrate a consistent and statistically significant connection between flexibility in the curriculum and the overall emotional well-being of students and their academic performance. Therefore, provide empirical validation for the pedagogical worth of flexibility within medical curricula.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eThematic analysis\u003c/h3\u003e\n\u003cp\u003eWe conducted a thematic analysis of the open-ended survey questions, followed by an analysis of the interviews. Our analysis revealed three major themes: Challenges in the current curriculum, like fast-paced teaching, rigid schedules, and fixed assessments with no space for individualization; Suggestions for more practical and personalized learning with flexible assessments; Perceived benefits of curricular flexibility, like reduced burnout, improved learning with better engagement and motivation (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003e1. Challenges in the Current Curriculum\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe main challenges faced by students with the current curriculum were the rigid academic schedules, strict attendance policies, fast-paced curriculum, and clustering of exams (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e). Several students reported mandatory attendance as a huge challenge, as a student quoted, \u0026ldquo;Rigid schedule of classes and entirely rigid schedule of assessments with zero flexibility is the major challenge.\u0026rdquo; The attendance criteria have come across as a major challenge for some students, as a student commented: \u0026ldquo;The constant hassle to complete attendance, although we are just physically present, our minds are not there, which is just useless\u0026rdquo;.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eParticipants also reported that they get insufficient prep time compared to the bulk of the syllabus. A participant mentioned: \u0026ldquo;In our college, we get very little time to complete the syllabus as compared to other universities. We see that while other colleges provide 8 weeks for a module, ours allocates only 5 weeks for the same module.\u0026rdquo;\u003c/p\u003e\u003cp\u003eExams of all subjects together were also a serious concern: \u0026ldquo;Exam of all subjects together in one day is a difficult challenge for a medical student.\u0026rdquo; Another participant shared the same sentiment: \u0026ldquo;Broad and more subjects in a single assessment.\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u003cb\u003e2. Suggested Changes for Curriculum Flexibility\u003c/b\u003e\u003c/p\u003e\u003cp\u003eWhen asked to share their suggestions regarding changes to the current curriculum, several recurring themes were identified, including flexible scheduling and attendance options, assessment restructuring, and learner autonomy with integration of modern tools (Fig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThe most common suggestion was making attendance non-mandatory. A participant shared: \u0026ldquo;Attendance should not be compulsory, but the lecture should be interesting enough so that the whole class should be present.\u0026rdquo; Several participants also showed a desire for the option of online lectures for asynchronous learning. \u0026ldquo;Introduce recorded lectures or asynchronous content.\u0026rdquo;\u003c/p\u003e\u003cp\u003eSome students also shared that they would prefer a flexible exam schedule: \u0026ldquo;I would introduce flexible exam scheduling to allow students to take major assessments when they feel most prepared within a given window,\u0026rdquo; a participant suggested. \u0026ldquo;Exam should be structured similarly to international exams like USMLE, where you can give the exam whenever you are ready\u0026rdquo;.\u003c/p\u003e\u003cp\u003eA student suggested that they should have more autonomy in their scheduling: \u0026ldquo;more authority over my time and what to study\u0026rdquo;. Also, it will enable students to study according to their own pattern and give more time to what suits them.\u003c/p\u003e\u003cp\u003eA participant also suggested the use of modern tools to revolutionize education to meet the needs of personalized learning: \"I'd like to have more active learning tools incorporated into our curriculum\u0026rdquo;.\u003c/p\u003e\u003cp\u003e\u003cb\u003e3. Perceived Effects of Suggested Changes\u003c/b\u003e\u003c/p\u003e\u003cp\u003eMany students felt that having more flexibility in their schedule would reduce burnout, improve learning, and lead to greater engagement and motivation (Fig.\u0026nbsp;\u003cspan refid=\"Fig8\" class=\"InternalRef\"\u003e8\u003c/span\u003e). A participant put it simply: \u0026ldquo;Better academic performance, less mental pressure.\u0026rdquo; A student noted, \u0026ldquo;This change would reduce stress, promote deeper understanding, and improve performance by allowing students to study at their own pace and focus on true learning rather than cramming.\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eA flexible schedule can give students more time to spend on their weak areas: \u0026ldquo;It will allow students to take time for self-study and focus on their weak areas more efficiently instead of listening to the same lecture in the lecture hall with only 10 to percent of retention after leaving the classroom\u0026rdquo;.\u003c/p\u003e\u003cp\u003eWhen students control their pace, they can choose the period of maximum alertness to study important things, as noted by one participant: \u0026ldquo;I would like to do academic activities whenever I feel I can be more productive.\u0026rdquo; A participant shared that a more flexible schedule would increase the motivation to learn: \u0026ldquo;Would make me more eager to learn\u0026rdquo;.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study employs a mixed-methods approach across multiple institutions to investigate the attitudes of medical students towards curricular flexibility and its relationship with emotional well-being and academic achievement in the Pakistani undergraduate medical education system. Situated within a predominantly inflexible, teacher-centered model of learning, our findings offer important insights into structural determinants of student achievement, well-being, and engagement with learning. Drawing on data from 372 medical students, this study adds perspectives from a lower-middle-income country, where evaluations of curricular flexibility remain limited.\u003c/p\u003e\u003cp\u003eThe descriptive findings offer an important context. The relatively high mean for the flexibility dimension (M\u0026thinsp;=\u0026thinsp;3.91) indicates that students highly aspire for a flexible curriculum. Likewise, the mean for emotional well-being (M\u0026thinsp;=\u0026thinsp;3.76) indicates that inflexible curricular frameworks are viewed as detrimental to the psychological well-being of students. The academic performance score (M\u0026thinsp;=\u0026thinsp;3.90) also reflects the students' belief that a flexible curriculum will enhance their learning and performance.\u003c/p\u003e\u003cp\u003eBuilding on this, the inferential analysis revealed a statistically significant and conceptually consistent association between perceived curricular flexibility and significant learner outcomes. The observed predictive associations of flexibility with both emotional well-being and academic achievement support what has long been voiced anecdotally: rigid curricula can undermine not only academic success but also students\u0026rsquo; emotional health [7].\u003c/p\u003e\u003cp\u003eThe findings reported herein align with the growing corpus of interdisciplinary evidence backing curricular decompression principles, learner autonomy, and individualized pacing axioms upon which contemporary education models such as Competency-Based Medical Education (CBME) and self-determination theory (SDT) are founded [14]. The empirically substantiated predictive power of curriculum flexibility in our study underscores the fact that curriculum design cannot be considered as an inactive scaffold; rather, it is an active factor shaping student capability and accomplishment [15]. The fact that flexibility explained more variance in academic achievement than emotional well-being suggests that agency in the learning process functions not just as a buffer against stress but also plays a key part in facilitating cognitive and metacognitive activity [16]. Our research revealed gender differences in emotional well-being, with females being more affected by a rigid curriculum. This finding aligns with research from China, which also reports high psychological distress among female medical students associated with various societal, familial, and institutional pressures [17]. Nevertheless, flexibility and academic success perceptions were not gender-differentiated, indicating that consensus on structural curricular matters existed across demographic groups.\u003c/p\u003e\u003cp\u003eBetween-year comparisons revealed junior students reported higher perceived performance with a more flexible curriculum than senior cohorts. While previous research has demonstrated a decline in student satisfaction and self-efficacy during the clinical phases [18], our findings highlight a different challenge. Our study suggests that initial-year medical students face significant pressure while adapting to the rigid environment of their early curriculum and that they perceive flexible learning as a vital tool for improving their performance.\u003c/p\u003e\u003cp\u003eThe value in presenting qualitative findings lies not only in triangulation but in a sense of lived experiences, something not quantifiable. Students unanimously described a systemic sense of powerlessness to deal with on-campus schedules, attendance expectations, and content presentation that was packed to the point of bursting. The \"burnout\" theme, constructed emergently in dozens of comments, suggests an out-of-balance system in conflict with adult learning theory principles and psychological safety principles. Above all, students criticized long hours of lectures, packed exams, and rigid class timetables, which they frequently perceived as draining and counterproductive. This mirrors findings from US-based research demonstrating how misaligned academic structures can foster burnout and disengagement among medical students [19]. Even more importantly, students did not merely complain; they talked of possible, context-specific reforms aligned with international pedagogical trends. Suggestions like modular exams, asynchronous learning, flexible attendance, and adaptive scheduling have echoed in the contemporary global CBME innovations like the USMLE Step examination model, flipped classrooms, and learner-directed learning pathways.[20] Students demanded the addition of artificial intelligence platforms and optional subjects, which reflects a degree of curricular literacy and foresight not found in most South Asian students. This pattern is consistent with the contemporary trend in medical education, in which curriculum innovation is prioritized using a participatory approach, putting learners in the driver's seat rather than as passive responders to pedagogical change [21].\u003c/p\u003e\u003cp\u003eInterestingly, the suggestions offered were grounded in pragmatism rather than idealistic aspirations. The students elaborated clearly on links between suggested reforms and anticipated improvements in cognitive competence, emotional regulation, and motivation for learning. Their experiences demonstrated an awareness of their individual learning styles, limits of cognitive load, and motivational cues. This highlights the theoretical importance of learner-centered approaches that accommodate variations in learning rate, allow flexibility in preference, and cater to variations in readiness central tenets of mastery learning and adaptive expertise [22].\u003c/p\u003e\u003cp\u003eThe synthesis of our qualitative and quantitative results paints a clear picture of how the concealed costs of curricular inflexibility manifest themselves not just in undermined academic performance but also in the realms of student morale, identity construction, and long-term career advancement. Although medical education worldwide has progressed toward more integrated, flexible, and student-centered approaches, our study demonstrates that many medical institutions in Pakistan continue to rely on rigid structures that may undermine their intended educational outcomes. This research contributes to the global call for action aimed at curricular reforms in medical education, not through the imposition of complete systems from the Global West, but through genuinely incorporating the voices of students from local contexts. All future attempts at curriculum reform should be evidence-driven, inclusive, and responsive to the various needs of the student bodies that they aim to serve.\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eRecommendations\u003c/h2\u003e\u003cp\u003eFrom the findings emerging from this large-scale multi-institutional study, a set of requisite recommendations could be delineated for medical educators, curriculum planners, and medical education leadership. One thing is certain: there is a dire need to move away from didactic, time-restricted pedagogies to more student-centered, flexible curricular models. Medical schools in LMIC settings should be encouraged to implement modular course designs and student-directed learning spaces in which students can advance based on mastery rather than time. This change would take into account the various cognitive pacing and individual situations of the students, ease unnecessary academic pressures, and foster deep learning. Apart from this, current attendance policies that emphasize physical presence over engaged participation also require reevaluation. Use of recorded lectures and asynchronous learning content can indeed enable students to plan their learning schedules effectively, without any compromise on the quality of instruction. Moreover, the assessment environment must adapt itself; rigid and bunched assessments conventionally employed must give way to spaced, formative assessments where students can exhibit their competencies in a more personalized and less stress-inducing way. Such academic changes demand faculty preparedness. Therefore, sustained investment in faculty development initiatives is crucial to generate instructional flexibility, compassion, and incorporation of digital tools that complement pedagogy centered on flexibility. Finally, student wellness must be overtly recognized as an inherent education priority. Curriculum planning must integrate adequate rest periods, manageable workloads, and mental health provisions that foster holistic development. Medical education is not just designed to yield clinically proficient graduates but also emotionally resilient and intrinsically motivated professionals, a characteristic that is now linked more with curricular flexibility.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eLimitations\u003c/h2\u003e\u003cp\u003eAlthough this study provides valuable insights into the perceived effects of curriculum flexibility on medical students, several methodological limitations should be noted. The use of convenience sampling across five institutions restricts generalizability and may underrepresent some subgroups. Also, dependence on self-report measures raises issues about potential response bias. Excluding students with diagnosed psychiatric conditions may also have led to an underestimation of the true emotional impact of curricular rigidity. Students may have exaggerated or downplayed their ratings of well-being and academic success based on temporary mood states, personal expectations, or social acceptability. Another critical limitation is imposed by the cross-sectional design, which does not allow for causal inferences to be made. Despite the existence of strong correlations and predictive formulas, it cannot be assumed with absolute certainty that curriculum flexibility will lead to better academic performance or emotional well-being. It is equally possible that more academically efficacious or resilient individuals, by nature, may perceive the curriculum more favorably regardless of its structure. These limitations highlight the need for future studies using longitudinal and experimental designs, with broader institutional and demographic representation.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eFuture Directions\u003c/h2\u003e\u003cp\u003eExtending the conceptual and empirical work of this study, subsequent research should pursue longitudinal research following the impact of curricular flexibility at various points throughout a student's academic career. This would allow for comprehension of how views of flexibility evolve and how they intersect with academic transitions, clinical experience, and identity formation. Furthermore, controlled trials and experimental research must be conducted to evaluate the concrete results of individual reforms aimed at flexibility, like asynchronous modules, adaptive evaluation timetables, or elective learning pathways. It is also important to broaden the analytical focus beyond the voices of students. Institutional ethnographies and qualitative investigations facilitated by faculty members may yield key insights about the structural, cultural, and administrative challenges implicated in the provision of flexibility in medical education. Furthermore, an equity-focused methodology is important when examining how flexibility, or its absence, disproportionately impacts students from underrepresented groups, including students with caregiving responsibilities, mental illness, or socioeconomic constraints.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis research provides evidence that curriculum flexibility is not an extraneous luxury but an essential component of modern medical education. Drawing on the perspectives of 372 students at five prominent Pakistani medical schools, we demonstrate how rigid academic structures impact emotional well-being and academic performance while flexible, student-centered approaches are associated with more positive outcomes. In the LMIC context, where a combination of traditional and integrated curricula still coexist, these findings suggest that curriculum flexibility should be intentionally embedded as a conscious pedagogical decision, not as a compromise.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cul\u003e\n \u003cli\u003eMBBS – Bachelor of Medicine, Bachelor of Surgery\u003c/li\u003e\n \u003cli\u003ePMDC – Pakistan Medical and Dental Council\u003c/li\u003e\n \u003cli\u003eLMIC – Low- and Middle-Income Countries\u003c/li\u003e\n \u003cli\u003eCBME – Competency-Based Medical Education\u003c/li\u003e\n \u003cli\u003eSDT – Self-Determination Theory\u003c/li\u003e\n \u003cli\u003eMSWBI – Medical Student Well-Being Index\u003c/li\u003e\n \u003cli\u003eDREEM – Dundee Ready Education Environment Measure\u003c/li\u003e\n \u003cli\u003eEFA – Exploratory Factor Analysis\u003c/li\u003e\n \u003cli\u003eSD – Standard Deviation\u003c/li\u003e\n \u003cli\u003eSPSS – Statistical Package for the Social Sciences\u003c/li\u003e\n \u003cli\u003eANOVA – Analysis of Variance\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e\u003cp\u003eThe study was approved by the Research Ethics Committee of Liaquat University of Medical \u0026amp; Health Sciences (Approval No. LUMHS/REC/-713, dated 29 April 2025). Participation was entirely voluntary, and informed consent was obtained electronically from all respondents prior to completing the online questionnaire. All responses were anonymous, and no personal identifying information was collected to ensure confidentiality. The study was conducted in full accordance with the ethical principles of the Declaration of Helsinki.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003cp\u003eNot Applicable.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003eCompeting Interests\u003c/h2\u003e\u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e\u003cp\u003eThe author(s) reported that there is no funding associated with the work featured in this article.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eNW conceived the study, developed the research protocol, drafted the manuscript, and supervised all stages of the project. FS contributed to the study design, reviewed, and edited the final draft of the manuscript. RA facilitated ethics approval, coordinated institutional access, and contributed to data acquisition and manuscript revision. FSial assisted in data management, statistical and qualitative analysis. DR contributed to the literature review, data interpretation, and critical manuscript editing. All authors reviewed and approved the final version of the manuscript and agreed to be accountable for its content.\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e\u003cp\u003eThe authors acknowledge the cooperation of the participating medical colleges, faculty, and students. Special thanks are given to the experts who helped with questionnaire validation.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003e Higher Education Commission of Pakistan. MBBS revised curricula 2010\u0026ndash;2011. Islamabad: HEC Pakistan; 2011 [Internet]. [cited 2024 Dec 11]. Available from: https://hec.gov.pk/english/services/universities/RevisedCurricula/Documents/2010-2011/MBBS-Draft2010-11.pdf\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e Burney AA, Burney IA, Dherwani K. Integrated Curriculum in Medical Schools in Pakistan\u0026ndash;What? Why? When? and How Much. Annals of King Edward Medical University. 2024 Dec 31;30(4):433-9. DOI : https://doi.org/10.21649/akemu.v30i4.5618\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e Shankar PR, Azhar T, Nadarajah VD, Er HM, Arooj M, Wilson IG. Faculty perceptions regarding an individually tailored, flexible length, outcomes-based curriculum for undergraduate medical students. Korean Journal of Medical Education. 2023 Aug 31;35(3):235. DOI: 10.3946/kjme.2023.262\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e Mahmood A, Rehman N, Huang X, Riaz I. Barriers to undergraduate medical students\u0026rsquo; research engagement in Pakistan: a qualitative exploration. 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DOI: https://doi.org/10.3390/jcm14072263\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e Leslie K, Brown K, Aiken J. Perceived academic-related sources of stress among graduate nursing students in a Jamaican University. Nurse Education in Practice. 2021 May 1;53:103088. DOI: https://doi.org/10.1016/j.nepr.2021.103088\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e Irshad K, Ashraf I, Azam F, Shaheen A. Burnout prevalence and associated factors in medical students in integrated modular curriculum: A cross-sectional study. Pakistan Journal of Medical Sciences. 2022 Mar;38(4Part-II):801. DOI: https://doi.org/10.12669/pjms.38.4.5052\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e Dyrbye LN, Szydlo DW, Downing SM, Sloan JA, Shanafelt TD. Development and preliminary psychometric properties of a well-being index for medical students. BMC medical education. 2010 Jan 27;10(1):8. DOI: https://doi.org/10.1186/1472-6920-10-8\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e Roff SU, McAleer S, Harden RM, Al-Qahtani M, Ahmed AU, Deza H, Groenen G, Primparyon P. Development and validation of the Dundee ready education environment measure (DREEM). Medical teacher. 1997 Jan 1;19(4):295-9. DOI: https://doi.org/10.3109/01421599709034208\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e Ross S, Pirraglia C, Aquilina AM, Zulla R. Effective competency-based medical education requires learning environments that promote a mastery goal orientation: a narrative review. Medical teacher. 2022 May 4;44(5):527\u0026thinsp;\u0026minus;\u0026thinsp;34. DOI: https://doi.org/10.1080/0142159X.2021.2004307\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e Yang Y, Gielissen K, Brown B, Spak JM, Windish DM. 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DOI: https://doi.org/10.1001/jamanetworkopen.2021.19110\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e Enyoojo, S.F., Ijah, C.E., Etukudo, E.M. \u003cem\u003eet al.\u003c/em\u003e Satisfaction and learning experience of students using online learning platforms for medical education. \u003cem\u003eBMC Med Educ\u003c/em\u003e \u003cb\u003e24\u003c/b\u003e, 1398 (2024). https://doi.org/10.1186/s12909-024-06411-0\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e Ambrosetti \u0026Eacute;, Gaudin C, Flandin S, Poizat G. Students as co-designers in health professional education: a scoping review. BMC Medical Education. 2025 May 3;25(1):645. DOI : https://doi.org/10.1186/s12909-025-07110-0\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e Kua J, Lim WS, Teo W, Edwards RA. A scoping review of adaptive expertise in education. Medical Teacher. 2021 Mar 4;43(3):347\u0026thinsp;\u0026minus;\u0026thinsp;55. DOI : https://doi.org/10.1080/0142159X.2020.1851020\u003c/span\u003e\u003c/li\u003e\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":"Curriculum flexibility, medical education, academic performance, emotional well-being, student perceptions","lastPublishedDoi":"10.21203/rs.3.rs-7654000/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7654000/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eAmidst global calls for curricular flexibility in medical education, the undergraduate medical programs in Pakistan remain tightly structured and time-restricted. This multi-institutional study aims to explore medical students' perceptions of curricular flexibility and its perceived effects on their well-being and academic performance, and investigate the need for and methods of incorporating flexibility in the current curriculum.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA sequential explanatory mixed-methods design was used, with a cross-sectional quantitative survey followed by qualitative interviews. A total of 372 medical students from five different colleges in Pakistan participated in the survey from April 2025 to June 2025. For the quantitative strand, a convenience sample of undergraduate medical students spread across all academic years was selected. Data was collected using a contextually adapted, pilot-tested questionnaire based on validated instruments, with items rated on a five-point Likert scale. Quantitative findings were analyzed using descriptive statistics, t-tests, ANOVA, Pearson correlations, and multiple linear regression analyses. For the qualitative strand, 15 volunteer students were purposively selected to ensure variation in year of study and gender, and interviews were conducted until thematic saturation was reached. Data were analyzed using Braun and Clarke\u0026rsquo;s six-step thematic analysis.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eA total of 372 students participated (mean age 22.1 years, SD\u0026thinsp;=\u0026thinsp;2.16; 54.5% female, 45.5% male. Perceived curricular flexibility showed significant positive correlations with emotional well-being (r\u0026thinsp;=\u0026thinsp;0.537, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and academic achievement (r\u0026thinsp;=\u0026thinsp;0.587, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Regression analysis indicated that curricular flexibility explains more variance in perceived academic performance (r2\u0026thinsp;=\u0026thinsp;0.344) compared to well-being (r2\u0026thinsp;=\u0026thinsp;0.288), although both are meaningful. Females' scores on well-being showed more burnout with rigid curricula. than males (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01), and perceptions varied significantly across academic years (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Thematic analysis revealed challenges, including rigid schedules, mandatory attendance, and clustered exams; calls for recorded or asynchronous lectures, modular assessments, and greater learner autonomy; and perceived benefits of flexibility, such as reduced burnout, deeper learning, and enhanced motivation.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eStudents strongly linked curricular flexibility with academic gains and emotional well-being. Therefore, we propose that flexibility should be intentionally embedded in curricula, particularly in LMIC contexts, as a deliberate pedagogical strategy rather than a compromise.\u003c/p\u003e","manuscriptTitle":"Curricular Clocks and Cognitive Costs: A Multi-Institutional Study of Perceived Academic and Emotional Benefits of Flexibility in Undergraduate Medical Curricula","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-11 17:39:21","doi":"10.21203/rs.3.rs-7654000/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-12-31T17:04:41+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"140514684306201134395062628996001728396","date":"2025-12-31T16:51:01+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-30T20:47:00+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-29T22:42:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"63678895038404816762496070063441316505","date":"2025-12-29T20:31:47+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"7433490278183460864927243670345480454","date":"2025-12-29T07:46:21+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-23T11:52:28+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"328125309674681906148601207592344088260","date":"2025-12-13T00:32:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"50448377420965153317425945581721467885","date":"2025-12-11T13:57:35+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"238119131875596736137123631903055738049","date":"2025-11-15T06:31:32+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-29T16:01:37+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-10-08T11:16:16+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-03T09:45:35+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-02T13:32:26+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2025-10-02T08:45:55+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":"67c816de-4466-4cb4-960b-f40875f55fd6","owner":[],"postedDate":"November 11th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2025-12-31T17:08:32+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-11 17:39:21","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7654000","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7654000","identity":"rs-7654000","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}