52 Chapter 3 Approaches to learning describe students’ general intentions and strategies for approaching their studies (25–27). Originally, a surface and deep learning approach were identified. Students with a surface learning approach have the intention to pass a task or exam with a strategy relying on memorization, while students with a deep learning approach have the intention to understand with a strategy focusing on relating information. Later, a strategic approach was added in which students have an intention of high achievement and a strategy combining deep and surface elements (26). Research shows that students tend to change their approaches to learning over the course of their studies, becoming more strategic and deep learners (28,29), although not all studies find this same development (17). Research shows that approaches to learning are related to differences in students’ preferences for teaching and learning methods (12,30). Surface learners prefer to memorize clear-cut knowledge from lists and books, whereas deep learners prefer to engage with the content in challenging assignments. Strategic learners’ preferences depend on their perception of the effectiveness of certain methods for achieving a high grade. Research aim In a previous paper, we reported on first-year medical students’ appreciation of small-group active learning (12). We identified four profiles of students in that study: understandingoriented, assessment-oriented, group-oriented, and practice-oriented. These profiles described when and why students appreciated small-group active learning and were influenced by students’ epistemic beliefs and approaches to learning. The present study aims to investigate how and why students change during the Bachelor program by collecting data three years after the original study. With this knowledge, we could gain a better understanding of student development during their studies, and teachers could be better equipped to design and teach active learning classes at various stages of a study program. METHODS Setting and participants For this study, we invited medical students from a university in the Netherlands to participate. Medical education in the Netherlands consists of a three-year Bachelor program, followed by a three-year Master program (31). A national framework describes the required minimal end qualifications of medical training (32). The end qualifications integrate knowledge, skills, and attitudes, and are based on the CanMEDS framework (33). The students participating in this study were fourth-year students who just started their Master’s or were finishing their Bachelor’s. As such, they have had three years of a tutoring course. They started in September 2018 with this tutoring course in a face-to-face format. From March 2020, they made the switch to an online or mixed format due to the COVID19 pandemic. This course was designed as a small-group (max 12 students) active learning setting (34), in which students meet twice per week to discuss patient cases and complete associated assignments. The small-group meetings were linked to lectures, labs, and other
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