To support our overview, we reviewed the existing literature, searching for peer-reviewed articles, dissertation theses, and other electronic sources in multiple databases, including PubMed, PsychNet, and Research Gate. Our primary search keywords were medical education, theories, struggling students, academic advising, millennials, YouTube generation, osteopathic medicine, and student learning. After this initial, generic search, we refined our focus to learning theories, as they were extensively cited in the literature; our keywords then included behaviorism, self-efficacy, cognitivism, constructivism, acculturation, and ecological theories. 

Academic advising is a valuable resource for first- and second-year medical students as they navigate their preclinical years. Academic advisors can play an important role for medical students who are struggling, as students may need advising in multiple domains, such as personal issues, research, future career, residency, alumni, or academic achievement.¹⁰ However, advisors can struggle to find the right approach when working with these students. Some advisors follow a prescriptive style, while others follow a developmental style of advising.¹ Prescriptive advising is associated with the advisor's expertise, while developmental advising is associated with the student and advisor sharing authority and developing common goals as well as intended outcomes.¹¹ 

Academic advising can either be student- or faculty-driven, depending on each student's need. Student-driven advising through mentoring helps facilitate insight into the student's assumptions, learning strategies, and intended outcomes. Medical students who are struggling typically communicate with faculty due to repetitive examination/course failures or when suggested to do so to comply with school policy. In contrast, in faculty-driven advising, the student consults with the faculty on specific personal, social, or academic issues.¹² While different natures and styles of advising may help different students, an overall understanding of existing theoretical approaches can guide the advising process. 

Academic advising should also meet the changing needs of students, especially millennial students, as most of their learning occurs through online platforms. For example, in a study conducted by Barry et al¹³ with 73 students, 50 second-year medical students (in addition to 23 radiation therapy students) were administered a survey to indicate their learning preferences for anatomy courses. Study results showed that approximately 70% of students reported reliance on web-based resources, which suggests that traditional methods of teaching should be modified. These study findings indicate how the rapid growth of internet technologies, including social networking websites, virtual reality programs, and YouTube, have provided additional learning environments for millennial students. A study conducted by Farnan et al¹⁴ highlighted the advantages and disadvantages of online platforms in medical education. Online learning platforms, although very effective because of convenience, cost-effectiveness, and student engagement, are limited by possible copyright infringements and lack of a standardized professional code of behavior.¹⁴ 

Theoretical approaches can provide a distinct framework by which to understand a student's perspective, and they can help in formulating an intended plan of action in academic advising.¹⁵ For years, educators have advocated for the use of theoretical approaches in student advising, as they can provide structure and critical insight in advising.¹⁶ Theories can help guide different advising styles that can be beneficial to students who present with different personal, academic, cultural, or interpersonal issues. In the next few sections, we discuss the theoretical approaches and their application in medical education.¹⁷ 

In general, theories offer deeper understanding of a phenomenon, both from a conceptual perspective and practice perspective. They often help guide the development of a hypothesis and can be validated or modified through scientific inquiry. A review of current literature suggests that academicians have periodically used psychosocial theories to advise students.¹⁸ The Table presents the application of theoretical approaches during the preclinical years of medical education. Our review of theoretical these approaches found heavy emphasis on learning theories, as they can be easily understood from a learner's perspective.^18-20 Learning theories are a set of specific, guided principles that help explain how students learn, process, or understand knowledge acquired in various settings. Large-scale, “macro” theories such as acculturation and ecological system theory are also discussed, since learning theories are criticized for their lack of emphasis on the sociocultural context. 

This theory relies heavily on behavior that can be directly observed, evaluating the relationship between a stimulus and response. It is a teacher-centered approach that facilitates a desired response in the learner.⁸ Behaviorism operates on rewards and punishment for appropriate and inappropriate behaviors, respectively. Learning can occur through gradual conditioning from an external stimulus. Behavior change can happen only in small increments until a desired change is observed.^21,22 Application of behaviorist theory includes positive reinforcement, negative reinforcement, punishment, or systematic desensitization. Rostami and Khadjooi,²³ in their study on the implications of behaviorism in medical education, described how assessments could be designed for a higher completion rate. For example, students can be conditioned to complete a certain assignment on the premise that those who do so would have a higher chance of performing better on a specific test. Behaviorism is limited in its understanding of learning, as it does not account for cognition.²³ For example, positive reinforcement may not be helpful for some students if they are unable to prioritize or modify their study habits. 

Cognitivism relies on a learner's internal thoughts and processes to facilitate comprehension and understanding. Piaget emphasized that learners make sense of the interaction between their environment and personal experiences. Learners constantly restructure their schemata, or pattern of thoughts and behaviors, through assimilation and accommodation when new information is presented.²² Social cognitivism argues that social learning precedes development, and culture plays a key role in cognition development. 

The cognitive learning theory presents students with instructional training to improve learning. One application of this theory in medical education is memorization, especially in first-year medical science courses like pathology and anatomy, which demand a large amount of cognitive load.²⁵ Cognitive learning can be limited when a student lacks understanding when learning in a certain environment. For example, some students can study or test better in a classroom or library but get distracted in an unstructured environment, thereby affecting learning. 

The social learning theory proposes that behavior is learned through the environment by observation.²⁶ There is a continuous, reciprocal interaction among cognitive, behavioral, and environmental influences. The 4 main components of social learning are (1) attention, (2) retention, (3) motor reproduction, and (4) motivational process. One successful application of this theory in medical education is modeling. Some students, especially those who are struggling, may need more guidance and support than others. However, helping students identify successful study skills can help them perform better in the preclinical years of medical school.²⁷ 

The social learning theory was refined over time and became the social cognitive theory, a core component of which is self-efficacy. The self-efficacy theory proposed by Bandura²⁸ aims at understanding the competence of an individual in completing a task. The self-efficacy construct explains how motivation and confidence are important in completing a goal or a specific task. Our review found multiple studies suggesting the benefits of building self-efficacy, namely that improved self-efficacy has an impact on academic achievement.^5,29-31 Guntern et al³² found that self-discipline, social activity, and self-efficacy beliefs collectively predicted academic achievement during the preclinical years. 

Self-efficacy is also interdependent on self-regulated learning. ³³ A previous qualitative study of 55 students demonstrated the benefits of improved self-regulated learning.³⁴ This study explored self-regulated learning theory among first-year medical students who failed their year-end final assessment. The study suggested that students who did not perform well avoided seeking help and resisted changes to learning strategies, resulting in multiple failures. The study also suggested that maladaptive, self-regulated learning affects response to failure, including normalizing failure and a lack of self-reflection that could potentially prevent students from overcoming these failures.³⁴ However, self-efficacy does not always guarantee a positive outcome.³⁵ Individual experiences and distorted memories of previous performances can affect self-efficacy.³⁶ For example, it can be difficult to increase self-efficacy if the student has had multiple failures, a death in the family, or a family member with a terminal illness. 

This theory proposes that students learn by constructing their own reality. Students may create meaning from their environmental assumptions or personal experiences. It is important to understand that these assumptions are valid. When new material is presented, learners should be taught and coached through all of the steps. Learning is based on a process that connects new knowledge with prior, existing knowledge.³⁷ The constructivist learning theory is built on task-based learning. For example, first- and second-year medical students are taught basic science information, but later asked to apply this knowledge through simulation before they encounter real patients. Throughout this process, knowledge is being enhanced through problem-based and task-based learning.³⁷ Constructivist theory is applied in medical education through case-based learning. Students can discuss cases assigned to them and share interpretations with each other to make learning more effective.²¹ For medical student who are struggling, advisors can suggest study groups—either face-to-face or online, where participants are exposed to different learning methods, task-based learning, and problem-solving methods. However, this can be challenging in the absence of direction or proper guidance, which is a limitation of the constructivist approach.³⁸ 

Berry³⁹ proposed a multidimensional approach with 4 distinct elements of the acculturation theory: (1) assimilation, where individuals totally adapt to the receiving culture and reject the parent culture; (2) separation, where individuals reject the receiving culture and retain the parent culture; (3) integration or bicultural socialization, where individuals retain both the parent as well as the receiving culture and; and (4) marginalization, where individuals reject both the receiving and parent culture. An example of acculturation in medical education is the struggle faced by students with international backgrounds, while trying to adjust to their academic load. 

McGarvey et al,⁴⁰ in their study on international students in medical school in Ireland, examined students from Ireland, Europe, Africa, the Caribbean Islands, the Middle East, and Asia. These students showed varied responses to making social connections and friendships. Some ethnically diverse students found social adjustment more difficult than students who were citizens of the United States. The study reported that students from Malaysia and the Middle East were less well-adjusted compared with other international students. Another study suggested that international students are at highest risk in clinical skills training due to delayed acculturation.⁴¹ 

Although the acculturation theory incorporates culture as a major environmental influence, it narrows its understanding to immigrant populations. Therefore, we recommend using the ecological system theory. This theory offers a broader and better framework for understanding the needs of students who are struggling with different financial, cultural, educational, and/or social backgrounds. The theory is built on the idea that an individual has direct and indirect contact with his or her environment, comprising nested arrangements of different structures: immediate interaction with family, peers, church, camp, or workplace, as well as larger systems, such as social structures, culture, and law and order.⁴² The interactions between these systems can deter or promote a student's progress in the preclinical years of medical school. Students who are struggling often complain about family issues, social engagements, ineffective learning, and study-life balance. Academic advising can include evaluating all the systems with which a student who is struggling interacts and filtering out those that are most distracting. 

Medical schools enroll students from all different backgrounds and nationalities. These include nontraditional students who choose osteopathic medicine as a second or even third career. Many of these students may be single parents or have families with competing priorities. It is therefore important to understand the changing environment, advising structure, and learning methods that can be useful for medical students who are struggling to achieve success in the rapidly changing medical education system. 

Some of the common academic challenges encountered by students who are struggling in preclinical years have been identified and understood through multiple theoretical perspectives, all of which can be applied through role-modeling, mentoring, and collaborative or peer-group training. The Table illustrates examples of the challenges that medical students who are struggling may encounter. The choice of theory is based on the academic advisor's experience and practical approach. 

As with all literature reviews, the analysis in this review has its limitations. First, our interpretation is based on a limited number of studies applying theory to practice in medical education. Hence, interpretations cannot be generalized. Second, theories are dynamic and evolving, and there are different options about the application of each to different populations as well as their strengths and limitations.⁴³ Therefore, practitioners should keep themselves up-to-date with ongoing discussions and relevance in medical education. Third, using theories while advising students requires practice as well as knowledge, experience, and time. Therefore, advisors in medical education will need in-depth training in the theoretical approaches they want to use in practice. 

This article explores current learning theories that can be used to understand a medical student who is struggling. It also describes many pathways that an academic advisor can suggest while mentoring students who are performing poorly academically. Many times, students are aware of the issues that hinder their progress in medical school, but they cannot visualize how strong the impact is on their day-to-day life. Our review outlines how choice of a specific theory can help and support the advisor in guiding students, because medical students who are struggling may present themselves with multiple academic needs. It is important to identify the risk factors early and provide much-needed guidance to the medical students who are struggling. An early intervention for medical student who are struggling (during the first 2 years of medical education) will help provide support and direction, potentially preventing repeated failures and attrition.