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

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.