Institutional environment, academic attitude, and misconduct among medical students: a structural equation modeling and cluster analysis

Background Academic misconduct poses a severe threat to scientific integrity and medical ethics. While gender disparities in misconduct are widely documented, the underlying cognitive mechanisms explaining why males are more susceptible, and whether a supportive institutional environment can buffer these risks, remain underexplored in the context of Chinese medical education. Methods A multi-center cross-sectional study was conducted across medical universities in Southwest China. Standardized assessments measuring academic misconduct, academic attitude, institutional environment, and academic pressure were administered. Structural Equation Modeling (SEM) and K-means cluster analysis were employed to analyze the mechanisms and student profiles. Results From an initial cohort of 511 participants, 426 valid questionnaires were retained after rigorous quality screening (effective response rate: 83.4%). The study revealed a robust gender disparity, with male students reporting significantly higher engagement in misconduct ( β  = 0.69, p  < 0.001). SEM analysis demonstrated that Academic Attitude served as a critical mediator, accounting for 46.5% of the total gender effect. This suggests the gender gap is largely driven by a susceptibility to utilitarian cognitive framings among males. Contrary to the buffering hypothesis, the institutional environment did not significantly moderate the adverse effects of negative attitudes, indicating a "dominance of attitude." Furthermore, cluster analysis identified a distinct "High-Risk" phenotype (11.3% of the sample) characterized by the "toxic triad" of high pressure, negative attitude, and prevalent misconduct. Notably, this group was disproportionately male ( 60.4% ) and exhibited a "knowledge-behavior dissociation." Conclusion The gender gap in academic misconduct is primarily a cognitive issue rather than a behavioral inevitability. The failure of environmental factors to buffer risks challenges the reliance on external governance alone. To effectively mitigate misconduct, medical education must shift from "one-size-fits-all" rule enforcement to precision interventions . Strategies should prioritize cognitive restructuring to foster value internalization and targeted pressure management, specifically designed for the identified high-risk male subgroup.