Non-traditional learning resources—materials not produced by a student’s own institution or lecturers—have become central to medical education. These include peer-generated note decks, spaced repetition platforms, and commercial off-the-shelf learning platforms developed specifically for medical education labelled "MedED-COTS".¹ MedED-COTS, are widely used: in 2022, 96.2% of American medical students reported using non-traditional resources, with 36.6% using them daily.² Similar patterns have emerged internationally, for example 70% of clerks in the United Kingdom reporting utilization of medical apps such as UpToDate and uWorld.^3–7Their use has been linked to higher performance on standardized exams such as the USMLE.⁸ Outside the U.S., however, usage is less well studied, and it remains unclear whether patterns such as reduced class attendance are related to reliance on non-traditional resources.⁹ While a recent Best Evidence Medical Education (BEME) guide endorsed their value, most existing studies remain survey-based, with limited qualitative insight into students’ motivations.¹

A recent focus group study partially addressed this gap, reporting that pre-clerkship students preferred non-traditional tools for their efficiency, clarity, and peer endorsement.⁶ These findings highlighted the influence of high-stakes national exams like USMLE Step 1 and 2, but the study focused solely on the American context, and relied on focus groups, where disclosure may be constrained by social dynamics.

To date, while usage rates have been well documented,^2–6key questions remain about how and why students use these resources. Students appear to be selecting different resources to enable their own learning which fits within the framework of self-regulated learning (SRL). SRL is a cyclical process in which learners set goals, select strategies, monitor progress, and reflect on outcomes.¹⁰ Its four central features—motivation, goal setting, feedback loops, and self-monitoring—shape decisions about whether to rely on lectures or alternative tools. While curricula often prescribe overarching goals, students also develop personal objectives that drive study behaviors.¹¹ Feedback loops and self-monitoring enable adjustment and awareness, but SRL is not innate; early-stage medical students often require support to develop these competencies.¹⁰ SRL thus would appear to be a useful framework to guide analysis of student motivation and benefits and drawbacks of their chosen resources.

A growing body of research shows that most medical students rely heavily on MED‑COTS and other non‑traditional resources, yet little is known about why these tools are selected and how they shape their learning behaviors and study strategies. When students preferentially use external resources over institution‑developed materials, it raises important questions about the alignment between the formal curriculum and what learners perceive as high‑yield or clinically relevant. This misalignment has implications for faculty time, curriculum design, and the coherence of educational outcomes. Moreover, because these resources influence what students prioritize and retain, their use may ultimately shape clinical reasoning patterns and patient care.

In sum, although prior studies have quantified the prevalence of MED‑COTS use, none have examined the underlying motivations, decision‑making processes, or perceived trade‑offs in depth. Understanding why and how students turn to these resources is essential for informing curriculum development, supporting effective self‑directed learning, and ensuring that educational practices align with the competencies expected in clinical training.

Therefore, the purpose of this study is to explore the use of non-traditional resources in pre-clerkship and clerkship to examine “why and how” students use these resources and perceived advantages and disadvantages compared to traditional resources.

A total of 29 students (18 pre-clerkship students and 11 clerkship students) were interviewed. The average interview lasted 34 minutes (range: 18-65 minutes). Nine participants identified as male and 20 as female, and the majority (n=27) were from the English stream. Participants ranged in age from 21 years to over 30 years: 21–25 (n=26), 26–30 (n=2), and over 30 (n=1). Participant USMLE interest, lecture attendance patterns, and types of resource usage are shown in Table 1.

After defining non-traditional resources for all interview participants, 100% of students (n=29) described using some form of non-traditional resources, despite 8 (5 pre-clerkship students and 3 clerkship students) having stated otherwise in the pre-interview screening survey. Descriptions of the top 5 resources for both locally student-made and MedED-COTS resources can be found in Table 2.

We generated four themes from our participant interviews. The first two address the “why” or motivations for using non-traditional resources, the third addressing goal setting and the fourth addressing “how” students engage with resources.

In this study, we advanced understanding of medical students’ motivations and use of non-traditional learning resources^1,5,6 by employing an interview-based design that allowed deeper exploration of students’ experiences. We found near-universal utilization of such resources, at levels exceeding those reported in prior studies³ with dissatisfaction with the traditional curriculum serving as a central motivator. Peer influence, including both recommendations and resource development by upper-year students, was critical in guiding resource choice. These findings echo those of Lawrence,⁶ while extending the literature by identifying three distinct learner archetypes that provide a useful framework for conceptualizing resource use. We also found that students’ orientation—whether future- or present-focused—shaped resource selection, particularly in contexts where pass/fail curricula shifted attention away from exam performance.

Students identified several perceived shortcomings of the traditional curriculum, noting that lectures were inefficient, of limited relevance, and inconveniently scheduled. Scheduling has been previously shown to affect lecture attendance,¹⁷ as has the use of accelerated recordings. Some students acknowledged attending lectures primarily to ensure exposure to exam-relevant material, while others sought alternative or supplementary non-traditional resources, highlighting the motivational component of SRL. Still, students recognized enduring benefits of lectures, particularly the transmission of “clinical pearls” and the value of faculty expertise, leading to reluctance to eliminate lectures altogether.¹⁸

Consistent with prior studies^4–6 students in our study relied heavily on peer recommendations when selecting resources. Efficiency, relevance, and formatting were central to their choices, with accessibility and comprehensiveness being double-edged factors that could facilitate or overwhelm learning.^4,19 Notably, students in our Canadian context, who had little interest in writing the USMLE, reported less frequent use of resources that are highly popular in the United States.²⁰

Few students critically evaluated the quality or trustworthiness of non-traditional resources, highlighting a concerning gap in the monitoring component of SRL. Prior research found that one-third of students did not question the quality of medical apps, with fewer than 20% seeking peer ratings and only 12% checking against textbooks or lectures.4 In our study, some students appeared to validate resources by their alignment with short-term exam goals (“pass now”), while others prioritized clinical relevance (“study for the future”). These findings raise important concerns for faculty, as gaps in appraisal of resources may ultimately influence the quality of future patient care.

Our identification of three new archetypes—Reformers, Traditionalists, and Supplementers—adds nuance to existing literature. Reformers, who rarely attend class, rely almost exclusively on non-traditional resources, while Traditionalists, who prioritize lectures, view the curriculum as their central structure. Supplementers, positioned between these extremes, may be especially valuable in identifying gaps in the official curriculum. Prior literature described non-traditional resources as a “parallel curriculum” for USMLE preparation,²¹ but our findings suggest a “supplemental curriculum,” where students strategically combine traditional and non-traditional tools. This distinction advances prior work,^6,21 demonstrating that many students see value in institutional curricula while still seeking the efficiency and convenience of external resources. Importantly, even when institutions integrate external resources into curricula, students often continue to use their own preferred materials.²²

The archetypes, coupled with the dichotomy of present- versus future-oriented studying, map directly onto SRL constructs of motivation and goal setting. While all students ultimately aim to pass exams and develop clinical competence, their self-generated goals differ. Pre-clerkship students tended to view exams as the endpoint, relying heavily on peer-developed “high yield” resources to avoid “overstudying,” consistent with prior reports.⁶ In contrast, clerkship students were more likely to situate their studying in clinical contexts, recognizing exams as necessary but secondary to the development of practice-relevant knowledge. These differences illustrate how SRL manifests in distinct study strategies and priorities.

SRL is increasingly recognized as an essential skill for lifelong learning. Faculty may benefit from reframing student non-attendance at lectures—often criticized or considered unprofessional²³—as a potential marker of SRL engagement, particularly among Reformers who take an active role in directing their own learning. Our findings also highlight the complementary use of multiple non-traditional resources, such as combining question banks with content libraries, which was common across student archetypes. While multiple-resource use has been reported previously,⁶ our study adds insight into how students combine tools to engage in clinical reasoning and knowledge consolidation. The widespread use of question banks, even among students not preparing for the USMLE, illustrates how learners actively use feedback loops to identify gaps and monitor progress—key features of SRL.

A key strength of this study is the composition of the research team, which included four medical students representing both pre‑clerkship and clerkship stages, diverse levels of engagement with non‑traditional resources, and both English and French program streams. This diversity enhanced the study’s reflexivity and ensured that multiple learner perspectives informed data collection and interpretation. The major limitation of this study is its focus on a single Canadian medical school with a lecture‑ and small‑group–based curriculum, which may limit transferability to other contexts. As with all qualitative research, the aim is not generalizability but rather to provide rich, contextualized insights that may be informative to similar settings.

Self-selection is also a potential limitation, and while we did attempt to target individuals reporting no utilization of non-traditional resources, we found all students utilized these resources to some degree. While offered in French, no French stream participants ultimately choose to interview in French as well. The use of student interviewers also serves as a potential limitation although these interviewers purposely avoided interviewing their peers and friends. Additionally, for privacy and ethical reasons, linkage between this interview-based study and prior survey work on the same population was not possible.

Four themes emerged: two reflecting students’ motivations for turning to non‑traditional resources—the perception that the traditional curriculum is repetitive and inflexible, contrasted with the high‑yield flexibility of external tools; one highlighting differences in goal setting, with students studying either for today’s exam or tomorrow’s patient; and one illustrating how learners engage with resources through three distinct archetypes—the Traditionalist, the Supplementer, and the Reformer.

Taken together, we suggest that these findings point to several practical, potential steps for medical educators. Addressing curricular rigidity by streamlining lecture content, increasing flexibility in delivery, auditing scheduling practices, and co‑designing improvements with students may help reduce the inefficiencies that drive learners toward external tools. At the same time, institutions can better align with student practices by formally curating and vetting high‑yield non‑traditional resources, embedding selected tools within the curriculum, supporting faculty in their use, and developing partnerships to ensure equitable access. Strengthening students’ self‑regulated learning skills is also essential, including explicit instruction in goal setting, monitoring, and resource appraisal, as well as guidance to balance short‑term exam needs with long‑term clinical competence—particularly in pass/fail environments. Leveraging the three learner archetypes can further inform curriculum planning by recognizing diverse learning approaches, engaging Supplementers as indicators of curricular gaps, providing Traditionalists with structured pathways that incorporate vetted external resources, and viewing Reformers’ non‑attendance not as disengagement but as an expression of SRL, warranting supports that meet them where they are. Further, particularly more international, qualitative work, to explore resource utilization in other non-American settings, particularly in lower-resource settings as many of these resources are Internet and mobile device based, would further build on this and explore opportunities for curriculum development.