We are always worrying about medical student performance. Measures of performance, including grades and standardized test scores, are monitored and discussed regularly. After sitting on an academic performance committee for several years, I have noticed that some students that struggle are a surprise to the faculty. Oh sure, there are some students who have lower pre-matriculant variables (undergraduate science GPA, MCAT, performance in upper level science courses) prior to starting medical school. In those students we might expect a lower performance in medical school. But there are regularly, students who did well during undergraduate studies, they have MCAT scores that are fine, and they are coming before the academic committee because of poor performance-usually failing a course or multiple courses. Why does this happen? Educational researchers in the Netherlands (ErasmusUniversity Medical Centre) and the Centre for Research and Innovation in Medical Education) have tried to tackle this question. (1) Their research question was: what is the relationship between motivation, learning strategies, participation, and performance in medical school. They are interested in the concept of self-regulated learning (SRL) which can be thought of as a learner that uses meta-cognition, motivation, and behavioral proactivity to improve their own learning. Several things that can be seen in self-regulated learners (and I would say in high-performing medical students): they monitor their progress towards their own goals; they are interested in learning for the sake of learning; and they develop and utilize effective learning behaviors. This study was done in a medical school in Rotterdam, the Netherlands which has a six-year medical curriculum. First year students in 2008 and 2009 were included in the study. There were 303 students in 2008 (32% male) and 369 students in 2009 (37% male). Students were given a questionnaire that was about their study techniques and were given immediate feedback and recommendations for ways to improve. An 81 item survey with six motivation subscales and nine strategies subscales was given to measure their Self-regulated Learning. The survey used a Likert scale (1=not at all true of me to 7=very true of me). The questions were things like “understanding the subject matter of this course is very important to me” and “I ask myself questions to make sure I understand the material I have been studying for this course” and “I make sure I keep up with the weekly readings and assignments for this course.” Students also rated their attendance in lecture, clinical skills training, and assignments The authors found that Participation (lecture attendance, completing study assignments, and skill training attendance) was positively associated with Year 1 Performance and improvements in the mean GPA. Deep learning strategies were negatively associated with Year 1 performance. So students who utilized deep learning strategies more frequently as their study method, had more difficulty in the preclinical (Year 1) curriculum. So why does participation affect performance? Is it just because people that go to lecture are able to learn things and get explanations that are not in the available written information? Or is it because of the repetition of the material? They have heard it more times- a concept known as distributed practice (study effort is distributed over several study sessions). Or is it differential repetition? Material is presented in lecture, on-line modules, tutorials, small groups, skills training, and independent study which gives more opportunity to absorb and integrate the information into a structured knowledge base. Is it just because people that go to lecture are more in tune with the material covered and how it will be tested? Since they go to lecture, they know what is going to be on the test based on the cues and clues from the faculty. This is an area that needs more research. We want students to utilize deep learning strategies because information that is learned this way are more likely to retain that information. We don’t want students that do better on the test just because they show up, unless showing up leads to deeper learning and retention of information.