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 the risks associated with academic pressure and negative attitudes, 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 evaluating five core constructs, including academic misconduct, academic attitude, institutional environment, ethical climate, 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. The study revealed a robust gender disparity, with male students reporting significantly higher engagement in misconduct (β = 0.29, p < 0.001). SEM analysis demonstrated that Academic Attitude-operationally defined as utilitarian tolerance toward dishonesty-served as a critical mediator, accounting for 50.7% of the total gender effect. Contrary to the strict buffering hypothesis, the institutional environment did not significantly moderate the adverse effects of negative attitudes, partially due to severe range restriction in the highly-regulated sample. Furthermore, cluster analysis identified a distinct "High Misconduct-High Strain" phenotype (11.3% of the sample) characterized by high pressure, negative attitude, and prevalent misconduct. Notably, this group was disproportionately male (60.4%) and exhibited a behavioral phenotype consistent with moral disengagement. CONCLUSION: The gender gap in academic misconduct is primarily driven by utilitarian cognitive framings rather than behavioral inevitabilities. The limited buffering capacity of environmental factors challenges the reliance on external governance alone. To effectively mitigate misconduct, institutions should avoid over-educating the resilient majority and move toward targeted educational strategies. Interventions should prioritize non-universal cognitive restructuring specifically tailored for the identified high-risk subgroup.