In concordance with the previous studies that validated this construct, the current study revealed an acceptable validity and reliability of the gauge among preclinical students at Alfaisal University, which makes it suitable for the analysis of factors that can be associated with the measurable outcomes. Our study demonstrated that all domains are positively correlated to each other, which signifies that students’ ratings in each domain were very similar to their scores in other domains. This is consistent with the finding of WHO-QOL study from Iran where medical students addressed a similar satisfaction in all the assessed components [1]. Another study compared the QOL of medical students with the general population and found that medical students scored lower in physical health, psychological health and environment but not in social relations [9]. Similarly, this study entailed the highest rating in social relations where the students reported a positive attitude towards their interactions with their friends and the support they provide to each other. This is a remark of a positive implication for their future as physicians are in necessity of embracing this friendly character in order to polish their doctor-patient relationship [22]. On the other hand, the physical health had the lowest rank among other domains and the “sleep and rest” component attained the lowest rating than other physical health items. For instance, as medical students comply with their large academic load, many of them do not devote much time for rest or sleep especially when it is close to their exams [23].

The academic performance of medical students has shown to be a positive predictor for their developed professional competence in their long term career [18]. In addition, examining the association of academic performance and other factors with students’ self-scoring of physical, psychological health, social life and environment is essential. In this study, students with higher academic performance scored higher in all domains and male students are better than female students in physical and psychological health domains. The previous international data about the academic performance of medical students based on their genders is varied, where mostly reported a better performance of female students [24, 25] and one study reported no difference [26]. A study from a local university revealed that females procured a higher GPA than male students [27]. Upon examining the relationship between the two demographic factors in this study; gender and GPA, results suggest a lack of GPA difference between male and female students. Hence, both gender and GPA are considered independent correlates with the domains.

Students who devote more time for their academia tend to score better in physical health than those who merely pass. Previous studies deduced that physical health and the academic performance of students run in parallel [28]. A study among undergraduate students in US revealed that students with high GPA are more engaged in physical health in comparison to their peers with low academic outcomes [29]. However, a study on college of science graduates extrapolated a lack of significant effect of physical health on GPA [30]. The latter finding is supported by another study that claimed for an existence of other potential influences that can strongly impact the GPA; like hard-work and commitment, both of which can escalate the academic performance [31]. Our data suggests that as students move from one level of GPA to a higher one, an associative increase of around 5 % is noted in the physical health domain (Table 1). A possible explanation for this stratified increment is that energetic students tend to spend ample time studying the provided materials and their effort pays back in exams. Also, the high energy in these students may engage them into other daily living activities and may also provide them a greater capacity to work in their field of interest. On the other hand, below average students face difficulties in involving in other activities as their academic performance negatively impacts their energy and makes them less interested for taking part in other day-to-day activities [29]. Despite the lack of a significant correlation of the sleep with the GPA in the current study, a previous date averted that high academic achievers sleep longer (>9 h) than those with less academic performance. This could be due to the proper time management by students with high GPA, allowing them to go to bed earlier and wake up early and on-time [32].

A wide range of studies have ascertained the effect of scholastic performance on various components of psychological health including emotional intelligence, anxiety and depression [33, 34]. Still, very few studies investigated the items that belong to this domain in the short version of WHO-QOL survey. In this study, gaining five points in psychological health is associated with one level increment in the GPA. In order to testify this effect, each item belongs to this domain was assessed and results showed that all items were positively correlated with the academic performance. Several studies reported that an inflation of GPA was attributed to an incline in the level of spirituality, intelligence, motivation and self-esteem, and a decline in depression [35, 36]. As the interplay among these components becomes coherent and consolidated, one shall feel flourishing of his/her psychological health. Self-attainment of these components is heavily required by medical students as they will demand spirituality, motivation, positive feelings and self-esteem to deal with long working hours in their future clinical endeavors. Thus, an excellent academic achievement is associated with fulfilling highly demanding components necessary for the career prosperity of future doctors.

In regards to social relations, medical students did not explicitly demonstrate any difference in scoring this domain when compared to general population as discussed before [9]. Even though the overall high scoring of this section is associated with high GPA, a clear difference in GPA can be noted among below average students in comparison to other groups but not between excellent, good and average students (Table 1). As this domain assesses social support and personal relationships of preclinical students, both of these items are enormously essential for their future clinical endeavor. As high achievers in the academia seem to spend ample time in improving their scholastic outcome, they also tend to have a contextual enhancement in their e and social interaction skills.

The matriculation of physical activities in medical students’ life may be considered a mean for possessing an improvement in their environment. Many studies have enlightened the relationship between the scholastic achievements and physical environment where high achievers are more prone to impose a positive remark on their physical activity [29]. The current data coincides with these studies in regards to the positive correlation of GPA with preclinical students’ surrounding environments. Certain items from psychological health; such as self-esteem, also contribute to the physical activity of college students [36]. The financial issue, in turn, is one of the commonest concerns for medical students worldwide [37]. The system at Alfaisal University allows students to apply for merit-based or need-based scholarships in order to cover part of their tuition fees. The rest of the fees along with students’ daily expenses are usually covered by their parents. There might be two possible rationales behind the phenomenon of honor students entailing more financial support in this study. First, as long the parents start feeling a positive progress of their sibling in his/her academia, they may provide more financial support as an amicable award for his/her hard-work. Secondly, the merit-based scholarships are offered to honor students which, in turn, relieve the burden of student-loans for such preclinical students. Despite the latter rationale is seemingly more acceptable, both are imperative implication for offering a better environment for medical students.

The gender-specific effect on scores of physical and psychological health domains was noted. Similar to the current study, previous studies have demonstrated a higher rating of male students in physical and psychological health than the female counterparts [10, 38] and the proposed rational behind this is that females are more sensitive to pressure than their male peers [39]. A local study evaluated the gender based difference in physical activity among adults and deduced that females’ contribution in physical activity and exercise is significantly lower than their male peers [40]. There are limited studies tackling the change of quality of life across the preclinical years. All these factors can play an influential role in reducing the quality of life of female preclinical students.

There are limited studies tackling the change of quality of life across the preclinical years. The current study did not depict any difference in students’ ratings in the four domains across different years. A previous study from China reported that there was no difference in physical, psychological health and environment among the preclinical students in year 1 and 2, since year 3 students are already in clinical phase as per their curriculum. Socials relations, on the other hand, was the only domain that was rated less by second year students and this was due to the heavy workload that Chinese students have prior to the start of clinical phase. As the preclinical phase at Alfaisal University is covered over three years, covering the materials over this amount of period might mitigate the difference reported in the previous study [10].

As medical colleges strive to provide the optimal learning environment to students, more attention needs to be directed towards consistent measurement of students’ quality of life. Medical schools should build reforms in medical education and provide recreation centers in order to minimize the stress and burnout of students. It should also provide a positive environment and greater support for preclinical students who are poor in their academic performance. This can be achieved by establishing counseling facilities that can serve those with physical and psychological difficulties, aiming for a positive change towards their quality of life especially before the preclinical phase. Preclinical students, on the other hand, have to identify the impediments they face and seek for an advice from the faculty in order to find solutions for it. Furthermore, preclinical students who encounter difficulties in progressing in their academia should also ask for help and appeal for a positive change.

The main limitations of the study include; 1) The sample size of the study was drawn from one private institution where students and their parents may be financially stressed, in addition to students functioning in a very competitive setting, 2) The weak correlation could be due to the presence of other factors that were not examined including confidence in career development, students’ hometown location and interest in area of studies, and these factors need to be taken into account in future studies [10]. Finally, 3) not all students are exposed to same facilities and they might have some other academic factors that may influence their quality of life.