A key aim of educational course design is to encourage students to adopt deeper approaches to learning. This article reports the findings of three studies that explored how medical students responded to three carefully designed educational course units. The findings suggest that while a subgroup of the students responded by adopting deeper approaches (as intended by the designers of the course units), another subgroup responded by adopting more surface approaches. Two further subgroups displayed minimal changes in their approaches despite significant changes in their learning contexts. The finding (in all three studies) of a notable proportion of students adopting more surface approaches is of particular concern, as this could adversely affect the impact of even the most carefully designed educational program. These findings suggest that the context-dependent nature of approaches to learning merits further investigation as it may be more complex than previously described in the literature.