The COVID-19 pandemic has affected all levels of medical student training from in-person didactics and clinical rotations, to the AAMC, to testing centers. To our knowledge, this is the first study to assess medical students’ learning environment, QoL, and school response amid the COVID-19 pandemic. We found that the medical students who responded to our survey had positive perceptions of the online learning environment and moderate QoL with disruptions to concentration and sleep. We also identified three themes (communication, online learning environment, and empathy and support) that encapsulate their positive and negative perceptions regarding their SoM’s response to the pandemic. Surveying medical students during this pandemic is both timely and relevant as the educational environment has an impact on students’ perceived well-being, satisfaction, and educational achievement [17]. Overall, we believe that our findings can be used to inform a medical school’s response during the continuation of the current COVID-19 pandemic [18], as well as mitigate reactionary responses by schools of medicine during future pandemics or crises.
Most respondents quantitatively reported positive perceptions of the online learning environment during the pandemic, noting knowledgeable teachers, relevant content, and the ability to ask questions. These findings may not be unexpected as medical schools have been transitioning to online curricula for more than a decade, particularly in the pre-clinical years [20, 21]. In addition, medical schools may have also applied lessons learned from medical school closures in Hong Kong and Canada during the SARS-CoV-1 epidemic from 2002 to 2004 [22]. However, M2 students reported considerably less favorable perception compared with peers in other classes. We attribute this difference to the timing of our survey given the uncertainty surrounding preparation and scheduling of the step 1 board exam. Preparing for boards is one of the greatest stressors of the M2 year. The timing of the COVID-19 pandemic significantly compounded this stress as students typically sit for step 1 in May or June, a period of the pandemic during which testing sites were forced to close, some with only 24 h of notice. Although testing site closure was occurring nationally with the closing of testing cites beyond the SoM’s control, many M2 students expressed concern and frustration about a lack of a contingency plan should they be unable to take step 1 until their third year. Of concern was the amount of time, if any, they would be given during clinical rotations to sit for the exam.
In addition to concerns about board exams, many students expressed frustration with technical difficulties in content delivery, which they attributed qualitatively to instructors’ perceived lack of technological knowledge. This sentiment corroborates a study of pre-licensure nursing students in remote learning programs that found students to have considerable expectations of an instructor’s technological competency [19]. Qualitative responses to our survey indicate that schools should prepare and test their online learning environment as well as provide instructors with standard recording equipment and considerable real-time coaching on the use of those technologies.
Students’ quantitative responses to QoL items serve as a testament to their resilience as the majority were satisfied with their overall QoL, health, safety, and social support. However, a discouragingly low percentage of students in all classes reported being able to concentrate, which may be the result of competing demands on their time resulting from being confined to their apartment or parents’ home. Closely related to overall QoL is the students’ belief in their ability to contribute meaningfully to the healthcare setting. However, most students believed they were being underutilized, a view that aligns with observations made during the SARS-CoV-1 epidemic in which Canadian medical students were removed from wards to their frustration [23]. A survey of Canadian medical students following the SARS-CoV-1 epidemic found that most believed they have an obligation to volunteer during a pandemic [24]; responses to our survey provide a similar sentiment. That said, the role of the medical student during a health crisis is debated and definitely should not be taken lightly [25, 26], as any student involvement must be weighed cautiously against student safety, particularly amid shortages of PPE. Nonetheless, precedent exists for medical student involvement in patient care during crises as medical students responded during the Spanish flu outbreak of 1918, the polio epidemic, and more recently, the terrorist attacks in New York City on September 11, 2001, and Hurricane Rita in 2005 [27, 28]. In the current COVID-19 pandemic, some medical schools in the USA, Italy, and the UK graduated medical students early on the condition that they serve as frontline clinicians [10]. Students are also volunteering in call centers, creating patient-education materials, and helping with grocery shopping, among other activities, while adhering to social distancing guidelines and supervision [11]. Further, medical student involvement can provide valuable medical training at a time when other healthcare professionals may be ill and unable to work [25]; however, as this pandemic continues and students return to clinical duties, medical schools will need to consider strategies to handle potential exposures and infections among their students. As epidemics and pandemics occur, it behooves medical schools and hospitals that medical students as future physicians are well-trained in the use of PPE and conversant with infection control measures.
In addition, medical students provided praise and criticism regarding communication from the SoM during the pandemic. Previous research on nursing students in online learning environments reported a need for open and prompt communication to reduce anxiety and minimize resistance to online learning [19]. Accordingly, students expressed praise for the SoM’s communication in regard to the class-specific town halls where students could ask questions directly to administration as well as praise for the initial communication during the pandemic. This was contrasted with frustration regarding the infrequency of updates as the pandemic continued. Given the extraordinary nature of the pandemic, students did report understanding some slowing of communication; however, absence of any communication was clearly unacceptable. In our survey, students recommended weekly updates that may simply state that no changes have occurred or the presentation of several scenarios that are in the realm of possibility. Medical schools should designate a single spokesperson to deliver communication to students and student access to a continuously updated calendar.
Medical students also expressed praise and criticism in their perceptions of empathy and support provided in the SoM’s response. Some students reported that administration, faculty, and staff have done everything possible to support students amid the pandemic, whereas others reported that the response to the pandemic appeared to conflict with the health and safety of students as well as their future academic success. Students in our survey proposed that the school acknowledge the possible implications of the pandemic on students’ educational success and residency placement and admit to mistakes if and when they are made. Further, the school might consider involving students in the decision-making process and offer students more autonomy in scheduling their clinical experiences. Specific to M2 students, there was a perceived lack of support from the school regarding the preparation and scheduling of the step 1 board exam. Students suggested the SoM help students prepare for these exams with town halls to answer questions regarding the exams and time off during rotations.
Previous research has shown that medical students suffer from anxiety and depression at substantially higher rates than the general population worldwide [29, 30]. During the COVID-19 pandemic, social distancing policies and physical isolation may result in adverse mental health consequences in medical students [31]. Further, COVID-19-related stressors, including economic stressors, effects on daily life, and academic delays, were associated with increased anxiety symptoms of Chinese college students [32]. Our survey mirrored these findings as up to one-in-four students have feelings such as blue mood, despair, anxiety, and depression. Furthermore, one in five M2, M3, and M4 students indicated that their medical school experience had been disappointing, whereas one out of five graduating M4 students would not enroll in medical school again. These feelings of disappointment may reflect a combination of early symptoms of the aforementioned adverse mental health consequences, feelings of underutilization during a medical crisis, and fears of the effects of the pandemic on academic achievement and residency placement. For M4 students, the survey responses may be capturing frustration following the cancellation of Match Day and graduation ceremonies and festivities, which are the culmination of years of delayed gratification. Additionally, our survey may also reflect the feelings of M4 students as they grimly stare down the notoriously intense first year of residency amidst a devastating pandemic, which has seen social distancing from family, PPE shortages [33], and mounting death tolls [2]. It is important to note that our survey was conducted in the early days of the pandemic and the impact of COVID-19 on the mental health of medical students may not be fully comprehended for years. It is known that mental health distress in medical students can negatively impact their academic performance [34]. Further, studies surveying online nursing students found that perceived support from their school correlated with achievement [19]. Thus, a perceived lack of support and empathy on the part of the medical school may compound mental distress among medical students. Schools should strive to increase student perception of support and empathy from the school to improve mental health and academic achievement among their students during a pandemic.