The COVID-19 pandemic affected medical schools worldwide, requiring schools to respond quickly by adapting to virtual learning environments and by modifying clinical placements. Medical students were expected to manage these changes in addition to the universal challenges of a global crisis, giving them a unique perspective during the pandemic. The population of Malaysia includes three major ethnicities and a broad distribution of socioeconomic groupings, which is reflected by the medical student population. By surveying all medical students in Malaysia, it was possible to characterize the perspectives shared by students nationally and those which may be related to specific ethnographic groups. The results indicate that student perceptions converge on eight domains relating to well-being, depth of learning experience, and communication. Interestingly, none of the components included items relating to technical delivery of virtual learning, suggesting that any technical challenges were independent of the pandemic-related experiences of students and are not an underlying factor in student well-being or motivation [6, 13].
The components identified in this study align with self-determination theory and help to understand the intrinsic motivation of students during the pandemic. Of concern, a large percent of students met the risk threshold for experiencing MDD or GAD. This was supported by claims about having depressed or anxious symptoms and experiencing considerate, or even overwhelming, concern and was validated through student comments. While baseline mental health and wellness are unknown, students did comment that their mental health has been negatively affected by the pandemic, as seen elsewhere [13, 35, 36]. Importantly, levels of mental health and wellbeing, which are intricately related to each psychological need, suggesting that motivation may also be low[37]. Results like these have been of concern, as the reduction in mental health will also affect both student learning and personal satisfaction [25, 38, 39]. Indeed, strategies to improve student well-being and maintain motivation are being developed to specifically target students emotionally affected by pandemic-related restrictions [40].
While well-being may affect each motivational need, other components corresponded to specific needs. Communication, for example, is required for relatedness and autonomy, as the interaction with others can promote emotional connectedness and independence, respectively [41, 42]. Communication is also integral to education, making it an important measure of the effectiveness of instruction and experiences of students. Here, students provided negative sentiments about engagement in the classroom and formative and summative assessment, suggesting that communication with instructors has been impeded and may indicate low feelings of relatedness [43]. Similarly, while students some consultation in decision making about pandemic-related modifications, numerous comments regarding the student role, or lack thereof, in decision-making processes, suggesting that student choice may not have been implemented. This overall reduction in communication suggests that students feel that they are not being validated, subsequently leading to reduced autonomy and motivation [44]. This is supported by reported evidence that positive relationships with instructors and being provided choice are related to feelings of autonomy [42, 45, 46]. Unfortunately, these opportunities were limited in Malaysia given the need to respond to frequent changes in COVID-19-restrictions, making it difficult to establish relationships or effectively consider student feedback [47]. These results show that better communication strategies should be prioritized to improve student engagement in the classroom and incorporate student choice to promote relatedness and autonomy.
Developing competence is a priority to educators, given that the ultimate learning objectives of any programme are to develop student competencies. However, competence is also a component of self-determination and is intrinsic to the learning process, since only someone who is convinced about their ability to accomplish a task would be motivated to attempt the task [25, 26]. Here, perceptions about depth of learning and preparedness provided insight to students’ self-perceived competence during the pandemic. Importantly, students indicated an overall satisfaction with their MBBS programmes and that the quality of their education has not been greatly changed. This suggests that there must be some degree of competence felt by the students. Comparatively, students responded that they are being under prepared for their profession and exhibited negative feelings towards formative feedback and the accuracy of some virtual assessments. These perceptions may relate to low self-confidence and difficulty interpreting their standings, likely leading to reduced feelings of competence [37, 43]. This may have arisen since guidance to help students better understand their progression, which requires a social context, has likely been hindered during the pandemic [48–50]. Taken with the overall student satisfaction, competence in students likely exists, but may not be self-evident resulting in lowered motivation.
The self-determination profile of Malaysian medical students, as evidenced by the negative perceptions towards relatedness, autonomy, and competence, indicate an overall reduction of intrinsic motivation during the COVID-19 pandemic. More work is needed to determine the implications of these findings, but indicate that supports should be considered for each of the psychological needs to holistically mitigate the impacts of covid-related modifications on student motivation [44]. Further, as the pandemic resolves, student experiences will carryforward, impacting future learning and success if negative experiences are not remedied.
Perceptions about the COVID-19 pandemic were also evaluated for trends in sub-populations of students, with notable differences occurring between pre-clinical and clinical stages. While overall mental health and concern was similar between pre-clinical and clinical students, their learning experiences varied greatly. This is most attributed to the need for specific modifications from the different style of programme delivery for each group [8, 51, 52]. In Malaysia, preclinical students were transitioned to a virtual learning space, providing consistent, if not preferred, learning opportunities. This consistency may be why pre-clinical students more often felt that their overall well-being was being considered in the decision making of modifications. In contrast, pre-clinical students showed higher risk of depression and indicated that instructional delivery was less student-centered compared to clinical students. These perceptions may stem from the virtual wall if students have felt forgotten or isolated and may imply a reduction in autonomy and relatedness [13, 44, 45]. Conversely, clinical students were more affected by timing modifications, likely due to frequent changes to time, depth, or quality of clinical placements, and which have resulted in less satisfaction towards modifications made during the pandemic. The disruption to clinical teaching may also relate to their greater feelings of unpreparedness and concerns about securing housemanship positions, indicating a lowered sense of competency and to some degree of autonomy [8, 14, 53]. However, clinical students generally supported participation in clinical postings during the COVID-19 pandemic, and though some safety concerns or the ability to communicate their concerns were evident, this suggests that any reductions in motivation did not undermine the desire to contribute [54]. Different in experiences of pre-clinical and clinical students are expected, so characterizing them is useful to identify the specific needs of each group.
The diversity of students represented by the Malaysian medical student body provides an opportunity to explore whether there are ethnographic contributors to perceptions on educational experiences during the pandemic. This is of particular interest as the fundamental concepts of self-determination theory are universal, though there is less known about motivational profiles between demographic variables, particularly during the pandemic [37, 55]. Here, gender was related to the largest difference in experiences between students during the pandemic. Female students exhibited significantly worse mental health, perceived less depth of learning and student centredness, and were more concerned about delays on preparedness, implying reduced levels of intrinsic motivation. Since a recent Malaysian study reported no significant difference in online learning readiness during the pandemic between male and female students [56], these differences are not likely due to capabilities. Interestingly, prior to the pandemic, women have consistently expressed have a more self-determined profile than male counterparts, so it is curious which aspects of the pandemic-experience have contributed to these differences [27]. Given the similar life-stage of medical students in Malaysia, it is more likely that these feelings may arise from deeper internalization of concern, loneliness, and social separation, particularly given the striking difference in mental health [57–59]. Also, it is possible that female students who had returned home for virtual learning took on more household responsibilities. Globally, women have been disproportionately burdened with these responsibilities during the pandemic, which has attributed to different emotional responses of the genders [57, 59]. The disparities between gender needs should be particularly highlighted during challenging times to provide appropriate support and ensure existing systemic biases are not exacerbated.
Ethnicity was also related to perceived experiences and motivational profiles of Malaysian medical students during the pandemic. The biggest difference arose in mental health and the impacts of change made to graduation. Interestingly, compared to their peers, Chinese students reported better mental health and were less concerned about family members developing COVID-19, perhaps indicating greater confidence during the pandemic. International students reported the lowest levels of mental health, which may be related to feelings of isolation if they are distanced from their native community or culture, since they also reported more concern about family developing COVID-19. Interestingly, ethnicity was also related to perceptions about modifications made to graduation, as Indian students were least concerned about the impact of any delay. Attributing these findings to specific cultural norms would be inaccurate and insensitive in this context [55], but does indicate the need to ensure that all students, regardless of ethnicity, are properly supported, particularly in populations with such diverse representation.
Malaysian medical students from each income bracket are entitled to enter MBBS programmes through various streams including affordable, yet competitive, public universities, various funding initiatives, or more costly private universities [60]. Here, student groupings from different income brackets were found to have significantly different levels of concern, specifically those in the lowest income bracket who reported more concern about financial impacts from the pandemic. This may indicate a lower level of relatedness and autonomy, particularly if other students do not share the same concern or if additional costs may be incurred for virtual learning. They also indicated receiving less formative feedback, which may be related to technical issues. Indeed, it has been reported that, in addition to the fact that students in remote areas have faced technical challenges during remote learning, the economic impacts of the pandemic have disproportionately affected people in lower income groups [10]. Equity in education is essential and students from lower income bracket might need additional financial support in securing equal learning opportunities during the COVID-19 pandemic [6, 61]. While alleviating financial constraints can be challenging, it is understood that institutions are trying to distribute resources to affected students, which would improve accessibility as well as helping students to feel validated.
Characterizing the experiences of medical students during the COVID-19 pandemic will help to develop inclusive strategies meant to mitigate any long-term impact caused by the pandemic-related modifications made to undergraduate medical education. This will, of course, require accommodation of diverse student needs and recognition that needs may be complicated by co-variates. While the scope of this study excludes a comprehensive analysis of how demographic features interact, we did find some demographic variances within subgroups. For example, Malay students in clinical stages expressed that they received more formative feedback and were more confident in their ability to voice safety concerns, which may relate to higher feelings of autonomy, despite average inclinations of students towards reduced communication during the pandemic. Some other differences were also seen within components of the survey, like feelings of preparedness or concerns about securing future positions, but more work is needed to better interpret these findings.