COVID-19 pandemic has caused a lot of controversy about the role of medical undergraduates, especially final-year students. Attitudes and decisions varied among countries. Some institutions prompted medical students to participate in supporting medical staff and HCWs during the epidemics, while some others considered graduating them earlier. For example, during the Spanish flu outbreak in 1918, medical students at the University of Pennsylvania were assigned the roles of physicians and nurses in order to care for patients, often without supervision.
Integrating medical students in the health care process during crises and defining their role has been the subject of numerous previous studies. Several studies were carried out in Saudi Arabia during the MERS-CoV outbreak aiming at assessing some aspects related to medical knowledge, attitudes and readiness to engage the medical colleges students in the healthcare system. Other studies focused on the assessment of awareness, perception, and medical knowledge of seasonal influenza among medical students in Pakistan, Vietnam and the United States.
In Syrian scenario, thousands of doctors fleet their ways out of the country. It was announced, allegedly as a part of the response plan to COVID-19, that final year medical students should be put on-call in order to be integrated into medical teams as soon as possible should needed. This study aimed to evaluate the preparedness and willingness of these students to be part of the first-line medical teams in the battle against COVID-19.
Results revealed that the overall level of general knowledge related to risk groups, prevention measures, diagnosis and treatment was considerable. It showed that (60.71%) of sixth-year participants scored 4 points out of 5 or higher in the general medical knowledge section, whereas, only 10.34% of the participants scored less than 3 points. Several studies tried to assess the level of medical knowledge of COVID-19 in different populations. In a study held in Iran it was found that Iranian medical students have a high level of COVID-19-related medical knowledge. Another study aimed at investigating the knowledge about COVID-19 among HCWs globally, the results revealed that HCWs have insufficient knowledge about COVID-19, but they showed a positive perception of COVID19.
Importantly, the present study did not conclude any significant association between the year of study and the level of general medical knowledge. This may be due to the ease of access to reliable information resources related to COVID-19 and to the fact that the study targeted only the second educational cycle of medical school (fourth, fifth, and sixth year) in which the basic medical and epidemiological knowledge in every year is quite close to those in the others. Furthermore, the results indicated that the general COVID-19 related medical knowledge did not correlate with the type of information source, which may be explained by the high availability of information on most platforms.
Results of the clinical judgment assessment, on the other hand, revealed that most (58.5%) of the final-year medical students had a score of 3 or more out of 5. These results could be justified by the fact that the final-year medical students in Syria have relatively good encounter with patients.
The results of our study also showed that the final-year medical students had better clinical judgment than the fourth-year students (mean 2.69 points [1.12] vs 2.47 points [1.15]; adjusted P = 0.01). This is comparable to a study conducted by Boshuizen et al. on 223 students, showing that students with good clinical reasoning are those who had passed more tests at medical school and had achieved more progress in academic years.
On the other hand, having previous clinical experience did not have significant correlation with clinical judgment. This was in contrast to a previous study which demonstrated that clinical experience correlated with increased clinical knowledge. It was also in contrast to a study conducted by Humbert et al. on 314 fourth-year medical students; 40 Emergency Medicine residents, and 13 expert emergency physicians, which showed improvement in clinical test performance with more clinical experience. This difference between our results and the results of the previous study could be due to the lack of considerable differences in clinical experiences between these three clinical years, as applied in Syrian Universities.
Our results showed that 72.4% of the final-year participants had an overall score of 7 points or more in the overall score (mean 6.39 points [SD 1.57]). This finding was similar to another study conducted by Fürstenberg et al. on 67 advanced undergraduate medical students, which showed that the average clinical reasoning scores was 2.78 (± 0.58, maximum score of 5) and the medical knowledge was 73.3 (± 9.1, maximum score of 100).
Interestingly, our study showed that females achieved better clinical judgment scores than their male peers (P-value < 0.001). A previous study that included 290 medical students showed that females scored significantly higher in clinical reasoning problems (CRPs) than males. The researchers explained this result by the women's tendency to be more thorough and deliberate when considering clinical problems.
Our results showed that students who had fears of being infected expressed the need of supervision. This need was also demonstrated during the Influenza pandemic in the UK when HCWs expressed the need for the support and supervision of their managers.
The present study showed that the better knowledge scores the students had, the more likely they would be afraid of getting infected. This also goes in accordance with a previous Serbian study conducted by Smolovic et al. on 69 university students, which showed that the more knowledge the students had about Tuberculosis, the more they had fears of the infection.
The willingness to participate in the medical efforts against COVID-19 was significantly lower in students who had fears of the infection. This result, again, may complete some conclusions drawn from previous studies that have been held during other pandemics. For example, a Singaporean study that assessed the risk perception among more than 15,000 HCWs of first-responders during the SARS epidemic in 2003, showed that 76% of the respondents were afraid of the infection, but 69.5% of them accepted the risk as a part of their job. However, another study from Germany revealed that 28% of participating HCWs may give up work to protect themselves and their families.
Regarding preventive measures, our results showed that although 1036 (86.4%) of the final-year students answered, subjectively, that they know how to follow the prevention rules, only 707 (58.9%) of them answered prevention-related questions correctly. This is comparable to a study conducted by Modi et al. on 1562 medical students and staff members in Mumbai which showed that 71.2% of respondents correctly answered questions related to COVID-19 awareness, knowledge, and infection control.
Having advanced English level was associated with answering general medical knowledge questions correctly and it has a profound effect on clinical judgment score and overall score. This may reflect the relationship between English proficiency and the ability to gain more access generally to reliable medical information, and particularly to those related to COVID-19. These findings are comparable to those of some other studies that demonstrated the importance of English proficiency in medical education.[34, 35] An important aspect of this study is the large number (1199 final-year students) of participants. This number may represent approximately one-third of all the final-year medical students nation-wide, which allowed us to make adequate analysis that led to the results that may be considered as representative. Moreover, this study was designed to assess various aspects of general knowledge and clinical judgment in the most possibly comprehensive way and the survey was distributed in conjunction with the very first documented cases of COVID-19 in Syria. This, in our opinion, helped to minimize the potential bias that may result from stress.
However, our study has several limitations. Firstly, only students from Syrian Universities were included, that being said, we think that further studies from other countries may confirm our conclusions. Secondly, the survey wasn’t time-limited. This aspect was treated carefully because of the mediocre quality of internet connection in some areas.
On the other hand, this survey was conducted online. We do believe that in the light of the lockdown procedures, and in accordance with the WHO recommendations about social distancing, this study is an adequate proof that online surveys may serve as a practical, low-cost, and reliable mean to conduct such studies.
In fact, more efforts are to be made in order to integrate advanced technologies in medicine and biomedical research fields, while trying at the same time to enhance the trust and security of such techniques.[22, 37]