This immediate, comprehensive, post-COVID-19 outbreak study describes the long-term impact of the pandemic on medical student education and training. Although international descriptions of changes in medical education due to the pandemic have emerged, little to no work had described the impact of COVID-19 on the medical student experience in the U.S. Several major findings emerged: (1a) Anywhere from 20–50% of in-person learning was cancelled immediately following the outbreak and clinical students reported an average loss of 11 hours/week in clinic and 29 hours/week in the hospital; (1b) To counteract that, online and virtual learning increased substantially; (2) A non-negligible percentage of students (up to 16%) had been required to provide needed clinical care immediately following the outbreak and more than half of fourth-year students were allowed to graduate early to join this direct care; (3) Students were also personally affected by the pandemic, with increases in financial stress and burnout; (4) COVID-19 affected institutional and national policies, such as scheduling, grading, clerkships, and national exams, and students perceived the effects of COVID-19 changes to be long-lasting, with clinical students particularly concerned with their residency applications. These findings are discussed in greater detail below.
Transitioning from In-Person to Virtual Learning
The majority of students (> 50%) reported an interruption in either classroom on patient-based clinical experiences immediately following the COVID-19 outbreak and subsequent reductions in in-person patient visits. With more than a quarter of students reporting immediate cancelation of third or fourth year rotations, this is particularly worrisome. In the third year of medical school, students rotate through required clerkships,11 while fourth year medical students typically complete elective rotations and away rotations in their discipline of interest.13 It is unknown whether these virtual opportunities provide the same learning experience as traditional opportunities, particularly in preparation for residency (e.g. core competencies, requisite skills, measures of readiness for the next level of training).12,13
Challenges of virtual medical education have been a topic of discussion prior to the COVID-19 pandemic.14–15 and common challenges that educators face when teaching virtually have been described,16 including educators’ lack of familiarity with new technology and additional time needed to prepare material for a new platform or interface.17 Addressing these concerns (e.g. providing additional staff or technology support for educators) can improve the virtual educational experience both students and educators.
Students providing clinical care:
Students reported being asked to provide patient care despite health and safety concerns, with fourth year medical students given the option to graduate early (almost 65%). Besides for the clear health concerns faced by working directly with patients in a hospital setting, it is also unclear whether 3.5 years of training is sufficient for entering residency.11 Recruitment of final-year medical students for early graduation and immersion in patient care has been seen both internationally and domestically.1,18−20 Some posit that work on the medical front lines may aid in advanced medical students’ education, particularly in an outpatient or non-COVID setting.1,21 A thorough description of the benefits of early graduation and joining of the workforce is currently unknown, given the recency of the pandemic.
Impact of COVID-19 on Financial and Mental Health
Respondents reported significant impacts of the COVID-19 pandemic on their financial and mental health. Some institutions offered some sort of financial remittance or an additional kind of financial assistance; interestingly, this was more likely seen in public than private institutions. Although this has been discussed at the undergraduate level nationally, this should also be considered for medical students who may have decreased clinical training during this time.
Students also reported higher anxiety both in general and about their education. Limited international work22 has suggested this as well. Some work has discussed resident and healthcare personnel concerns regarding lack of personal protective equipment,1, 23–24 but no empirical data has specifically measured this in medical students. This is particularly important given pre-COVID literature indicating that medical students are more likely to show signs of depression and burnout compared to the general population.25–26 Together, our findings indicate that both students and educators should be aware of and directly address the challenges of COVID-19 not just in the classroom, but as it relates to financial and mental health.
Long-Term Impact of COVID-19 at the Institutional and National Level
On May 11, the Coalition for Physician Accountability issued its recommendations for the upcoming (current) academic year, which limited or restricted medical student away rotations.4 At the time this survey was distributed, many institutions had cancelled third-year clerkships, with some continuing to be impacted at present. More empirical work is needed to see if supplemental education (such as virtual “away” rotations, streaming-based open houses or town halls, etc.)27–29 may provide an adequate alternative to typical in-person networking and training, given that away rotations provide students opportunities to network, obtain letters of recommendation,12 and demonstrate an interest in specific programs. On the other hand, this shift may be beneficial to students who will save money on housing and other rotation expenses (for example, in 2016, it was estimated that a single away rotation cost the average student $958.)30
Although it is too early to tell how COVID-19 will affect the upcoming residency match cycle, students expressed worry that changes to their education would impact their applications. Recent articles responding to this “match panic” 31 by students have expressed concern that the important interview process cannot be replicated virtually.32 Limited recent research has emphasized the importance of utilizing mentoring33 during this process, getting to know programs via virtual means (such as open houses or town halls), and familiarizing oneself with relevant technology (e.g. video conferencing) for optimal participation in interviews and remote networking.34 Students may also feel underprepared if applying to more competitive specialties, or for vulnerable applicants from smaller medical schools that may not have a wide breadth of affiliated programs or home specialty experience.
Finally, a substantial portion of respondents also indicated that their national exams had been either postponed or delayed (up to 66%). The USMLE examinations administered at Prometric testing centers were cancelled from mid-March through May of 2020.35 Examinations continue to be limited due to the small capacity of testing centers following social distancing protocols. Some virtual changes have been made, with the traditionally in-person Step 2 CS being conducted virtually until at least June 1, 2021.36 This is of particular concern given that national examinations have a large impact on the careers of medical students. According to the NRMP 2018 Program Director Survey, 94% of program directors valued USMLE Step 1 score or COMLEX Level 1 score and 80% of PDs valued Step 2 CK score or COMLEX Level 2 score.37 Rescheduling important national examinations adds to uncertainty for both medical students and medical educators, and a lack of credentialing at appropriate milestones presents predicaments for institutions wondering if they should pass students to the next level or not.
Survey studies present the inherent bias of utilizing a convenience sample. Participants were recruited via email and social media, which may have some self-selection bias. However, this survey accrued a sample of participants on par with those published previously in this topic and via these recruitment methods. In addition, the demographic characteristics of the participants are similar to those reported across medical schools nationally.