The unique and unprecedented circumstances of the pandemic are potential driving forces for detrimental changes in student wellness. Upon evaluating demographic variables, such as gender, medical school year, and location, significant changes in overall wellness were not observed. However, there were significant differences depending on respondents’ race, specifically when comparing Asian respondents to Black and White respondents respectively. Studies have shown that Black students are particularly susceptible to the effects of discrimination as race is strongly linked to their self-identity.8 This may explain Black respondents reporting lower overall wellness. Interestingly, other studies have shown that burnout is more common amongst nonminority students than minority students.9 Therefore, additional studies are required to further investigate the relationship between race and wellness in medical students.
During the time of survey administration, nearly all medical students were removed from in-classroom and clinical settings, per AAMC Guidelines. 10 As a result, many schools transitioned to virtual learning in an attempt to replace traditional medical training. However, studies have shown that there are many barriers to virtual medical education, including inadequate implementation of technical skills, insufficient resources, and lack of institutional guidance and peer support. 11,12 Despite these known challenges with virtual learning, most medical schools did not provide adjustments to tuition, which costs an average of $50,201 annually. 13 Therefore, the transition to online learning may contribute to the statistically significant reductions in intellectual, occupational, and financial wellness found in this study, including: less confidence in medical education, less comfort in providing patient care, less satisfaction with work/schoolwork, less financial satisfaction, and worrying about finances more frequently.
Further, removing students from clinical rotations and labeling students as “non-essential” could hinder academic and personal growth. In previous emergency crises, students assisted on the frontlines and learned valuable lessons regarding critical decision-making and emergency care.14 However during the first few months of the pandemic, students could not participate in similar, irreplaceable learning opportunities, which many have been disappointing and contrary to their personal missions in medicine.15 Likewise, students could not interact with or “carry their own” patients, a valuable responsibility and learning opportunity.16 This could explain the noted reductions in intellectual and occupational wellness. Moreover, a medical student’s personal identity is strongly tied to their professional identity in medicine and service, and studies have shown that identity roles contribute to one’s sense of purpose.16,17,18 Therefore, the removal of students from the clinical environment, labeling students as “non-essential,” and restricting students from assisting on the frontlines offers an explanation for their reduced spiritual wellness, including decreased satisfaction with their sense of purpose.
Other dramatic changes that occurred during the COVID-19 period include changes regarding the scheduling of national licensing exams, such as United States Medical Licensing Examination (USMLE) Step 1 and 2 and Comprehensive Osteopathic Medical Licensing Exam of the United States (COMLEX-USA) Level 1 and 2. Students across the country had these exams rescheduled, canceled, or postponed.19 These exams are already a significant source of stress and anxiety, and these changes could have led to reductions in emotional wellness, including increased stress, anxiety, depression, and burnout.20,21
The residency application process also changed due to COVID-19, as visiting student rotations were cancelled (unless meeting an AAMC Exception) and residency interviews occurred virtually as opposed to in-person.22 This step is crucial for career planning and is a source of anxiety. Some students may excel during in-person interviews where they can interact with the program director, faculty, current residents, and other candidates. However, with a virtual platform, these interactions may be less organic or not be possible. This new platform could also explain increased stress and anxiety. Moreover, for fourth year students, cancellation of celebratory events like Match Day and graduation may have played a role in their worsened emotional wellness.
Societal changes induced by COVID-19 have affected medical students as well. With quarantine and social distancing orders in place, students spent more time at home with less in-person interactions. Although studies suggest that reduced contact hours and increased free time to explore one’s interest could in fact increase levels of wellness, the quality of free time during COVID-19 was drastically different.23 Stay-at-home orders and closures of local businesses may limit one’s physical activity and foster a sedentary lifestyle.24 Sedentary lifestyles are associated with numerous adverse health outcomes, including obesity, depression, and anxiety.25,26,27 This may help explain the reduced physical and emotional wellness found in this study, including lower energy, less satisfaction with nutrition and exercise, and increased feelings of depression and anxiety.
To minimize COVID-19 exposures, on-campus meetings and courses were limited or nonexistent, removing medical students from their classmates, usual study groups, and social environment. Studies have shown that study groups, social interaction, and student communities are important for medical students from both social and educational perspectives.28,29 This may explain the observed reductions in social and environmental wellness, including students feeling less supported by their social environment and less comfortable in their daily environments.
Our study is not without limitations. While we aimed to minimize sampling bias by contacting administrators from all US allopathic and osteopathic schools, the survey distribution was largely dependent on each individual medical school’s survey policy. Additionally, distribution via social media was limited to those who use social media and saw the postings and was thus another component of sampling bias. As a result, the number of respondents from each school varied. Another limitation of our study included non-response bias. It is not improbable that those who completed the survey have different opinions than those who did not. For this reason, the response rate was not calculable. Furthermore, our informal survey was not validated prior to its use. Ultimately, these limitations may have been mitigated due to the large sample size of the study and diversity of student demographics, permitting a degree of generalizability.