Medical Student Wellness in the United States During the COVID-19 Pandemic: a Nationwide Survey

Abstract

Background: As United States (US) medical students suffer higher rates of depression and anxiety than the general population, medical student wellness has been studied in recent years. One definition describes wellness as having eight dimensions: Intellectual, emotional, physical, social, occupational, financial, environmental, and spiritual. As the coronavirus (COVID-19) pandemic poses unique challenges for medical students, we aimed to compare medical student wellness before and during the COVID-19 pandemic.

Methods: An informal survey was created to assess the eight wellness dimensions and distributed via Survey Monkey to US allopathic and osteopathic medical students via email and social media. The survey was administered from March 29, 2020 to June 23, 2020. Univariable and multivariable linear mixed-effects models were used to estimate the change in students’ overall wellness using an 11-point scale ranging from 0 (least well) to 10 (most well). Generalized estimating equations were used to compare students’ responses to the eight dimensions before and during the COVID-19 pandemic.

Results: On multivariable analysis, students reported a decline in their overall wellness during COVID-19 (M_diff  = -1.04; p < .001), with Asian respondents reporting almost no change in overall wellness (M = -0.69) compared to White respondents (M = -1.18; p = .049) and Black respondents (M = -1.78; p = .03). Students felt less supported and comfortable with their social (OR = 0.47) and daily (OR = 0.45) environments and expressed decreased satisfaction with their exercise (OR = 0.85), sense of purpose (OR = 0.33), and financial status (OR = 0.75). Students also expressed lower confidence (OR = 0.15) and satisfaction (OR = 0.11) with their medical education and increased anxiety (OR = 3.37) and depression (OR = 2.05).

Conclusions: Medical students reported declines in overall wellness and individual wellness dimensions. These findings can be used to implement changes to improve medical student wellness. 

Background

Compared to the general population, United States (US) medical students have significantly higher rates of depression, anxiety, burnout, and suicidal ideation.^1,2,3 Given these alarming statistics, the relationship between medical education and student wellness has been extensively studied in recent years. One popular and inclusive definition describes wellness as having eight dimensions: Intellectual, emotional, physical, social, occupational, financial, environmental, and spiritual. These eight dimensions intertwine in creating one’s overall wellness.⁴

The coronavirus (COVID-19) pandemic has posed new and unique challenges for medical students. As a result of national and institutional mandates, including stay-at-home orders, students are grappling with curricular and lifestyle changes that affect their future careers and current daily lives. On top of their taxing education, these challenges place students at higher risk for reduced wellness.

Few studies have examined the pandemic’s effects on medical student wellness. One study found that psychological wellbeing and work performance were decreased in medical students in Saudi Arabia during the pandemic.⁵ Another study found that medical students in India had worse mental health during COVID-19, including higher anxiety and stress levels, which were linked to poor sleep quality.⁶ Though these studies examined some components of wellness, no studies have examined the eight dimensions of wellness, particularly in US medical students. Analyzing medical student wellness during this unique time could highlight ways to improve the structure of medical education and promote wellness in the future. Therefore, the aim of our study was to utilize the eight domains of wellness to assess and compare US medical student wellness before and during the COVID-19 pandemic.

Methods

An informal survey (see Supplementary File 1, .pdf, Medical Student Wellness During the COVID-19 Pandemic, which is a copy of the survey) was created by the authors to measure the eight dimensions of wellness. The survey was sent via Survey Monkey to medical education coordinators, student affairs leaders, and medical student wellness groups from allopathic and osteopathic schools across the US, who were asked to share it with medical students at their institutions. Additionally, the survey was shared on social media sites, including Facebook, Twitter, and Instagram. Responses were collected from March 29, 2020 through June 23, 2020, and participation was completely voluntary. Informed consent was obtained from participants. Respondents were asked to complete the survey only one time, and incomplete survey responses were included in the analysis. The study was submitted to the Institutional Review Board (IRB) for the Protection of Human Subjects at Loyola University Chicago Health Sciences Division before beginning any study procedures and received IRB exemption.

Results

Due to the snowball sampling plan, the response rate is not estimable. However, there were 1,389 respondents from 38 states. Among these individuals, 11 (0.8%) were excluded because they did not list their academic institution, and one respondent (0.07%) was excluded because he was living outside the United States at the time of the survey (Table 1).

Most of the remaining 1,377 respondents were living in a state with a high (n = 629 or 46%) COVID-19 incidence rate at the time of survey; only 20% (n = 272) were living in a state with a moderate COVID-19 incidence rate, while another 35% (n = 476) were living in a state with a low COVID-19 incidence rate. Most identified as White (n = 908 or 66%), female (n = 922 or 67%), and were in their first or second year of medical school (n = 729 or 53%); another 33% (n = 459) of respondents were in their third year of medical school, while few (n = 189 or 14%) reported that they were in their fourth year of medical school. Nearly every respondent reported that their school suspended in-person meetings (n = 1,375 or 99%), and the majority reported that they were taking a required class or clerkship (n = 1,049/1,376 or 76%) that capitalized on recorded (n = 1,004/1,363 or 74%) as well as live online lectures (n = 1,058/1,365 or 78%). As expected, the majority reported that their class or clerkship required examinations (n = 1,129/1,365 or 83%). Finally, at the time of the survey, few participants reported they were taking an elective class or clerkship (n = 407/1,371 or 30%) or were actively involved in COVID-19 relief efforts (n = 508/1,376 or 37%). In fact, a sparse number of respondents were providing in-patient care (n = 50/1,376 or 3.6%) or caring for COVID-19 patients (n = 27/1,376 or 2.0%).

Overall, students rated their wellness during the COVID-19 pandemic about 1 point lower than their pre-pandemic response (M_diff = -1.04, 95% CI: -1.23 to -0.85; p < .001). This change score nominally depended on the respondents’ race (overall p = .01) with Asian students reporting almost no change in overall wellness (M = -0.69) when compared to White respondents (M = -1.18; p = .049) and Black respondents (M = -1.78; p = .03). That is, Asian respondents reported a change score that was about 0.49 (95% CI: 0.001 to 0.97) points higher than White respondents but about 1.09 (95% CI: 0.08 to 2.10) points higher than Black respondents. See Table 2. Similarly, students taking an elective class or clerkship reported a change score (M = -0.96) that was nominally higher than those not taking an elective class or clerkship (M = -1.36; M_diff = 0.40, 95% CI: 0.11 to 0.69; p = .01). Results were similar for those taking versus not taking a class or clerkship that required live online lectures (M_diff = 0.34, 95% CI: 0.02 to 0.66; p = .04).

Compared to their pre-COVID response, students reported sleeping more during the pandemic (OR = 3.25, 95% CI: 2.80–3.77) and that their sleep was more satisfactory (OR = 1.26, 95% CI: 1.12–1.43). Despite their increased sleep and quality of sleep, however, students also reported lower levels of energy during the pandemic (OR = 0.28, 95% CI: 0.24–0.32). Regarding students’ nutrition and exercise behaviors, they reported exercising more frequently during COVID-19 (OR = 1.25, 95% CI: 1.11–1.41) but also reported lower satisfaction with their exercise regimen (OR = 0.85, 95% CI: 0.74–0.98) and lower overall satisfaction with their nutritional intake (OR = 0.73, 95% CI: 0.65–0.83). Further, students reported less satisfaction with their social environment during COVID-19. For example, even though students spent more time (days) engaging with their family each week (OR = 2.10, 95% CI: 1.89–2.34), they also reported low levels of support from their social environment (OR = 0.47, 95% CI: 0.42–0.53) and low overall comfort with their daily environment (OR = 0.45, 95% CI: 0.39–0.52). Similarly, students reported low satisfaction with their sense of purpose (OR = 0.33, 95% CI: 0.29–0.36) despite spending substantially more time reflecting on their sense of purpose (OR = 3.28, 95% CI: 2.96–3.63). Also, compared to their pre-COVID response, students spent more time (days) worrying about their finances (OR = 1.71, 95% CI: 1.59–1.85) and less satisfaction with their finances (OR = 0.75, 95% CI: 0.70–0.79). See Table 3 (see Supplementary File 2, .docx, Summary frequencies for Table 3, which indicates summary frequencies for ordinal scale questions).

Table 3 also shows that students spend more time studying each week during COVID-19 (OR = 3.96, 95% CI: 3.43–4.56) but are increasingly concerned about their grades (OR = 1.12, 95% CI: 1.03–1.22) and lack confidence in their medical education (OR = 0.15, 95% CI: 0.13–0.17), satisfaction with their training (OR = 0.11, 95% CI: 0.09–0.13), and enjoyment of their schoolwork (OR = 0.25, 95% CI: 0.22–0.28). Students also expressed higher levels of stress (OR = 2.89, 95% CI: 2.59–3.42), anxiety (OR = 3.37, 95% CI: 2.99–3.81), depression (OR = 2.05, 95% CI: 1.88–2.23), and burn out (OR = 1.60, 95% CI: 1.43–1.80) compared to their pre-COVID response.

Additionally, students were less likely to endorse schoolwork (58% vs 84%), friends or family (80% vs 82%), hobbies (51% vs 55%), or community service (32% vs 51%) as activities that strengthen their sense of purpose during COVID. Instead, they were more likely to endorse reflection (45% vs 38%) or other activities (4.1% vs 2.1%) as strengthening their sense of purpose. See Table 4.

Discussion

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.

Conclusion

This is the first study examining wellness amongst US medical students during the COVID-19 pandemic. Our study demonstrates that during the COVID-19 time period, medical students reported lower levels of wellness overall and in all eight dimensions: Intellectual, emotional, physical, social, occupational, financial, environmental, and spiritual. Our findings shed light on the vulnerability of medical student wellness. Further research is needed to evaluate targeted strategies to improve and promote medical student wellness during times of crises.

Declarations

Ethics approval and consent to participate

The authors declare that this study did not require human ethics approval and did not include experiments on animal or human subjects. This study was submitted to the Institutional Review Board (IRB) for the Protection of Human Subjects at Loyola University Chicago Health Sciences Division. This project was determined to be exempt from IRB review. All methods were carried out in accordance with relevant guidelines and regulations. Respondents were informed that their participation in the survey was completely voluntary and there were no risks associated with their participation.

Consent for publication

Informed consent was obtained, and the authors attest that the respondents were aware of the study purpose, risks, and benefits.

Availability of data and materials

The Collector Investigators will make the dataset generated and analyzed during this study available to Recipient Investigators upon reasonable request and under a signed data use agreement.

Competing interests

The authors declare that they have no competing interests.

Funding

Not applicable.

Authors’ contributions

LN and AW created the study concept and survey design. LN, AW, and PB analyzed and interpreted preliminary data regarding medical student wellness pre-COVID-19 versus during COVID-19. LN and AW drafted the manuscript. PB and WA critically revised the manuscript. WA performed statistical analysis of the data. PB supervised the entirety of the study. All authors contributed to and approved the final manuscript.

Acknowledgements

Not applicable.

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