Knowledge, attitudes, social responsibilities and career plans toward Corona Virus Disease 2019 (Covid-19) among Chinese clinical medical students

: Purpose: To assess knowledge, attitudes and social responsibilities toward Covid-19 among Chinese clinical medical students. Method: Self-administered questionnaires were used to collect data for 889 clinical medical students from 3 well-known Chinese medical universities. The questionnaire was comprised of three domains which consisted of 7 items for knowledge, 5 items for attitudes and social responsibilities and 4 items for career planning. Results: It was found that 47.2%, 46.9% of the clinical medical students were willing to be volunteers in Hubei Province or stick to their own hospitals if they had been back to work, mainly because of responsibilities of doctors(92.7%). About 74.1% of the participants had a clear career plan for the future. 12.5% of the participants preferred several departments with the heaviest workload during the outbreak(Department of infectious disease, 1.2%; Department of respiration, 3.6%; ICU or emergency, 7.7%). Besides, students at clinical learning stage mastered better than basic learning students in the knowledge of Covid-19 especially in clinical manifestations(p < 0.001). There were significant differences between graduated and new-enrolled medical students in the attitudes of becoming a front-line doctor of Wuhan and the professional happiness of doctors(p < 0.001). Conclusions: Students at clinical learning stage mastered better than basic learning students in the knowledge of Covid-19 especially in clinical manifestations. The expectations of professional happiness and social responsibilities in new-enrolled clinical medical students were higher than those in graduated medical students which could be easily influenced and had no relation with different clinical major. Therefore, future strategies for medical education reform in China should focus on keeping the professional identity and sense of belonging of medical students.

(SARS-COV-2) [3]. The genome of SARS-CoV-2 is a single positive RNA of β genus, which shares a highly homologous sequence with coronavirus in bats [4][5][6]. Compared with SARS, COVID-19 has the characteristics of long incubation period, strong infection and no obvious upper respiratory symptoms [4,[7][8][9][10][11][12]. According to the latest data released by WHO on March 12, there were about 81,000 confirmed cases in China and over 40,000 confirmed cases in other countries cumulatively [13], resulting in numerous deaths, panic, and economic losses. Therefore, the Chinese government has implemented strict public health measures against the spread of Covid-19 and dispatched medical personnel from all over the country to support the first line of Hubei epidemic situation [14][15][16].
In recent years, conflicts between doctors and patients in China are still difficult to resolve, caused by the contradictions in the accumulation and distribution of medical resources, the defects of the medical system itself and the low social trust between doctors and patients [17,18]. The total number of medical damage liability disputes was around 18112 during 2019, almost 1.7 times of 2018 [19,20]. As The Lancet reported [21][22][23], Chinese doctors are under threat, which may explain the reason of the low professional happiness of Chinese doctors and the low conversion rate of Chinese medical students to doctors after graduation [17,[24][25][26][27]. The relationship between doctors and patients seems to be more harmonious during this epidemic. Medical students in China, who cannot start their new term but isolate at home, may be responding strongly to Covid-19 pandemic, but no data are available to describe their perception are available to describe their perception of and behaviors related to this infectious disease.
The present study investigated the attitudes, knowledge and career plans of Chinese clinical medical students in response to the epidemic for the first time, with the aim to compare the differences between medical students of different stages and better the design and focus of phased culture of clinical medical students in the context of Chinese excellent doctor education program reform.

2.1Development of the questionnaire
The modified questionnaire, derived from the seventh edition of diagnosis and treatment plan for pneumonia infected by novel coronavius [28], was composed of four blocks as follows: Demographic characteristic of clinical medical students, Attitudes and social responsibilities toward the epidemic, Knowledge related to Covid-19 including epidemiology, clinical manifestations of Covid-19 and Future career plan.
The first section collected demographic data including age, gender, family, major and grade. The next five indicators assessed respondents' attitudes and social responsibilities Center(n=217). The interviewers were either one of the current authors or a limited number of professional investigators. With informed consent, we explained the aim of the study and ensured anonymity before distributing the questionnaires. Respondents were asked to finish the questionnaire independently.

2.3Statistical analysis
Data were expressed as the means and SDs in the case of normally distributed data.
Pearson's or Spearman's correlation tests were conducted to determine the correlations between variables. The associations between the independent variables and the dependent variables related to medical education were assessed by using univariate odds ratios (ORs) and their 95% confidence intervals (CIs). Social Sciences version 19 (SPSS 19.0) was used for data analyses, with p-value < 0.05 as the level of statistical significance.

2.4Ethics
All participants signed an informed consent document as required by the institutional ethics committee. This study was approved by the ethics committees of the 3th Xiangya Hospital of Central South University.  We also studied the specimens that could detect nucleic acids of SARS-CoV-2 and the criteria for the release of isolation and discharge of patients, which showed students in clinical stage mastered better than students in basic stage(p < 0.001)( Table 3).      Table 4). The percentage of totally correct answers in Group A were higher than that in Group B in most of the questions of epidemiology and clinical manifestations of Covid-19(p < 0.001, Table 5). Interestingly, there were significant differences between the two groups in the attitudes of become a front-line doctor of Wuhan and the professional happiness of doctors. Further sub-analysis about the items above showed that Group B seemed more active than Group A (Fig 1).

Fig 1.
Questions that were considered to be reflected social responsibilities.
(1) Are you willing to support Wuhan?
(2) If your family is against it, do you insist on supporting Wuhan?

Discussion
This was one of the first hospital-based attempts to obtain an initial estimate of Chinese clinical medical students' attitudes, knowledge and social responsibilities toward Covid-19.
Especially, what has never been studied to our knowledge, was whether the stage of medical students exerted an impact on the attitudes, knowledge and social responsibilities during the epidemic. Our study tried to expound the attitudes and behavior of clinical medical students at different learning stages facing epidemic, so as to provide effective suggestions for clinical medical students' education.
The majority of medical participants chose medical major for dream and hobby, and were willing to make full use of medical specialty in order to dedicate to the prevention and control of the epidemic. However, opinions seems to differ greatly when talking about the professional happiness of doctors which was definitely related to the high ratio of medical disputes in China [29][30][31]. Almost 26% of the participants had no unambiguous future career plans.
Therefore, clinical medical education needs to pay more attention to the cultivation of professional happiness and career plans.
Students at clinical learning stage mastered better than basic learning students in the knowledge of Covid-19 especially in clinical manifestations. However, less than 30% of the participants knew SARS-CoV-2 is the the correct name of the virus first-occurred in Wuhan, nearly 70% confused the concepts of Covid-19 and SARS-CoV-2. Both groups had no significant differences between the epidemiological questions of the distributions and masks that can obstruct SARS-CoV-2. Medical students in clinical learning stage were found to possess a high level of clinical manifestations, accessory examinations and discharge criteria regarding Covid-19 than the ones in basic learning stage. Interestingly, we noticed that the mentalities changing from medical students to doctors were likely to drive them to learn more clinical knowledge [32,33].
Professional happiness is the key to maintain the quantity and quality of new entrants [32,34], which may explain the low transformation rate from medical students to doctors in China. Our results showed new-enrolled medical students expected too much for professional happiness, which was much higher than that in the graduated group. So how to maintain the high level of happiness of new-enrolled medical students is also a significant problem for medical education in the future. Surprisingly, we indicate the decisions new-enrolled students made could be easily influenced by various factors by comparing the intentions of volunteer to support Wuhan and the same options if their family objected. All questions about pneumonia knowledge had significant differences except the masks.
In addition, our analysis demonstrated that social responsibilities of 8-year clinical medical students were similar to those in 5-year students, after controlling factors including age, gender, political affiliation, residence, grade and family.
Being aware of the high conflict rate between doctors and patients in China, systemic managements and normalized media coverage and volunteerism have been performed to improve this situation [35][36][37]. How to protect doctors from injuries in the process of practicing has always been the attention of the whole society [21,23,29]. The Basic Health Care and Health Promotion Law will come into force on June 1, 2020 [38], which is the first basic and comprehensive law in Chinese health field. The public have gradually realized the limitations of medicine during this epidemic, which will be helpful to build a stable foundation between the doctors and patients in China. Medical education is also constantly being reformed to cultivate modern high-quality doctors [39,40]. Nowadays, medical education pays attention not only to the cultivation of professional knowledge and clinical skills, but also to the comprehensive qualities including communicative abilities and empathy [39][40]. The overwhelming majority of medical students are motivated by dreams and beliefs. It is necessary to keep the professional identity and sense of belonging of medical students, which will be one of the focal points of medical education reform in China.
However, there are some limitations in our study that must be acknowledged. (1) The participants may be worried about the confidentiality of this study since it was conducted by their peers, which may have impact on their responses. (2) We only focused on students in some well-known Chinese medical universities, which is a good attempt but further research will need to be carried out to expand the context covering medical colleges at different levels.
Despite these limitations, our work provides a basis for international comparisons of clinical medical students attitudes and behaviors and knowledge toward great public emergency health and safety problems.

Conclusions
Students at clinical learning stage mastered better than basic learning students in the knowledge of Covid-19 especially in clinical manifestations. The expectations of professional happiness and social responsibilities in new-enrolled clinical medical students was higher than those in graduated medical students which could be easily influenced and had no relation with different clinical major. Future strategies for medical education reform in China should focus on keeping the professional identity and sense of belonging of medical students.

Conflicts of interest
On behalf of all authors, the corresponding author states that there is no conflict of interest.

Ethics approval
This study was approved by ethics committee of the 3th Xiangya Hospital of Central South University. All data remained confidential, participants provided an informed consent before taking part in the study, and they were allowed to quit the study at any stage.

Acknowledgments
This study was supported by the New Xiangya Talent Project of the Third Xiangya Hospital of Central South University(no.JY201718). We would like to express our deepest gratitude to the medical students who completed the questionnaires. We would also be grateful to the team members, the volunteers and coordinators who assisted in this data collection.

Authors' contributions
Yang HJ, Zheng Y and Wang F designed the study, all authors contributed to collecting the data, Yang HJ conducted data analysis, Yang HJ, Zheng Y and Wang F contributed to writing. The author(s) read and approved the final manuscript.

Availability of data and materials
The datasets generated and/or analysed during the current study are not publicly available due to ethics approval but are available from the corresponding author on reasonable request.