Now, I think doctors can be heroes … Medical student’s attitudes towards the COVID-19 pandemic’s impact on key aspects of medical education and how the image of the medical profession has changed due to the COVID-19 pandemic

The COVID-19 (coronavirus disease 2019) pandemic hit the world in early 2020. For most people in developed countries, it is the first health crisis ever experienced. It influenced and still influences not only our private life due to social distancing, lockdowns, and curfews, but it also impacts medical education worldwide [1]. Distance learning, seminars with attendance, and clinical placements under the risk of infection became immediate problems to solve for universities, but also subsequent challenges are interwoven.

In March 2020, Austrian universities were forced to switch rapidly to online teaching and assessment [2, 3]. Even without the special challenge of distance learning, medical students are often exposed to performance pressure and suffer from impaired mental health [4, 5]. Guse et al. showed that students feel burdened by the effects of the pandemic, that their motivation is decreased, and that many students are worried that the situation will impact their education negatively [6]. “Worried” was the most often mentioned emotion towards medical education in a study of Polujanski et al. [7]. For students already involved in patient care, the situation could be especially troublesome, as studies show that health care workers exposed to COVID-19 show a high prevalence of psychological problems [8, 9]. Additional challenges for the future medical workforce are personal safety during patient care, telehealth literacy, ethical aspects in pandemic planning like triage or elective surgery, and the importance and impact of medical research for the development of test and treatment methods or vaccines [1, 3, 10‐12].

Before the pandemic, telehealth/telemedicine was a neglected topic and the increased use during the pandemic was a necessity, not a choice [13]. Medical education must catch up and include empathy in telehealthcare teaching “webside manner” as well as bedside manner [14].

However, not all doctor–patient encounters are manageable via telemedicine. Treating patients bears a special risk of contracting the disease. Nevertheless, medical students rely on clinical practical training to finish their education, as well as the health care system relies on the work medical students contribute to the system [15].

Even before the pandemic, the Liaison Committee on Medical Education stated that every medical education program should include instructions in medical ethics and humanities [16]. The COVID-19 pandemic was a cruel reminder of the impact of ethical decisions on patients’ health and life—decisions like who gets a ventilator or an intensive care bed when not everyone can, or which surgery is not urgent enough and can be postponed despite a clear medical need, and many more [11, 17]. Additionally, there is a moral obligation to learn and conduct research, and to work on vaccines, drugs, and new treatment methods [17].

This leads to another field of medicine exposed to keen interest and harsh critique due to this pandemic [18]. Literature suggests that research is often underrepresented in the curricula; therefore, students are ill prepared in epidemiology, statistics, and scientific investigation [18‐20]. Kyaw et al. also conclude that a supportive and positive environment is needed to improve skills and knowledge and thereby encourage students to conduct research [21].

In addition to these topics, other questions arise: How has this pandemic affected the image of being a doctor for the students? Has the image of the medical profession changed?

These are key aspects for present and future medical education, but research on the attitudes of medical students towards these topics is lacking.

This study aims to explore:

To answer these questions, a cross-sectional survey was conducted among all undergraduate medical students of the Medical University of Vienna. The data were collected via the internal online evaluation tool of the Medical University of Vienna. The questionnaire was online between December 2, 2020, and January 31, 2021; all students received an invitation via their student email account.

The internal data protection commission as well as the internal research clearing board of the Medical University of Vienna approved this study.

This study aimed to shed light on the COVID-19 pandemic’s influence on key aspects of medical education, i.e., research, ethics, telemedicine, infection risk, and patient care, as well as distance learning. The data showed that the COVID-19 pandemic has raised awareness for the key aspects, which were content of the questionnaire. In all key aspects, the feeling of preparedness of students is limited. Constraints in practical training, distance learning, and social isolation concern a majority of students. Most students are strongly aware of personal security measures and, as medical students, feel a special responsibility to be role models and inform the public about safety measures. Neutral, positive, and negative themes emerged in the qualitative data analysis. For male and younger students, the changes seem to be more positive. A large proportion of positive comments was dedicated to the relevance and deeper meaning of the medical profession. Infection risk and the demanding nature of the medical profession were predominant in negative comments.

A lifelong commitment to reflective learning, the ability to evaluate information and its sources critically, and contribute to the creation, dissemination, application, and translation of new medical knowledge is crucial for all physicians [24]. Even though 70% of all students think research is essential for clinical practice, only 37% feel prepared for a research career or agree that the university invests enough time on research and its significance. This lack of focus on research may result in low numbers of research engagements and publications. Top US Universities Stanford and Duke have publication rates of up to 75% during mandatory research education [25]. In our study, only around 7% first- or co-authored a paper, and only 20% engaged in a research project at the university. Most research activities start towards the end of the study, during the fourth or fifth year. Chang and Ramnanan found that early research experiences may be a motivating factor for research engagement; simultaneously with the duration of research experiences, first authorships increase, and students’ perceptions of research experiences are enhanced [26]. For universities, this is a signal to encourage and promote students’ early involvement in research and build an environment that offers suitable opportunities in which to participate. Only a minority of students think that experts in other fields should primarily conduct medical research; therefore, medical education has to prepare students for a research career properly. Interestingly, students of the first 3 years feel better prepared for research as well as for ethical and telehealth challenges than students towards the end of their studies. Reasons for this may include that the whole extent of subject matter is unclear at the beginning of the course or that students at the end of their studies—facing real responsibility in the near future—tend toward a more modest assessment of their abilities.

In professional ethics, two topics of this study come close: Personal infection risk and professional decision-making in times of limited medical care options. McChullough et al. took up this topic and developed a framework for teaching professional formation between the poles “taking reasonable risks” and “self-sacrificing” [27]. In our study, only about half of the participants felt prepared for the ethical challenges. Many participants only became aware of the extensive ethical aspects of medicine due to the pandemic. The great responsibility going hand in hand with the medical profession was one of the major topics in the qualitative data—often with a negative connotation. Therefore, it seems especially important to support and prepare students with expertise in this field. Up until the COVID-19 pandemic, rationing and scarcity were uncommon terms in medical care in Western countries and also in Austria. The pandemic has raised several questions about these topics [28]. Han et al. identified allocation of scarce resources as the dilemma arising from the pandemic and refer to guidelines to “lift the moral accountability of each decision out of the hands of the few at the bedside and distribute it among a collective conscience” [29]. They also recommend introducing trainees to an active conversation about basic ethical principles like principles of maximization of benefit, equal treatment of all patients, and priority to the sickest. DeFoor and colleagues found that there is a strong and often unmet need and interest in formal ethics education [30]. Accordingly, only 2.3% of our participants would prefer other experts to render ethical decisions for medicine, even if only half of all students feel prepared for this challenge themselves.

However, personal risk is also a topic highlighted by this pandemic; this is an ethical problem, too. The code of ethics of the American Medical Association states clearly that taking reasonable risks is an ethical obligation for medical professionals—this might be the heroic part of this profession—but taking unreasonable risks is not heroic but reckless [16]. In our study, about 40% of the participants had become aware of this topic due to the pandemic. Only half of all participants feel prepared for infection risks and, accordingly, almost as many think that only specially trained doctors should care for infectious patients. Even though infection risk was an often negatively connoted topic in qualitative data, the participants found clear words for doctors who hide from their ethical obligation and abandon their patients or turn away from their roots in science. This leads to another ethical obligation held by the medical profession: identifying means to prevent pandemics and educate the public about them [31]. The participating students widely agreed that they try to inform and educate others about infection prevention, and more than half of them felt they bear a special responsibility to do so as medical students. Most of them were also ready to follow governmental rules to prevent the virus from spreading. Accordingly, Komasawa et al. found in a sample of Japanese medical students that they exercised self-control regarding their lifestyle [32].

An important way of reducing infection risk for medical professionals is switching from in-person treatment to telehealth consultations. Muntz et al. outline the possibility that limited clinical internships could be replaced by telehealth activities [33]. Both the health care system as well as the students would profit. In our study, only a minority of students feel prepared for the challenges of telehealth. For most of them, the personal contact between patient and doctor is irreplaceable. Despite this fact, almost 40% see a need for implementing telehealth throughout the curriculum. Dawidzuik and Grandhewar underlined the importance of digital health literacy, especially in handling mass information from the internet, and the challenges of communicating complex information to patients [34]. These findings are a clear wake-up call for medical educators.

Another way of keeping students safe is distance learning. The students participating in this study see positive aspects of distance learning and hope that several distance-learning offers will remain after the pandemic. Nevertheless, the social isolation coming with distance learning burdens more than 60% of the participants. Accordingly, Silva et al. found that students’ quality of life was severely impaired by distance learning. They recommend interaction with professors as a key coping tool [35]. The students in this study also feel that contact with university staff and fellow students is irreplaceable. Almost 60% of all students report severely limited patient contact, and 46.5% of all students think that their practical skills training is insufficient for future practice. Bellini et al. propose that presumably, the whole educational offer from the academic institutions will learn from this pandemic and evolve to a changed model, where new and traditional formats will work side by side [36].

Despite the different challenges and problems the COVID-19 pandemic causes, many students expressed that this situation intensified their wish to become doctors and help to overcome this or future crises. In this study, the positive statements outweigh the negative ones, too. Especially male students provided more positive statements, particularly in the subsets “relevant/meaningful profession” and “acknowledgment.” The medical profession is culturally and historically linked to masculinity and male-attributed behavior is still seen as prototypical for physicians [37, 38]. This may be a reason why male students more often claim the relevance and meaningfulness of this profession for themselves than female students do. Female students’ comments highlighted the crisis-proof nature of the medical profession. This underpins the finding of Piasna and Plangnol, that job security and prospective parenthood are closely intertwined only for women [39].

Qualitative analysis revealed that the “beginners” group, compared to the advanced students’ group, was more likely to make positive comments. An overly positive attitude towards the demanding nature of the medical profession may be challenged by the approaching reality of demanding and potentially risky working conditions.

However, Komasawa et al. found that Japanese medical students were passionate about becoming doctors, too [32]. Therefore, the world seems full of passionate young people; for some of them, the deeper meaning of the medical profession has only become clear due to this crisis. As one participant answered:

I had the classic image of the medical profession: normal job, good money, and respect from the society, but not world-shaking. Now I think that doctors can be real heroes and that there is more to this job than meets the eye.

Data were obtained at only one university. Self-selection of participants—through voluntary participation—can always lead to systematically skewed data. Conclusions beyond the surveyed population should be drawn with caution.

During the data-collection phase, Dec 20/Jan 21, the EMA authorized a vaccine. The question formulated with “if a vaccine were to be authorized” was therefore outdated in the middle of the survey. An evaluation leads the authors to the conclusion that the sense and meaning of the question was not impaired by this fact.