key: cord-1005146-5qdgds5b
authors: ElHawary, Hassan; Salimi, Ali; Barone, Natasha; Alam, Peter; Thibaudeau, Stephanie
title: The effect of COVID-19 on medical students’ education and wellbeing: a cross-sectional survey
date: 2021-06-30
journal: Can Med Educ J
DOI: 10.36834/cmej.71261
sha: 94505eaa73d53840d20e3b1a6db3ee02def7d221
doc_id: 1005146
cord_uid: 5qdgds5b

BACKGROUND: Canadian medical school curriculums have undergone major restructuring during the COVID-19 pandemic. This study’s goal was to assess the perceived impact of COVID-19 on medical students’ education and wellbeing. METHODS: An online survey was distributed to Canadian medical students. Descriptive analyses and ANOVAs were used to assess changes in mental health, health habits and quality of education during the pandemic. RESULTS: 248 medical students from 13 schools across Canada participated in this study. 74% reported a reduction in the quality of their education since COVID-19. 58% of students found online to be inferior to in-person teaching. 65% of students had more time for wellness and leisure activities, about half of the cohort felt more depressed (48%) and lonelier (52%). Student’s overall health habits worsened after the start of the pandemic (F=37.4, p < 0.001). Alcohol drinking, time spent seated, and screen time also increased since the pandemic (p < 0.001). During the pandemic, students with a prior history of depression or anxiety expressed increased depressive symptoms (66% vs. 42%, p =0.003), increased anxiety (69% vs. 41%, p < 0001), worse sleep quality (34% vs. 18%, p = 0.031), and poorer quality of life (55% vs. 65%, p = 0.024) versus those with no prior history. CONCLUSION: Canadian medical student’s education and wellbeing has been negatively impacted during the pandemic.

Contexte : Les cursus des facultés de médecine canadiennes ont subi une restructuration majeure pendant la pandémie du COVID-19. L'objectif de cette étude était d'évaluer l'impact perçu de la pandémie sur l'éducation et le bien-être des étudiants en médecine.

Méthodes : Un sondage en ligne a été distribué aux étudiants en médecine au Canada. Des analyses descriptives ont été effectuées et une analyse de variance a été réalisée pour évaluer le changement de quatre habitudes de santé pendant la pandémie.

Résultats : 248 étudiants en médecine de 13 établissements au Canada ont participé à cette étude. 74% d'entre eux ont signalé une baisse de la qualité de leur enseignement depuis le début de la pandémie. 58% des étudiants ont trouvé que l'enseignement en ligne était inférieur à l'enseignement en présentiel. 65% des étudiants ont déclaré avoir plus de temps à consacrer à leurs loisirs et à des activités en lien avec le bien-être, environ la moitié de la cohorte s'est sentie plus déprimée (48 %) et plus seule (52 %). Les habitudes de santé des étudiants se sont considérablement détériorées à l'arrivée de la pandémie (F=37,4, p < 0,001). La consommation d'alcool, le temps passé assis et le temps passé devant un écran ont également augmenté de manière significative depuis le début de la pandémie (p < 0,001). Pendant la pandémie, les étudiants ayant des antécédents de dépression ou d'anxiété ont présenté des niveaux plus élevés de symptômes liés à ces états (66 % contre 42 %, p = 0,003 pour la dépression et 69 % contre 41 %, p<0001 pour l'anxiété), ils avaient une moins bonne qualité de sommeil (34 % contre 18 %, p = 0,031) et une moins bonne qualité de vie en général (55 % contre 65 %, p = 0,024) que ceux qui n'avaient pas de tels antécédents.

Conclusion : L'éducation et le bien-être des étudiants en médecine canadiens ont été touchés négativement pendant la pandémie.

The novel Corona Virus Disease (COVID-19) pandemic is a serious global health threat. In December 2019, originating out of Wuhan, China, it was first described as cases of pneumonia of unknown origin. 1 As of January 30 th , 2020, the WHO classified COVID-19 as a public health emergency and as of March 11, 2020 due to the alarming increase in spread it was characterized as a pandemic. 2 Large efforts have been taken to help 'flatten the curve' and reduce the speed of viral transmission to prevent a surge of hospital admissions. The implemented public health measures included the shutdown of Canadian academic institutions. Across all provinces, medical students' clinical rotations and in-person classes were cancelled. As with any emergency and unprecedented situation, decisions needed to be made quickly. With the highly compacted nature of medical curriculums, a dire need to find alternate teaching methods to compensate for the loss of in-person large group lectures and in-hospital teaching resulted in a quick shift to online teaching platforms. While previous studies have examined the effects of the current pandemic on medical education, 3 there is a paucity in data with regards to Canadian medical students' perception of the novel online curriculums and how this form of learning compares to the traditional method of medical education.

While social distancing was a crucial measure taken to reduce the transmission of COVID-19, emerging evidence shows its negative impact on wellbeing; a person's physical, mental, social and environmental state. [4] [5] [6] Furthermore, previous studies have shown that compared to individuals of similar age, medical students tend to experience higher levels of stress. [7] [8] [9] Health habits (sleep, alcohol, exercise, and smoking) which are associated with a student's self-care and wellbeing impact medical student education, emotional adjustment and functioning as physicians. 10 By better understanding the effects of the COVID-19 pandemic on medical students' health habits, medical school wellness programs could better target the ones mostly affected.

To that end, the goal of our study was to assess the effect of the COVID-19 pandemic on medical students' wellbeing and medical education, in Canada, specifically with regards to their perception of the currently practiced online medical education. By comparing their health habits and the resulting impact on mental health prior to, and during the pandemic, we wanted to better understand how their learning overall training and mental health were affected.

This cross-sectional survey measured the effect of the COVID-19 pandemic on medical students' education in Canada and their overall mental and physical wellness (components of wellbeing). McGill University Institutional Research Board (IRB) approval was obtained prior to the study commencement. All participants voluntarily signed an electronic consent form on the front page of the questionnaire.

A secure and encrypted cloud-based software was used to develop an online survey with a total of 36 questions (Appendix A). The questionnaire was adapted from previous similar studies on the effect of COVID-19 on the general public's mental health and wellbeing. 11, 12 Data collection occurred over four weeks, from June 1 st to June 28 th which corresponds to the end of the academic year (winter/summer semester). The questionnaire was sent to all 17 Canadian medical schools to be distributed through the student body's official listserv/electronic mailing list. All survey responses were kept and analyzed in the study. To maintain full anonymity of participants, no personal identifiable information was obtained. Data collected pertaining to health habits prior to COVID-19 were based on participant recall.

The Shapiro-Wilk test verified that the continuous data respected the parameters for normality. Descriptive analyses were performed for the demographic data of the sample. Analysis of Variance assessed the change in the health habits, from before the pandemic to during the pandemic with subsequent post-hoc tests. The health habits included time spent seated, time spent in front of a screen, amount of alcohol consumed, and time spent performing moderate and vigorous physical activity. Subanalysis of data stratified based on the baseline mental health disorders was performed using Pearson's chi-square test. All statistical analyses were performed using SPSS 25.0 (IBM, New York, USA) with significance set at p < 0.05.

The study was comprised of 248 Canadian medical students from 13 Canadian medical schools. A total of 63% of the participants were females, which is equivalent to the Canadian medical student cohort (63% in 2018). 13 Demographic characteristics of the cohort is further described in Table 1 . Prior clinical diagnosis with anxiety or depression was reported among 25% of students. 98% of the students were non-smokers, and 36% had not consumed any alcoholic beverages over the last six months. Pre-COVID-19, the students reported to have spent on average 5.86±2.53 hours per day seated, 5.43±2.53 hours per day in front of a computer screen, 4.47±3.90 hours per week performing moderate physical activities, and 2.08±2.41 hours per week performing vigorous physical activities. Table 1 also contrasts the demographics of those with and without prior diagnosis of depression or anxiety and highlights no differences at baseline between the two groups. 

Most students (76%) believed that COVID-19 affected their medical education, of which 71% felt they were experiencing a reduction in the quality of their medical education during the pandemic. Moreover, 58% of all participants found online teaching inferior and less efficient compared to in-class teaching. While 77% of all participants supported online teaching as a complementary method to in-person teaching, only 28% favored it as a preferred method. Furthermore, 67% claimed having more study time compared to 14% who had less time available for studying in comparison to the pre-COVID-19 era.

Sixty-eight percent of the students reported an improvement in the promotion or the structure of the wellness programs offered since the onset of the pandemic, only 11% accessed these resources. Despite the pandemic affecting both the students with a known prior mental illness and those without, the former experienced significantly more depressive episodes since the start of the pandemic (Table 2) . Specifically, 66% of these students experienced depressive symptoms during the pandemic in contrast to 42% among those with no prior psychiatric history (p = 0.003). Similarly, 69% of them felt stressed-out (compared to 41% among those with no prior history; p < 0.001), and 34% reported worsening sleep quality (compared to 18% of those without prior history; p = 0.031). The overall quality of life was worse among those with a prior mental illness (55%) compared to those without (35%; p = 0.024). 

The current study demonstrates the significant effects that the COVID-19 pandemic has had on medical students' education and wellbeing. Specifically, our results show that the majority of the students believe their medical education worsened during the pandemic. Most Canadian medical students reported having more time to participate in leisure activities and take care of their wellbeing. However, our results show that their overall wellbeing and health related habits significantly worsened during the pandemic.

The COVID-19 pandemic has had a substantial impact on the structure of our society. As we enter the second COVID-19 wave, the need to implement measures such as social distancing and wearing facial masks to reduce the transmission of this virus has become clear. 14 However, what still remains unclear is whether the measures implemented for teaching and maintaining medical education were successful during the first wave. The results of the current study demonstrate that while the vast majority (over three quarters of our sample) supported online teaching as a complementary method to in-person teaching, only a minority favoured it as the principal method of education. Similarly, almost two thirds of our sample found online teaching to be less effective than in-person lectures. One reason online lectures may be considered less effective by medical students is that inperson lectures provide more opportunity for meaningful social interactions. 15, 16 Moreover, in-person observed patient simulation activities (which have been mostly ceased due to social distancing measures) allowed students to practice and receive guided feedback on their interpersonal skills. Developing these social skills is an integral part of any medical curriculum and therefore continued efforts should be made to facilitate their development during medical school. 19 Another factor to consider is the novelty of online teaching for instructors/faculties. Aside from the learning curve to using online platforms, instructors and faculty may not have had the time or support to adapt their courses and properly develop teaching materials to deliver their courses in an online format. 17, 18 Developing healthy social skills is not only an important competency for future physicians, it also has a protective effect on mental health. 20 While social isolation has been an integral part in the fight against COVID-19 and a major factor in 'flattening the curve,' 21 previous studies have shown that this can come at the cost of peoples' mental health, 22 which is in line with what our study demonstrated. Interestingly, our study showed that while students had more time for leisure and wellness, almost half of them were more depressed or lonelier, which sheds light on the direct effect of the pandemic on mental health. This deterioration in mental health was accompanied by a statistically significant increase in alcohol consumption, an overall worsening in health habits, and a more sedentary lifestyle.

As we continue to 'flatten the curve', medical schools need to address the secondary effects COVID-19 and social isolation have on medical students' mental health and wellbeing. Our sub-analysis shows that medical students with a pre-existing mental illness (such as depression or anxiety) were at a higher risk of experiencing negative mental health symptoms due to COVID-19. One way to mitigate the negative effects of COVID-19 on medical education and students' mental health is by relying on mentors for guidance and support. Mentorship has long been rooted in medical education but as students face these uncertain times, its need has never been more critical. 23, 24 Having entered a second COVID-19 wave, the authors urge physicians, residents, and senior medical students to provide guidance and support to their junior colleagues as we advance through this pandemic together.

Having entered a second wave of COVID-19, it is more imperative than ever before to understand the first wave's impact on medical students' wellbeing and education.

There are several takeaway messages from our study. The first is that medical students' wellbeing has worsened during the COVID-19 pandemic. Second, students with a prior history of depression and anxiety were more affected. Lastly, with regards to their education, students found that online learning was inferior to in-person teaching and that the quality of their learning had declined since the start of the pandemic. Future studies should explore specific methods in which medical education could be delivered in a safe way while in keeping with the competencies that students strive to achieve. Since COVID-19, I have -Sleeping better than before -Sleeping as well as before -Sleeping worse than before

Since COVID-19, I am -Lonelier than before -As lonely as before -Less lonely than before

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