Carl joshua N.

Balanlay
G12-Friendliness
TITLES
COVID-19 pandemic's effects on medical students: a multicenter
quantitative investigation
Aaron J. Harries

BMC Medical Education

AUTHORS AND AFFLIATIONS

The Association of American Medical Colleges (AAMC) issued an

unprecedented nationwide recommendation to halt all student clinical
rotations involving in-person patient care due to the COVID-19 outbreak,
which caused significant disruptions to the US medical education system. In
order to inform medical education policy, this study examines the
psychological and educational consequences of the pandemic on US medical
students as well as their responses to the AAMC suggestion. It is a quantitative
analysis.
ABSTRACT

The Association of American Medical Colleges (AAMC) issued an

unprecedented nationwide recommendation to halt all student clinical
rotations involving in-person patient care due to the COVID-19 outbreak,
which caused significant disruptions to the US medical education system.
This study examines the psychological and educational impacts through a
quantitative approach.

INTRODUCTION

The COVID-19 epidemic has put healthcare systems to the test and
called into question established methods in medical education. Due to
the pandemic's quick growth, important choices about medical students'
training in the US had to be made quickly and with little to no input or
direction from the students themselves. The main national regulating
body of US medical schools, the Association of American Medical
Colleges (AAMC), released guidelines on March 17, 2020, marking the
first time in modern US history that such guidance had been issued.
 advising medical students to halt any clinical rotations right away in
order to give themselves more time to learn about the dangers of
COVID-19 and get ready for future safe participation. In addition to
minimizing exposure for healthcare workers (HCWs) and the general
public, this decisive move would conserve limited resources like testing
kits and PPE and safeguard students' education and well-being [1].
A comparable precedent was established outside of the US during the
2003 SARS-CoV1 pandemic, when students were expelled from hospital
systems in Hong Kong, Singapore, and Toronto due to an initial cluster
of infection among medical students in Hong Kong [2, 3]. Afterwards,
Research findings indicated that the absence of Canadian students from
such clinical settings led to their unhappiness over missed educational
opportunities and their helplessness [3]. Research from around the
world also indicates that medical students have an ethical duty to take
part in pandemic response, and they are prepared to take part in
situations akin to the COVID-19 crisis even though they think their
personal risk of infection is low [4,5, 6].

Following local tragedies, some US medical students have been abruptly

removed from classroom environments, which has had serious effects
on both their academic and personal lives. When Hurricane Katrina
forced Tulane University School of Medicine to close, it was estimated
that one-third of medical students suffered from depression or post-
traumatic stress disorder (PTSD) in some capacity in 2005 [7].

We could not locate any research on the impact of pandemics on the US

medical education system or its students prior to the present COVID-19
pandemic. Two previous worldwide coronavirus surges, SARS and
MERS, provide the scant evidence on medical students' opinions;
additionally, research on student concern connected to pandemics is
restricted to non-US populations [3, 8, 9]. There are worries that
students might be losing out on valuable educational opportunities and
months of clinical training due to the unusual nature of the present
COVID-19 pandemic, with unclear consequences for their future well-
being or career paths [10].

medical education policy by examining the effects of the pandemic on US

medical students and their responses to the AAMC suggestion.

2.METHODS
Using emails sent to all clinically rotating medical students at six US medical
schools—University of California San Francisco School of Medicine (San
Francisco, CA), University of California Irvine School of Medicine (Irvine, CA),
Tulane University School of Medicine (New Orleans, LA), and University of
Illinois College of Medicine (Chicago, Peoria, Rockford, and Urbana, IL)—we
conducted a cross-sectional survey during the first peak phase of the COVID-
19 pandemic in the United States, from 4/20/20 to 5/25/20.Zucker School of
Medicine at Hofstra/Northwell and Ohio State University College of Medicine
(Columbus, OH) (Hempstead, NY). In the United States, a four-year medical
school curriculum consists of two years of pre-clinical classroom instruction
and two years of clinical training that involves providing direct patient care.
Medical students enrolled in their clinical training years who were targeted by
the AAMC guidance statement were considered study participants. This
comprised the projected graduation class years of 2020 (graduating 4th year
student), 2021 (rising 4th year student), and 2022 (rising 3rd year student),
exclusive of planned time off, depending on the curriculum of each medical
school.The participating schools were chosen with care to ensure that they
represented a wide range of kids from the West, South, Midwest, and East
regions of the country, each with a varied COVID-19 prevalence. We didn't
include medical students who hadn't started their clinical rotations yet. These
Institutional Review Boards decided that this study was exempt.

We created a survey questionnaire that included items from validated stress

measures and was based on one that was used in a previously published, peer-
reviewed study assessing the impact of the COVID-19 pandemic on emergency
physicians [11]. In order to gather information about medical students'
perceptions of the following domains, a modified version of the survey was
created and distributed to them. These domains included perceived impact on
medical student education, ethical beliefs regarding clinical participation
obligations during the pandemic, perceptions of personal infection risk,
pandemic-related anxiety and burnout, willingness to return to clinical
rotations, and the preparation required for students to feel safe in the clinical
setting.After being constructed, the survey was subjected to an iterative
process of evaluation and feedback from our team of authors who have
expertise with psychometric measures and survey methodology. This allowed
us to optimize the survey's validity and content. Five medical students
participated in a pilot test of our draft instrument, which we used to verify
survey completion in about ten minutes and to check the clarity of the
questions. There were 29 Likert, yes/no, multiple choice, and free answer
questions in the final poll. Three follow-up emails were sent out with the
survey to boost response rates, and it was distributed by student class leaders
and deans of medical schools via email. Anonymized data collection was done.
For instance, participants were asked, "To what extent has the COVID-19
pandemic affected your stress or anxiety levels? " in order to gauge the impact
on students' anxiety.use a unipolar seven-point rating system (1 = not at all, 4
= slightly, and 7 = excessively). In order to gauge the participants' willingness
to resume clinical rotations, they were asked to rate their agreement with the
following statement: "To the extent possible, medical students should
continue with normal clinical rotations during this pandemic" on a bipolar
scale (1 = strongly disagree, 2 = disagree, 3 = somewhat disagree, 4 = neither
disagree nor agree, 5 = somewhat agree, 6 = agree, and 7 = strongly agree)
(Survey Instrument, Supplemental Table 1).
Qualtrics, which is hosted by the University of California, San Francisco, was
used to manage survey data. We utilized STATA v15.1 (Stata Corp, College
Station, TX) for data analysis. We used raw counts, frequency percent,
medians, and interquartile ranges (IQR) to describe respondent
characteristics and important replies. We created an agreement percentage for
bipolar questions by adding up positive answers (strongly agree, agree, or
slightly agree). We employed a signed rank test with p value < 0.05 to
demonstrate statistical difference in order to compare differences in
medians.The following sub-groups were compared using stratified data in a
secondary analysis: female versus male, graduation year, COVID-19
prevalence (high, medium, low) in the local community, and students
participating in clinical rotations that involved in-person patient care. A chi
square test with a p value less than 0.05 was employed in this secondary
analysis to display the statistical difference between the sub-group agreement
percentages.
Outcomes

741 students (or 29.5% of the total) responded to our contact out of 2511 pupils. Of these, 27.7%
of responses came from the class of 2020, 53.5% from the class of 2021, and 18.7% from the
class of 2022. Of these, 63.9% of respondents were female and 35.1% from the male category,
with 1.0% indicating a different gender identity. (Table 1, Demographics 1).
Table 1: Statistics

Full size table

The majority of student respondents (74.9%) stated that COVID-19 caused their clinical rotation
to be canceled or shortened, and 93.7% said they were not enrolled in clinical rotations that
entailed face-to-face patient contact at the time of the study. Perceptions of the cancelled
rotations (which allowed for a range of responses) among students revealed that: 75.8% thought
it was appropriate; 34.7% felt guilty for not being able to assist patients and colleagues; 33.5%
felt dissatisfied; and 27.0% felt relieved.
The majority of students (74.7%) concurred that the epidemic had severely impacted their
medical studies. Additionally, 72.1% of students said they were able to locate worthwhile
educational opportunities during the pandemic. Examples of such responses were enrolling in a
new COVID-19 pandemic elective course,

electives in research or education, volunteer work connected to COVID-19, both clinical and non-clinical,
and self-directed independent study electives. 72.7 percent of students thought their medical schools
were doing everything in their power to assist students in adjusting. The majority of respondents
(61.4%) believed the pandemic had hampered their capacity to acquire the skills necessary to get ready
for residency; however, fewer respondents (45.7%) believed it had hampered their ability to apply to
residency. (Figure 1, Educational Impact).

Figure. 1.

Medical students' perceptions of the COVID-19 pandemic's effects on their education

Full size image

A majority of medical students agreed they should be allowed to continue with normal clinical
rotations during this pandemic (61.3%). Most students agreed (83.4%) that they accepted the risk
of being infected with COVID-19, if they returned. When asked if students should be allowed to
volunteer in clinical settings even if there is not a healthcare worker (HCW) shortage, 63.5%
agreed; however, in the case of a HCW shortage only 19.5% believed students should
be required to volunteer clinically. (Willingness to Participate Clinically, Fig. 2).
Fig. 2

Willingness to participate clinically during the COVID-19 pandemic

37.8% of respondents who were asked if they thought medical students had a moral,
ethical, or professional duty to assist during the current pandemic agreed that they did.
This contrasts with how they felt about doctors: 87.1% of students felt that doctors had a
duty to assist during the COVID-19 pandemic. When asked if this duty continued in the
absence of proper PPE, students in both groups gave different answers. Of them, just
10.9% thought medical students had this duty, while 34.0% thought physicians did.
(Figure 3, Ethical Obligation).
Figure. 3.

Full size image

Ethical obligation to volunteer during the COVID-19 pandemic
Full size image

Students believed that having access to appropriate PPE was the most crucial element in a safe
return to clinical rotations, followed by adequate testing for infection (19.3%) and antibody
testing for potential immunity (16.2%), given the assumption that there won't be a COVID-19
vaccine until 2021. Just 5% of students said they wouldn't feel comfortable until a vaccine was
available. Students were somewhat prepared to utilize PPE during this pandemic in the clinical
context, with a median score of 4 (IQR 4,6), and somewhat confident in identifying the
symptoms most alarming for COVID-19, with a median score of 4 (IQR 4,5). On a scale of 1 to
7, 1 being not at all, 4 being somewhat, and 7 being extremely.PPE was best learned by students
through online modules (47.7%), in-person or Zoom-style conferences (44.7%), and video
demonstrations (76.7%).75.6% of students thought they would definitely get COVID-19 in
general, even if they didn't go back to the clinical setting. The majority of participants (90.5%)
thought that missing some work or school would be a likely outcome, but only a small
percentage of students thought that hospitalization (22.1%) or death (4.3%) would be very,
considerably, or extremely likelyThe COVID-19 pandemic was shown to have a median (IQR)
impact on students' stress or anxiety level of 5 (4, 6). Of those surveyed, 84.1% reported feeling
somewhat nervous as a result of the pandemic. One is not at all, four is somewhat, and seven is
excessively on a scale of 1 to 7. Students' perceived emotional exhaustion and burnout before the
pandemic was a median of 2 (IQR 2,4), and after it started,. Subgroup differences were
statistically demonstrated by secondary evaluation of significant questions. Women were
significantly more likely than males to agree that the pandemic had affected their anxiety. The
median score was 4 (IQR 2,5), with a median difference of Δ = 2, p value < 0.001. When
comparing the 2020, 2021, and 2022 classes, several notable differences were observed.In
particular, the 2020 group was less likely to mention that their schooling had been disrupted, to
favor going back to rotations, and to mention that their anxiety had been affected. There were no
significant differences. when comparing students who continued to provide in-person patient
care to those who did not. Students were less likely to claim that the pandemic had disrupted
their schoolwork when comparing places with high COVID-19 prevalence at the time of the
survey (New York and Louisiana) with medium prevalence (Illinois and Ohio) and low
prevalence (California). The majority of students in locations with low prevalence agreed that
rotations for medical students should resume. Subjective anxiety effects and acceptance of the
chance of infection recurrence did not differ between prevalence groups. (Table 2, Stratification).
Table 2: Arrangement

Full size table

Discussion
The COVID-19 pandemic has had a profound impact on education across the board, from pre-
school to graduate school. The impacts of COVID-19 on undergraduate medical education have
not been extensively studied to far [14], despite the fact that modifications to K–12 and college
education have been well reported [12, 13]. In order to preserve the delicate equilibrium between
the urgent need to teach future doctors and the safety and well-being of studentsDecisions on
students' roles in the clinical setting must be made with their input in mind. Medical students
may have emotional responsibilities as members of the patient care team even when they are not
in a clinical setting, as evidenced by their concerns about the pandemic and their willingness to
resume rotations in spite of the hazards. This study provides guidance on how to best assist
medical students returning to clinical rotations, how to get them ready for successful careers in
the future, and how to make plans for their possible participation in pandemics in the future.Even
though 40% of Canadian students in one study believed there was a high chance of contracting
the disease, earlier international studies of medical students' attitudes toward hypothetical
influenza-like pandemics showed a willingness (80%) [4] and a perceived ethical obligation to
volunteer (77 and 70%). In the midst of the COVID-19 epidemic, our participants believed that
there was a larger chance of infection at 75.6%, but they agreed less that medical students had an
ethical duty to volunteer in the clinical setting at 37.8%. It's possible that students' views of the
ethical criterion are altered more by the stress of an ongoing pandemic than by their motivation
to assist, as seen by their willingness to be permitted to volunteer freely (63.5%).87.1% of
students felt that doctors had an ethical duty to treat patients during the COVID-19 epidemic.
This may be a reflection of how they see the ethical divide between paying for college and
becoming a paid professional.There were many people worried about potential shortages of
health care workers at the time our study was done. It was unclear if medical students would be
expected to volunteer to help out when residents fell unwell, or if they would even be required to
graduate early in order to begin residency training right away (as happened at half of the schools
surveyed).We were able to get a really special viewpoint from medical students at this time of
year, most of whom said that the pandemic had made them more anxious and burned out. At the
same time, maybe as a result of regular updates and virtual town halls, students believed that
their medical schools were making every effort to assist them.
Subsequent analytical trends indicate significant variations in the pandemic's effects.
Compared to males, women were more likely to report feeling anxious, which could indicate
larger gender differences in anxiety among medical students [15]. However, further research is
needed to rule out distinct pandemic pressures based on gender. In general, graduating medical
students (class of 2020) reported less anxiety and impact on their medical education, as well as a
decreased desire to return to rotations. However, they expressed equal acceptance of the risk of
infection in clinical settings, which may have been due to their attention being diverted from
their remaining months of undergraduate medical education to their upcoming intern year. Since
this class’s responses decreased overall agreement on these questions, educational impacts and
anxiety effects may have been even greater had they been assessed further from graduation.
Interestingly, students from areas with high local COVID-19 prevalence (New York and
Louisiana) reported a less significant effect of the pandemic on their education, a paradoxical
result that may indicate that medical student tolerance for the disruptions was greater in high-
prevalence areas, as these students were removed at the same, if not higher, rates as their peers.
Our results suggest that in future waves of the current pandemic or other disasters, students may
be more patient with educational impacts when they have more immediate awareness of strains
on the healthcare system.
The survey response rate was one of our study's limitations, however this was to be expected
considering the difficulties that students were having. Some might not have been living close to
the university; others might have stopped checking emails because they graduated early or had
restricted access to them; and still others might have been facing additional personal difficulties
as a result of the pandemic. In an effort to boost response rates, we issued reminders for
completion along with the study directly from the deans and administration of the individual
medical schools and the class reps. Since there were no incentives associated with the survey,
students who thought that their education was most harmed were inclined to reply, as evidenced
by the greater response rate in the class of 2021 across all institutionsThe secondary analysis,
which we conducted in order to eliminate this potential source of bias, revealed no differences
between respondents from 2021 and 2022. An further constraint was the innate problem with
gathering survey data on absent answers for certain topics, which surfaced in a limited quantity
of surveys. Due to this, there was some variability in the total number of replies for several
questions, but it was not statistically significant. We presented our data in the Tables by listing
each total response and denominator in order to be open and honest about this restriction.
.This initial study lays the groundwork for future investigations and next steps. With 72.1% of
students agreeing that they were able to find meaningful learning in spite of the pandemic, future
research should investigate novel learning modalities that were successful during this time.
Educators should consider additional training on PPE use, given only moderate levels of student
comfort in this area, which may be best received via video. It is also important to study the long-
term effects of missing several months of essential clinical training and identifying competencies
that may not have been achieved, since students perceived a significant disruption to their ability
to prepare skills for residency. Next steps could be to study curriculum interventions, such as
capstone boot camps and targeted didactic skills training, to help students feel more comfortable
as they transition into residency. Educators must also acknowledge that some students may not
feel comfortable returning to the clinical environment until a vaccine becomes available (5%)
and ensure they are equally supported. Lastly, it is vital to further investigate the mental health
effects of the pandemic on medical students, identifying subgroups with additional stressors,
needs related to anxiety or possible PTSD, and ways to minimize these negative effects.

3. Results
A total of 741 pupils (29.5%) gave a response. At the time of the study, nearly
all students (93.7%) were not participating in clinical rotations that entailed
face-to-face patient interaction. There was a mixed response to removal;
75.8% thought it was appropriate, 34.7% felt guilty, 33.5% upset, and 27.0%
felt relieved.
The majority of students (74.7%) felt that the pandemic had seriously
interfered with their medical education, and 61.3 percent said that their
clinical rotations should continue as usual during this pandemic. 83.4% of
respondents said they would be willing to assume the risk of contracting
COVID-19 if they went back to the clinical setting.

Students' stress and anxiety levels were assessed to have been moderately
affected by the epidemic; 84.1% of respondents said they felt at least
somewhat nervous. To feel comfortable going back to clinical rotations, proper
personal protective equipment (PPE) ranked highest (53.5%), followed by
adequate testing for infection (19.3%) and antibody testing (16.2%).
The COVID-19 pandemic has had a profound impact on education across the
board, from pre-school to graduate school.

The impacts of COVID-19 on undergraduate medical education have not been extensively
studied to far [14], despite the fact that modifications to K–12 and college education have been
well reported [12, 13]. Student participation must inform decisions about their involvement in
the clinical setting in order to preserve the delicate balance between student safety and wellbeing
and the urgent requirement to teach future physicians. Medical students may have emotional
responsibilities as members of the patient care team even when they are not in a clinical setting,
as evidenced by their concerns about the pandemic and their willingness to resume rotations in
spite of the hazardsThis study provides guidance on how to best assist medical students returning
to clinical rotations, how to get them ready for successful careers in the future, and how to make
plans for their possible participation in pandemics in the future.
Even though 40% of Canadian students in one study believed there was a high chance of
contracting the virus, previous international studies of medical students' attitudes toward
hypothetical influenza-like pandemics showed a willingness (80%) [4] and a perceived ethical
obligation to volunteer (77 and 70%).
..In the midst of the COVID-19 epidemic, our participants believed that there was a larger chance
of infection at 75.6%, but they agreed less that medical students had an ethical duty to volunteer
in the clinical setting at 37.8%. It's possible that students' views of the ethical criterion are altered
more by the stress of an ongoing pandemic than by their motivation to assist, as seen by their
willingness to be permitted to volunteer freely (63.5%). 87.1% of students felt that doctors had
an ethical duty to treat patients during the COVID-19 epidemic. This may be a reflection of how
they see the ethical divide between paying for college and becoming a paid professional.

There were many people worried about potential shortages of health care workers at the time our
study was done. It was unclear if medical students would be expected to volunteer to help out
when residents fell unwell, or if they would even be required to graduate early in order to begin
residency training right away (as happened at half of the schools surveyed). We were able to get
a really special viewpoint from medical students at this time of year, most of whom said that the
pandemic had made them more anxious and burned out. At the same time, maybe as a result of
regular updates and virtual town halls, students believed that their medical schools were making
every effort to assist them.

Subsequent analytical trends indicate significant variations in the pandemic's effects. Compared
to males, women were more likely to report feeling anxious, which could indicate larger gender
differences in anxiety among medical students [15]. However, further research is needed to rule
out distinct pandemic pressures based on gender. In general, graduating medical students (class
of 2020) reported less anxiety and impact on their medical education, as well as a decreased
desire to return to rotations. However, they expressed equal acceptance of the risk of infection in
clinical settings, which may have been due to their attention being diverted from their remaining
months of undergraduate medical education to their upcoming intern year. If the class's responses
had been evaluated further, the effects on anxiety and education might have been even more
pronounced because there was less overall agreement on these topics.As these students were
expelled at the same, if not higher, rates as their peers, it is interesting to note that students from
high-prevalence local COVID-19 areas (New York and Louisiana) reported a less significant
effect of the pandemic on their education. This paradoxical result may suggest that medical
students' tolerance for the disruptions was greater in high-prevalence areas. Our findings imply
that when students are more immediately aware of the pressures on the healthcare system, they
may be more understanding of the educational effects of future waves of the current pandemic or
other calamities.
The survey response rate was one of our study's limitations, however this was to be expected
considering the difficulties that students were having.

Some might not have been living close to the university; others might have stopped checking
emails because they graduated early or had restricted access to them; and still others might have
been facing additional personal difficulties as a result of the pandemic. In an effort to boost
response rates, we issued reminders for completion along with the study directly from the deans
and administration of the individual medical schools and the class reps. Since there were no
incentives associated with the survey, students who thought that their education was most
harmed were inclined to reply, as evidenced by the greater response rate in the class of 2021
across all institutions.The secondary analysis, which we conducted in order to eliminate this
potential source of bias, revealed no differences between respondents from 2021 and 2022. An
further constraint was the innate problem with gathering survey data on absent answers for
certain topics, which surfaced in a limited quantity of surveys. Due to this, there was some
variability in the total number of replies for several questions, but it was not statistically
significant. We presented our data in the Tables by listing each total response and denominator in
order to be open and honest about this restriction.
This preliminary study establishes the foundation for additional research and subsequent actions.
Given that 72.1% of students felt that the pandemic did not prevent them from finding
meaningful learning, more studies should look into innovative learning strategies that worked at
this period.

Given that students are only somewhat comfortable using PPE, educators should think about
providing more training on the subject, which would be best taught via video. Researchers
should also look into the long-term consequences of missing several months of crucial clinical
training and discover any competencies that may not have been attained because students felt
 that their ability to prepare for residency was seriously disrupted.Subsequent actions can involve
researching curriculum interventions, such capstone boot camps and focused didactic skills
training, to make students feel more at ease during their residency transition. Teachers must also
recognize that 5% of students might not feel safe returning to the clinical setting until a
vaccination is available, and they must make sure these kids receive the same care. Finally, more
research on the pandemic's effects on medical students' mental health is essential. This includes
identifying subgroups with heightened stressors, needs for anxiety or potential PTSD, and
strategies for mitigating these detrimental effects.

Conclusions
We present a picture of the pandemic's effects on US medical students in this
cross-sectional survey, which was carried out during the first peak phase of the
COVID-19 epidemic. We also get insight into the students' responses to the
groundbreaking AAMC national suggestion that they be removed from clinical
rotations. Respondent students from all across the United States acknowledged
that their medical education had been significantly disrupted, expressed a
desire to continue with in-person rotations, and expressed a willingness to
assume the risk of contracting COVID-19. Our groundbreaking findings offer a
strong basis for guiding medical students' roles in the clinical setting both now
and in the future during pandemics.

vailability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding
author on reasonable request.
References
1. Association of American Medical Colleges. Interim Guidance on Medical Students’ Participation
in Direct Patient Contact Activities: Principles and Guidelines. https://www.aamc.org/news-
insights/press-releases/important-guidance-medical-students-clinical-rotations-during-
coronavirus-covid-19-outbreak. Published March 17, 2020. Accessed April 1, 2020.

2. Clark J. Fear of SARS thwarts medical education in Toronto. BMJ.

2003;326(7393):784. https://doi.org/10.1136/bmj.326.7393.784/c.

Article Google Scholar

3. Loh LC, Ali AM, Ang TH, Chelliah A. Impact of a spreading epidemic on medical students.
Malays J Med Sci. 2006;13(2):30–6.

Google Scholar
4. Mortelmans LJ, Bouman SJ, Gaakeer MI, Dieltiens G, Anseeuw K, Sabbe MB. Dutch senior
medical students and disaster medicine: a national survey. Int J Emerg Med.
2015;8(1):77. https://doi.org/10.1186/s12245-015-0077-0.

Article Google Scholar

5. Huapaya JA, Maquera-Afaray J, García PJ, Cárcamo C, Cieza JA. Conocimientos, prácticas y
actitudes hacia el voluntariado ante una influenza pandémica: estudio transversal con estudiantes
de medicina en Perú [Knowledge, practices and attitudes toward volunteer work in an influenza
pandemic: cross-sectional study with Peruvian medical students]. Medwave.
2015;15(4):e6136Published 2015 May 8. https://doi.org/10.5867/medwave.2015.04.6136.

Article Google Scholar

6. Herman B, Rosychuk RJ, Bailey T, Lake R, Yonge O, Marrie TJ. Medical students and
pandemic influenza. Emerg Infect Dis. 2007;13(11):1781–
3. https://doi.org/10.3201/eid1311.070279.

Article Google Scholar

7. Kahn MJ, Markert RJ, Johnson JE, Owens D, Krane NK. Psychiatric issues and answers
following hurricane Katrina. Acad Psychiatry. 2007;31(3):200–
4. https://doi.org/10.1176/appi.ap.31.3.200.

Article Google Scholar

8. Al-Rabiaah A, Temsah MH, Al-Eyadhy AA, et al. Middle East respiratory syndrome-Corona
virus (MERS-CoV) associated stress among medical students at a university teaching hospital in
Saudi Arabia. J Infect Public Health. 2020;13(5):687–
91. https://doi.org/10.1016/j.jiph.2020.01.005.

Article Google Scholar

9. Wong JG, Cheung EP, Cheung V, et al. Psychological responses to the SARS outbreak in
healthcare students in Hong Kong. Med Teach. 2004;26(7):657–
9. https://doi.org/10.1080/01421590400006572.

Article Google Scholar

10. Stokes DC. Senior medical students in the COVID-19 response: an opportunity to be proactive.
Acad Emerg Med. 2020;27(4):343–5. https://doi.org/10.1111/acem.13972.

Article Google Scholar

11. Rodriguez RM, Medak AJ, Baumann BM, et al. Academic emergency medicine physicians’
anxiety levels, stressors, and potential mitigation measures during the acceleration phase of the
COVID-19 pandemic. Acad Emerg Med. 2020;27(8):700–
7. https://doi.org/10.1111/acem.14065.
 Article Google Scholar

12. Sahu P. Closure of universities due to coronavirus disease 2019 (COVID-19): impact on
education and mental health of students and academic staff. Cureus. 2020;12(4):e7541Published
2020 Apr 4. https://doi.org/10.7759/cureus.7541.

Article Google Scholar

13. Reimers FM, Schleicher A. A framework to guide an education response to the COVID-19
pandemic of 2020:
OECD. https://www.hm.ee/sites/default/files/framework_guide_v1_002_harward.pdf.

14. Choi B, Jegatheeswaran L, Minocha A, Alhilani M, Nakhoul M, Mutengesa E. The impact of the
COVID-19 pandemic on final year medical students in the United Kingdom: a national survey.
BMC Med Educ. 2020;20:206–16. https://doi.org/10.1186/s12909-020-02117-1.

Article Google Scholar

15. Dyrbye LN, Thomas MR, Shanafelt TD. Systematic review of depression,
anxiety, and other indicators of psychological distress among U.S. and
Canadian medical students. Acad Med. 2006;81(4):354–
73. https://doi.org/10.1097/00001888-200604000-00009.