Original Article

Comparison of Multinational Medical School Students Experiences in the Face of the COVID-19 Pandemic: A Qualitative Analysis

Alexandra C. Skoczek¹, Patrick W. Ruane², Cassidy Onley³, Torhiana Haydel⁴, Maria Valeria Ortega⁵, H. Dean Sutphin⁶, Alexis M. Stoner⁷

doi: http://dx.doi.org/10.5195/ijms.2022.1616

Volume 10, Number 4: 353-360
Received 20 07 2022; Rev-request 27 08 2022; Rev-request 28 09 2022; Rev-request 02 09 2022; Rev-recd 05 10 2022; Accepted 25 11 2022

ABSTRACT

Background:

In the midst of the COVID-19 pandemic, countries, and governments around the world have implemented different measures and guidelines for the containment and mitigation of the COVID-19 virus. In addition to implemented policies and initiatives, social media and personal beliefs have affected medical students’ social, emotional, financial, and academic stability and success both domestically and internationally.

Methods:

This qualitative study, recruited students enrolled in the Global Seminar for Health and Environment elective course in their respective medical schools to complete a weekly, non-graded journaling assignment for 6 weeks. To measure outcomes, open-ended questions were asked to students across four different countries (United States, El Salvador, Dominican Republic, and Honduras) regarding the COVID-19 pandemic including personal beliefs and knowledge, policies and initiatives within their country, global policies and initiatives, and social media presentations. Thematic analysis was then completed using the QCoder package in R Studio.

Results:

A total of 142 assignment submissions were collected and analyzed. International medical students reported more restrictions in their country, a larger mental health impact, and more individuals in their country showing a lack of regard for policies and initiatives. United States medical students were more likely to express a decrease in academic opportunities and academic performances.

Conclusion:

The COVID-19 pandemic continues to affect medical students globally. The pandemic has changed the medical school experience for both international and United States medical students, and affected them not only academically but also mentally, and socially.

Keywords: COVID-19; Medical Student; Mental Health; Academic Performance (Source: MeSH-NLM).

Introduction

As the progression of the COVID-19 pandemic has tested the limitations of the healthcare systems throughout the world, medical students have been challenged to adjust to this new normal. The adjustment of online learning and social limitations have altered the social and mental well-being of the medical student.¹ At the height of the pandemic, there was a concern that students may be missing out on meaningful educational experiences and months of clinical training with unknown effects on their current well-being or professional trajectory.²

Among medical professionals, being a medical student has the highest odds of psychological symptoms of depression and anxiety.³ Medical students are a vulnerable population globally and according to one study, are known to show higher rates of depression, suicidal ideation, and stigmatization around depression, and are also less likely to seek support.⁴ Medical students are also more susceptible to report depressive symptoms compared to college and university students of similar age from the general population. Even though certain aspects of mental health (e.g., depressive symptoms) improve as students become residents and early career physicians, medical students are predisposed to have depression and other psychological distresses compared to their counterparts at different stages of life.³

Medical students use social media to not only obtain breaking news on the ongoing pandemic, but also cope with and express their emotions.⁵ Social media platforms have played a positive and negative role during the COVID-19 pandemic. From a positive perspective, social media rapidly spreads necessary information to identify symptoms, share treatment plans/algorithms, and employ control measures from other countries, and adapt these measures with available resources.⁶ Yet, from a negative perspective, the dissemination of information has also been linked to anxiety and depression.⁷ As previously reported, social media has a significant correlation on spreading panic about COVID-19 amongst medical students, negatively impact their psychological health.⁵

The impact on psychological health is not just seen in the United States, but also globally. In previous pandemics, such as the 2003 SARS-CoV outbreak in Taiwan, it was reported that international medical professionals had negative effects on their wellbeing, including post-traumatic stress disorder (PTSD).^4,8 The effects of post-traumatic stress disorder (PTSD) primarily occurred due to the social distancing and isolation.8 At present, international nations such as the Dominican Republic, Honduras, and El Salvador continue to have an disproportionate impact on social well-being due to differences in policy and resources.⁹ Latin America regularly faces widespread health problems due to overcrowding, limited sanitation, food insecurity and poor nutrition, and unpredictable environmental conditions that affect citizens with lower socioeconomic status.^9,10 Underfunded state-run hospitals are, in most cases, the only source of medical care available to these populations.¹⁰

This study sought to assess medical student’s perspectives on domestic and global response and messaging, attitudes on how they have been personally affected, and insights on their personal understanding of the virus in the face of the COVID-19 pandemic and determine if differences exist between countries. Due to differences in global response and media portrayal, international medical students in countries such as El Salvador, Honduras, and the Dominican Republic will be impacted differently with regards to COVID-19 policy strictness, social and mental health, financial and academic stability, and overall attitude towards the pandemic than the United States medical students.

Methods

A qualitative phenomenological study on the COVID-19 pandemic was conducted using open-ended question responses from medical students from the United States and international medical schools to evaluate global impacts on medical education.

Setting and Participants

Over a 6-week period in the beginning of 2021, medical students enrolled in the Global Seminar for Health and Environment course at their respective medical schools were encouraged to complete a weekly writing assignment on their perspective on the COVID-19 pandemic. Participants attended one of the four Edward Via College of Osteopathic Medicine (VCOM) campuses in the United States, or one of three medical schools located in Central America and the Caribbean. VCOM campuses included VCOM-Virginia, VCOM-Carolinas, VCOM-Auburn, and VCOM-Louisiana. International medical schools included El Instituto Tecnológico de Santo Domingo (INTEC), Universidad Tecnológica Centroamericana (UNITEC), and Universidad Evangélica de El Salvador (UEES), located in the Dominican Republic, Honduras, and El Salvador respectively. Medical students were assigned an ID number to access the assignment questions and submit responses through the Qualtrics platform.¹¹ Researchers were never made aware of the participants ID numbers so that the study would remain confidential, anonymous, and voluntary. This study was reviewed and approved by the Edward Via College of Osteopathic Institutional Review Board (IRB # 2020–013)

Open-Ending Question Design

Open-ended questions were developed by the Global Seminar for Health and Environment course administration to analyze multiple aspects of the participants, lives regarding COVID-19. The goal of the questions was to provide the students with a platform to express multiple different perspectives on their beliefs and knowledge, perspectives on interventions and prevention methods within their country and internationally, and the impact social media had on the pandemic. The complete list of open-ended questions is available as Supplementary Material 1. The questions had been used in 2020 in the Global Seminar for Health and Environment course and modified as needed for clarity. A panel of experts including a retired CDC infectious disease physician with 8 years of experience in Central America, US physicians, and international physicians provided “Content Validity” instrument items to match research objectives. In addition to the open-ended question responses, demographic information was collected, including country of residency and year in medical school.

Study Outcomes and Analysis

Responses from students were analyzed by members of the research team to identify recurring themes in four different categories: personal beliefs and knowledge, policies and initiatives, international policies and initiatives, and social media presentations. Open-ended question responses and themes were then coded and compared to ensure consistency between theme usage. Qualitative analysis was completed using R and QCoder software and packages.^12–13 The number of times that a theme was expressed was divided by the number of total responses to determine the percentage of times a given theme was expressed. Data was then exported from QCoder and the number of times each theme was expressed, stratified by country, was compared.

Results

A total of 142 submissions were collected and analyzed from 76 participants. This included 19 submissions from INTEC, 30 submissions from UEES, 18 submissions from UNITEC, 28 submissions from VCOM Auburn, 18 submissions from VCOM Carolinas, 17 submissions from VCOM Louisiana, and 12 submissions from VCOM Virginia. The 67 submissions from INTEC, UEES, and UNITEC were considered international submissions, and the 75 submissions from VCOM Auburn, VCOM Carolinas, VCOM Louisiana, and VCOM Virginia were considered as the United States submissions. Not all submissions contained answers to all the questions asked, making the total number of responses dependent on the question.

Both internationally and in the United States, COVID-19 has had a large impact on medical students, with, their perspectives distinct in personal beliefs (Table 1), policies in their country (Table 2), policies in other countries (Table 3), and social media (Table 4). International medical students believed that their country’s COVID-19 response contained more restrictions than the global response, with the theme being expressed in 16.4% of international responses compared to 1.3% of US responses. This was enforced by the US medical students’ views that the United States had fewer COVID-19 restrictions.

United States medical students had a higher number of responses with the theme “more restrictions internationally”, which was present in 28% of the responses. An international student’s response with the theme “less restrictions internationally” is as follows:

“There are many variations of the preventions countries might have, but I think that there are many restrictions such as mask obligations that should be applied, as well as imposing a mandatory quarantine to people that have been exposed to the virus in the past days.”

However, medical students internationally and in the United States did believe that their countries generally had good healthcare and good initiatives and policies. 11.1% of international responses and 26.3% of United States responses mentioned the theme “good healthcare” regarding their own countries, while 26.3% of international responses and 38.6% of United States responses mentioned the theme “good initiatives and policies”. Respondents primarily mentioned preventative measure messaging and vaccine distribution.

United States medical students were more likely to express a decrease in the number of academic opportunities and academic performances. The theme “decrease in academic opportunities and performance” was present in 15 of 75 United States responses (20%) compared to 9 of 67 international responses (13.4%). Only 1 of 75 United States responses mentioned a positive experience of academic opportunity and performance. A United States response containing the theme “decrease in academic opportunities and performance” stated:

“I have had to adjust to a new way of doing school, mainly online, as well as coming to terms with the fact that I am not getting to experience many of the social aspects of medical school that I was looking forward to.”

International students were more likely to express views on negative mental health impacts due to their personal beliefs (27.3%) and social media influence (22.2%). The United Sates responses showed less of a mental health impact due to personal beliefs (1.7%) and social media (8.5%), and expressed stronger negative views on how COVID-19 was handled, with 40 of 75 US responses (53.3%) reporting the theme “need better initiatives and policies”. The theme “mental health impact” included responses such as: “My anxiety and panic have risen to such levels that it is hard for me to tolerate casual touch and proximity. I don’t remember the last time I hugged a friend.”

Understanding of COVID-19 and its policies was a major theme reported for both international and United States medical students with the theme “Understanding of COVID-19, Policies, and Preventative Methods” as seen in 45.5% of international responses and 43.3% of United States responses.

Medical students internationally were more likely to believe that social media was informative with 27.8% of responses containing the theme “informative information” while 25.9% of responses contained the theme “misinformation”. The opposite was seen in the United States with 16.9% of students believing that social media was informative and 30.5% of students believing that social media spread misinformation. International students were also more likely to report positive messaging on COVID-19 (46.3%) than United States medical students (25.45%). An example of an international student’s response containing the theme “informative information” is as follows:

“Thanks to the social networks, I have been able to be informed about the development of the modern laboratory vaccine, including the published advances on how patients with this contagious disease were being treated.”

Discussion

The pandemic of COVID-19 has affected medical students’ social, emotional, and academic stability and success both domestically and internationally since it began in 2019. The psychological well-being of the medical student is also based on their perception of COVID-19. The results of this study suggest this perception is influenced by restrictions, restriction changes, social media, and personal beliefs.

Mental health was seen to be a common theme among medical students, both from the international schools and the United States, with over 1 out of 4 of the participants reporting the experience of increasing stress and anxiety during the pandemic. As previously mentioned, medical students are an already vulnerable population with one of the highest rates of depression, burnout, and suicidal ideations.⁴ This supports the notion that the current pandemic is only worsening an already widespread condition among students. Moreover, students from the international schools reported a much higher effect on their mental health than United States students. In a recent meta-analysis, the pooled prevalence of depression and anxiety among medical students internationally and domestically negatively increased with the progress of the pandemic.¹⁴ The study concluded a prevalence of depression and anxiety, which was 37.9%−33.7% higher than that of the general population and healthcare workers.¹⁴ Supporting our hypothesis, these meta-analysis findings indicated that international students who perceived higher levels of pandemic-related stress may have had a negative impact on their academic performance in medical school.¹⁵ However, even though mental health was a common theme, it was only listed in 27.3% of the responses of the international students and 1.7% of the responses of the United States students. Future studies exploring how the different medical students contributed to the medical care in their countries during the pandemic could further elucidate the difference in mental health.

The stress of having their medical education negatively impacted by the pandemic only added to the overall impact as over 1 out of 3 of the participants reported concerns of delayed graduation, decrease in academic opportunities and performance as well as inability to interact with patients in the clinical setting, and inability to go on rotations. As reported in the current literature, sudden change impacted the traditional training of medical students, with limited access to clinical internships.^16–17 These findings support previous results where students expressed their desire to return to rotations, despite the pandemic, in order to assist as healthcare staff and move forward with their education.¹⁸

When asked about their perspectives on the national and international COVID-19 interventions, there were contrasting responses between the United States and international medical students. International medical students, generally, reported more restrictions in their country, which was supported by the United States medical students claiming that there were more restrictions internationally. This finding also confirms our hypothesis and current literature, that perceived social support is a protective factor and influences the mental health status of the medical student.¹⁵ It is worth noting that United States medical students had political critiques of how COVID was handled at the beginning of the pandemic, which was not seen in the international responses. As reported, the government plays an important role in reducing mental health disparities with efficient intervention and appropriate policy changes.¹⁴ This may have influenced the United States medical students’ personal beliefs at the peak of the pandemic. Since the responses critiquing the political reactions were vague accurate prevalence of the themes were unable to be calculated.

Both international and US responses considered that there were “good responses internationally”, 45.3% and 42.4% respectively. These findings could be attributed partially to the fact that, international participants considered that first world countries have better access to medical care, better quality of care, technology, etc. allowing a better response as compared to their own countries.¹⁹ They also mentioned that there was a better enforcement of the regulations by the police and that there was better technology to allow citizens to continue with their daily lives while ensuring social distance and lockdown.

Limitations

All responses were obtained in English. However, 55.9% of the participants were native Spanish-speakers, with English being their second language. For this reason, the data obtained was limited to our participants’ English proficiency levels. Limited responses in each week also reduced the accuracy of the study. The international students participating in this study were all of similar cultural backgrounds. A multicentered study with participants from backgrounds in Europe, Asia, and Africa could be of future interest.

Conclusion:

COVID-19 continues to impact the globe, not only through health impacts but also through its impacts on individuals social, emotional, and educational lives. COVID-19, as seen in the responses, affect the mental health and educational opportunities of medical students. These have a direct impact on a medical student’s ability to successfully practice medicine, not only in their clinical education, but also as future residents and attending physicians. Further research would evaluate the long-term implications of COVID-19’s impact on medical students and its effects on physicians and patient care. Regardless, it must be acknowledged that the medical school experience has changed for both international and the United States medical students and affected them not only academically but mentally, and socially.

Summary – Accelerating Translation

Title: Comparison of Multinational Medical School Students Experiences in the Face of the COVID-19 Pandemic: A Qualitative Analysis

Background: The COVID-19 pandemic has presented unique challenges for countries and governments are the world requiring them to implement different laws, policies, and guidelines to minimize the spread of the virus. The ever-changing landscape of the pandemic required these laws, policies, and guidelines to frequently be revised and new policies and guidelines added. Medical students around the world have been affected by these policies and guidelines as well as their own personal beliefs about the pandemic, and the social media portrayal of the pandemic.

Aim: This study sought to assess medical student’s perspectives on how the COVID-19 pandemic was handled within their own country and internationally, with regards to the different policies and guidelines. In addition, it aimed to analyze medical students’ attitudes and understanding on the pandemic, and how they have personally been affected in their social and academic lives. Lastlythis study also determined how these views differ between countries.

Methodology: Students who were enrolled in the Global Seminar for Health and Environment elective course in their respective medical school were recruited to participate in the study. Participating students were enrolled in medical schools across four different countries (United States, El Salvador, Dominican Republic, and Honduras). For 6 consecutive weeks, students completed a non-graded journaling assignment by answering open ended questions about their personal beliefs and knowledge of the COVID-19 pandemic, COVID-19 policies and guidelines in their country, COVID-19 policies and guidelines in other countries, and social media presentations of the COVID-19 pandemic. The responses were then analyzed by researchers through the identification of common themes. These themes were then compared across medical schools.

Results: A total of 142 assignment submissions were collected and analyzed. Medical students who attended an international medical school (El Salvador, Dominican Republic, and Honduras) reported more governmental policies and restrictions in their countries, a larger mental health impact, and more individuals within their country showing a lack of regard for the policies and restrictions set by the government. Medical students in the United States were more likely to express a decrease in academic opportunities and academic performance. Compared to United States medical students, international students believed that social media with informative and helpful. Both international and United States medical students reported that they felt as if they had a good understanding of the COVID-19 pandemic.

Conclusion: The COVID-19 pandemic continues to affect medical students globally. The pandemic has changed the medical school experience for both international and United States medical students and affected them not only academically, but mentally, and socially.

Acknowledgments

We would like to acknowledge the international medical schools who participated in this study: El Instituto Tecnológico de Santo Domingo (INTEC), Universidad Tecnológica Centroamericana (UNITEC), and Universidad Evangélica de El Salvador (UEES).

Conflict of Interest Statement & Funding

The Authors have no funding, financial relationships or conflicts of interest to disclose.

Author Contributions

Conceptualization: HDS, AMS. Data Curation: ACS, PWR. Formal Analysis: ACS, PWR, CO, TH, MVO. Funding Acquisition: HDS, AMS. Investigation: ACS, PWR, HDS, AMS. Methodology: HDS, AMS. Project Administration: ACS, PWR. Resources: ACS, PWR, CO, TH, MVO. Software: ACS. Supervision: HDS, AMS. Validation and Visualization: ACS, PWR. Writing – Original Draft Preparation and Writing – Review & Editing: ACS, PWR, AMS.

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Alexandra C. Skoczek, 1 MPH, OMS-III. Edward Via College of Osteopathic Medicine – Auburn, Auburn, AL, United States

Patrick W. Ruane, 2 OMS-III. Edward Via College of Osteopathic Medicine – Carolinas, Spartanburg, SC, United States

Cassidy Onley, 3 OMS-III. Edward Via College of Osteopathic Medicine – Virginias, Blacksburg, VA, United States

Torhiana Haydel, 4 MHA, OMS-III. Edward Via College of Osteopathic Medicine – Louisiana, Monroe, LA, United States

Maria Valeria Ortega, 5 OMS-III. Edward Via College of Osteopathic Medicine – Louisiana, Monroe, LA, United States

H. Dean Sutphin, 6 PhD. Edward Via College of Osteopathic Medicine – Virginias, Blacksburg, VA, United States

Alexis M. Stoner, 7 PhD, MPH. Edward Via College of Osteopathic Medicine – Carolinas, Spartanburg, SC, United States

About the Author: Alexandra C. Skoczek is currently a third-year medical student of osteopathic medicine at VCOM-Auburn in Auburn, AL.

Correspondence: Alexis M. Stoner. Address: 2265 Kraft Dr SW, Blacksburg, VA 24060, United States. Email: astoner@carolinas.vcom.edu

Editor: Francisco J. Bonilla-Escobar Student Editors: Duha Shellah & Diego Carrion Alvarez Copyeditor: Leah Komer Proofreader: Laeeqa Manji Layout Editor: Ana Maria Morales Process: Peer-reviewed

Open ended journal questions:

• What are your personal beliefs and knowledge of the novel coronavirus and COVID-19? How has it affected you at a personal level?
• What is your perspective on the interventions and prevention initiatives that have been taken in your country, region, and city? What would you change, if any?
• What is your perspective for the interventions and prevention initiatives of other countries or regions? What knowledge or information have you received about them?
• How has social media and news outlets presented the novel coronavirus/COVID-19 in your country, region, city? How has that affected you?

Cite as Skoczek AC, Ruane PW, Onley C, Haydel T, Ortega MV, Sutphin HD, Stoner AM. Comparison of Multinational Medical School Students Experiences in the Face of the COVID-19 Pandemic: A Qualitative Analysis. Int J Med Stud. 2022 Oct-Dec;10(4):353-60.

Copyright © 2022 Alexandra C. Skoczek, Patrick W. Ruane, Cassidy Onley, Torhiana Haydel, Maria Valeria Ortega, H. Dean Sutphin, Alexis M. Stoner

This work is licensed under a Creative Commons Attribution 4.0 International License.

International Journal of Medical Students, VOLUME 10, NUMBER 4, December 2022