Voluntary Commitment of Medical Students During the COVID-19- Pandemic

medRxiv preprint doi: https://doi.org/10.1101/2020.11.21.20236067; this version posted November 23, 2020. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

It is made available under a CC-BY-NC-ND 4.0 International license .

Voluntary commitment of medical students during the COVID-19- pandemic

Lorenz Leopold Mihatsch1,2, Mira von der Linde3, Franziska Knolle4,5, Benjamin Luchting6, Konstantinos Dimitriadis7, and Jens Heyn8

1) Department of Statistics, Ludwig-Maximilians University, Munich, Germany; 2) TUM School of Medicine, Technical University of Munich, Munich, Germany; 3) Department of Psychology, Westfälische Wilhelms-Universität Münster, Münster, Germany; 4) Department of Neuroradiology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany; 5) Department of Psychiatry, University of Cambridge, Cambridge, UK 6) Interdiciplinary Pain Center, Klinikum Landsberg am Lech, Landsberg am Lech, Germany; 7) Department of Neurology, Ludwig-Maximilians University Munich, Munich, Germany; 8) Department of Anaestesiology and Intensive Care Medicine, Ludwig- Maximilians University Munich, Munich, Germany.

NOTE: This preprint reports new research that has not been certified by peer review and should not be used to guide clinical practice. medRxiv preprint doi: https://doi.org/10.1101/2020.11.21.20236067; this version posted November 23, 2020. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

It is made available under a CC-BY-NC-ND 4.0 International license .

Abstract

Introduction: Due to the spreading of COVID-19, one key challenge was to reduce

potential staff shortages in the healthcare sector. Besides a reactivation of retired

healthcare workers, medical students were considered to support this task. We

herein analysed the commitment of medical students during the COVID-19-pandemic

as well as their burdens and anxieties.

Methods: Via an online survey, medical students in Germany were asked regarding

these themes. The survey period took place during a two-week period in April and

Mai 2020. 1241 questionnairs were included in the analysis.

Results: 67.9% [65.3; 70.5] of the participants reported that they volunteered during

the pandemic. Simultaneously, 88.9% [86.9; 90.5] of the participants stated to be

against a compulsory recruitment in this context. Students who volunteered showed a

significantly lower anxiety index than students, who did not volunteer. Concerns

about transferring the virus to patients or relatives were significantly higher than

concerns about the students’ own infection.

Conclusion: The results of this survey study suggest that the majority of students

are working voluntary during the pandemic. They declared mostly that they had

adequate opportunities to protect themselves. Finally, their biggest fear was to infect

other patients, relatives, or friends.

It is made available under a CC-BY-NC-ND 4.0 International license .

Introduction

At the beginning of the COVID-19 pandemic, the knowledge about the virus was very

limited. Early data from China suggested that health care workers have an increased

risk of infection with the virus [1]. Due to the spreading of COVID-19 and growing

numbers of infected persons, the question arose how to cover shortages of staff

within the health care sector [2]. During the search for potential practitioners, two

specific groups were identified namely retired healthcare workers and medical

students to support this task [3]. However, the reactivation of retired staff was

problematic, as it became clear that the risk of severe infection with COVID-19

increases with age [4].

Therefore, medical students moved into the main focus as workers of a heavily

polluted healthcare sector [3]. This idea is not fundamentally new. There are two

prominent examples from the past century when medical students were involved in

fighting and overcoming a pandemic/epidemic [5]. During the Spanish flu (1918),

medical students at the University of Pennsylvania took care of patients [6].

Approximately four decades later (1952), medical students were tasked with the

manual ventilation of tracheostomised patients during the Danish polio epidemic [7].

Based on the experiences of the past, it is not surprising that several countries tried

to accelerate the graduation in the field of medicine and to prepare freshly graduated

physicians to treat patients with COVID-19 [5]. Neither in the past nor during the

actual pandemic have medical students been analysed relating to their commitment

in a pandemic or their anxieties of a potential infection with the virus for instance. We

therefore addressed these questions in our questionnaire: (i) Are the students willing

to work voluntary? (ii) What are their biggest burdens and anxieties? (iii) Do they

have enough possibilities to protect themselves and have they already had a covid

infection? medRxiv preprint doi: https://doi.org/10.1101/2020.11.21.20236067; this version posted November 23, 2020. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

It is made available under a CC-BY-NC-ND 4.0 International license .

Methods

Ethics

The questioning was performed in accordance with the Declaration of Helsinki and it

was approved on 19.05.2020 by the institutional Review Board of the Ludwig-

Maximilians University of Munich (20-458 KB). All participants were enlightened with

respect to purpose, objectives and handling of the data which were captured in the

questionnaire. Informed consents were given by all participants.

Survey design

During the period of two weeks (25.05. - 07.06.2020), we systematically questioned

medical students in Germany via an online platform (provided by Technical University

of Munich) [8]. The questions dealt with different aspects of the student’s commitment

during the COVID-19 pandemic. We systematically contacted all student

representatives of medical faculties in Germany in order to share the link to the online

platform with the students. Furthermore, we also systematically contacted the

medical students via social media. We calculated our sample size to be at least n =

383 (with 95% - confidence interval, 5% error and population size of 100.000 medical

students in Germany).

Participants

In total, 1407 medical students participated in the questioning, 1241 were included in

the final analysis. Reasons for excluding participants from the analysis were

indicating medRxiv preprint doi: https://doi.org/10.1101/2020.11.21.20236067; this version posted November 23, 2020. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

It is made available under a CC-BY-NC-ND 4.0 International license .

to study in Bremen or Brandenburg in two cases (there are no medical faculties),

stating diverse as gender (there is no statistical inference possible with a single

person), and 163 students during their final year (commitment is obligatory in that

final year). There is no significant difference in the commitment of students from

northern (nnorth = 485 participants) and southern (nsouth = 746 participants) Germany

(p>0.99). We therefore assume our sample to be representative of the medical

students in Germany.

Index of anxiety

Adapted to the anxiety definition from Asendorf and Caspar we developed three

items for the purpose of measuring trait anxiety.9 These items were measured on a

ten-grades Likert scale. As a requirement of offsetting the answers to an index value,

we premised an internal test consistency of Cronbach’s Alpha > 0.8 and a selectivity

> 0.3 (Item-Scale-Correlation) between the respective questions. Those requirements

were fulfilled for the questions about anxiety (alpha: 0.81, selectivity: min. 0.64). The

index was calculated regarding to

∑ͧ 3 $Ͱͥ $ 27

Therefore, the index score takes values between of the interval [0, 1]. 1 is the

maximum and 0 the minimal index score. For measuring empathy by four items we

maximally scored a Cronbach’s Alpha = 0.62, which did not meet our premise.

Statistical analysis

Statistical analysis was performed using R Version 3.6.0 (R core team (2019),

Vienna, Austria). For group differences we used the Pearsons’s Chi2 test for medRxiv preprint doi: https://doi.org/10.1101/2020.11.21.20236067; this version posted November 23, 2020. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

It is made available under a CC-BY-NC-ND 4.0 International license .

categorical variables and the Wilcox rank sum test for quasi-steady variables. 95%

confidence intervals are given in square brackets. medRxiv preprint doi: https://doi.org/10.1101/2020.11.21.20236067; this version posted November 23, 2020. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

It is made available under a CC-BY-NC-ND 4.0 International license .

Results

The proportion of female participants in this survey was 75.8%, with male participants

24.2% respectively. Female medical students had a median age of 24 (with IQR from

22 to 27). Male students were slightly younger with a median age of 23 (with IQR

from 24 to 26). 67.9% [65.3; 70.5] of the students declared that they supported the

health care system voluntary during the COVID-19 pandemic. Out of these, the

proportion of male students was higher compared to female students (75.0% [69.7;

79.8] versus 65.7% [62.5; 68.7], p=0.003; figure 1A). 88.9% [86.9; 90.5] of the

interviewed students argued against an obligation of medical students to assist

during the COVID-19 pandemic (figure 2).

Concerning the type of commitment, there was no significant difference between the

sexes. Both, male and female students engaged most dominantly in a clinical context

(figure 1B). Slight regional differences between states in Germany were not

significant and do not suggest any geographic correlation. The proportions of

voluntarily committed students ranged from 50 - 83.3% (figure 1C – D).

In order to address possible differences between committed and non-committed

students we hypothesized that intrinsic traits, like anxiety and empathy, may

influence the willingness to engage oneself. Indeed, the calculated anxiety index

showed a respective relationship. Non-committed medical students showed

significantly higher index values, than committed students (p<0.001; figure 3A).

Overall female students showed a significantly higher anxiety index, then male

students (p<0.001).

The feeling of being able to protect oneself against COVID-19, measured on a Likert

scale from 1 (low) to 10 (high), had a median value of 7 for male and 6 for female

students (p<0.001). It was lowest in female students, that had no voluntary

commitment (median: 5, p<0.001). Besides intrinsic traits we also hypothesized medRxiv preprint doi: https://doi.org/10.1101/2020.11.21.20236067; this version posted November 23, 2020. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

It is made available under a CC-BY-NC-ND 4.0 International license .

financial difficulties as extrinsic motivational factors influencing one’s commitment.

Such financial difficulties occurred in 17.9% [15.8; 20.1] of all participants but were

not significantly different between the two groups (p=0.13; figure 3B).

As opposed to anxiety as a personal trait, we directly addressed concerns with

COVID-19 infections. It turned out that such concerns were significantly lowest to

one’s own person. It was higher in terms of infecting other patients and highest for

infecting people in one’s personal environment (figure 4A). Based on self-disclosure,

the overall infection rate for the students was estimated to be 1.5% [0.9; 2.4].

It is made available under a CC-BY-NC-ND 4.0 International license .

Discussion

With our study, we are able to provide first insights how a pandemic and a possible

commitment in fighting the pandemic impacts on the lives, thoughts and feelings of

medical students. Furthermore, we could show that the majority of medical students

committed voluntarily and refused an obliged commitment. Interestingly, students

were less concerned about their own infection with COVID-19, than about the

infection of patients and relatives. Overall less than 2% of all participants declared

that they have or had been infected with COVID-19.

During the past, medical students showed often that they favor the concept of

volunteering. They are willing to campaign for that. This was last proven, when

medical students protested against a reform of the licensing regulations, which

intended an obligatory rotation at a general practitioner during the last year of

medical school [10]. Therefore, it is not surprising that the vast majority of students

refuses an obligatory commitment in times of a pandemic. Since the majority of

students stated to support the health system voluntary during the pandemic, an

obligatory commitment seems to be not necessary.

In order to prevent further spread of the virus worldwide several businesses,

factories, stores and restaurants have been closed. Consequently, an enormous

number of jobs were lost or lead to short-term work, which resulted in a loss of

income [11,12]. Our data reflects this process also for medical students. About every

fifth student was affected by such loss of income and put them under financial stress

[11,12]. Therefore, the governmental decision of a financial support for students in

Germany was definitely in the spirit of the students [13]. medRxiv preprint doi: https://doi.org/10.1101/2020.11.21.20236067; this version posted November 23, 2020. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

It is made available under a CC-BY-NC-ND 4.0 International license .

Maner et al. [14] previously showed that young adults have a high level of trait

anxiety leads to avoid risky situations. Our results fit well into that scheme. We found

an inverse connection: higher trait anxiety was connected to less willingness to

volunteer during the pandemic and to be exposed to the risk of being infected. In a

survey that analyzed the psychic condition of 1000 Greek students from various

disciplines, students showed a significant increase in anxiety and depression during

the pandemic. Similarly, an increase in questioning the meaning of life was

documented [15]. In another work which was performed in China by Coa et al. [16]

the level of anxiety of medical students was analyzed. 75% of the students stated a

“normal” level of anxiety while only 3% reported a high level of anxiety. Furthermore,

the level of anxiety was depending on various factors, like economic factors,

prolonged study duration, changes in everyday life and social structure during the

pandemic [16]. The data of our survey confirmed this observed overall low level of

anxiety. However, the level of anxiety was significantly higher in female than in male

medical students. The level of anxiety was especially high in non-committed

students.

Wearing adequate protective gear is necessary for self-protection and effective in

preventing further viral spread [17]. At the beginning of the pandemic a bottleneck in

the delivery of protective gear was reported repetitively [18]. It was therefore of

interest to pick up on this central issue. The majority of medical students reported to

be able to sufficiently protect themselves. One could speculate that the opinion on

non-sufficient protection increases anxiety in this group and explains this lower

commitment.

One possible approach to further increase the commitment could be via improved

educational work on safety measures and risks. This education should also include medRxiv preprint doi: https://doi.org/10.1101/2020.11.21.20236067; this version posted November 23, 2020. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

It is made available under a CC-BY-NC-ND 4.0 International license .

the information that voluntary commitment does not necessarily mean to work directly

with COVID-19 patients. It would also be supportive if medical students support the

regular health care operations. Alternatively, they could support the healthcare

departments or to organize online medical education.5 This would be an excellent

option for students who are willing to be committed but worry about infection with

COVID-19.

Our study has some limitations:

- Data collection during a defined time reflects the impressions at this specific time

point. A dramatic increase in infected patients or the availability of a

vaccine/therapy may have an impact on these results

- After our systematic consultation of the student representatives of German

medical faculties, we had no influence on further distribution of the link. This may

lead to minor estimation biases. As we do not see significant differences in the

proportion of committed students between northern and southern Germany, we

still assume our study population to be representative of medial students in

Germany.

It is made available under a CC-BY-NC-ND 4.0 International license .

Conclusion

The results of this survey study suggest that the majority of students are working

voluntary during the pandemic. They decline an obligatory commitment for students

when fighting the pandemic. Most of them declared that they had adequate

opportunities to protect themselves. Their infection rates were comparable with the

German population. Finally, their biggest fear was to infect other patients, relatives,

or friends.

It is made available under a CC-BY-NC-ND 4.0 International license .

Acknowledgments and Disclosures

Author contribution: LLM, ML, FK, and JH designed the study. LLM, BL, and KD

collected the data. LLM performed the statistical analysis. All authors were involved

in the interpretation of the data. LLM and JH wrote the manuscript. ML, FK, BL, and

KD were involved in drafting the manuscript and revising it critically for important

intellectual content. All authors read and approved the final manuscript.

Other disclosures: JH is employee of Sandoz/Hexal. His occupation neither affected

on the planning and execution of the study nor on the manuscript. All other authors

declare no conflict of interest.

It is made available under a CC-BY-NC-ND 4.0 International license .

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Figure Legends

Figure 1

(A) Relative proportion of medical students in Germany with a voluntary

commitment. Numbers above columns indicate the absolute number of

students in each group. Test for statistical significance was performed using

the chi-squared-test.

(B) Relative proportion of different types of commitment. The type “organization”

refers to organizational work in the medical faculty. Test for statistically

significant differences between male and female students was performed

using the chi-squared-test.

In the states Bremen and Brandenburg, there are no medical faculties. The

number in each state refers to the proportion in % of voluntarily committed

students in each state.

(D) Visualization of the 95% confidence intervals of the estimated proportions of

committed students in German states. White vertical bars depict the estimated

proportions in %, black boxes refer to the confidence interval, numbers at the

beginning of each bar indicate the number of students questioned in the

corresponding state.

Figure 2 medRxiv preprint doi: https://doi.org/10.1101/2020.11.21.20236067; this version posted November 23, 2020. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

It is made available under a CC-BY-NC-ND 4.0 International license .

(A) Opinion of German medical students concerning an obligatory commitment

during the pandemic in relative numbers. Numbers above columns indicate the

absolute number of students in each group. Test for statistical significance

between committed and non-committed students was performed using the chi-

squared-test.

Figure 3

(A) Comparison of the anxiety index of committed versus non-committed students.

Calculation of the index is given in the method section. Test for significant

differences was determined using the Wilcoxon rank-sum test.

(B) Relative proportion of medical students, that faced a loss of income during the

COVID-19 pandemic. Test for statistical significance between committed and

non-committed students was performed using the chi-squared-test.

Figure 4

(A) Fear of committed and non-committed medical students of being infected

themselves, of unwillingly infecting patients and people of their personal

environment. Measured on a Likert scale from 1 (low fear) to 10 (high fear).

(B) Relative proportion in % of students, which have been infected with COVID-19

based on self-disclosure. Test for statistical significance between committed

and non-committed students was performed using the chi-squared-test.

Figure 1: Commitment of medical students during the COVID-19 pandemic A) Commitment B) Type of commitment medRxivmale preprintfemale doi: https://doi.org/10.1101/2020.11.21.20236067male ; this versionfemale posted November 23, 2020. The copyright holder for this preprint (which was not certified by peer100 review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. 100 p = 0.003 ** p = 0.947 n.s. It is made available under a CC-BY-NC-ND 4.0 International license . 75 225 75 618 140 386

50 50 323 75 54 155 25 students in25 % 22 54 9

Proportion of committed 22 Proportion of students % 0 0 yes no yes no other other clinically clinically organisation organisation

health authorities health authorities C) Commitment in Germany D) 95% - CI of proportion estimation 254 Baden Wurttemberg 67 241 Bavaria 83 52 13 Berlin 29 Hamburg 65 171 54 Hessen 6 Mecklenburg-West Pomerania 63 73 20 Lower Saxony 50 221 North Rhine Westphalia 65 73 57 Rhineland Palatinate

58 20 Saarland 30 75 Saxony 65 60 Saxony Anhalt 71 73 Schleswig-Holstein 46 Thuringia 0 25 50 75 100 Proportion of students in % Proportion of students in %

50 60 70 80 [ 95% - CI ] Figure 2: Attitude towards an obligation

Obligatorycommitment medRxiv preprintnon doi: https://doi.org/10.1101/2020.11.21.20236067; this version posted November 23, 2020. The copyright holder for this preprintcommitted (whichcommitted was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. 100 p = 0.119 n.s. It is made available under a CC-BY-NC-ND 4.0 International license . 362 740 75

25 103 36

Proportion of students in % 0 yes no yes no Figure 3: Factors influencing the commitment A) Anxiety B) Loss of income 1.00 medRxiv preprint doi: https://doi.org/10.1101/2020.11.21.20236067committed non ; this version posted November 23, 2020. The copyright holder for this preprint (which was not certified by peer100 review) is the author/funder,committed who has granted medRxiv a license to display the preprint in perpetuity. p < 0.001*** p = 0.124 It is made available682 undern.s. a CC-BY-NC-ND 4.0 International license . 0.75 337 75

0.50 50 Index

0.25 25 161 61

0.00 Proportion of students in % 0 committed non yes no yes no committed Figure 4: Risk of infection A) Concerns about infection B) COVID-19 infection medRxiv preprint doi:non https://doi.org/10.1101/2020.11.21.20236067; thisnon version posted November 23, 2020. The copyright holder for this committedpreprint (which wascommitted not certified by peer review)committed is the author/funder,committed who has granted medRxiv a license to display the preprint in perpetuity. p < 0.001 *** p < 0.001 *** 100 p = 0.94 n.s. 10 It is made available under a CC-BY-NC-ND341 4.0 International license . 695 75 8

6 50

4 25 135 Scale from 1 - 10 51 13 6 2 Proportion of students in % 0 yes no kA yes no kA

personally personally other patients other patients

personal environment personal environment