Charlotte Jones, GED (1); Amanda R. Sergesketter, MD (2); Scott T. Hollenbeck, MD (2)

(1) Duke University, Durham, NC

(2) Division of Plastic, Maxillofacial, and Oral Surgery, Duke University, Durham NC

Corresponding Author:

Scott T. Hollenbeck, MD

Associate Professor of Plastic, Oral, and Maxillofacial Surgery

Division of Plastic, Oral, and Maxillofacial Surgery

Duke University Medical Center

Durham, NC 27710

HIGHLIGHTS

·      The majority of Duke pre-health students intend to continue to pursue a Doctor of Medicine despite the effects of the COVID-19 pandemic.

·      Many students are more interested in working in private practices, as opposed to working in hospitals.

·      Decreased extracurricular involvement, objective measures may become more important differentiating factors in the medical school application process.

·      Students are also dissuaded from working in large metropolitan areas, as a consequence of the COVID-19 pandemic.

·      The medical workforce will likely remain stable after the pandemic.

ABSTRACT

BACKGROUND: The COVID-19 pandemic in the U.S. has created many new challenges for the medical community in the United States, and it remains unknown the effects on recruitment into healthcare fields. This study aims to determine whether or not pre-health students are being deterred from the medical field due to the COVID-19 pandemic.

METHODS: An online survey was administered to all (1654). Pre-Health students at Duke University. Students’ fears about potential upcoming medical school applications and changes in extracurricular activities prior to and during the COVID-19 pandemic were collected. Students’ relative interest in the medical field prior to the COVID-19 pandemic and the number of changes in career plans following its impact were compared using a Wilcoxon Signed-Rank test. RESULTS: Of the 255 respondents, the majority noted intention to pursue a Doctor of Medicine (M.D.) (90.6%). Overall, relative mean and (SD) interest (0-10) in pursuing a medical career was similar before and after COVID-19 [Before: 8.94 (1.42) vs. After: 8.92 (1.47); p=0.71]. However, students were significantly less interested in attending medical school in a metropolitan area (p=0.003), working in a metropolitan area following medical school (p=<0.001), and were more interested in private practice (vs. hospital) (p=0.001) as a result of the pandemic. Students also reported decreased involvement in research (-19.2%), clinic/hospital volunteering (-45.0%), shadowing (- 36.1%), and laboratory work (-41.9%) during the pandemic (all p<0.001). Accordingly, 65% of students felt that their medical school applications would be negatively impacted by COVID- 19, and nearly two-thirds of students (64.2%) reported being more likely to take a “gap year”. CONCLUSIONS: The COVID-19 Pandemic has not deterred student interest away from pursuing medical careers, suggesting that the medical workforce will likely remain stable after the pandemic. However, the long-standing popularity of medical schools and medical jobs in major metropolitan areas and major academic centers may shift. With diminished extracurricular involvement and students feeling the need for additional developmental time, increased students may take a gap year before attending post-graduate schools.

INTRODUCTION

As the United States has become the epicenter of the COVID-19 pandemic, both the physical and psychological wellbeing of healthcare workers has become tested. Healthcare workers are on the front lines of the response to COVID-19, placing themselves at risk for both viral contraction and becoming confronted with staggering rates of mortality.1-3 At the time of writing, the Center for Disease Control (CDC) reports that 124,813 healthcare workers have tested positive for COVID-19, and 600 have died (as of August 6, 2020). In addition to personal health risks, the pandemic has forced many physicians to re-shape their practice and even redeploy to other specialties.

The acute workplace stress resulting from the COVID-19 pandemic is further compounded by all-time high baseline rates of physician burnout (include metric/statistic).1-5 Even before the pandemic, nearly half of physicians in the United States reported experiencing burnout,6 a phenomenon that contributes to high rates of mental illness. The pandemic has further exacerbated mental health illness among physicians across the globe, even leading to post-traumatic stress disorders (PTSD) and acute stress disorders.1,3-5,7-13 Overall, the COVID-19 pandemic has further stressed the already-tenuous mental and physical well-being of physicians.

Due to high rates of burnout within the specialty, concern has already been rising in recent years regarding the interest of U.S. students in pursuing a medical career. This concern has since heightened in the setting of the challenges related to COVID-19. While the pandemic has been reported to have significant effects on prospective medical students, to date, students’ perspectives on pursuing a healthcare career in light of COVID-19 remain largely unknown. Moreover, it is also unknown how the COVID-19 pandemic has affected undergraduate students’ career goals and preparation for medical school. Thus, the aim of this study is to assess how the COVID-19 pandemic is affecting undergraduate student interest in medical careers.

METHODS

After Institutional Review Board (IRB) approval, a survey was created and administered to Duke University undergraduate pre-health students using Qualtrics survey software in July 2020. The survey was first piloted to about ten Duke undergraduate pre-health students to ensure the ease and flow of the survey and then administered to all (1645) pre-health undergraduate students via an aggregate listserv. Participants were also entered into a raffle for three $10 Amazon e-Gift cards as an incentive to partake in the survey.

Survey design

The survey consisted of 26 questions, beginning with demographics including age, gender, and planned career. Students were asked to use a Likert scale to rank their interest in a medical career before the COVID-19 pandemic, ranging from 1 (not at all interested) to 10 (highly interested) and likelihood of taking a gap year. Subjects were then exposed to CDC data that as of June 2020, 69,761 healthcare workers tested positive for COVID-19 in the United States, and from those healthcare workers, 368 had died. Students were again polled about relative interest in a medical career after the COVID-19 pandemic. Finally, students were polled about their extracurricular involvement, career goals (hospital vs. private practice), interest in attending medical school in a metropolitan area and working in a metropolitan area), and the likelihood of taking a gap year.

Outcomes of interest

The main outcome of the survey was to determine whether the COVID-19 pandemic has dissuaded undergraduate pre-health students’ interest in careers in medicine and how the pandemic has affected their career goals. Secondary outcomes included the impact of the pandemic on medical school applications.

Statistical analysis

The data from completed surveys was extracted from Qualtrics into Microsoft Excel and imported into statistical software for analysis. Participant characteristics (age, gender, undergraduate year) were summarized using either mean and standard deviation, or frequency and percentage for continuous and categorical measures, respectively. Histograms of reported interest in a medical specialty before and after exposure to COVID-19 statistics were generated. Differences in medical specialty overall interest and career goals before and after COVID-19 were tested using a Wilcoxon Signed-Rank test. All data analysis was performed with JMP® (Version 13, SAS Institute Inc., Cary, NC) or Graph-Pad Prism (GraphPad Software, Inc., Version 8.0, La Jolla, CA, USA).

RESULTS

Demographics and Interest in a Medical Career

In total, 255 students out of 1,654 total pre-health students responded to the survey, (response rate of 15.4%). From the responses, 78 (30.7%) of students were from the class of 2023, 72 (28.3%) were from the class of 2022, 71 (28.0%) were from the class of 2021, and 33 (13.0%) were from the class of 2020. The majority of responders were female (74%) and median (IQR) age of responders was 20 (18-24). When asked which healthcare career path they were planning on pursuing before the pandemic, 235 (90.6%) of responders selected Doctor of Medicine (M.D.), Table 1.

Baseline, mean (SD) rated interest in pursuing a career in medicine prior to the pandemic was 8.94 (1.42). During the pandemic, rated interest was 8.92 (1.47); overall, there was no significant difference in pre-health students’ interest in pursuing a career in medicine before and during the pandemic (mean difference 0.02; p=0.71), Figure 1, Table 2. When asked if the pandemic had led to consideration of a different healthcare field, the majority of respondents disagreed (38.1%) or strongly disagreed (24.1%). In fact, the majority (62.3%) felt that COVID-19 positively influenced them to join the medical field. A minority (n=10; 4.1%) reported that they would consider a different career path as a result of the pandemic; alternative career paths included business, economics, pursuing a master’s degree, and software engineering.

Changes in Career Planning after COVID-19

Given the proximity of COVID outbreaks in large U.S. metropolitan areas and in major healthcare systems, we then assessed student’s interest in working in large cities and academic centers. Overall, pre-health students reported significantly decreased interest in attending medical school in a metropolitan area (mean difference -11.7%; p=0.003), working in a metropolitan area after medical school (mean difference -10.8%; p<0.001), and working in an academic center after medical school (mean difference -8.2%; p=0.001). In turn, students reported increased interest in working in private practice after medical school (mean difference +8.2%; p=0.001), Table 1, Figure 2.

Effects on medical school applications

With the substantial disruption in traditional schooling programs, we wanted to determine the effect of COVID-19 on pre-health students’ medical school applications. Overall, 65.0% of pre-health students agreed or strongly agreed that their medical school applications would be hurt by COVID-19, Table 2. Student involvement in pre-health extracurricular activities significantly decreased during the pandemic, including involvement in research (mean difference -21.7; p<0.001), hospital/clinic volunteering (mean difference -47.9%; p<0.001), shadowing (mean difference -39.6%; p<0.001), and laboratory work (mean difference -45.0%; p<0.001), Table 3, Figure 3. Accordingly, when asked about fears related to applying to medical school, majority of students (79.07%) expressed that their application would not be competitive enough and nearly half (48.06%) reported that they do not think they will have enough hands-on experience to decide whether they want to apply, Table 2. Furthermore, nearly two-thirds (64.2%) of pre-health students reported being more likely to take a gap year after graduating as a result of the pandemic.

DISCUSSION

In this study, we characterize the impact of the COVID-19 pandemic on pre-health students’ interest in careers in medicine and their overall perceived preparation for medical school applications. Overall, we found that despite the increased demands of the healthcare field during the pandemic, the majority of pre-health students are not deterred from joining the profession, and rather, many are more motivated to pursue medicine. However, pre-health students’ career goals may have shifted due to the pandemic, with students significantly less interested in attending medical school in a metropolitan area and working in a metropolitan area, and more likely to pursue private practice over academia. Moreover, involvement in pre-health extracurricular activities significantly decreased, and students report feeling less prepared for medical school and increasingly likely to take a gap year. Overall, these findings highlight that the medical workforce will likely remain stable after the pandemic, though types of practices sought after by aspiring physicians may shift away from metropolitan and academic settings. Paralleling an increasing rate of physician burnout, in recent years, fear has grown regarding the stability of the medical workforce. As data continues to emerge citing high rates of mental illness among physicians related to long work hours, compensation, and system-related stressors,14-16 the question arises whether undergraduate students will continue to pursue careers in medicine. The COVID-19 pandemic impacting the United States invoked an undeniable mental and physical toll on physicians across the country,17 with statistics showing that thousands of physicians have contracted COVID-19 as a result of their practice, with hundreds of positive cases resulting in death.18 As a result, the pandemic placed physicians at even higher risk of mental health illness.1-5,7,9-13

The results of this study support that the statement that COVID-19 pandemic has further motivated pre-health students to pursue careers in medicine. This may be due in part to a service calling at the core of aspiring physicians, with the pandemic and the sudden need for medical care further motivating prospective students to join the healthcare force. Our results  reassure that after the pandemic, there will likely no longer be a shortage of new physicians. However, popular practice settings and specialty choice may now change following the pandemic. Coinciding with high numbers of COVID-19 cases and outbreaks in major metropolitan areas and high burdens in major healthcare systems, prospective pre-health students reported significantly decreased interest in either working or attending medical school in these areas. This phenomenon may additionally lend itself to changes in specialty interest among medical students. Thus, in coming years, the medical field may see physicians steer away from practices in metropolitan areas. Further investigation of current physicians and medical students is needed to determine how physician distribution by specialty may change after the pandemic.

In addition, our study highlights the challenges that prospective medical students are currently facing when applying to medical school. Compounded by difficulties incurred by the changing policies regarding undergraduate grades and shifting MCAT schedules, we find that the majority of students’ involvement in extracurricular activities significantly decreased over the course of the pandemic, with research the only activity a large proportion of students (49.6%) were able to maintain over this time. These extracurricular activities are formative experiences both to reaffirm and guide interest in medicine, and also to supplement applications.19 For example, many letters of recommendation stem from extracurricular activities including research and volunteering. As a result, most students reported a fear that their applications would not be strong enough due to the pandemic and, in turn, reported being more likely to take a gap year. As medical schools across the United States prepare for the next wave of applicants, this data may guide prioritization of other objective measures to be considered in the application (i.e. pre-COVID grade point average, MCAT) as differentiating factors among applicants. Furthermore, based on our study, the overall number of medical school applicants this calendar year may decline, and then shoot up the following year as a result of many prospective medical students on a gap year.

Ultimately, we aim for this study to overall provide positive reinforcement that the medical workforce will remain stable or even increase after the pandemic. Our study is limited in that only a limited number of the pre-health students  at a single university were polled, and  that those students who were not originally pre-health, but changed career interests toward medicine in reaction to COVID-19 were unable to be polled.  The single institution sample limits the generalizability of all pre-health students across the country. The survey results could also be skewed by non-response bias, as non-respondents may represent students who have already changed career paths during the pandemic away from careers in medicine, as, the largest percentage of non-responders in our study came from the recent graduates of the 2020 class, many of whom may have shifted focus. However, we find in our respondents that pre-health students are not deterred and are more motivated to pursue medicine after the pandemic, a trend that persists despite students losing hands-on experience through clinical extracurriculars. Further investigation on this topic should include surveys of medical students and physicians to further assess the impact that the COVID-19 pandemic will have on the medical workforce.

CONCLUSIONS

Despite the increased demands of the healthcare field during the pandemic, pre-health students are not deterred from joining the medical filed and many are more motivated to pursue medicine in reaction to COVID-19. However, career goals may shift after the pandemic, with students reporting significantly less interest in attending medical school and working in a metropolitan area or academic setting after the outbreak. Overall, this study aims for these findings to highlight that the medical workforce will likely remain stable after the pandemic, though types of practices sought after by aspiring physicians may shift. Furthermore, with decreased extracurricular involvement, objective measures may become more important differentiating factors in the medical school application process.

TABLES AND FIGURES

Figure 1. Rated interest in a medical career (0-10 scale) a) before and after COVID-19, and b) relative change in medical career interest after COVID-19

Table 1. Change in student-reported interest in medical specialties and career paths after Covid-19.

Figure 2. Change in prospective medical student interest in attending medical school and practicing in metropolitan areas and pursuing an academic career before and after COVID-19.

Figure 3. Overall percent reported change for medical careers and career pathways among pre-health students after COVID-19.

Table 2. Survey responses among pre-health students (N=255).

Figure 4. Change in reported pre-health student extracurricular involvement before and after COVID-19.

Table 3. Change in extracurricular activity involvement after Covid-19 among pre-health students.

REFERENCES

1. El-Hage W, Hingray C, Lemogne C, et al. [Health professionals facing the coronavirus disease

2019 (COVID-19) pandemic: What are the mental health risks?]. Encephale.

2020;46(3S):S73-S80.

2. Berlin J. Palpable Fear: COVID-19&#39;s Toll on Physician Morale and Mental Health.

Tex Med. 2020;116(6):12.

3. Blake H, Bermingham F, Johnson G, Tabner A. Mitigating the Psychological Impact of

COVID-19 on Healthcare Workers: A Digital Learning Package. Int J Environ Res Public Health. 2020;17(9).

4. Restauri N, Sheridan AD. Burnout and Posttraumatic Stress Disorder in the Coronavirus

Disease 2019 (COVID-19) Pandemic: Intersection, Impact, and Interventions. J Am Coll

Radiol. 2020;17(7):921-926.

5. Bansal P, Bingemann TA, Greenhawt M, et al. Clinician Wellness During the COVID-19

Pandemic: Extraordinary Times and Unusual Challenges for the Allergist/Immunologist.

J Allergy Clin Immunol Pract. 2020;8(6):1781-1790 e1783.

6. Medscape. Medscape National Physician Burnout & Suicide Report.

https://www.medscape.com/slideshow/2020-lifestyle-burnout-6012460. Published 2020.

Accessed.

7. Li W, Frank E, Zhao Z, et al. Mental Health of Young Physicians in China During the

Novel Coronavirus Disease 2019 Outbreak. JAMA Netw Open. 2020;3(6):e2010705.

8. Duffy JC, Litin EM. Psychiatric Morbidity of Physicians. JAMA. 1964;189:989-992.

9. Balasubramanian A, Paleri V, Bennett R, Paleri V. Impact of COVID-19 on the mental

health of surgeons and coping strategies. Head Neck. 2020;42(7):1638-1644.

10. Que J, Shi L, Deng J, et al. Psychological impact of the COVID-19 pandemic on healthcare

workers: a cross-sectional study in China. Gen Psychiatr. 2020;33(3):e100259.

11. Lai J, Ma S, Wang Y, et al. Factors Associated With Mental Health Outcomes Among Health

Care Workers Exposed to Coronavirus Disease 2019. JAMA Netw Open. 2020;3(3):e203976.

12. Elbay RY, Kurtulmus A, Arpacioglu S, Karadere E. Depression, anxiety, stress levels of

physicians and associated factors in Covid-19 pandemics. Psychiatry Res. 2020;290:113130.

13. Taylor WD, Blackford JU. Mental Health Treatment for Front-Line Clinicians During and

After the Coronavirus Disease 2019 (COVID-19) Pandemic: A Plea to the Medical Community. Ann Intern Med. 2020.

14. Mata DA, Ramos MA, Bansal N, et al. Prevalence of Depression and Depressive Symptoms

Among Resident Physicians: A Systematic Review and Meta-analysis. JAMA. 2015;314(22):2373-2383.

15. Wurm W, Vogel K, Holl A, et al. Depression-Burnout Overlap in Physicians. PLoS One.

2016;11(3):e0149913.

16. Center C, Davis M, Detre T, et al. Confronting depression and suicide in physicians: a

consensus statement. JAMA. 2003;289(23):3161-3166.

17. Shah K, Chaudhari G, Kamrai D, Lail A, Patel RS. How Essential Is to Focus on Physician's

Health and Burnout in Coronavirus (COVID-19) Pandemic? Cureus. 2020;12(4):e7538.

18. Ing EB, Xu QA, Salimi A, Torun N. Physician deaths from corona virus (COVID-19)

disease. Occup Med (Lond). 2020;70(5):370-374.

19. Monroe A, Quinn E, Samuelson W, Dunleavy DM, Dowd KW. An overview of the medical

school admission process and use of applicant data in decision making: what has changed since the 1980s? Acad Med. 2013;88(5):672-681.