COVID-19 Pandemic and Medical Student Mental Health

On Wednesday March 11th, 2020 at 1:02 PM President Gabel notified the University of Minnesota community that in-person instruction, due to the COVID-19 pandemic, was suspended and all courses would return in virtual form. Those on clinical clerkships finished the week but soon afterward, the wards and clinics were empty of medical students. Faced with the prospect of student training grinding to a halt across the UME continuum, faculty and staff responded swiftly and in remarkably innovative ways. Course directors and the Curriculum team scrambled to transform the Year 1 and 2 Pre-Clerkship Foundation courses to an all virtual platform. Year 3 and 4 Clerkships were split with didactic components (and Shelf Exams) placed in virtual (Part A) courses while the (Part B) clinical experiences were deferred to an undetermined future period. On May 25th, four miles away from the Twin Cities Campus, the challenges of COVID were exacerbated when the murder of George Floyd sent reverberations across the world and reminded us of the other ongoing pandemic of institutional racism. All students faced increased isolation, uncertainty about their futures, living in fear of being infected with COVID-19, and concerned about the equity of their education. Meanwhile, nationwide, average anxiety and depression severity scores

By Michael H. Kim, MD and Wm. Scott Slattery, PhD

Michael H. Kim, MD Wm. Scott Slattery, PhD

increased 13% from August to December 2020.1 Data is now emerging suggesting that impacts on medical students associated with the pandemic resulted in even higher levels.2 As the year progressed, uncertainties lingered, and the new-normal set in. The 2020 graduates were left with a virtual Match Day and Commencement and entered residency programs clouded by an evolving pandemic few were prepared for. The class of 2021 lost access to advanced training and away rotation opportunities, faced a virtual Match, and joined their 2022 peers in encountering a seemingly relentless barrage of USMLE Board exam cancellations. These same 3rd year peers also faced a summer without clinical experience, and concerns about being adequately prepared to be doctors. The Class of 2023 completed their first year virtually and faced the prospect of another year of isolation from classmates. Lastly, the incoming matriculants of 2020 didn’t physically meet most of their classmates until a year later. In short, this has been an unquestionably horrible year, and, with the customary world of medical education turned on its head, how are we doing? Prior to the 2020 Spring, considerable efforts were already underway to improve the mental health support of our medical students. Described previously3 and built upon a prevention model, efforts focused on a theoretical conceptualization of wellbeing in terms of three interdependent dimensions: 1. impact of the learning and working environment; 2. access to supportive relationships and community; and, 3. ability to engage in an effective self-care plan. Prevention efforts in each dimension further intersect to foster a sense of belonging, emotional capacity, and self-efficacy. These efforts guided responses to the impacts of the dual pandemics as well as how to monitor and respond to them. For example, the year before a pulse survey process where randomized student groups across classes were surveyed on wellbeing, empathy, and depression at the start of the school year and then longitudinally as part of follow-up groups

over the subsequent 10 months. This process allowed us to monitor the health of students across the four years. Our preliminary data showed stable levels of depression and increased empathy across all four years during the early months of the COVID pandemic. These unexpected findings are suggestive of a resilient and highly empathetic group of students and validating our initiatives to support their mental health. From the perspective of a safe and effective learning environment, downsizing the Year 1 and 2 curricula and implementing more small group active learning experiences facilitated an effective transition to the virtual learning environment. The reduced number of in-person laboratory sessions enabled wearing full PPE to be more realistic, and the prior transition to a Pass-Fail assessment process eased student concerns of working over Zoom. For Year 3 and 4 virtual Clerkship courses, residents and faculty provided small group didactic and case presentations that students felt were adequate preparation for their eventual return in Fall of 2020. Without the requirement of didactic demands, these shortened clinical experiences were appreciated by students as often being more immersive. Regarding community support, the academic advising program was a mainstay for students (especially in the first six months). In the face of persistent uncertainties, our Academic Advisors were critical in providing peace of mind to students through flexible month-to-month scheduling solutions in the face of regular Step exam cancellations, uncertain transitions back to the clinical environment, and a need to accelerate specialty discernment. Our newly created in-house Confidential Bridging Counseling program saw little disruption in support to students as it transitioned to a telehealth service platform. In many respects, this shift offered greater access and flexibility for students, especially those on Clerkships where the ability to find an hour to step away, meet with our psychologist, Dr. Reilly-Spong, and then return to their clinical assignments was notably less disruptive to all. Variant reminds us to remain vigilant but, again, lessons learned from efforts of past months combined with their resiliency are enabling students to make due and continue the process of learning how to be great doctors.

In the face of persistent uncertainties, our Academic Advisors were critical in providing peace of mind to students through flexible month-to-month scheduling solutions in the face of regular Step exam cancellations, uncertain transitions back to the clinical environment, and a need to accelerate specialty discernment.

To date, nearly 25% of medical students accessed the short-term counselling offered with the program. Supporting a self-care plan was challenging due to availability limitations such as closures to UMN Rec Center facilities and uncertainties in how to stay active. However, efforts such as expanding time off for rest and relaxation during Clerkships (from two to three and a half days every two weeks) were appreciated. Overall we believe it can be said that our students persevered and signs of returning to some semblance of normalcy are emerging. Nearly all impacted students in the 2021 Class graduated on time and despite virtual interviews we had one of our best Match rates in recent times. Strong vaccination rates enabled the Class to hold their commencement in Northrup, and we welcomed our new Class this Fall with a mostly in-person orientation and more classes on campus. The hospital halls are abuzz again with students, albeit looking similar in scrubs and masks. The Delta Dr. Michael Kim obtained his MD and specialty training in Internal Medicine-Pediatrics at the University of Minnesota. He became the Assistant Dean for Student Affairs in 2015. He advocates for and promotes student academic success, a culture of wellbeing, and a supportive learning environment.

Wm. Scott Slattery, PhD joined the Office of Medical Education as Director of Learner Development in 2014 after previously serving as a Sr. Psychologist at the University of Minnesota’s Student Counseling Services. Dr. Slattery earned his bachelor’s degree from the College of William and Mary, and doctorate at the University of Pittsburgh.

References 1. Jia H, Guerin RJ, Barile JP, et al. National and

State Trends in Anxiety and Depression Severity Scores Among Adults During the COVID-19

Pandemic — United States, 2020–2021. MMWR

Morb Mortal Wkly Rep 2021;70:1427–1432. 2. Nikolis, L., Wakim, A., Adams, W. et al. Medical student wellness in the United States during the COVID-19 pandemic: a nationwide survey.

BMC Med Educ 2021;21,401. 3. Kim, MH and Slattery WS. Evolving Support for the Mental Health of Medical Students.

MetroDoctors 2020;22(3):18-19.