Educational, psychosocial, and clinical impact of SARS-CoV-2 (COVID-19) pandemic on medical students in the United States

Table 1 Respondent distribution across the United States

State	N = 397 (%)
Missouri	139 (35.0)
California	68 (17.13)
Pennsylvania	39 (9.82)
Massachusetts	33 (8.31)
Washington	28 (7.05)
Florida	25 (6.3)
Texas	17 (4.28)
Nebraska	8 (2.02)
Illinois	5 (1.26)
New York	4 (1.01)
Wisconsin	4 (1.01)
New Jersey	3 (0.76)
Colorado	3 (0.76)
Ohio	3 (0.76)
Minnesota	2 (0.50)
Alabama	2 (0.50)
Nevada	2 (0.50)
Michigan	1 (0.25)
Arizona	1 (0.25)
North Carolina	1 (0.25)
Virginia	1 (0.25)
Maine	1 (0.25)
Georgia	1 (0.25)
Washington DC	1 (0.25)
Louisiana	1 (0.25)
South Carolina	1 (0.25)
North Dakota	1 (0.25)
Kansas	1 (0.25)
Idaho	1 (0.25)

Table 2 Sample population characteristics

Characteristics	N = 309 (%)
Age (years)1	26 (2.43)
Gender
Male	119 (38.51)
Female	189 (61.17)
Prefer not to say	1 (0.32)
Current year of medical school
1	101 (32.79)
2	68 (22.08)
3	77 (25)
4	56 (18.18)
MD	3 (0.97)
Research year	2 (0.65)
Other	1 (0.32)

¹Reported as mean ± SD. All data are presented as numerators and denominators with percentages in parentheses unless otherwise specified.

Table 3 Univariate analysis on sample population general impact of coronavirus disease 2019

General impact	Low anxiety, N = 90 (%)	High anxiety, N = 219 (%)	Total, N = 309 (%)	Sig.
Usual living situation during the school year (i.e. before the pandemic)				0.97
Home with family	8 (30.77)	18 (69.23)	26 (8.41)
Off-campus housing Apartment- House	78 (28.89)	192 (71.11)	270 (87.38)
Campus housing – School dormitory or apartment	4 (30.77)	9 (69.23)	13 (4.21)
Change in living situation during the pandemic				0.04
No	63 (33.33)	126 (66.67)	189 (61.17)
Yes	27 (22.5)	93 (77.5)	120 (38.83)
Currently living with				0.54
Alone	13 (28.89)	32 (71.11)	45 (14.56)
With spouse partner	36 (34.29)	69 (65.71)	105 (33.98)
With family	27 (25.47)	79 (74.53)	106 (34.3)
With roommates	14 (29.17)	34 (70.83)	48 (15.53)
Temporarily staying with friends or couch surfing	0 (0)	3 (100)	3 (0.97)
Other	0 (0)	2 (100)	2(0.65)
I have easy access to testing for COVID-19 through my medical school/center if needed				0.23
1 = Strongly disagree	9 (21.95)	32 (78.05)	41 (13.27)
2 = Disagree	18 (22.5)	62 (77.5)	80 (25.89)
3 = Neutral	26 (31.71)	56 (68.29)	82 (26.54)
4 = Agree	22 (31.88)	47 (68.12)	69 (22.33)
5 = Strongly agree	15 (40.54)	22 (59.46)	37 (11.97)
Do you currently feel sick with symptoms of COVID-19?				0.36
No	90 (29.32)	217 (70.68)	307 (99.35)
Yes	0 (0)	2 (100)	2 (0.65)
Have you been tested for COVID-19				0.82
No	86 (29.35)	207 (70.65)	293 (95.13)
Yes, awaiting test result	1 (25)	3 (75)	4 (1.3)
Yes, result was negative	3 (33.33)	6 (66.67)	9 (2.92)
Yes, result was positive	0 (0)	2 (100)	2 (0.65)
Has a close relative or friend tested positive for COVID-19?				0.2
No	70 (31.25)	154 (68.75)	224 (72.73)
Yes	20 (23.81)	64 (76.19)	84 (27.27)
Resources used to educate about COVID-19-WHO CDC?				0.67
No	14 (31.82)	30 (68.18)	44 (14.24)
Yes	76 (28.68)	189 (71.32)	265 (85.76)
Resources used to educate about COVID-19-Reading publications?				0.9
No	22 (29.73)	52 (70.27)	74 (23.95)
Yes	68 (28.94)	167 (71.06)	235 (76.05)
Resources used to educate about COVID-19-Lectures educational resources from school?				0.52
No	27 (76.73)	74 (73.27)	101 (32.69)
Yes	63 (30.29)	145 (69.71)	208 (67.31)
Resources used to educate about COVID-19-Social media?				0.17
No	40 (33.61)	79 (66.39)	119 (38.51)
Yes	50 (26.32)	140 (73.68)	190 (61.49)
Medical school or center providing adequate access to PPE: Gowns				0.27
No	81 (28.32)	205 (71.68)	286 (92.56)
Yes	9 (39.13)	14 (60.87)	23 (7.44)
Medical school or center providing adequate access to PPE: Gloves				0.35
No	81 (28.42)	204 (71.58)	285 (92.23)
Yes	9 (37.5)	15 (62.5)	24 (7.77)
Medical school or center providing adequate access to PPE: Face shield or eye protection				0.21
No	81 (28.22)	206 (71.78)	287 (92.88)
Yes	9 (40.91)	13 (59.09)	22 (7.12)
Medical school or center providing adequate access to PPE: Surgical mask				0.35
No	81 (28.42)	204 (71.58)	285 (92.23)
Yes	9 (37.5)	15 (62.5)	24 (7.77)
Medical school or center providing adequate access to PPE: N95 or FF3 masks				0.14
No	82 (28.18)	209 (71.82)	291 (94.17)
Yes	8 (44.44)	10 (55.56)	18 (5.83)
Medical school or center providing adequate access to PPE: None				< 0.01
No	85 (32.2)	179 (67.8)	264 (85.44)
Yes	5 (11.11)	40 (88.89)	45 (14.56)
Medical school or center providing adequate access to PPE: I do not know				0.02
No	14 (18.42)	62 (81.58)	76 (24.6)
Yes	76 (32.62)	157 (67.38)	233 (75.4)

COVID-19: Coronavirus disease 2019; CDC: The Center for Disease Control and Prevention; PPE: Personal protective equipment; WHO: World Health Organization.

Table 4 Univariate analysis on sample population educational impact of coronavirus disease 2019

Educational impact	Low anxiety, N = 90 (%)	High anxiety, N = 219 (%)	Total, N = 309 (%)	Sig.
Was your current academic activity (for example clinical rotations, in-personal class, etc.) cancelled, and not moved online?				0.29
Yes	20 (24.39)	62 (75.61)	82 (26.62)
No	69 (30.53)	157 (69.47)	226 (73.38)
Were your future academic activities cancelled?				0.02
Yes	31 (22.63)	106 (77.37)	137 (44.34)
No	59 (34.3)	113 (65.7)	172 (55.66)
Is information being supplemented through distance/online learning?				< 0.01
No	0 (0)	17 (100)	17 (5.52)
Yes	89 (30.58)	202 (69.42)	291 (94.48)
How has your overall workload been affected?				< 0.01
Increased	5 (11.36)	39 (88.64)	44 (14.24)
Decreased	60 (36.14)	106 (63.86)	166 (53.72)
Unchanged	25 (26.6)	69 (73.4)	94 (30.42)
Does not apply	0 (0)	5 (100)	5 (1.62)
How has your research productivity been affected?				< 0.01
Increased	15 (38.46)	24 (61.54)	39 (12.62)
Decreased	23 (25.56)	67 (74.44)	90 (29.13)
Unchanged	20 (50)	20 (50)	40 (12.94)
Does not apply	32 (22.86)	108 (77.14)	140 (45.31)
Has the school year end date been:				0.04
Cancelled	1 (14.29)	6 (85.71)	7 (2.27)
Postponed	0 (0)	8 (100)	8 (2.59)
Unchanged	76 (30.89)	170 (69.11)	246 (79.61)
Moved forward	2 (16.67)	10 (83.33)	12 (3.88)
Does not apply	8 (53.33)	7 (46.67)	15 (4.85)
I don’t know	3 (14.29)	18 (85.71)	21 (6.8)
Has graduation been:				0.24
Cancelled	15 (23.08)	50 (76.92)	65 (21.1)
Postponed	3 (60)	2 (40)	5 (1.62)
Unchanged	44 (32.59)	91 (67.41)	135 (43.83)
Moved forward	0 (0)	5 (100)	5 (1.62)
Does not apply	21 (30.43)	48 (69.57)	69 (22.4)
I don’t know	7 (24.14)	22 (75.86)	29 (9.42)
If applicable have your USMLE exams or equivalent state exams been postponed?				< 0.01
Yes	25 (19.84)	101 (80.16)	126 (40.78)
No	11 (36.67)	19 (63.33)	30 (9.71)
Does not apply	53 (38.41)	85 (61.59)	138 (44.66)
Not sure	1 (6.67)	14 (93.33)	15 (4.85)
If the COVID-19 pandemic extends until or past August, I am concerned it will have a major effect on my continuing semesters or residency position				< 0.01
1 = Strongly disagree	3 (100)	0 (0)	3 (0.97)
2 = Disagree	12 (70.59)	5 (29.41)	17 (5.5)
3 = Neutral	6 (26.09)	17 (73.91)	23 (7.44)
4 = Agree	34 (41.98)	47 (58.02)	81 (26.21)
5 = Strongly agree	27 (17.2)	130 (82.8)	157 (50.81)
Does not apply	8 (28.57)	20 (71.43)	28 (9.06)
How effectively have your medical school leadership been managing this outbreak?				< 0.01
Inadequate	11 (13.58)	70 (86.42)	81 (26.47)
Appropriate	79 (36.07)	140 (63.93)	219 (71.57)
Excessive	0 (0)	6 (100)	6 (1.96)
Which of the following best describes your medical school communication efforts to students?				< 0.01
Overly frequent updates	8 (33.33)	16 (66.67)	24 (7.79)
Adequately frequent updates	69 (35.38)	126 (64.62)	195 (63.31)
Infrequent updates	11 (14.47)	65 (85.53)	76 (24.68)
No regular updates	2 (15.38)	11 (84.62)	13 (4.22)

COVID-19: Coronavirus disease 2019; USMLE: The United States Medical Licensing Examination.

Table 5 Univariate analysis on sample population psychosocial impact of coronavirus disease 2019

Psychosocial impact	Low anxiety, N = 90 (%)	High anxiety, N = 219 (%)	Total, N = 309 (%)	Sig.
I am worried about COVID-19 pandemic in general				< 0.01
1 = Strongly disagree	3 (75)	1 (25)	4 (1.29)
2 = Disagree	11 (68.75)	5 (31.25)	16 (5.18)
3 = Neutral	15 (48.39)	16 (51.61)	31 (10.03)
4 = Agree	46 (34.59)	87 (65.41)	133 (43.04)
5 = Strongly Agree	15 (12)	110 (88)	125 (40.45)
I am worried about contracting COVID-19				< 0.01
1 = Strongly disagree	11 (55)	9 (45)	20 (6.47)
2 = Disagree	25 (39.06)	39 (60.94)	64 (20.71)
3 = Neutral	31 (34.44)	59 (65.56)	90 (29.13)
4 = Agree	21 (18.92)	90 (81.08)	111 (35.92)
5 = Strongly agree	2 (8.33)	22 (91.67)	24 (7.77)
If applicable, how has your utilization of mental health resources changed?				< 0.01
Increased	9 (17.31)	43 (82.69)	52 (16.83)
Decreased	2 (7.41)	25 (92.59)	27 (8.74)
Unchanged	59 (32.07)	125 (67.93)	184 (59.55)
Does not apply	20 (43.48)	26 (56.52)	46 (14.89)
Mental health services the university provides: Psychologist				0.29
No	31 (33.33)	62 (66.67)	93 (30.1)
Yes	59 (27.31)	157 (72.69)	216 (69.9)
Mental health services the university provides: Psychiatrist				0.84
No	59 (29.5)	141 (70.5)	200 (64.72)
Yes	31 (28.44)	78 (71.56)	109 (35.28)
Mental health services the university provides: 24 hour emergency hotline				0.7
No	41 (28.08)	105 (71.92)	146 (47.25)
Yes	49 (30.06)	114 (69.94)	163 (52.75)
Mental health services the university provides: Does not apply				0.02
No	73 (26.84)	199 (73.16)	272 (88.03)
Yes	17 (45.95)	20 (54.05)	37 (11.97)
On a scale of 1-10, how accessible do you find mental health services?				0.21
1	3 (33.33)	6 (66.67)	9 (2.95)
2	0 (0)	5 (100)	5 (1.64)
3	4 (21.05)	15 (78.95)	19 (6.23)
4	1 (11.11)	8 (88.89)	9 (2.95)
5	10 (19.23)	42 (80.77)	52 (17.05)
6	8 (25.81)	23 (74.19)	31 (10.16)
7	17 (32.08)	36 (67.92)	53 (17.38)
8	20 (36.36)	35 (63.64)	55 (18.03)
9	4 (19.05)	17 (80.95)	21 (6.89)
10	20 (39.22)	31 (60.78)	51 (16.72)
Most Stress: Residency applications				0.03
No	68 (33.01)	138 (66.99)	206 (66.67)
Yes	22 (21.36)	81 (78.64)	103 (33.33)
Most Stress: Community well-being				0.12
No	56 (26.42)	156 (73.58)	212 (68.61)
Yes	34 (35.05)	63 (64.95)	97 (31.39)
Most Stress: Personal well-being				0.31
No	57 (31.32)	125 (68.68)	182 (58.9)
Yes	33 (25.98)	94 (74.02)	127 (51.1)
Most Stress: Family well-being				0.08
No	56 (33.33)	112 (66.67)	168 (54.37)
Yes	34 (24.11)	107 (75.89)	141 (45.63)
Most Stress: Clinical education related to COVID-19				0.05
No	70 (32.41)	146 (67.59)	216 (69.9)
Yes	20 (21.51)	73 (78.49)	93 (30.1)
Most Stress: Limited to only essential activities				0.04
No	47 (24.87)	142 (75.13)	189 (61.17)
Yes	43 (35.83)	77 (64.17)	120 (38.83)

COVID-19: Coronavirus disease 2019.

Table 6 Multivariate analyses of anxiety association factors after Least Absolute Shrinkage and Selection Operator

Survey questions	Rate ratio	Confidence interval	Sig.
I feel disenchanted with the healthcare system due to inadequate response, lack of PPE, lack of testing, etc.
Disagree (2) vs Strongly disagree (1)	0.93	0.5-1.72	0.81
Neutral (3) vs Strongly disagree (1)	1.39	0.85-2.27	0.19
Agree (4) vs Strongly disagree (1)	1.48	0.95-2.31	0.09
Strongly agree (5) vs Strongly disagree(1)	1.39	0.86-2.25	0.18
Does not apply vs Strongly disagree (1)	0.93	0.5-1.72	0.81
Volunteer Activities - Child care for health care workers: Yes vs No	0.68	0.49-0.93	0.02
Is the distance learning beneficial to you?
Agree vs Strongly agree	0.87	0.6-1.27	0.47
Neutral vs Strongly agree	0.93	0.62-1.37	0.7
Disagree vs Strongly agree	0.98	0.66-1.46	0.93
Strongly disagree vs Strongly agree	0.84	0.57-1.23	0.36
If applicable, have your USMLE exams or equivalent state exams been postponed?
No vs Yes	0.87	0.76-0.99	0.03
Does not apply vs Yes	1.01	0.87-1.18	0.85
Not sure vs Yes	1.19	0.96-1.48	0.12
How concerned are you that COVID-19 will affect the residency application process?
Slightly concerned (2) vs Not concerned (1)	1.3	0.79-2.13	0.3
Moderately concerned (3) vs Not concerned (1)	1.22	0.79-1.88	0.36
Very concerned (4) vs Not concerned (1)	0.86	0.58-1.26	0.43
Extremely concerned (5) vs Not concerned (1)	1	0.6-1.68	1
Does not apply vs Not concerned (1)	1.3	0.79-2.13	0.3
On a scale of 1-5 how supportive have school administration and faculty been regarding COVID-19?
2 vs Not supportive	0.81	0.63-1.04	0.1
Moderately supportive vs Not supportive	0.75	0.65-0.87	< 0.011
4 vs Not supportive	0.79	0.6-1.03	0.09
Extremely supportive vs Not supportive	0.89	0.78-1.02	0.11
Have you experienced episodes of depression during this time?	1.6	1.38-1.85	< 0.011
I am concerned about being unable to complete exams or rotations if I contract COVID-19
Strongly disagree (1) vs Strongly agree (5)	0.66	0.26-1.7	0.39
Disagree (2) vs Strongly agree (5)	0.77	0.62-0.96	0.02
Neutral (3) vs Strongly agree (5)	1.11	0.95-1.3	0.2
Agree (4) vs Strongly agree (5)	1.05	0.84-1.31	0.68
Does not apply vs Strongly agree (5)	0.88	0.69-1.14	0.34

¹These covariates were significant using a cut-off P value of < 0.01. COVID-19: Coronavirus disease 2019.

Table 7 Univariate analysis on sample population clinical impact of coronavirus disease 2019

Clinical, future, and financial impact	Low anxiety, N = 90 (%)	High anxiety, N = 219 (%)	Total, N = 309 (%)	Sig.
COVID-19 has increased the community perception of physicians and healthcare workers				0.1
1 = Strongly disagree	1 (25)	3 (75)	4 (1.29)
2 = Disagree	7 (26.92)	19 (73.08)	26 (8.41)
3 = Neutral	11 (18.64)	48 (81.36)	59 (19.09)
4 = Agree	44 (30.14)	102 (69.86)	146 (47.25)
5 = Strongly agree	25 (34.72)	47 (65.28)	72 (23.3)
Does not apply	2 (100)	0 (0)	2 (0.65)
Are you required to assist in the healthcare system currently due to COVID-19?				0.06
Yes I am being put to work wherever I a needed	0 (0)	3 (100)	3 (0.97)
Yes I am continuing to work in the same clinical role that I was in pre-pandemic	0 (0)	10 (100)	10 (3.24)
No	90 (30.41)	206 (69.59)	296 (95.79)
Do you have the option to volunteer to work in the hospital for COVID-19?				0.31
No	66 (27.5)	174 (72.5)	240 (77.92)
Yes	23 (33.82)	45 (66.18)	68 (22.08)
Would you like to volunteer?				0.34
Yes	46 (30.26)	106 (69.74)	152 (49.35)
No	28 (32.94)	57 (67.06)	85 (27.6)
Cannot due to external factors	16 (22.54)	55 (77.46)	71 (23.05)
Cannot volunteer due to external factors: I live or help out with family and or friends who I do not want to risk exposure				0.1
No	81 (30.92)	181 (69.08)	262 (84.79)
Yes	9 (19.15)	38 (80.85)	47 (15.21)
Cannot volunteer due to external factors: I am concerned about my own safety				0.56
No	88 (29.63)	209 (70.37)	297 (96.12)
Yes	2 (16.67)	10 (83.33)	12 (3.88)
Cannot volunteer due to external factors: I have to work elsewhere for financial reasons				0.11
No	90 (29.7)	213 (70.3)	303 (98.06)
Yes	0 (0)	6 (100)	6 (1.94)
Volunteer activities: Fundraising or obtaining PPE for hospitals				0.52
No	81 (29.89)	190 (70.11)	271 (87.7)
Yes	3 (21.43)	29 (76.32)	38 (12.3)
Volunteer Activities: Helping answer COVID-19 phone lines				0.41
No	84 (29.79)	198 (70.21)	282 (91.26)
Yes	6 (22.22)	21 (77.78)	27 (8.74)
Volunteer Activities: Child care for healthcare workers				0.02
No	78 (27.37)	207 (72.63)	285 (92.33)
Yes	12 (50)	12 (50)	24 (7.77)
On a scale of 1-5, how prepared to you feel to work with COVID-19 patients?				0.38
1 = Not at all prepared	37 (72.79)	99 (72.79)	136 (44.16)
2	26 (26.26)	73 (73.74)	99 (32.14)
3 = Adequately prepared	14 (42.42)	19 (57.58)	33 (10.71)
4	5 (27.78)	13 (72.22)	18 (5.84)
5 = Extremely well prepared	0 (0)	3 (100)	3 (0.97)
Does not apply	7 (36.84)	12 (63.16)	19 (6.17)
On a scale of 1-5, how prepared to you feel to work in the general healthcare system (caring for internal medicine patients, surgical patients, etc.)?				0.5
1 = Not at all prepared	17 (34)	33 (66)	50 (16.18)
2	25 (28.74)	62 (71.26)	87 (28.16)
3 = Adequately prepared	23 (25.27)	68 (74.73)	91 (29.46)
4	17 (33.33)	34 (66.67)	51 (16.5)
5 = Extremely well prepared	2 (13.33)	13 (86.67)	15 (4.85)
Does not apply	6 (40)	9 (60)	15 (4.85)

COVID-19: Coronavirus disease 2019; PPE: Personal protective equipment.

Table 8 Univariate analysis on sample population financial impact of coronavirus disease 2019

Financial impact	Low anxiety, N = 90 (%)	High anxiety, N = 219 (%)	Total, N = 309 (%)	Sig.
Has the pandemic affected you financially?				< 0.01
Strongly Agree	1 (5.56)	17 (94.44)	18 (5.83)
Agree	13 (20.31)	51 (79.69)	64 (20.71)
Neutral	25 (22.73)	85 (77.27)	110 (35.6)
Disagree	36 (39.56)	55 (60.44)	91 (29.45)
Is financial assistance available to you if needed?				0.3
Yes	37 (35.24)	68 (64.76)	105 (33.98)
No	10 (20.83)	38 (79.17)	48 (15.53)
I do not know	35 (27.34)	93 (72.66)	128 (41.42)
Does not apply	8 (28.57)	20 (71.43)	28 (9.06)

Table 9 Univariate analysis on sample population future impact of coronavirus disease 2019

Future impact	Low anxiety, N = 90 (%)	High anxiety, N = 219 (%)	Total, N = 309 (%)	Sig.
I anticipate having similar outbreaks in the future				0.35
1 = Strongly disagree	1 (100)	0 (0)	1 (0.32)
2 = Disagree	6 (46.15)	7 (53.85)	13 (4.22)
3 = Neutral	11 (31.43)	24 (68.57)	35 (11.36)
4 = Agree	46 (29.3)	111 (70.7)	157 (50.97)
5 = Strongly agree	25 (25)	75 (75)	100 (32.47)
Does not apply	1 (50)	1 (50)	2 (0.65)
I am fearful of how future public health crises will be handled?				< 0.01
1 = Strongly disagree	2 (100)	0 (0)	2 (0.65)
2 = Disagree	15 (65.22)	8 (34.78)	23 (7.52)
3 = Neutral	16 (43.24)	21 (56.76)	37 (12.09)
4 = Agree	31 (24.8)	94 (75.2)	125 (40.85)
5 = Strongly agree	25 (21.19)	93 (78.81)	118 (38.56)
Does not apply	1 (100)	0 (0)	1 (0.33)
I think the lessons we learn from this outbreak will help us cope with future crises?				0.04
1 = Strongly disagree	3 (37.5)	5 (62.5)	8 (2.59)
2 = Disagree	11 (34.38)	21 (65.63)	32 (10.36)
3 = Neutral	9 (17.65)	42 (82.35)	51 (16.5)
4 = Agree	38 (25.68)	110 (74.32)	148 (47.9)
5 = Strongly agree	28 (40.58)	41 (59.42)	69 (22.33)
Does not apply	1 (100)	0 (0)	1 (0.32)
I think we need medical school curricula in national mass casualty planning?				0.13
1 = Strongly disagree	0 (0)	4 (100)	4 (1.3)
2 = Disagree	7 (41.18)	10 (58.82)	17 (5.52)
3 = Neutral	22 (28.21)	56 (71.79)	78 (25.32)
4 = Agree	49 (33.56)	97 (66.44)	146 (47.4)
5 = Strongly agree	11 (17.74)	51 (82.26)	62 (20.13)
Does not apply	0 (0)	1 (100)	1 (0.32)