Learning in the Pandemic: Medical Students’ Perceived Effects of COVID-19 on Their Clinical Experiences and Career Choices During the Internal Medicine Clerkship

Abstract

Introduction

The COVID-19 pandemic forced changes to undergraduate medical education with its impact still not fully understood. This is the first US study to assess the pandemic’s perceived impact on medical education after return to in-person clerkships.

Materials and Methods

We conducted a survey of third-year medical students completing their medicine clerkship during the 2020–2021 and 2021–2022 academic years (AY). Survey questions assessed students’ attitudes on perceived risk of COVID-19 infection, impact on clinical encounters, and students’ specialty interests.

Results

Of 312 students enrolled, 283 (90.71%) completed the survey. Concern for COVID-19 infection was highest in the second rotation (3.98 [95% CI 3.64, 4.31]) of the 2020–2021 AY and the third rotation of the 2021–2022 AY (3.41 [95% CI 3.06, 3.76]), corresponding to the surges of COVID-19 cases and subsequent variants. Conversely, as incidence increased, students reported a greater perceived impact on histories, physicals, and time spent with patients with no differences in patient rapport or specialty interests.

Discussion

Although concern for infection was initially high, it decreased after the introduction of the COVID-19 vaccine despite increasing incidence nationally and then peaked again during the Omicron surge. The degree of concern did not exceed initial levels, despite unprecedentedly high disease prevalence. Higher infection rates correlated with greater perceived impact on clinical experiences. Our study underscores the importance of vaccination, highlights learners’ concerns and resilience throughout the pandemic, and should be considered in balancing student exposure with maintaining clinical opportunities.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40670-022-01589-8.

Introduction

The COVID-19 pandemic is an unprecedented event in the history of modern medicine that ushered in a period of rapid change. Clinical medical education, a field that relies heavily on close person-to-person interactions, experiential learning, and bedside teaching, has experienced, and continues to experience, significant upheaval during the pandemic.

As of March 31, 2020, New Jersey was second only to New York with the highest number of COVID-19 cases in the USA. Seven-day cumulative incidence rates in New Jersey between March 31 and April 7, 2020, ranged from 209.9 to 498.6 per 100,000, compared to a national average of 56.2 to 119.6 per 100,000 in the same period [1]. On March 17, 2020, the Association of American Medical Colleges (AAMC) released guidelines urging a nationwide pause on clinical rotations for medical students out of concern for student and patient safety [2].

Studies published to date have focused on medical students’ attitudes regarding the interruption of clinical education due to the pandemic. One study showed that medical students supported a return to patient-facing activities despite ongoing risk of contracting COVID-19 [3]. At that time, many students also believed their career choice would be impacted due to limited exposure to specialty services upon return to clerkships [4]. Early international medical student data showed that respondents felt at risk of contracting COVID-19 during patient care [5]. That study, however, reflected attitudes at only a single time point in November 2020, before subsequent waves of infections. No study has yet focused on the experience of US medical students throughout the academic year since resumption of clinical rotations.

On June 29, 2020, with increasing availability of personal protective equipment (PPE) and decreasing local COVID-19 incidence, all third- and fourth-year medical students at Rutgers NJMS returned to clinical rotations. Prior to resuming rotations, third-year students were enrolled in a 4-week mandatory virtual curriculum with a focus on basic and clinical science of COVID-19 as well as telemedicine, mental health, and health inequities in the pandemic. Upon returning, students resumed full clinical responsibilities with the notable provision of avoiding direct contact with patients with COVID-19 infection. Clerkship didactics were delivered through a hybrid model of virtual and in-person instruction. Beginning mid-December 2020, the COVID-19 vaccine was available to both medical students and faculty. Vaccination was mandated for medical students and faculty with a deadline of August 1, 2021. The COVID-19 booster became available to medical students and faculty starting September 29, 2021, with a mandated deadline of January 31, 2022. Students were permitted to participate in direct care of patients with COVID-19 infection starting January 3, 2022, coinciding with a large local surge of Omicron infections and hospitalizations.

Our study builds upon prior work to examine medical students’ perceptions of safety and clinical learning in the USA since the initial peak of the COVID-19 pandemic. We surveyed third-year students after completion of their internal medicine clerkship at seven distinct points during the 2020–2021 and 2021–2022 academic years. This time period encompassed significant changes in COVID-19 incidence, the introduction of COVID-19 vaccines, emergence of new variants, and changes in our institutional policies around student involvement in COVID-19 patient care. Students were asked to gauge their perceived risk of becoming infected with COVID-19, as well as the apparent impact of the pandemic on their educational experience and prospective specialty choice. This study aimed to better understand how US medical trainees adapted personally and professionally to the dynamic conditions of the ongoing COVID-19 pandemic beyond its initial peak.

Materials and Methods

Third-year medical students at Rutgers NJMS were surveyed upon completion of their internal medicine clerkship during the 2020–2021 academic year and the first three rotations of the 2021–2022 academic year. Of the 312 students enrolled in the clerkship, 283 students completed the survey (response rate 90.71%). Survey questions were added to the mandatory standardized clerkship evaluations, completed via the online Education Management System (EMS) at the end of each 10-week block. This study was deemed exempt by the Rutgers University Institutional Review Board (IRB).

Due to the COVID-19 pandemic, the start of the 2020–2021 academic year was delayed by 2 months. There was no change in duration of the medicine clerkship in comparison to prior academic years. The number and content of students’ mandatory clinical encounters remained the same, with completion rates similar to academic years prior, and alternative experiences continuing to be available to students. Of note, third-year elective time was decreased from three to two blocks (2 weeks each). The rotation dates were as follows: rotation 1 (R1), June 29 to September 4, 2020; rotation 2 (R2), September 8 to November 13, 2020; rotation 3 (R3), December 7, 2020, to February 19, 2021; rotation 4 (R4), February 22 to April 30, 2021; rotation 1′ (R1′), May 3 to July 9, 2021; rotation 2′ (R2′), July 26 to October 1, 2021; and rotation 3′ (R3′), November 8, 2021, to January 21, 2022.

The survey contained 5 questions designed to assess students’ attitudes on perceived personal risk of COVID-19 infection, the impact of the pandemic on clinical encounters, and its effect on students’ specialty interests (Table 1). Questions on clinical encounters were broken down into several components: patient rapport, history gathering, and physical examinations. For questions 1–4, students were asked to rate their attitudes on a Likert scale (1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, 5 = strongly agree). Question 5 was a yes/no response. Each question was followed by an open comment section. While students were required to provide comments for rotations 1 and 2, these were voluntary during rotations 3 and 4 due to an EMS system update. Students were again required to provide comments for rotations 1′ through rotation 3′.

Table 1.

Survey questions and mean results by rotation

#	Question	Rotation 1	Rotation 2	Rotation 3	Rotation 4	Rotation 1′	Rotation 2′	Rotation 3′
		n = 47 [95% CI]	n = 41	n = 41	n = 40	n = 33	n = 42	n = 39
1	“During the Medicine Clerkship, I was worried about infecting myself, my family and/or friends with COVID-19.”	3.62 [3.35, 3.89]	3.98 [3.64, 4.31]	2.95 [2.57, 3.33]	2.55 [2.18, 2.92]	2.21 [1.85, 2.58]	3.02 [2.68, 3.36]	3.41 [3.06, 3.76]
2	“Overall, I spent less time in patient rooms and/or with patients than I would have liked due to my concerns around COVID-19 transmission.”	2.17 [1.83, 2.51]	2.83 [2.47, 3.19]	2.66 [2.35, 2.97]	2.90 [2.57, 3.23]	1.64 [1.37, 1.90]	2.50 [2.20, 2.80]	2.67 [2.29, 3.04]
3	“Overall, my histories and physical examinations were limited due to my concern around COVID-19 transmission.”	2.02 [1.73, 2.31]	2.61 [2.26, 2.96]	2.49 [2.20, 2.77]	2.63 [2.31, 2.94]	1.48 [1.27, 1.70]	2.45 [2.15, 2.75]	2.62 [2.25, 2.98]
4	“I believe that patient rapport was impacted by my concerns around COVID-19.”	2.02 [1.67, 2.37]	2.46 [2.09, 2.84]	2.49 [2.19, 2.79]	2.53 [2.20, 2.85]	1.58 [1.31, 1.84]	2.33 [2.04, 2.62]	2.62 [2.24, 2.99]
5	“I believe that the COVID-19 pandemic has influenced and/or changed my choice of specialty.”	8.5% [2.4–20.4%]	19.5% [8.8%, 34.9%]	17.1% [7.2%, 32.1%]	20.0% [9.1%, 35.6%]	9.1% [1.9%, 24.3%]	16.7% [6.9%, 31.4%]	20.5% [9.3%, 36.5%]

Statistical analysis was performed using IBM SPSS Statistics, Version 27. Confidence intervals were calculated using one-sample, two-tailed t tests at 95% confidence for each of questions 1–4 by rotation. Ninety-five percent confidence intervals for question 5 were calculated using the binomial test. Data regarding daily, new, PCR-confirmed COVID-19 cases were gathered from publicly available online resources published by the New Jersey Department of Health (NJ DOH) [6].

Student comments were reviewed and categorized according to common themes, with representative examples selected by study personnel, excluding comments “not applicable.”

Results

In total, 312 students were enrolled in the medicine clerkship from June 29, 2020, to January 21, 2022, and 283 (90.7%) completed the post-rotation survey. Each rotation had similar survey completion rates: R1, 47 of 48 (97.9%); R2, 41 of 49 (83.7%); R3, 41 of 47 (87.2%); R4, 40 of 46 (86.9%); R1′, 33 of 36 (91.7%); R2′, 42 of 42 (100%); and R3′, 39 of 44 (88.6%).

For the first survey question, focusing on students’ concerns over becoming infected with or infecting family members with COVID-19, the mean Likert scores for each rotation changed across the study period. Between the first two groups, a non-significant increase in score was noted, correlating with an increase in local infection rates (R1, 3.62 [95% CI 3.35, 3.89]; R2, 3.98 [95% CI 3.64, 4.31]) (Table 1). During the third rotation, however, while infection rates remained relatively high (Fig. 1), student concern for becoming infected saw a significant decrease in mean Likert score (R3, 2.95 [95% CI 2.57, 3.33]) and remained low through the end of the academic year (R4, 2.55 [95% CI 2.18, 2.92]). This period notably coincided with the availability of the COVID-19 vaccine in late December, with clinical students having had the option to receive both doses before the end of the third rotation.

Fig. 1.

Questions 1–3 and new PCR-confirmed COVID-19 cases [6] over time. A Question 1, B questions 2 and 3

This downward trend continued through the summer, comprising a new cohort of clinical students (R1′, 2.21 [95% CI 1.85, 2.58]). Subsequent groups, however, reported significantly higher mean Likert scores, again corresponding to increased concern for becoming infected with COVID-19 during the fall and into the winter months (R2′, 3.02 [95% CI 2.68, 3.36], and R3′, 3.41 [95% CI 3.06, 3.76]). This increased concern paralleled rising new daily PCR-confirmed COVID-19 cases (Fig. 1) and change in students’ ability to see COVID-19 patients despite access to the original 2-dose COVID-19 vaccine and FDA-approved boosters in late September 2021.

Narrative comments were gathered across the academic year, and students were able to comment after each standardized survey question. With respect to concern over viral exposure, multiple comments demonstrated themes relating to fear over secondary exposure via faculty/residents (n = 13) and treating patients in the emergency department (n = 16). Additional themes included the hospital setting being associated with an inherent infection risk (n = 21) as well as appreciation for the availability of PPE (n = 16) and the COVID-19 vaccine (n = 10) (Table 2).

Table 2.

Common themes and representative student comments by question number

Q1	Themes	n	Example comments
n = 164
	Baseline risk	21	“Being in the hospital in and of itself makes it more likely to become infected. Complete avoidance would ruin any chance of education.” (R1) “I already knew that COVID is something that will not disappear and will infect practically everyone, regardless of vaccination status, as shown with Omicron. To be constantly worried about something that will inevitably happen is foolish to prevent additional care for patients.” (R3′)
	Concern over faculty and resident exposure	13	“I wasn’t concerned from patient interactions, but it was frustrating when residents and some attendings wouldn’t wear masks during meetings.” (R3′)
	Concern over ED	16	“Trips to ED were inevitable, and you couldn’t predict if a covid + patient was there. I stayed away from loved ones because I feared infecting them.” (R2)
	Appreciation of PPE	16	“PPE was always available and the fellows/attendings made sure to check the COVID status of patients.” (R2′)
	Appreciation of vaccine	10	“Since vaccination began during the clerkship…I felt less worried about the possibility of contracting and transmitting the infection.” (R3) “Being fully vaccinated made me more at ease.” (R2′)
Q2	Themes	n	Example comments
n = 142
	No impact on time spent	70	“I think it was important to spend more quality time with a patient because some felt bad to gown up with PPE and then just ask 1 or 2 questions and then immediately leave, so I tried to make it a point to spend quality time to get to know the patient.” (R3′)
	Fewer overall patient encounters	8	“Attendings rounded by themselves to avoid bringing students… to patient rooms. I feel that this was detrimental to my educational experience.” (R2)
	Less time spent with each patient	13	“I think having masks on at all times and being concerned about the especially sick limited some interactions.” (R2′)
Q3	Themes	n	Example comments
n = 126
	No impact on physical exam	84	“I felt safe conducting histories and physicals due to my vaccine and appropriate PPE.” (R1′)
	Limited exams	9	“Oftentimes I did a subpar HEENT exam because I was worried about getting too close to the patient’s face.” (R1) “Limited neuro exams and overall, some patients did not want students in order to limit interactions with people.” (R3′)
	Concern over ED	5	“I am reluctant to go to the ED…Revisits of admitted patients not affected.” (R4)
Q4	Themes	n	Example comments
n = 127
	No effect on patient rapport	82	“Covid didn’t really stop me from interacting with patients.” (R1′)
	Positive impact on conversation	3	“I think I had more to talk about with patients. The topic of ‘COVID’ was an easy transition into other parts of their history. I think COVID forced us to be more painstaking with our histories and rapports.” (R2)
	Negative impact due to PPE	20	“Personally, I believe there is an argument for non-verbal communication being more important than verbal communication and this element is being robbed with more Telehealth visits and through the wearing of masks.” (R3′)
Q5	Themes	n	Example comments
n = 134
	No impact on specialty choice	92	“Already planned to enter medicine. Unlikely to change given the recurrent nature of pandemics.” (R3′)
	Impacted specialty choice	17	“I realized that I don’t want to do a specialty that will not prepare me to be on frontlines of a crisis like this.” (R1) “We lost elective time…Not enough time to explore non-mandatory rotations.” (R4)

The second and third survey questions focused on the impact of the pandemic on the quality of students’ clinical education, including the amount of face-to-face time spent with patients and its perceived impact on histories and physical exams. Overall, most students did not believe the pandemic had a negative impact on these aspects, with Likert values less than 3 indicating disagreement. When compared across the first academic year, however, an upward trend in mean values is demonstrated with significant differences present between the first and last rotations for both questions 2 (R1, 2.17 [95% CI 1.83, 2.51]; R4, 2.90 [95% CI 2.57, 3.23]) and 3 (R1, 2.02 [95% CI 1.73, 2.31]; R4 2.63 [95% CI 2.31, 2.94]) (Table 1). This pattern repeated the following academic year in R2′ and R3′, after a relative nadir during R1′. The increase in mean Likert scores occurred during a period of increasing and sustained COVID-19 incidence (Fig. 1) and persisted despite the introduction and availability of the vaccine. Many comments reinforced that COVID-19 had no or minimal impact on time spent. Negative themes relating to its impact on histories reflected on fewer patient encounters and decreased time spent with each patient. Regarding the effect on physical examination, multiple students wrote about conducting limited HEENT exams for risk of virus transmission.

Questions 4 and 5 surveyed how perceived patient rapport and students’ specialty interests were affected by the COVID-19 pandemic. For each statement, most students disagreed, indicating the pandemic did not hinder their rapport with patients and that their specialty interests were not significantly impacted. These attitudes remained stable throughout the study period, with no significant differences observed between rotations except for a decrease in mean score on question 4 during rotation R1′ (Table 1). While many comments noted no impact on patient rapport (n = 82), some mentioned a positive impact of additional conversation time (n = 3) and a negative impact of masks on rapport (n = 20). Finally, many comments (n = 92) for question 5 stated the pandemic did not influence their career choice.

Discussion

This study is the first to examine third-year US medical students’ attitudes during clinical rotations since the start of the COVID-19 pandemic. It thereby affords dynamic insight into the perception of risk and quality of clinical education as students adapt to changing rates of infection and hospitalizations, as well as availability of PPE and the COVID-19 vaccine. It spans two academic years, encompassing not only significant changes in COVID-19 incidence and the introduction of COVID-19 vaccines, but also emergence of new variants as well as changes in Rutgers institutional policies around student involvement in COVID-19 patient care. At the start of our study period, the mean perceived concern of students for becoming infected or infecting family members with COVID-19 was relatively high (R1, Table 1). This was observed despite relatively low new daily case counts and may be a result of several contributing factors. These students were the first group in our cohort to return to clerkships after being pulled from clinical rotations during the initial COVID-19 outbreak, an unprecedented event in recent history. Although students were not directly involved in the care of COVID-19 patients until R3′, they were embedded in teams responsible for their care throughout the entire study period. Student comments reflect this concern of secondary exposure attributed to restricted workspaces and lack of consistent masking by the healthcare team during meetings, in addition to concern over seeing patients in the emergency department, where patients’ COVID-19 status is not always known (Table 2).

Students’ fear predictably increased with the next major surge in cases and a parallel rise in hospital census. This also reflected the time public health restrictions broadened and community awareness increased. This trend reversed with subsequent cohorts of students during the academic year 2020–2021. Although daily case counts initially remained high, the mean survey scores for rotations 3 through 1′ showed significantly lower perceived risk of becoming infected with COVID-19. This period most notably coincided with the initial rollout and widespread availability for the FDA-approved two-dose vaccine for faculty, residents, hospital employees, and students in mid-December 2020. Previous studies assessing vaccination hesitancy among healthcare professional students found perceived moderate to very high risk of infection with SARS-CoV-2 to be a significant predictor of intention to get vaccinated [3, 4]. Given the statistically significant decrease in concern about infecting oneself and/or close contacts despite high daily case counts, without changes to hospital policy, PPE availability, or clerkship structure, we can hypothesize based on academic year 2020–2021 data that medical students prioritized the vaccine for a feeling of safety, even more so than adequate PPE identified previously [5].

This observed decrease in perceived risk is also reflected among common themes identified in students’ open response comments. Students throughout the study period reported appreciation for sufficient access to PPE while many also cited the vaccine, since its widespread availability, as a reason for “[feeling] less worried about the possibility of contracting and transmitting the infection” (Table 2).

Students’ perceived risk remained low, reaching a nadir during the rotation finishing on July 9, 2021 (R1′), a period of both post-vaccine availability and relatively low new daily case counts. During the academic year 2021–2022, however, students’ perceived risk would rise again with increasing COVID-19 incidence comprising both the Delta and subsequent Omicron surges. This change is likely multifactorial and represents the response to new variants with their unique physiology, epidemiology, and cultural context. First, it is possible that a “recency effect” contributed to the rise in perceived risk many months after students would have completed their two-dose vaccine schedule. This would make sense given a rise in breakthrough infections first with Delta and then Omicron. Although vaccination was still largely protective against serious infection, our study did not delineate between perceived risk of serious vs mild vs asymptomatic transmission. Additionally, the magnitude of the Omicron surge must be noted in comparison to the entire study period, with its peak new daily case count of 27,975 in the state of New Jersey during R3′. Despite this, it is interesting to note that students’ perceived risk did not rise proportionally to the staggering daily case count, nor did it surpass mean survey scores in R1 and R2, the first two rotations of our study, possibly owing in part to FDA approval of COVID-19 booster doses in late September of 2021. It is possible that vaccination of others, including faculty, residents, and patients, also aided in reducing perceived risk, as it mitigated the risk of infection due to students’ proximity to members of the healthcare team throughout the rotation. This encourages the idea that while the prevalence may fluctuate with waves of the pandemic, the practices of the healthcare personnel can influence the level of comfort for medical students and ultimately impact the practice and mastery of core clinical skills.

As medical schools attempt to mitigate medical students’ exposure to COVID-19, this effort may impact the quality of clinical education by means of limited history and physical examinations. Although most students disagreed for questions 2 and 3, indicating that their concern over becoming infected did not impact their clinical experiences, there was a statistically significant negative impact on the time spent with their patients and the quality of their history and physical examinations at the end of the academic year as compared to the beginning. This pattern was seen during both academic years surveyed and corresponded with the hospital’s surge during the 2020–2021 academic year and Omicron surge during the 2021–2022 academic year. The trend was recognized despite a decline in students’ perceived risk of infecting themselves or others during R3 and R4 and with the introduction of COVID-19 vaccines toward the latter half of academic year 2020–2021. While the rated impact on clinical education was the lowest in R1′ of the second academic year and trended upward for R2′ and R3′, the perceived impact did not increase in proportion to Omicron prevalence as it did with the previous surge. This suggests that the negative impact on clinical experiences did not solely result from personal fear of infection or by prevalence rates. Students’ responses to questions 2 and 3 did not seem to change with the availability of the COVID-19 vaccination and boosters despite their significant impact on responses to question 1. Instead, student comments further elucidate this impact as having fewer patient encounters from teams limiting the number of students in patient rooms or in the ER while rounding. The physical examination was also commonly limited by omission of the HEENT portion due to concerns about exposure (Table 2). During both academic years, students commented on the appreciation of available PPE, which likely helped mitigate the pandemic’s impact on their clinical experiences (Table 2). While previously published studies propose a negative impact on clinical experiences due to medical student fear of infection [5, 7, 8], our study demonstrates an increasingly negative impact despite a decline in perceived risk. To preserve the variety and breadth of patient diagnoses, medical schools should be mindful of the COVID-19 policies set in place, weighing the risks versus benefits of allowing students to participate in the care of COVID-19 patients. The availability of PPE is obviously a major determining factor.

As with the perceived impact of the pandemic on history taking and physical examinations, most students generally disagreed that rapport was negatively affected by the pandemic. Through R4, there was no statistically significant difference observed in student perceptions across rotations. Students’ perceived ease of developing relationships with patients may have been facilitated by policies that required students to only provide direct patient care to patients that had screened negative for the virus. Comments, in fact, revealed a positive effect of having increased conversation time and allowing discussion of COVID-19 to serve as a transition to other parts of the history (Table 2). In R1′, there was a statistically significant decrease in the average score, with most students strongly disagreeing that there was any impact on their rapport-building efforts. In R2′ and R3′, the score increased to a disagree-neutral range, coinciding with the evolution of the Omicron variant surge, a rising fear of infection among our students (Q1), and the institution’s decision to begin allowing students to see patients with positive COVID PCR results during R3′. Narrative responses that detailed negative impact on rapport cited PPE use but also acknowledged the necessity of PPE in clinical settings. Despite the rise and fall of COVID cases across the rotations, as well as our school’s changing COVID policies, it can be safely stated that medical students overall did not compromise on building relationships with patients during the pandemic.

According to published works dating prior to return to in-person rotations, students cited limited elective time and subsequent decreased exposure to specialties as possible influences of career choice [4]. Interestingly, our study found that a majority of the students reported COVID-19 had no impact on their career choice (Table 1), despite a decrease in elective time by 2 weeks during academic year 2020–2021. In fact, only one student commented on lost elective time as limiting their career choice. Although there was no statistically significant difference in responses to question 5 across the academic year, there was an upward trend in percent of students that felt COVID-19 impacted their career choice. As compared to R4, more students at the end of R1 claimed the pandemic had no effect on considered specialties. Similarly, as compared to R3′, more students at the end of R1′ reported that the pandemic did not influence their intended specialty choice. This is likely because many students start their clinical years as “undifferentiated” and open minded about future career paths. This temporal phenomenon can lead to differences in responses between earlier and later rotations, while not necessarily correlating with fluctuating local COVID-19 prevalence. Interestingly, this pattern persisted throughout both academic years surveyed. However, narrative comments allowed insight into how the pandemic could guide decisions, in the manner of both increasing and decreasing the number of specialties considered by students. Specialties such as emergency medicine, infectious diseases, and pulmonary/critical care had high risk of COVID-19 exposure, and while this deterred some students, others wanted to pursue a specialty that would “prepare [them] to be on the frontlines of a crisis like this” (Table 2). It is reassuring that despite student-reported limited patient interactions, they did not feel that this limited their career options.

It should be noted that Rutgers’s students were allowed to directly participate in the care of patients with COVID-19 beginning January 3, 2022, toward the end of R3′ due to high prevalence of the virus in the community. However, even with this change in policy, there were no statistically significant changes noted to survey response between R2′ and R3′ across all questions. As Omicron surged to the highest case levels seen in the pandemic to date, students’ concern for infection or their perceived impact of the virus on clinical education never reached levels as seen prior to vaccine availability. One can argue that Omicron is a largely different entity. As prevalence rates of Omicron skyrocketed, hospitalization rates were not as high as with the original COVID-19 surge, and patients were less acutely ill from the virus. Booster vaccines were made available to Rutgers’s students and employees on September 29, 2021, further mitigating student fears. Further, the student cohort for academic year 2021–2022 had the known precedent of their upperclassmen having completed their clerkship training during the 2020–2021 academic year in the era of COVID-19. Finally, more information about COVID-19 is known and available to students and the public as the pandemic progresses and evolves. A combination of these factors created a different learning environment for future students who may never have the same level of concern related to COVID-19 as the first cohort in R1. The representative data is still early in its stage, and future studies should continue to look at these trends.

While our study brings a unique perspective, some limitations should be noted. Firstly, survey responses obtained at each time point comprised groups of students at different stages in their clinical education. Changing levels of student comfort in clinical rotations may have contributed to differences in perceived risk independently and in addition to variation in COVID-19 incidence. Additionally, without extended follow-up, we were unable to track students through to medical school graduation to explore how individual attitudes changed or to identify their eventual career path. Future studies implementing a long-term analysis of student attitudes would be vital to distinguishing the temporal effect from the impact of environmental factors on perceived risk of infection and eventual career path. Lastly, because our study is one of the first to assess attitudes after a return to clinical rotations, there is limited national data available for comparison.

Conclusions

In this novel study surveying US medical students following their return to clinical rotations, we found that although student concern of COVID-19 infection initially trended with local infection rates, perceived risk significantly declined after introduction of the COVID-19 vaccine. However, the perceived risk rose once again with the emergence of new variants and an increased disease prevalence, despite the availability of booster vaccinations. Higher rates of infection correlated with students’ perception of its impact on clinical experiences, including time spent with patients and quality of history and physical examination, but not patient rapport. Interestingly, students’ perceptions of infection risk or its impact on clinical education never exceeded survey numbers seen pre-vaccination. Anticipated career specialty selection was also largely unaffected by the pandemic at our institution. As medical schools continuously bolster and revise curricula to ensure mastery of core clinical skills, an appropriate balance between mitigating medical student exposure and maintaining opportunities for clinical education should be carefully considered. To further maximize student comfort without sacrificing teaching, vaccination should be strongly encouraged of both students as well as faculty and residents. Rutgers was one of the first institutions to mandate vaccinations of students on or returning to campus, with what appears as positive reception to the vaccine. Expanding the foundation of this study to include national data can compare student perceptions with regional differences in vaccination rates and attitudes toward COVID-19. Future work can provide insight into the long-term impacts of COVID-19 on the continuum of undergraduate to graduate medical education.

Supplementary Information

Below is the link to the electronic supplementary material.

Author Contribution

All of the authors have provided substantial contributions to the conception and design, acquisition, and interpretation of the data, and/or the drafting and revisions for intellectual content. All of the authors have provided final approval for publication and agree to be accountable for all aspects of the work.

Declarations

Ethics Approval

Approved by the Rutgers University eIRB as an exempt study; submission #Pro2020001973; Health Sciences IRB – Newark Campus.

Conflict of Interest

The authors declare no competing interests.