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Korean J Med Educ > Volume 36(2); 2024 > Article
Choi and Yeo: Medical students’ professionalism attributes, knowledge, practices, and attitudes toward COVID-19 and attitudes toward care provision during pandemic amidst the COVID-19 outbreak according to their demographics and mental health

Abstract

Purpose

This study examines various aspects related to medical professionalism in medical students during coronavirus disease 2019 (COVID-19) pandemic, focusing on their medical professionalism attributes, KPA (knowledge, practices, and attitudes) toward COVID-19 and attitudes toward provision of care in pandemic. We assessed whether these aspects related to medical professionalism were varied by their demographics and mental health level.

Methods

Six questionnaires related to medical professionalism were distributed online to medical students in six grades at a single medical school. A one-way analysis of variance was used to examine differences in scores related to medical professionalism based on their demographics, for examples, gender, grade, residence, religion, as well as their mental health levels. Pearson correlation analysis was used to examine correlations between each variable.

Results

Female students scored higher on medical professionalism attributes and attitudes toward duty-to-care than male students. Medical professionalism attribute scores were higher with higher relationship satisfaction and resilience levels but lower with higher anxiety levels. Furthermore, these scores were significantly associated with attitudes toward COVID-19 preparedness. However, COVID-19 knowledge and practice scores were negatively associated with attitudes toward COVID-19 preparedness and careers after graduation. Meanwhile, students who took the leave of absence related to 2020 doctors’ strike had significantly lower scores on attitudes toward COVID-19 preparedness and duty to care than those who did not.

Conclusion

Our findings suggest that mental health of medical students is strongly related to their various aspects related to medical professionalism, especially their attitudes toward COVID-19 preparedness. Good mental health was positively linked to medical professionalism attributes and attitudes toward COVID-19 preparedness. However, knowledge and practice of COVID-19 were negatively associated with willingness to participate in the pandemic response. Additionally, the experience of the 2020 leave of absence impacted the attitudes of medical students toward COVID-19 preparedness (p=0.015) and their duty to care (p=0.012) negatively.

Introduction

The coronavirus disease 2019 (COVID-19) pandemic, which began in 2019, entered South Korea in 2020, with an outbreak centered in the Daegu region in February. In early March, 700–900 new cases were reported every day, prompting Daegu to be declared a special disaster area. In the face of the sudden surge in COVID-19, Daegu’s major hospitals were filled with infected patients, and Daegu’s healthcare workers volunteered to serve at the outbreak site, exposing themselves to infection risk and doing their best to clean up the mess. However, stigmatization of these frontline workers was a problem at the time, with some denying them access to public facilities and evicting their families [1,2]. Furthermore, in August 2020, the medical community went on strike and shut down the country in protest of the expansion of medical school capacity and the establishment of public medical schools. The mass class boycott and strikes in South Korea have raised serious concerns among young doctors and prospective doctors about the professional obligations imposed on healthcare providers during an infectious disease crisis [3].
It was not just in South Korea that the coronavirus pandemic had had a significant impact on medical professionalism. A review article published in 2022 examined the various ethical issues that arise in the face of a public health crisis, particularly the issue of involving medical students in infectious disease crises, the lack of protective equipment, the care of unvaccinated patients, and the issue of burnout of medical personnel exacerbated by the pandemic, and argued that existing standards of professionalism should be redefined [4]. However, the pandemic is not the only threat to medical professionalism. Some argue that the pandemic can allow medical students to learn professionalism by awakening them to the need for social responsibility and promoting their participation in related activities [5].
From a medical education perspective, more effective education tools and directions on the topic of medical professionalism have been called for in the wake of the COVID-19 crisis [6]. Internationally, qualitative studies have been conducted on the perceptions of professionalism of medical students during the COVID-19 pandemic [7,8]. Similar studies have been conducted in Korea for nursing students [9], but to date, only a few studies have explored the perceptions of professionalism of Korean medical students among the public health crisis. Identifying factors affecting medical professionalism in medical students during public health crisis is imperative for advancing professionalism education within medical school. Notably, certain demographic characteristics—gender [10], socioeconomic status [11], religious affiliation [12]—have been noted to influence medical students’ perception of medical professionalism, warranting further investigation. Additionally, mental well-being of medical students was found crucial to maintain professional identity [13]. Moreover, the 2020 COVID-19 pandemic in Daegu provided medical students in this region with an opportunity to get the firsthand understanding of the public health crisis, shaping their perception of their roles as healthcare providers. Nonetheless, their engagement with the August leave of absence in the same year had a profound impact on their perceptions of professionalism.
This study examines various factors affecting professionalism aspects among medical students in Daegu in 2020, encompassing their demographic characteristics, mental health, and significant event (e.g., medical students’ leave of absence). We explore several hypotheses: (1) Demographic factors may affect medical students’ professionalism during the COVID-19 pandemic. (2) Mental health status may influence their professionalism. (3) Their experiences during the 2020 leave of absence may influence their professionalism. Through this study, we aimed to enrich our understanding of medical students’ perceptions of professionalism during the COVID-19 pandemic and shed light on the future development of these students’ professionalism education.

Methods

1. Participants and data collection

This study surveyed a medical school in South Korea. A total of 654 students in six grades were surveyed, including 220 premedical and 434 medical students. The survey received 588 responses (89.9%), with 400 responses (61.2%) being analyzed for sincerity. The survey was conducted online from August 3 to October 4, 2020. This study was approved by the Institutional Review Board of Kyungpook National University in July 2020 (KNU-2020 0069). Informed consent was obtained from all individual participants included in the study.

2. Variable and the research instrument

Independent variables in this study included gender, grade, current residence, residence in February–March 2020, healthcare type, religion, survey timing (before or after September 25), and a five-question scale asking about changes in satisfaction with relationships (self, family, friends, school, and community) before and after COVID-19. Although the survey’s timing was not specified in the questionnaire, the researchers found that the doctor’s strike and the alliance leave of absence occurred during the survey, which may have contributed to differences in the professionalism scores. The variables of emotional characteristics included, first, a nine-item questionnaire on emotional fear of coronavirus, with questions graded on a 4-point scale. Second, four instruments for measuring mental health were included (i.e., anxiety, depression, post-traumatic stress, and resilience).
The study incorporated dependent variables encompassing six aspects across three overarching domains pertaining to medical professionalism. These three domains comprised medical professionalism attributes, knowledge, practice, and attitude (KPA) towards COVID-19, as well as attitude toward care provision during pandemics. Within the domain of “medical professionalism attributes,” respondents were asked about two aspects: their inherent medical professionalism attributes and their self-assessed changes in these attributes after COVID-19 outbreak. The assessment of the KPA score regarding COVID-19 involved inquiries directed at medical students concerning their KPA as future physicians. Furthermore, the investigation delved into respondents’ attitudes regarding their career after graduation and sense of duty toward care provision amidst pandemics, to elucidate their stance on care provision during such exigencies. Accordingly, we assessed six aspects related to medical professionalism, including medical professionalism attributes, self-assessed changes in medical professionalism attributes after COVID-19 outbreak, knowledge and practice about COVID-19 as future physician, attitude toward COVID-19 as future physician, attitude toward careers after graduation, and attitude toward duty to care during pandemic.

1) Medical professionalism attributes

Currently, there is no widely recognized assessment tool for medical professionalism. For this study, we developed a brief self-assessment of medical professionalism attributes based on a widely cited concept of professionalism in the medical community. We constructed a questionnaire based on the definition of medical professionalism mentioned in the world-renowned book “Measuring medical professionalism” by David Thomas Stern [14]. The definition of medical professionalism by Arnold and Stern [14] served as the foundation for the evaluation of the attribute of medical professionalism. According to the American Board of Internal Medicine’s Professionalism Project, they defined medical professionalism in terms of seven domains of attributes: excellence, altruism, respect, compassion, empathy, honesty, and accountability [14]. The professionalism attributes questionnaire included seven questions on these topics, which respondents were asked to rate on a 7-point scale. All elements indicated that the Cronbach’s α values were greater than 0.7, with the total value of 0.832, indicating the reliability of the instrument.

2) Self-assessed changes in medical professionalism attributes after COVID-19 outbreak

A self-assessment questionnaire on medical professionalism attributes was used to determine whether there have been self-assessed changes in these attributes after COVID-19 outbreak. A professor majoring in medical humanities and education reviewed the content to ensure its validity. Participants were asked to rate each item on a 7-point scale, ranging from 7 (=very much so, 4=no change) to 1 (=very much the opposite). The closer the score is to 7, the more students evaluate that they have changed positively, and the closer it is to 1, the more negative the students evaluate themselves to have changed.

3) Knowledge and practice about COVID-19 as future physicians

This questionnaire was designed to measure the knowledge and practice of medical students about COVID-19. The knowledge and practice section were developed by referencing Zhong et al. [15] and Olum et al. [16], which measured KPA toward COVID-19 among Chinese trainees during the early stages of the outbreak, but were modified to suit Korean medical students. It consisted of 11 yes/no questions, including nine questions about COVID-19 knowledge and two questions about practice for prevention. We asked various COVID-19 knowledge including its symptom, transmission route, preventive measures, and so forth. Furthermore, the actions taken to prevent COVID-19 were asked to measure practice for prevention.

4) Attitude toward COVID-19 preparedness as future physicians

Zhong et al. [15], who evaluated attitudes and preparedness for crises and disasters, served as an inspiration for the attitudes section, and Gillani et al. [17] served as an inspiration for the disaster preparedness section. The “attitude” questionnaire had 13 items and was rated on a 7-point scale. We surveyed them regarding their leadership, self-assurance, and awareness of their role as future physicians during the pandemic in order to determine their level of preparedness.

5) Attitude toward post-graduation careers and duty to care during pandemic.

The questionnaire on attitudes toward pandemic response after graduation was developed in-house and consisted of four items, rated on a 7-point scale. The attitude toward duty to care during pandemic was adapted from Herman et al. [18], who developed a questionnaire on medical students’ duty to treat during the pandemic medical workforce shortage, with six items to be selected on a 7-point scale. The questionnaires 1) to 5) can be found in Appendix 1.

6) Mental health

Seven questionnaires were used to measure psychological status. Beck Anxiety Inventory (BAI: Cronbach’s α=0.91) [19], which measures anxiety, and the Generalized Anxiety Disorder seven-item (GAD-7: Cronbach’s α=0.92) [20], the Beck Depression Inventory II (BDI-II) was used to assess the appearance and severity of depressive symptoms (Cronbach’s α=0.91) [21] and the Patient Health Questionnaire-9 (PHQ-9) (Cronbach’s α=0.84) [22], primary care post-traumatic stress disorder (PTSD) screen for DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition) (PC-PTSD-5) [23] to measure post-traumatic stress, Connor-Davidson Resilience Scale (CD-RISC) (Cronbach’s α=0.93) [24] to measure resilience and the Korean version of experiences in the revised Close Relation Questionnaire (ECRR-K14) [25] (Cronbach’s α=0.93, 0.92) to assess intimacy.

3. Data analysis

Descriptive statistics were used to examine the general characteristics of the study subjects as well as the total score of each test index. First, a one-way analysis of variance was performed to determine whether there were any differences in six variables related to medical professionalism by medical students’ demographics: gender, grade, current residence (August–October), and residence during the February–March period, religion, and type of medical coverage. Scheffe’s test was used for post-hoc testing. Second, Pearson’s correlation analysis was conducted to examine the correlation between six variables related to medical professionalism. Third, Pearson’s correlation analysis was used to analyze the relationship between six major variables associated with medical professionalism and mental health. All statistical significance levels were p<0.05, and IBM SPSS Statistics for Windows ver. 25.0 (IBM Corp, Armonk, USA) was used.

Results

1. Participant demographics

Among the 400 respondents, 66.3% (265) were male, 98.8% (395) were single and 68.3% (273) did not adhere to any specific religion. At the time of the COVID-19 outbreak, 75.9% (303 students) lived in Daegu, 19.3% (77 students) lived alone without a partner, and 96.5% (386 students) received benefits from national health insurance. Demographic characteristics by grade level are summarized in Table 1.

2. Differences in scores related to medical professionalism by gender and grade level

Among the medical professionalism attribute scores, the highest and lowest scores are for respect and altruism, respectively (i.e., excellence, 5.61; respect, 6.00; empathy, 5.77; compassion, 5.41; honesty, 5.64; responsibility, 5.80; and altruism, 4.48). Female students scored significantly higher than male students on the basic attribute of medical professionalism (p=0.002), specifically in terms of respect (p=0.002), compassion (p=0.001), and honesty (p=0.017). Furthermore, women also scored significantly higher than men in attitudes toward duty to care (p=0.024) (Table 2).
When comparing mean scores across grades, first-year medical students scored significantly higher than fifth year ones on their attitudes toward COVID-19 (p=0.020). Moreover, first-year medical students scored significantly higher than fifth year medical students (p=0.003) regarding aspects such as working in public hospitals after graduation. This suggests that first-year premedical students are more confident in their attitudes and preparations for the pandemic and have stronger intentions to enter public healthcare service (Table 2).

3. Differences in scores related to medical professionalism by residency, type of healthcare coverage, and religion

We found no difference in six scores related to medical professionalism based on whether the current residence was Daegu or whether the primary residence was Daegu in February and March 2020. When we tested whether a difference exists in terms of religion, students with religious affiliations reported higher self-assessed changes in their medical professionalism attributes following COVID-19 compared to their non-religious counterparts (p=0.008). Their scores for attitudes toward COVID-19 as future physicians and attitudes toward career after graduation were also higher (p=0.44, p=0.34), respectively (Table 3).

4. Differences in scores related to medical professionalism by the experience of leave of absence in 2020

We then split the responses between before and after medical students returned from the 2020 leave of absence (as of September 25, 2020). We found that students who responded after the leave of absence had significantly lower scores on the attitudes of medical students toward COVID-19 (p=0.015) and their obligation to participate in care (p=0.012) than those who responded before that (Table 4).

5. Correlation between scores related to medical professionalism and mental health

First, professionalism attributes of medical students was positively associated with relationship satisfaction scores (r=0.098, p<0.05) and resilience (r=0.572, p<0.001), whereas it was negatively associated with anxiety (BAI: r=−0.188, p<0.001, GAD-7: r=−0.138, p<0.001), depression (BDI-II: r=−0.328, p<0.001, PHQ-9: r=−0.239, p<0.001), post-traumatic stress (r=−0.226, p<0.001), attachment anxiety (r=−0.292, p<0.001), and attachment-avoidance (r=−0.484, p<0.001). It did not correlate with emotional fear of coronavirus.
Second, as above, the self-assessed changes in medical professionalism attribute after COVID-19 outbreak was positively related to relationship satisfaction (r=0.199, p<0.001) and resilience (r=0.388, p<0.05), but negatively related to anxiety (BAI: r=−0.108, p<0.05), depression (BDI-II: r=−0.328, p<0.001, PHQ-9: r=−0.239, p<0.001), post-traumatic stress (r=−0.226, p<0.001), attachment anxiety (r=−0.292, p<0.001), and attachment-avoidance (r=−0.484, p<0.001). Emotional fear of coronavirus was not correlated with GAD-7 anxiety scores.
Third, unlike the above, the knowledge and practices score of medical students was not correlated with any of the affective scores.
Fourth, “attitude toward COVID-19 preparedness” as future physician showed a positive correlation with relationship satisfaction scores (r=0.174, p<0.001) and resilience total scores (r=0.419, p<0.001). The scores of the four sub-domains of resilience (hardness, persistence, optimism, and spiritual support) showed positive correlations with the “attitude toward COVID-19 preparedness,” respectively (r=0.399, r=0.405, r=0.345, r=0.354, r=0.241, p<0.001). In contrast, “attitude toward COVID-19 preparedness” showed negative correlations with anxiety (BAI: r=-0.241, p<0.001; GAD-7: r=-0.219, p<0.001), depression (BDI-II: r=-0.320, p<0.001; PHQ-9: r=-0.240, p<0.001), post-traumatic stress (r=-0.251, p<0.001), attachment anxiety (r=-0.242, p<0.001), and attachment-avoidance (r=-0.352, p<0.001). It was also negatively correlated with emotional fear of the coronavirus (r=−0.130, p<0.001).
Fifth, attitudes toward career after graduation were only statistically correlated with resilience total scores (r=0.279, p<0.001) and the four subdomains: hardness, persistence, optimism, and spiritual support, respectively (r=0.265, r=0.262, r=0.260, r=0.176, r=0.198, p<0.001). On the other hand, it was negatively related to anxiety (BAI: r=−0.194, p<0.001, GAD-7: r=−0.207, p<0.001), depression (BDI-II: r=−0.257, p<0.001, PHQ-9: r=−0.243, p<0.001), post-traumatic stress (r=−0.130, p<0.001), and attachment-avoidance (r=−0.176, p<0.001). Meanwhile, attitudes toward career after graduation were unrelated to relationship satisfaction, fear of COVID-19, or attachment anxiety.
Sixth, attitude of the duty to care during is determined by the resilience total score (r=0.279, p<0.001) and the four subdomains: hardness, persistence, optimism, and spiritual support, each of which showed a positive correlation with it (r=0.265, r=0.262, r=0.260, r=0.176, r=0.198, p<0.001). However, it was negatively related to anxiety (BAI: r=−0.169, p<0.001, GAD-7: r=−0.200, p<0.001), depression (BDI-II: r=−0.246, p<0.001, PHQ-9: r=−0.184, p<0.001), post-traumatic stress (r=−0.117, p<0.001), and attachment-avoidance (r=−0.111, p<0.001). Meanwhile, attitudes toward careers were not related to relationship satisfaction, fear of COVID-19, or attachment anxiety. The details are shown in Table 5.

6. Correlation between each score related to medical professionalism

The correlations between the six scores related to medical professionalism showed that medical professionalism attributes were significantly and positively related to self-assessed changes in medical professionalism attributes after COVID-19 outbreak (r=0.426, p<0.001), attitudes toward COVID-19 as a future physician (r=0.397, p<0.001), attitudes toward post-graduation careers (r=0.355, p<0.001), and attitudes toward physicians’ duty to practice (r=0.150, p<0.001). Self-assessed changes in medical professionalism after COVID-19 were significantly positively correlated with the attitude score as a future physician (r=0.324, p<0.001), attitude score toward post-graduation careers (r=0.355, p<0.001), and attitudes toward physicians’ duty to practice (r=0.296, p<0.001). The attitude score of medical students was significantly positively correlated with attitudes toward post-graduate career paths (r=0.604, p<0.001) and attitudes toward physicians’ duty to care (r=0.394, p<0.001). The attitude toward post-graduation career was significantly positively correlated with the attitude toward the obligation to practice (r=0.492, p<0.001). In conclusion, medical professionalism, self-assessed changes in medical professionalism, COVID-19 attitude score, attitude toward post-graduation career, and attitude toward physicians’ duty to treat were highly correlated (Table 5).
However, overall scores related to medical professionalism were not significantly correlated with knowledge and practice scores, nor were knowledge and practice scores significantly correlated with attitudes as future physicians and attitudes toward post-graduation careers. Furthermore, the knowledge and practice score of medical students were significantly negatively correlated with their attitude toward physicians’ duty of care (r=−0.133, p<0.001).

Discussion

The correlation between the scores related to medical professionalism and demographic characteristics was significantly different in terms of gender, grade, medical coverage type, and religion than for other factors like current residence and time of residence in Daegu. When examining the distribution of scores on the attributes of medical professionalism by demographics, this study determined that gender differed more than other factors. Significant differences exist between men and women in the areas of respect (p=0.002), compassion (p=0.001), and honesty (p=0.017). In our study, while female students appeared to be more positive about participating in pandemic care obligations than male students, other studies [26] found no significant gender differences in preceptors’ perceptions of their obligations to provide pandemic care, or even another systematic review [27] which found that female physicians with parental responsibilities during the pandemic were less likely to continue practicing, contrary to our findings. However, previous studies involved women with caregiving responsibilities, whereas our study focused on female students without caregiving obligations, leading our researchers to interpret the differing results in pandemic care participation based on gender between our study and previous research.
Students with religious affiliation showed more self-assessed changes in medical professionalism in positive way after COVID-19 than non-religious students. This result was consistent with higher scores on attitudes toward COVID-19 preparedness and attitudes toward career after graduation among religious students. This result resonates the result of previous research in Brazil showing high attitudinal score of religious students than non-religious students [12].
The scores related to medical professionalism were associated with greater satisfaction and resilience in relationships and lower levels of anxiety, suggesting that professionalism is highly correlated with mental health. A large body of literature has recognized the importance of maintaining good mental health in maintaining professionalism, with medical students experiencing high levels of burnout [13]. Burnout is strongly associated with self-reported professional deviant behavior and decreased altruistic values among medical students. Our findings are consistent with previous research indicating that the mental health of medical students should be addressed to maintain and promote.
Medical professionalism attribute was also found to be significantly related to both self-assessed changes in medical professionalism attribute after COVID-19 outbreak, and attitudes toward COVID-19 preparedness scores, indicating the importance of medical professionalism attributes in disaster preparedness. However, knowledge and practice scores on COVID-19 were negatively associated with attitudes toward COVID-19 preparedness scores and intentions to work in a public hospital after graduation, suggesting that knowledge and practice did not positively impact attitudes toward disaster response. The discovery that first-year students with less exposure to medical school learning had significantly higher attitudinal scores on the COVID-19 preparedness and intentions to work in public hospitals after graduation than fifth year students showed deviation from previous findings. Further research is warranted to explore specific reasons why first-year students without prior clinical medicine exposure or hospital practicum experience exhibited higher attitude scores towards COVID-19 preparedness and greater willingness to engage in public hospital service post-graduation compared to higher-year students who had undergone hospital practicum.
Duty to care and COVID-19-related attitude scores were significantly lower among those who experienced the student leave of absence of August 2020 compared to those who did not. It is widely assumed that medical students and early-career physicians are more supportive of physician strikes and are less likely to regard them as unethical as more senior physicians who are directly responsible for patient outcomes [28]. Given these findings, medical students who participated in the August 2020 student leave of absence were more likely to be sympathetic to the strike’s cause, and as a result, their perceptions of medical professionalism were influenced more. Due to their exposure to the hostility of Korean citizens displayed toward doctors during the 2020 strike, medical students’ sensitivity to their duty to care during the pandemic may have decreased. It is important to note that medical students’ perceptions of medical professionalism may be influenced by their experience with 2020 leave of absence. There will be a need for discussion in terms of doctors’ social accountability. According to the 2023 report of the Research Institute for Healthcare Policy, policy measures to strengthen the social responsibility of medicine include education on the value of social responsibility in medicine, specification of educational content related to social responsibility in medicine, and content of social responsibility education in the medical school curriculum. Proposals were made on the role of related organizations to strengthen integration and social responsibility education [29]. The Association for Medical Education in Europe guideline also emphasized the responsibility of medical schools for community health and presented methods [30]. In the future, it seems necessary to discuss educational cases and curriculum development in medical schools in terms of doctors’ social participation and social responsibility.
In conclusion, the 2020 coronavirus pandemic posed new challenges for physicians and raised questions about how to teach professionalism to medical students. This study examined how the level of medical professionalism among a sample of medical students during the 2020 pandemic was related to students’ personal characteristics, including mental health and attitudes surrounding the pandemic. The results showed that the scores on the medical professionalism were strongly associated with attitudes toward the COVID-19 preparedness. However, COVID-19 knowledge and practice scores were negatively correlated with attitudes toward the COVID-19 preparedness and post-graduation public hospital employment. This indicates that knowledge of COVID-19 does not significantly impact the willingness to participate in the pandemic response. Furthermore, the findings suggest that various efforts to support mental health are necessary to maintain professionalism during the pandemic. These results may imply that maintaining professionalism during the pandemic requires efforts to support mental health, which may even be more significant than simply spreading knowledge of the pandemic.
Meanwhile, students who experienced the 2020 medical student strike had lower scores on both attitudes toward the COVID-19 preparedness and their obligation to participate in care. Based on these findings, future research should study the educational content and methods needed to promote professionalism and encourage participation in infectious disease outbreak response during upcoming epidemics.

Acknowledgments

None.

Notes

Funding
This research was supported by Kyungpook National University Research Fund, 2020..
Conflicts of interest
Sanghee Yeo serves as an Editorial Board member of the Korean Journal of Medical Education but has no role in the decision to publish this article. Except for that, no potential conflict of interest relevant to this article was reported.
Author contributions
Conception or design of the work: EKC; data collection: SY; data analysis and interpretation: SY; drafting the article: EKC, SY; critical revision of the article: EKC, SY; and final approval of the version to be published: all authors.

Table 1.
Demographic Characteristics of Respondents per School Grade
Variable Premedical course
Medical course
Total
1st 2nd 1st 2nd 3rd 4th
Total 76 (19.0) 57 (14.2) 90 (22.5) 70 (17.5) 49 (12.3) 58 (14.5) 400 (100.0)
Gender (male) 60 (78.9) 42 (73.7) 55 (61.1) 44 (62.9) 27 (56.3) 37 (63.8) 265 (66.3)
Marital status (no) 76 (100) 57 (100) 89 (98.9) 70 (100.0) 49 (100.0) 54 (93.1) 395 (98.8)
Religion (no) 42 (55.3) 34 (59.6) 71 (78.9) 50 (71.4) 34 (70.8) 42 (72.4) 273 (68.3)
Residence DGa) (February to March) 55 (72.4) 45 (78.9) 64 (71.1) 57 (81.4) 38 (79.2) 44 (75.9) 303 (75.8)
Residence DGa) 54 (71.1) 41 (71.9) 69 (76.7) 57 (81.4) 46 (95.8) 53 (91.4) 320 (80.0)
Living alone (yes) 3 (3.9) 3 (5.3) 15 (16.7) 28 (40.0) 13 (27.1) 14 (24.1) 77 (19.3)
Healthcare coverage type
 Medical aids type 1 3 (0.8) 3 (0.8) 1 (0.3) 0 3 (0.8) 1 (0.3) 11 (2.8)
 Medical aids type 2 0 1 (0.3) 2 (0.5) 0 0 0 3 (0.8)
 National health insurance 73 (18.3) 53 (13.7) 87 (21.8) 70 (17.5) 46 (11.5) 57 (14.2) 386 (96.5)

Data are presented as number of participants to be analyzed (%).

a) In the case of living in the Daegu city and Gyeongbuk province in Korea from February to March 2020.

Table 2.
Scores Related to Medical Professionalism Including Medical Professionalism Attributes, Knowledge and Practice, Attitude toward COVID-19, and Attitude toward Care Provision during Pandemic of Respondents per Gender and School Grade
Gender
School grade
Male Female t-value p-value 1st 2nd 3rd 4th 5th 6th Total F p-value Scheffé
Medical professionalism attributes
1. Medical professionalism attributes 38.1±6.04 39.8±4.72 -3.12 0.002** 40.6±5.11 38.7±6.30 38.1±5.94 38.4±5.68 37.7±5.59 38.4±5.10 38.7±5.68 2.216 0.052
2. Self-assessed changes in medical professionalism attributes after COVID-19 outbreak 32.0±6.24 32.4±5.75 -0.639 0.523 33.1±6.26 31.1±5.87 32.5±6.74 31.4±5.41 31.1±5.71 33.4±5.73 32.2±6.09 1.751 0.122
Knowledge practice and attitude toward COVID-19
3. Knowledge and practice about COVID-19 as future physicians 14.9±2.12 14.9±1.93 -0.112 0.911 15.2±1.95 15.2±1.70 14.8±2.19 14.5±1.86 15.1±2.30 14.7±2.25 14.9±2.06 1.351 0.242
4. Attitude toward COVID-19 prepared ness as future physicians 62.4±12.29 64.3±8.86 -1.826 0.069 66.3±11.05 62.3±10.86 63.8±10.69 62.6±12.2 59.3±9.55 61.7±12.18 63.0±11.29 2.722 0.020* 1>5
Attitude toward care provision during pandemic
5. Attitude toward post-graduation career 17.6±4.47 17.7±3.79 -0.288 0.773 19.2±4.27 18.0±3.86 17.3±4.09 17.1±4.39 16.3±4.15 17.6±4.25 17.7±4.24 3.636 0.003** 1>5
6. Attitude toward duty to care during pandemic 21.5±6.69 23.0±6.10 -2.273 0.024* 23.2±5.77 21.5±6.43 22.6±6.15 20.4±7.48 20.9±6.32 22.7±6.84 21.9±6.56 1.952 0.085

Data are presented as mean±standard deviation, unless otherwise stated. Year: 1=pre-medical course 1st, 2=pre-medical course 2nd, 3=medical course 1st, 4=medical course 2nd, 5=medical course 3rd, and 6=medical course 4th.

COVID-19: Coronavirus disease 2019.

* p<0.05.

** p<0.01.

Table 3.
Differences in Scores Related to Medical Professionalism by Residency, Healthcare Coverage, and Religion
Current residence
Residency (February to March)
Medical coverage type
Religion
A B t-value p-value C D t-value p-value E F t-value p-value G H t-value p-value
Medical professional-ism attributes
 1 38.6±5.59 38.7±6.11 0.101 0.920 38.7±5.53 38.8±6.03 0.146 0.884 38.9±4.55 38.7±5.73 -0.15 0.878 39.1±5.90 38.5±5.50 0.710 0.400
 2 32.1±6.13 32.0±5.58 -0.183 0.855 32.2±6.34 31.8±5.35 -0.624 0.533 35.3±6.50 32±6.04 -1.97 0.05 33.4±6.65 31.7±5.57 7.054 0.008**
Knowledge practice and attitude toward COVID-19
 3 15.0±2.06 14.6±2.04 -1.449 0.148 14.9±2.16 14.9±1.86 -0.052 0.958 15.4±2.44 14.9±2.04 -0.99 0.323 1.6± 0.55 14.8±2.12 0.154 0.695
 4 62.7±11.09 63.7±11.81 0.711 0.478 63.0±11.08 62.9±11.70 -0.022 0.982 65.8±6.65 62.9±11.4 -0.94 0.35 64.7±10.88 62.2±11.40 4.089 0.044*
Attitude toward care provision during pandemic
 5 17.6±4.18 17.5±4.49 -0.357 0.721 17.7±4.26 17.3±4.26 -0.865 0.388 20.1±3.51 17.6±4.25 -2.25 0.025* 18.3±4.45 17.4±4.10 4.501 0.035*
 6 21.9±6.35 22.2±7.36 0.377 0.706 21.9±6.28 22.1±7.19 0.311 0.756 25.0±6.60 21.9±6.60 -1.77 0.077 22.8±6.06 21.7±6.64 3.085 0.080

Data are presented as mean±standard deviation, unless otherwise stated. 1: Medical professionalism attribute, 2: Self-assessed changes in medical professionalism attributes after COVID-19 outbreak, 3: Knowledge and practice about COVID-19 as future physician, 4: Attitude toward COVID-19 preparedness as future physician, 5: Attitude toward post-graduation careers, and 6: Attitude toward duty to care. A: In the case of living in the Daegu city and Gyeongbuk province in Korea, B: In the case of living outside of the Daegu city and Gyeongbuk province in in Korea, C: In the case of living in the Daegu city and Gyeongbuk province in Korea from February to March 2020, D: In the case of living outside of the Daegu city and Gyeongbuk province in Korea from February to March 2020, E: Medical aids, F: National health insurance, G: Person with religion, and H: Person without religion.

COVID-19: Coronavirus disease 2019.

* p<0.05.

** p<0.01.

Table 4.
Differences in Scores Related to Medical Professionalism by the Experience of Leave of Absence in 2020 (September 25th)
Scores related to medical professionalism Responses before September 25th
Response after September 25th
F p-value
No. Mean±SD No. Mean±SD
Medical professionalism attributes
 1. Medical professionalism attributes 362 38.8±5.71 42 38.0±5.40 0.622 0.431
 2. Self-assessed changes in medical professionalism attributes after COVID-19 outbreak 362 32.1±6.07 42 32.5±6.31 0.127 0.721
Knowledge, practice, and attitude toward COVID-19
 3. Knowledge and practice about COVID-19 as future physicians 362 14.9±2.04 42 15.3±2.21 1.601 0.207
 4. Attitude toward COVID-19 preparedness as future physicians 362 63.5±11.14 42 59.0±11.90 5.964 0.015
Attitude toward care provision during pandemic
 5. Attitude toward post-graduation careers 362 17.7±4.19 42 17.2±4.70 0.564 0.453
 6. Attitude toward duty to care 362 22.2±6.44 42 19.6±7.24 6.324 0.012

SD: Standard deviation, COVID-19: Coronavirus disease 2019.

Table 5.
Correlation between Scores Related to Medical Professionalism and Mental Health Scores, and Correlation between Each Score Related to Medical Professionalism
Medical professionalism attributes
Knowledge, practice, and attitude toward COVID-19
Attitude toward care provision during pandemic
1. Medical professionalism attributes 2. Self-assessed changes in medical professionalism attributes after COVID-19 outbreak 3. Knowledge and practice about COVID-19 as future physician 4. Attitude toward COVID-19 preparedness as future physician 5. Attitude toward post-graduation career 6. Attitude toward duty to care
Correlation between scores related to medical professionalism and mental health scores
 Relationship satisfaction 0.098* 0.199** -0.032 0.174** 0.066 0.044
 Resilience-total score 0.572** 0.388* 0.012 0.419** 0.279** 0.218**
 Resilience-hardness 0.523** 0.357** -0.004 0.399** 0.265** 0.197**
 Resilience-persistence 0.598** 0.353** 0.029 0.405** 0.262** 0.208**
 Resilience-optimism 0.487** 0.392** 0.018 0.345** 0.260** 0.199**
 Resilience-support 0.447** 0.262** -0.046 0.354** 0.176** 0.156**
 Resilience-spiritual 0.261** 0.283** 0.05 0.241** 0.198** 0.165**
 BAI scores -0.188** -0.108* 0.008 -0.241** -0.194** -0.169**
 GAD-7 scores -0.138** -0.057 -0.011 -0.219** -0.207** -0.200**
 BDI-II scores -0.328** -0.219** -0.04 -0.320** -0.257** -0.246**
 PHQ-9 scores -0.239** -0.208** -0.009 -0.240** -0.243** -0.184**
 PCL-5 scores -0.226** -0.126* -0.046 -0.251** -0.130** -0.117*
 Attachment-anxiety -0.292** -0.092 -0.027 -0.242** -0.096 0.003
 Attachment-avoidance -0.484** -0.219** -0.104 -0.352** -0.176** -0.111*
Correlations between each score related to medical professionalism
 1 1
 2 0.426** 1
 3 0.071 -0.088 1
 4 0.397** 0.324** -0.021 1
 5 0.355** 0.355** -0.046 0.604** 1
 6 0.150** 0.296** -0.133** 0.394** 0.492** 1

COVID-19: Coronavirus disease 2019, BAI: Beck Anxiety Inventory, GAD-7: Generalized Anxiety Disorder seven-item, BDI-II: Beck Depression Inventory II, PHQ-9: Patient Health Questionnaire-9, PCL-5: PTSD Checklist for DSM-5, PTSD: Primary care post-traumatic stress disorder, DSM-5: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.

* p<0.05.

** p<0.01.

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Appendix

Appendix 1. Survey Questions about Medical Students’ Professionalism during COVID-19 Outbreak

kjme-2024-293-Appendix-1.pdf
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