Medical education in times of COVID-19: German students' expectations - A cross-sectional study.

BACKGROUND: Since the COVID-19 pandemic has affected the education of medical students, medical faculties have faced the challenge of adapting instruction to digital platforms. Although medical students are willing to support pandemic response efforts, how the crisis will affect their medical training remains uncertain. Thus, in this study, we investigated the teaching- and learning-related stressors and expectations of medical students in Germany during the COVID-19 pandemic.
METHODS: A cross-sectional survey was distributed online to undergraduate medical students at medical faculties in Germany. Students answered questions about COVID-19 and teaching (on a 7-point Likert scale from 0 ("not at all") to 6 ("completely")) and completed mental well-being measurements, including the State-Trait Anxiety Inventory (STAI), the Generalised Anxiety Disorder scale (GAD-7) and the Perceived Health Questionnaire (PHQ-9). Descriptive data analysis, a t-test and Pearson correlations were performed to process the data.
RESULTS: Medical students felt well-informed about COVID-19 in general (M = 5.64, SD = 1.28) and in the medical context (M = 5.14, SD = 1.34) but significantly less informed about the pandemic in the academic context, M = 2.47, SD = 1.49, t(371) = 31.98, p < .001. Their distress levels were high (STAI: M = 45.12, SD = 4.73) and significantly correlated with the academic context (rp = .164, p < .01) but not their private lives. Concerning how they were taught, they most often expected online lectures (91.7%) and live broadcasts (67.2%) and less often expected innovative digital teaching strategies, including serious games (17.3%) and virtual-reality exercises (16.7%). DISCUSSION: Medical students seem to be aware of the COVID-19 pandemic and its consequences for academic and healthcare contexts. They also seem to think that their teachers will enhance their digital competencies during the pandemic. Therefore, faculties of medicine need to rapidly and adequately digitalise their approaches to teaching.

Introduction

The COVID-19 pandemic has dramatically changed countless aspects of life around the world. The education of medical students is no exception, and in response to the pandemic, faculties of medicine worldwide have faced the challenge of adapting instruction to digital platforms. Beyond that, the role of medical students, as clinicians in training, in possibly helping to manage the pandemic has been discussed, especially regarding whether they should graduate early to serve on the frontlines [1-3]. That possibility is supported by the fact that medical students remain updated about the COVID-19 pandemic and demonstrate high levels of related knowledge and preventive behaviours [4]. Indeed, medical students have even developed student-led organisations to efficiently mobilise their peers who are interested in participating in COVID-19 response efforts [5-7]. In Germany in particular, within days of the government’s request for assistance, 20,000 German medical students agreed to offer their support in combatting the pandemic [8].

Despite that overwhelming solidarity, medical students, as students of all disciplines, have had to grapple with the hallmark feature of the COVID-19 pandemic: uncertainty due to novelty of the virus. At present, no one can reliably predict how the pandemic will unfold or what rapid, flexible, ad hoc decision-making will be necessary, and such uncertainty affects medical training at all levels [9]. Classroom lectures, seminars and clinical placements can no longer be performed in the usual face-to-face settings, and some observers have even called for care activities directly provided to patients, usually a core part of medical training, to be banned [10, 11]. At the same time, the debate continues over whether final-year medical students should be fast-tracked through their studies so that they can support the healthcare system or even begin practice before being licensed [12, 13].

To maintain the quality of medical training under the circumstances of the COVID-19 pandemic, medical educators need to think outside the box [9]. As one set of solutions, digital technologies have been used to support innovative teaching on e-learning platforms, virtual training or video-conferencing [9, 14–16]. Several authors have also suggested combining technology-enhanced learning experiences with traditional ones [9, 14, 15, 17]. Nevertheless, little is known about medical students’ perspectives on continuing their training during the summer semester 2020 as the pandemic persists.

Aim of the study

In the study reported here, we aimed to investigate the teaching- and learning-related stressors and expectations of medical students in Germany during the COVID-19 pandemic. We also assessed their current distress levels and strategies of coping with such stressful situations. To the best of our knowledge, our study was the first to examine those topics.

Methods

Study design, participants and procedure

The explanatory, cross-sectional study was performed across faculties of medicine in Germany. All faculty-affiliated undergraduate medical students were invited to participate in the online survey, which commenced in late March 2020 and lasted three weeks.

Ethics

The study received ethics approval from the Ethics Committee of Tuebingen Medical Faculty (no. 314/2020BO2). Participation was voluntary, and students did not receive any reimbursement for participating. All participants provided their written informed consent, and all of their responses and data were kept anonymous.

Measurements

Demographic characteristics

Demographic data (i.e. gender, age, year of study and place of study) were collected via the survey.

Topics concerning COVID-19

Students rated their level of knowledge about COVID-19 in general, as well as in the medical and academic contexts, on a 7-point Likert scale ranging from 0 (“not at all”) to 6 (“completely”). They also answered multiple-option questions about how they had accessed that information. They rated their fear and felt probability of being infected with COVID-19 (0% to 100%); their ability to handle a crisis in general; the pandemic’s general and specific burdens on their private and academic lives; their distress in response to the pandemic; and their access to means of coping with the pandemic. Last, they indicated whether they felt ready to provide support during the crisis (i.e. “Yes” or “No” question) and, if so, then in what ways (i.e. multiple-option question).

Mental well-being measurements

For mental well-being measurements of the students’ personal experiences during the COVID-19 pandemic, three validated questionnaires were used:

The State–Trait Anxiety Inventory (STAI) [18], particularly the “State anxiety” dimension, to measure the intensity to which they felt distress on a 4-point scale from 1 (“not at all”) to 4 (“very much so”);

The Generalised Anxiety Disorder (GAD7) [19] and Perceived Health Questionnaire (PHQ9) [20] to measure anxious and depressive symptoms on a 4-point Likert scale from 0 (“not at all”) to 3 (“nearly every day”) [19-21]; and

The Internal External Locus of Control scale [22] to measure perceived control over the environment on a 5-point Likert scale from 0 (“not at all”) to 5 (“completely”).

Education

Students rated their desired and expected course content for the summer semester 2020 as well as possible long-term changes in their medical education due to the circumstances of the pandemic (i.e. multiple-option questions). On a 7-point Likert scale from 0 (“not at all”) to 6 (“completely”), they rated the consideration of their study-related needs by federal student representatives and their worry over losing a semester. Added to that, they reported whether their state examinations had been postponed due to the pandemic (i.e. “Yes” or “No” question) and their expectations of the national government, their faculties of medicine and their teachers (i.e. multiple-option questions and open comments). Last, they stated stressors relevant to studying during the pandemic (i.e. open comments).

All items concerning COVID-19 and education were based on literature [1, 4, 5, 23].

Data analysis

The normal distribution of the data was confirmed by using the Kolmogorov–Smirnov test. Descriptive data, including mean values (M), standard deviations (SD), sum scores, frequencies and percentages of relevant factors, were calculated, and any missing value was replaced with the mean value. To compare the results, a t test for independent samples and Pearson correlations were performed. The Statistical Package for the Social Sciences version 26.0 (IBM, Armonk, NY, USA) was used for data analysis. The level of significance was set to p < .05. All questionnaires that were filled in at least 80% were included in the study.

Results

Demographic characteristics

Of the 679 students who received the survey, 372 responded in full, for a response rate of 55.1%. By gender, 279 were women (75.0%), 92 were men (24.7%), and one was other (0.3%), and by age, they were 23.92 years old on average (SD = 4.21, range = 18–48). Students came from all levels of medical school: first year of study (n = 57, 15.3%), second year (n = 79, 21.2%), third year (n = 64, 17.2%), fourth year (n = 58, 15.6%), fifth year (n = 78, 21.0%) and final year (n = 36, 9.7%). Of 38 German faculties of medicine, 28 were represented.

Topics concerning COVID-19

Level of knowledge in general, medical and academic contexts

Students felt well-informed about COVID-19 in general (M = 5.64, SD = 1.28) and in the medical context (M = 5.14, SD = 1.34). However, they felt significantly less informed about the virus and pandemic in their academic contexts, M = 2.47, SD = 1.49, t(371) = 31.98, p < .001. Students reported retrieving their information mostly from governmental webpages (n = 248, 66.7%) and television (n = 238, 64.0%).

Students rated their felt probability of getting infected with COVID-19 at around 58% and their fear of being infected at 29.5%, both on average. Most students (n = 270, 72.6%) agreed that they were able to cope with the crisis (M = 5.06, SD = 1.12), and fewer than half (n = 139, 37.4%) reported feeling distressed in their private lives due to the pandemic (M = 3.95, SD = 1.52). By contrast, the majority of students (n = 229, 61.6%) reported feeling significantly more distressed over their studies due to COVID-19, M = 4.82, SD = 1.71, t(371) = 54.31, p < .001). Less than a third (n = 116, 31.2%) wanted recommendations on how to cope with their distress (M = 3.47, SD = 1.94). Slightly more students, t(371) = 30.93, p < .001, preferred recommendations about relaxation techniques (n = 125, 33.6%, M = 3.33, SD = 1.97) or sought psychotherapeutic interviews (n = 69, 18.5%, M = 2.83, SD = 1.77). Last, 89.8% of students were willing to offer support during the COVID-19 pandemic; 271 (72.8%) were willing to treat patients without COVID-19, and 220 (59.1%) were willing to treat patients with the virus (Fig 1).

Fig 1

Medical students’ rating of domains they are willing to support during COVID-19 pandemic.

Psychometric characteristics

The current distress level among students was high (cut-off > 43) in view of STAI scores (M = 45.12, SD = 4.73). They also showed mild (cut-off > 5) anxious and depressive symptoms (MGAD7 = 5.73, SDGAD7 = 4.70; MPHQ9 = 5.59, SDPHQ9 = 4.66). Regarding their locus of control, the students on average presented a high (cut-off > 7) internal level of control (M = 8.19, SD = 1.31) and a normal external level of control (M = 4.31, SD = 1.48). The mean STAI sum score was significantly correlated with the students’ academic context (r = 0.164, p < .01) but not their private lives.

Students rated their desired and expected content for the summer semester 2020, as well as anticipated possible long-term changes in medical education, as shown in Table 1.

Table 1

Medical students’ ratings of teaching approaches that should be used during the COVID-19 pandemic, will be implemented during the pandemic and will remain after pandemic.

Approach	Implementation	n	%
	Should be used during the pandemic	219	58.9
Podcasts	Will be implemented	65	17.5
	Will remain after the pandemic	97	26.1
	Should be used during the pandemic	341	91.7
Online lectures	Will be implemented	297	79.8
	Will remain after the pandemic	281	75.5
	Should be used during the pandemic	163	43.8
Independent collaborative work	Will be implemented	244	65.6
	Will remain after the pandemic	129	34.7
	Should be used during the pandemic	250	67.2
Live broadcasts	Will be implemented	119	32.0
	Will remain after the pandemic	108	29.0
	Should be used during the pandemic	192	51.6
Online chats with teachers	Will be implemented	89	23.9
	Will remain after the pandemic	66	17.7
	Should be used during the pandemic	18	4.8
Online chats with chatbots	Will be implemented	5	1.3
	Will remain after the pandemic	7	1.9
	Should be used during the pandemic	161	43.3
Online exams	Will be implemented	40	10.8
	Will remain after the pandemic	65	17.5
	Should be used during the pandemic	119	32.0
Online collaborative work	Will be implemented	24	6.5
	Will remain after the pandemic	60	16.1
	Should be used during the pandemic	62	16.7
Virtual- or augmented-reality exercises	Will be implemented	1	0.3
	Will remain after the pandemic	21	5.6
	Should be used during the pandemic	64	17.3
Serious games	Will be implemented	3	0.8
	Will remain after the pandemic	12	3.3
	Should be used during the pandemic	125	33.9
Asynchronous interactive formats	Will be implemented	24	6.5
	Will remain after the pandemic	32	8.7
	Should be used during the pandemic	21	5.6
Other (e.g. recommended literature readings)	Will be implemented	39	10.5
	Will remain after the pandemic	33	8.9

Students rated the consideration of their study-related needs significantly higher, t(368) = 72.46, p < .001, by federal student representatives (M = 3.66, SD = 0.97) than the government (M = 2.18, SD = 1.04). They feared missing study materials (M = 4.01, SD = 1.87) and not having sufficient protective gear when working in healthcare (M = 4.72, SD = 1.68); however, they were less afraid of missing aspects of their daily lives, M = 2.42, SD = 1.49, t(371) = 31.19, p < .01. They were also afraid of losing a semester due to COVID-19 (M = 4.21, SD = 2.18). Only 40 students (10.8%) reported that their state examinations had been postponed.

In their comments, the students reported general uncertainty and scarcity of information (n = 173) as their greatest stressors, followed by more specific study-related worries about their state examinations, practical years and training terms abroad (n = 54). They also worried about the disadvantages of studying online, which meant having less social contact, having more complicated interactions with teachers and missing training in clinical skills (n = 43).

When working with patients, most students sought content (n = 320, 86.0%) and inter-professional (n = 242, 65.1%) discussions about patients’ cases, and exactly half of them (n = 188) wanted more information on resilience training. Furthermore, students expected their teachers to be willing to enhance their digital competencies (n = 264, 71%) and to be lenient with them about examinations (n = 247, 66.4%), as detailed in Fig 2.

Fig 2

Medical students’ rating of their expectations of teachers.

In their comments, the students reported wanting more transparency, clarity and communication (n = 65) from the government. They indicated preferring consistent regulations about academic study, schools, examinations, hospitals and social life (n = 28). They also expected the government to provide sufficient safety precautions and protective equipment (n = 27).

Concerning their faculties of medicine, the students reported wanting more communication, clarity and information about the summer semester 2020 in light of the COVID-19 pandemic, particularly about their examinations (n = 131). They were also afraid of the disadvantages that final-year students would face (n = 43). They wanted to play an active role in necessary adaptations and demanded thoughtfulness, especially about students with special situations—for example, ones helping out in the crisis or home-schooling their children (n = 33).

Finally, students expected their faculties of medicine to provide good online offerings for teaching and practical alternatives for training and examinations (n = 23).

Discussion

This study revealed the teaching- and learning-related expectations and stressors of medical students in Germany regarding the COVID-19 pandemic. The results showed that the students were highly aware of the pandemic and its consequences for medical and academic contexts.

Medical students’ perspective on COVID-19

The results indicated that medical students were well-informed about COVID-19 in general [4]. Most of them (89.8%) were willing to provide support during the pandemic, and 59.1% were even willing to treat patients with COVID-19. Such high willingness amongst medical students to participate in pandemic response efforts has previously been reported by other national and international surveys [5, 8]. At the same time, the study’s medical students reported being concerned about their education because they felt less informed about how it would proceed [24]. This seems reasonable as most medical faculties were struggling themselves with this pandemic and its accompanying issues. They also reported that their study-related needs were considered more by federal student representatives than the government, and they indicated wanting more transparency, clarity and communication from the government. Having information or being informed may thus present a key element of being able to cope with the COVID-19 pandemic, for senior medical students and students working in emergency rooms were less afraid of getting infected [4]. Thus, frequent and timely information on any changes made or even merely discussed concerning study-related issues might contribute to lessening students’ distress level. It seems to be secondary who is providing this information: besides established institutions including federal government, universities and faculties, students’ representatives may offer a valuable source of information.

Medical students are concerned on high distress level [25, 26]. This study showed that the medical students’ current distress level was high compared to a reference group [18]. Such results suggest that high distress is associated with study-related concerns and less to matters in their personal lives due to COVID-19. Most students were also afraid of losing a semester due to the pandemic.

Education during the COVID-19 pandemic

The COVID-19 pandemic poses two particular challenges for medical education: the necessity to rapidly and adequately digitalise teaching content and the possibility of integrating medical students into the healthcare system [27].

The medical students in the study expected that traditional teaching approaches would be transferred online (e.g. online lectures and live broadcasts) but did not anticipate the use of more innovative teaching tools (e.g. virtual- and augmented-reality exercises and serious games), which reflects the fact that medical training in Germany continues to use conventional modes of instruction. That there was little hope for more innovative, creative digital teaching may be due to experiences thus far in which a mixture of reservations, technical problems and legal requirements hindered instruction.

Nevertheless, the students thought that their teachers were willing to enhance their digital competencies and that some online teaching formats (e.g. online lectures and live broadcasts) would persist after the COVID-19 pandemic [27]. Those findings support the results of Theoret and Ming [8], who found that online teaching and continued online communication may become pillars of medical training [28]. Online teaching has indeed been shown to foster self-learning, be as successful as traditional didactics and provide an enjoyable experience for participants [28-30].

Altogether, although most German medical teachers are directly involved in providing patient care and thus currently experiencing considerable stress, the COVID-19 pandemic offers numerous opportunities like VR technologies [31]. It may even promote long-lasting changes towards sharing educational resources worldwide and funding schemes. It can be hoped that the current wave of digitalisation will not recede but push medical education into a real digital transformation [32].

Simultaneously, medical students worried about the disadvantages of studying online. Thus, students need to be prepared to deal with the necessary digital transformation of medical education. Furthermore, not all parts of medical education should be digitalised. Classic teaching formats like bed-side teaching or clinical examination course should be preserved in their current form.

Strengths and limitations

This survey strengthens the perspectives of medical students regarding their medical education during COVID-19 including a huge sample of almost 700 medical students and half of the German medical faculties. One limitation of our survey was that the results were not generalizable, because we surveyed only medical students in Germany. In the limitations, we also need to consider a selection bias. Surely, students that were interested in this topic were more willing to complete this questionnaire. Further, 75% of our medical students were female which is not representative (11% higher). Also, although method of contact was the same for each medical school, some medical faculties had no participating students. This may pose a potential source of bias; however, analyses yielded no explanatory patterns. Furthermore, we did not assess the perspectives of teachers’ or faculties of medicine on teaching during the COVID-19 pandemic. Future studies should focus on how teachers and faculties of medicine intend to adapt medical education during the pandemic and beyond, as well as the challenges that they face in the process.

Conclusion

This study summarised the expectations and stressors of undergraduate medical students during the COVID-19 pandemic. Medical students are well-informed about COVID-19 and willing to support pandemic response efforts, although they may be distressed about their studies. They desire more communication, clarity and information about the summer semester 2020, especially about their examinations. At the same time, they expected that their teachers would enhance their digital competencies in order to adequately adapt instruction. In sum, the COVID-19 pandemic offers numerous opportunities to adapt medical education and promote a lasting digital transformation that allows transparency and communication between medical students and their teachers.

4 Sep 2020

PONE-D-20-21365

Medical education in times of Covid-19: German students’ expectations– a cross-sectional study

PLOS ONE

Dear Dr. Herrmann-Werner,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Oct 19 2020 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

We look forward to receiving your revised manuscript.

Kind regards,

Jenny Wilkinson, PhD

Academic Editor

PLOS ONE

Journal Requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

2. Please include additional information regarding the survey or questionnaire used in the study and ensure that you have provided sufficient details that others could replicate the analyses. For instance, if you developed a questionnaire as part of this study and it is not under a copyright more restrictive than CC-BY, please include a copy, in both the original language and English, as Supporting Information.

3. Thank you for including the following funding information in the acknowledgements section of your manuscript; "We acknowledge support by Deutsche Forschungsgemeinschaft and Open Access Publishing Fund of University of Tuebingen."

We note that you have provided funding information that is not currently declared in your Funding Statement. However, funding information should not appear in the Acknowledgments section or other areas of your manuscript. We will only publish funding information present in the Funding Statement section of the online submission form.

Please remove any funding-related text from the manuscript and let us know how you would like to update your Funding Statement. Currently, your Funding Statement reads as follows:

"The authors received no specific funding for this work "

4. Please include your tables as part of your main manuscript and remove the individual files. Please note that supplementary tables (should remain/ be uploaded) as separate "supporting information" files

Additional Editor Comments (if provided):

Thank you for your submission, two reviewers have provided comments to improve the work. More description is needed for the questionnaire, particularly methods of validations and how various types of bias that may be present in the work may be controlled. For example, differences in key characteristics between respondents and non-respondents, whether the finishing are skewed due to one or more medical school being over-represented in the respondents and whether consideration was given to the possible impact of social desirability (i.e. respondents proving responses they deemed socially desirable).

Although the reviewers noted that Table 1 was missing I have checked the submission and this was included.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Partly

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: No

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: No

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Note: Table 1 was missing from the manuscript I reviewed.

The authors did not specify how many times students were contacted to participate in the survey, particularly those who did not respond to the first (only?) invitation. Given that a little over half of those invited (55.1%) responded, subsequent invitations to non-respondents may have increased the response rate.

It was interesting to note that women constituted some 75% of respondents. Is this representative of the percentages of women in German medical education as a whole?

Some 10 medical schools had no respondents. Was there any reason for this?

It is most reasonable that students would "feel less informed about how it (medical education) would proceed," given that most faculties are themselves struggling this this and many attendant issues. The current state of such decision-making would be a useful addition to the discussion, but is not mandatory.

Recommendation: publish as presented.

Reviewer #2: The authors present an interesting study investigating COVID-19-related stressors and expectations of medical students towards education during the pandemic in a German cohort of 679 medical students.

The authors conclude that the participating students were aware of the pandemic and its consequences regarding both in the medical and academic context.

However, there are several methodological issues, which need to be addressed.

Introduction:

- All in all, a clear introduction with a comprehensible aim of investigation.

Methods:

- Besides the validated parts of your survey (STAI, GAD-7, PHQ-9): how was the questionnaire validated? Is it based on the literature? Was it pilot tested?

- As this is an online-based, cross-sectional study, did you use the STROBE or CHERRIES checklist?

- For better understanding, please consider providing your questionnaire as supplementary material.

Results:

- P8, I160,161: As 372 participants fully completed the questionnaire, how did you deal with the non-responders? If you separately included them in your analysis as well, please consider providing the particular completion rate for each question of the questionnaire.

- As you chose for a 7-point Likert scale, why did you break down your results on mean and SD? Please consider providing more detailed results for each particular question.

- Table 1 is noted in the text, but missing in the data.

Discussion & Conclusion:

- P13, I297-299: “It can be hoped that the current wave of digitalisation will not recede but push medical education into a real digital transformation“. Very interesting aspect! However, as some participants of your survey are „worried about the disadvantages of studying online (...)“ (P10, I222), you should consider also taking these critical statements into account. Furthermore, are there maybe parts of medical education being (or at least seeming) unsuitable for digitization?

- P13, I303, 304 (limitations): Regarding your sample size and study set-up, please consider discussing various types of bias and how you dealt with them - e.g. selection bias due to the way you recruited your participants, selection bias due to the fact that interested students are more likely to complete the questionnaire, or social desirability, meaning that participants choose the answer that they assume is favorable. Which methods against bias did you employ?

Language:

- Overall, the manuscript is well written and comprehensible.

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: Yes: Roman Kloeckner

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

16 Oct 2020

Dear Prof. Heber,

Thank you very much for consideration of the revised version of our manuscript “Medical education in times of Covid-19: German students’ expectations – a cross-sectional study”.

We highly appreciate the effort reviewers have to undergo and are very grateful for their contributions to the scientific community in general and our manuscript in particular.

Please find below our detailed responses to the comments of reviewer 1 and reviewer 2.

Reviewers' comments:

Reviewer #1:

Note: Table 1 was missing from the manuscript I reviewed.

Thank you for this hint, we apologise for this misunderstanding and have uploaded Table 1.

The authors did not specify how many times students were contacted to participate in the survey, particularly those who did not respond to the first (only?) invitation. Given that a little over half of those invited (55.1%) responded, subsequent invitations to non-respondents may have increased the response rate.

Thank you for this valid point. Unfortunately, it was only one contact but we absolutely agree that in future studies subsequent invitations will be sent to participants to increase response rate.

It was interesting to note that women constituted some 75% of respondents. Is this representative of the percentages of women in German medical education as a whole?

Thank you for your comment. The 75% are not representative of the percentages of women in German medical education. Figures from winter term 18/19 show 62% female medical students. We added a corresponding sentence to the discussion.

Some 10 medical schools had no respondents. Was there any reason for this?

This is a good question. It was an open invitation with no control over response behaviour. The ap-proach to each medical school was always the same. We can’t give the answer why some places had no participants. Analyses for patterns also showed no results. To clarify, we have added a corresponding sentence in the discussion.

It is most reasonable that students would "feel less informed about how it (medical education) would proceed," given that most faculties are themselves struggling this this and many attendant issues. The current state of such decision-making would be a useful addition to the discussion, but is not mandatory.

Thank you for your valuable comment. We added a sentence to the discussion

Recommendation: publish as presented.

Reviewer #2: The authors present an interesting study investigating COVID-19-related stressors and expectations of medical students towards education during the pandemic in a German cohort of 679 medical students.

The authors conclude that the participating students were aware of the pandemic and its consequences regarding both in the medical and academic context.

However, there are several methodological issues, which need to be addressed.

Introduction:

- All in all, a clear introduction with a comprehensible aim of investigation.

Thank you for your appreciation.

Methods:

- Besides the validated parts of your survey (STAI, GAD-7, PHQ-9): how was the questionnaire validated? Is it based on the literature? Was it pilot tested?

Thank you for your comment. The construction of the questionnaire was based on existing literature. The items were carefully chosen including expert discussions; however, there was no pilot test as such. We added a clarifying sentence in the methods.

- As this is an online-based, cross-sectional study, did you use the STROBE or CHERRIES checklist?

CHERRIES

We mainly used the STROBE checklist as we focused on the cross-sectional study design and also had no classical online study as such. We still also considered the CHERRIES checklist where applicable. Additionally, we used a reliable software programme checked by our University (questback) for the assessment rendering many points of the CHERRIES checklist no longer relevant.

- For better understanding, please consider providing your questionnaire as supplementary material.

In general we are not opposed to providing the questionnaire. However, as it was a German study, the questionnaire is also in German. To be scientifically sound, we would need to do a forward backward translational process with certified translators. As big parts of the questionnaire are official ones (STAI, GAD-7, PHQ-9) anyway, we thought that a mere description in the body of the manuscript was sufficient for the message of the paper. Thus, we restrained from a translation process. However, if this is a requirement for publication, we are more than happy to do so. Please let us know.

Results:

- P8, I160,161: As 372 participants fully completed the questionnaire, how did you deal with the non-responders? If you separately included them in your analysis as well, please consider providing the particular completion rate for each question of the questionnaire.

Thank you for your comment. We excluded non-responders and included all questionnaires that were filled in at least 80%. We added a sentence in the method section.

- As you chose for a 7-point Likert scale, why did you break down your results on mean and SD? Please consider providing more detailed results for each particular question.

As the data of the 7 point Likert scale were normally distributed we decided to present mean and standard deviations as relevant significant values (see also Fahrmeir et al., 2016). Further, we did not provide more detailed results as this would lead to over-presentation of data. As there was no intervention in this study, we did not calculate any effect sizes. Of course, we are happy to present further statistical values. Just let us know which ones you consider relevant.

- Table 1 is noted in the text, but missing in the data.

Thank you for this hint, we apologise for this misunderstanding and we uploaded Table 1.

Discussion & Conclusion:

- P13, I297-299: “It can be hoped that the current wave of digitalisation will not recede but push medical education into a real digital transformation“. Very interesting aspect! However, as some participants of your survey are „worried about the disadvantages of studying online (...)“ (P10, I222), you should consider also taking these critical statements into account.

Thank you for your comment. We added this point to the discussion.

Furthermore, are there maybe parts of medical education being (or at least seeming) unsuitable for digitization?

Thank you for your comment. We added this point to the discussion.

- P13, I303, 304 (limitations): Regarding your sample size and study set-up, please consider discussing various types of bias and how you dealt with them - e.g. selection bias due to the way you recruited your participants, selection bias due to the fact that interested students are more likely to complete the questionnaire, or social desirability, meaning that participants choose the answer that they assume is favorable. Which methods against bias did you employ?

Thank you, we are aware of the selection bias that students who are interested in this topic are more willing to complete this questionnaire. We tried to reduce this risk by contacting all German medical students via Email through the German national student body. However, as the study was on voluntary base we could not completely exclude this risk. We looked for patterns in the participants but could not find any. Further, as the survey was anonymous and the participants had no contact to the investigator we think that the percentages of students acting socially desirable might be very low. However, it is a valid point to talk about biases and so we have added these points to the discussion.

Language:

- Overall, the manuscript is well written and comprehensible.

Thank you for this appreciative comment.

We hope that we could satisfyingly address all issues and concerns and that our manuscript in its revised version is now suitable for publication.

If you have any further questions, please do not hesitate to contact us any time

Thank you for your consideration, and we look forward to hearing from you.

Sincerely,

Anne Herrmann-Werner

Submitted filename: Response letter.docx

Click here for additional data file.

20 Oct 2020

Medical education in times of Covid-19: German students’ expectations

– a cross-sectional study

PONE-D-20-21365R1

Dear Dr. Herrmann-Werner,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Jenny Wilkinson, PhD

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Thank you for your responses and revisions; these have satisfactorily addressed the reviewer comments of the previous version.

Reviewers' comments:

10 Nov 2020

PONE-D-20-21365R1

Medical education in times of Covid-19: German students’ expectations – a cross-sectional study

Dear Dr. Herrmann-Werner:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr Jenny Wilkinson

Academic Editor

PLOS ONE