Polish medical students facing the pandemic-Assessment of resilience, well-being and burnout in the COVID-19 era.

INTRODUCTION: Recent reports indicate that COVID-19 pandemic has significant influence on medical professionals' mental health. Strict limitations in clinical practice and social interactions within academic community, which had to be introduced, could lead to significant psychological distress in medical students. The aim of the study was to assess resilience, well-being and burnout among Polish medical students in the COVID-19 era.
METHODS: The online survey consisting of validated questionnaires assessing resilience (Resilience Scale 14; RS-14), well-being (Medical Student Well-Being Index) and burnout (Maslach Burnout Inventory) as well as self-created survey concerning mental health problems, use of stimulants, SARS-CoV-2 infection, work in COVID-19 units, medical education and social attitude towards health care professionals in the pandemic era was distributed via Facebook and other online students' platforms. 1858 MSs from all polish medical schools agreed to fill in the survey.
RESULTS: 'Very low', 'low' and 'on the low end' levels of resilience were found in 26%, 19.1% and 26.9% of the study group, respectively. Students with higher resilience level presented better attitude towards online and hybrid classes. 16.8% of respondents stated that they worked, currently work or plan to work voluntarily at the pandemic frontline. In terms of burnout, these respondents presented lower exhaustion (p = 0.003) and cynicism (p = 0.02), and higher academic efficacy (p = 0.002). That group also showed greater resilience (p = 0.046). The SARS-CoV-2 infection among respondents, their relatives and friends did not influence the results. 39.1% of respondents declared the need of the psychological or psychiatric consultation in relation to pandemic challenges. 231 (26.4%) participants previously diagnosed with mental health disorders noticed worsening of their symptoms. Increased intake of alcohol, cigarettes or other stimulants was noticed by 340 (28.6%) respondents. 80.2% of respondents thought that social aversion and mistrust towards doctors increased during the pandemic and part of them claimed it affected their enthusiasm toward medical career.
CONCLUSIONS: The majority of medical students presented low levels of resilience and high burnout at the time of pandemic. Providing necessary support especially in terms of mental health and building up the resilience of this vulnerable group seems crucial to minimize harm of current pandemic and similar future challenges.

Introduction

The overwhelming scale of the global crisis and the number of problems faced by all countries with the SARS-CoV-2 outbreak such as hospital overload, economic crisis, income instability, social isolation, constant anxiety about rapidly changing circumstances, and an unpredictable future are the cause of exhaustion in society as a whole. Medical students, who are more vulnerable to experiencing psychological distress than the general and peer population, had to combat an additional specific set of challenges connected with their studies and professional future—e.g., helping in medical facilities [1, 2] which posed a risk of infection and transmitting the virus to loved ones. A major challenge was also halting clinical training [2] which is crucial for an effective medical education, and moving to e-learning as the leading form of medical education during the pandemic [3, 4]. Besides, the closing of universities and public libraries may have forced some students into an inadequate learning environment [5].

The pandemic extended the role of online learning in medical education. It was reported that prolonged exposure to a computer or other device was associated with burnout, increased levels of stress, and the occurrence of stress-related mental and physical symptoms, which has an impact on an individual’s quality of life and daily activities. Furthermore, it can be related to the development of mental health problems in students including moderate-to-severe depression [6]. Universities have been forced to strictly limit students’ clinical practice and work placements due to the pandemic. Extra-curricular activities like attending conferences and conducting one’s own research were also constricted which may have resulted in worries about career development [7]. These new difficult circumstances tested medical students’ perseverance, stress management, and coping abilities. However, besides all the inadequacies associated with online education, it must be indicated that in these exceptional circumstances, it allowed communication with relatives and friends and contact with the academic community, enabling learning and teaching.

The first case of COVID-19 in Poland was confirmed on the 4th of March 2020. Restrictions were implemented by virtue of the statute signed by the President of Poland on the 7th of March 2020. All mass events were canceled. Schools and universities were closed, and online learning was recommended. Crossing borders was restricted, with obligatory quarantine for every in-coming person. In the following days, parties and private meetings were forbidden. It was strongly recommended by the government to stay at home and leave only when essential. There was also a limited number of people allowed to stay in closed spaces like shops or means of public transportation. Walking in parks, woods, or on beaches or boulevards was also forbidden. Hairdressers, beauty salons, rehabilitation centers, and all shops except for grocery stores, pharmacies, and newsagents were closed. In April 2020, the cabinet council instituted regulations that obligated everyone to cover their mouth and nose in public spaces.

It may be hypothesized, that these extraordinary actions such as social distancing and closing schools, offices, and entertainment venues might have taken a toll especially on those more susceptible to stress and less resilient individuals.

Resilience is defined as the process of, capacity for, or outcome of successful adaptation despite challenging or threatening circumstances [8], hence an ability for flexible adaptation to challenges [9]. It has an influence on other terms pertaining to an individual’s or a group’s mental state—well-being and burnout [10, 11]. Well-being is successful and fulfilling performance in the psychological and physical domains of life [12, 13]. It is a state in which a person is aware of their own abilities, can cope with stress, and can work efficiently. The World Health Organization considers well-being to be an integral part of health [14]. Burnout is a syndrome of emotional exhaustion, cynicism, and poor satisfaction caused by occupation-related stressors [15]. Our study assesses resilience, well-being, and burnout among medical students in the COVID-19 era due to the new challenges brought by the pandemic. Several compounding factors like mental health problems, use of stimulants, medical education in the COVID-19 era, the level of mistrust towards healthcare professionals, the presence of SARS-CoV-2 infections in respondents, their families, and friends, and volunteer or paid work in COVID-19 units were taken into account.

Methods

Study survey

A web-based survey hosted on the Survey Monkey application was distributed via various student Facebook groups and Instagram profiles (known as studygrams) assembling Polish medical students. The survey was sent to student council presidents of Polish medical schools to share with all the medical students from their universities, and to Polish students acting as influencers and promoting health and medical knowledge through their Instagram and Facebook profiles. All Facebook groups were open for medical students from the particular university, and Instagram profiles—for subscribers to the profile. The survey was conducted from the 5th January 2021 to the 6th February 2021 and posted once on all of the above-mentioned groups. The approximate time to complete the survey was expected to be 10–15 minutes. Due to the method of data collection (no computer IP numbers were collected) we could not prevent the same person filling out the questionnaire more than once.

The first page of the survey contained the informed consent. Expressing consent enabled proceeding to the next questions in the survey.

The study survey consisted of three validated questionnaires—Resilience Scale-14, Medical Students Well-Being Index, and Maslach Burnout Inventory—General Survey for Students, as well as self-created questions. All validated questionnaires were used in accordance with the license agreements.

The Resilience Scale (RS-14) is a 14-item survey validated in the population of Polish young adults (age 19–27) [16]. RS-14 uses a Likert scale with seven possible responses for each item ranging from 1 (strongly disagree) to 7 (strongly agree). All items are positively worded, and a higher score indicated greater resilience. RS-14 scores range from 14 to 98. The RS-14 score ranges indicate the level of resilience, as follows: very low resilience (14–56 points), low (57–64), on the low end (65–73), moderate (74–81), moderately high (82–90) and high (91–98 points). The RS-14 scores correlate significantly with measures of positive concepts (i.e., life satisfaction). Resilience was negatively related to indexes of perceived stress and the dimension of depression [8].

Medical Students Well-Being Index (MSWBI) is a validated tool in a medical student population and consists of 7 “yes or no” questions evaluating distress across a variety of dimensions including fatigue, depression, burnout, anxiety, stress, and mental as well as physical quality of life [17]. MSWBI scores range from 0 to 7, and 7 points indicate the greatest level of distress. The MSWBI was proven to be a useful tool in identifying students with severe distress, and the MSWBI scores correlate with quality of life, fatigue, recent suicidal ideation, burnout, and the likelihood of seriously considering dropping out of medical school [13].

The 16-item Maslach Burnout Inventory—General Survey for Students (MBI-GS(S)) is a validated tool used to measure burnout among student populations. The MBI-GS(S) (Mind Garden Inc., Menlo Park, CA), designed for college and university students, is divided into three distinct domains: emotional exhaustion (EE)—5 items, cynicism (CY)—5 items, and academic efficacy (AE)—6 items [15, 18]. The respondents were asked to report the frequency of particular feelings associated with their studying, and each statement was assessed on a time scale (never—0 points, a few times a year—1 point, once a month or less—2 points, a few times a month—3 points, once a week—4 points, a few times a week—5 points, and every day—6 points). By adding points for items in particular dimensions, burnout was classified as low, moderate, and high in all three dimensions (see Table 4 for reference values). High scores for CY and EE and low scores for AE meant greater burnout (three-dimensional burnout). Two-dimensional burnout has been described previously in the literature [19] and is defined as high cynicism and high emotional exhaustion. Since there was no Polish version of the MBI-GS(S) available, the authors of this study requested permission from Mind Garden Inc. to create a Polish translation. The translation was prepared, evaluated, and is now made available to all researchers via the Mind Garden platform (https://www.mindgarden.com/).

The questions in the self-created part of the survey aimed to assess:

The psychological condition of the respondent—diagnosis of psychological or psychiatric disorders, psychological care or psychiatric treatment, use of psychiatric drugs, OTC drugs (especially tranquilizers), use of alcohol, cigarettes, and other stimulants, change in self-esteem during the pandemic;

SARS-CoV-2 infections in respondents and/or their families as well as the clinical course of the infection;

COVID-19-related volunteer or paid work—extracurricular volunteer or paid work in the COVID-19 units as hospital orderlies, attitude and willingness to work after classes, or to volunteer during class hours, with COVID-19 patients instead of participating in online education, the level of fear connected with working or volunteering and the reasons behind it;

Medical education during the pandemic—the number of in-person classes, including practical and clinical classes, participation in summer clinical clerkships, evaluation of the online education—the preferred and most frequent form of online classes and the personal assessment of the impact of online education on practical skills, theoretical knowledge, and future work; the level of motivation, procrastination, and solitude during the pandemic;

Student views on cases of social aversion and mistrust towards healthcare professionals during the pandemic and their importance for the motivation to continue medical education.

The self-created part of the survey is provided as the (S1 File).

The pilot study of the self-created part of the survey was performed on a group of 25 students of different years, and their remarks on the quality of the questions were applied in the final version of the survey.

The demographic data collected as part of the survey included age, gender, year of study, and name of medical school.

All questions, except for informed consent, were answered voluntarily.

The study protocol was approved by the local ethics committee of the Medical University of Lodz.

Study group

Medical students of all years (1st–6th) from all 22 Polish medical schools (medical universities or medical faculties) that have the same formats of curriculum consisting of pre-clinical classes (anatomy, physiology, etc.), clinical surgical and non-surgical subjects, and summer clinical clerkships were eligible to complete the survey. Inclusion criteria were as follows: studying medicine at one of the Polish medical schools and consent to participate in the study. Out of 1,864 respondents who entered the survey, 1,858 respondents gave their consent. 55.5% of the respondents answered all questions. The average time to complete the whole survey was 7 minutes and 53 seconds. The study group characteristics are provided in Table 1.

Table 1

The study group characteristics (N = 1,858).

Characteristic (number of responses)	Number of respondents (%)
Gender (N = 1,847)
Male	407 (22%)
Female	1,435 (77.7%)
Other	5 (0.3%)
Age, years (N = 1,852)
18–20	473 (25.5%)
21–23	949 (51.3%)
24–26	378 (20.4%)
>26	52 (2.8%)
Year of study (N = 1,850)
1st	325 (17.6%)
2nd	384 (20.8%)
3rd	411 (22.2%)
4th	313 (16.9%)
5th	248 (13.4%)
6th	169 (9.1%)

Statistical analysis

Results are presented as mean ± standard deviation (SD) or median and interquartile range (IQR) depending on the normality of the distribution of each variable. Percent values are given in relation to the number of respondents who answered the particular question.

Statistical analysis was performed using Statistica ver. 13.1 PL software. Graphs were plotted with MS Excel and Statistica. T-test was used for comparisons between two independent groups. ANOVA and post-hoc tests were applied for comparisons of more than two groups. The Chi-square test was used for comparisons of categorical data. Correlations were assessed with Pearson’s method. Pairwise deletion of missing data was applied.

Results

Mental health condition

478 (40.2%) respondents stated that they had sought the help of a psychologist or psychiatrist in the past, and 463 (39.1%) confirmed that they noticed a need for a psychological or psychiatric consultation in relation to pandemic challenges (social isolation, restrictions, and fear of SARS-CoV-2 infection). There were 203 students who did not seek psychological help in the past but did feel such a need at the time of the pandemic. 280 (23.5%) respondents took medications prescribed by a psychiatrist, 558 (47%) admitted that they took over-the-counter (OTC) anti-anxiety medications during studies, and 323 (27.9%) reported an increase in the doses of these medications during the pandemic. As for diagnosed psychiatric conditions, 133 (11.2%) respondents were diagnosed with depressive disorders, 76 (6.4%)—anxiety disorders, 44 (3.7%)—stress-related disorders, 16 (1.3%)—personality disorders, and 2 (0.2%)—psychotic disorders; 28 respondents choose the option “other disorders”. 231 (26.4%) participants previously diagnosed with such disorders noticed worsening of their symptoms. 665 (56%) participants stated that the pandemic impacted their self-esteem negatively, 394 (33.2%) noticed no impact, and 128 (10.7%) declared a positive impact. 340 (28.6%) respondents declared that during the pandemic, they used alcohol, cigarettes, or other stimulants more often than before.

SARS-CoV-2 infection

237 (19.9%) respondents were infected with SARS-CoV-2 virus. Out of this group, in 39 (16.5%) the infection was asymptomatic, in 179 (75.5%) the course of the disease was mild, and in 19 (8%)—severe. 901 (75.8%) participants stated that at least one member of their family or a friend was infected with the coronavirus, and 132 (11.1%) confirmed that at least one of these people died in the course of COVID-19. The SARS-CoV-2 infection, both among respondents, their friends, and relatives did not influence the results of the survey.

In general, in Poland, there were 2,9 million confirmed cases and 75,600deaths due to COVID-19 by the end of September 2021.

Volunteer or paid work in COVID-19 units

93 participants worked, 31 currently work and 139 plan to start work voluntarily in the COVID-19 healthcare units. Asked about their attitude towards referral to work in the COVID-19 healthcare units, 505 (43.4%) stated that they would only do so to avoid potential consequences such as a financial penalty in the case of resignation from a previously accepted job or fear of condemnation by university authorities, 342 (29.4%) answered that they would be happy to help, 301 (25.9%) treat such work as their duty, and only 16 (1.3%) would even consider dropping out of medical school to avoid such work. 772 participants stated that they have several concerns regarding such voluntary work, these concerns are presented in Table 2. Only 125 (10.5%) participants stated that they are practically and theoretically well-prepared to take such a job, and this was significantly associated with the year of studies (Mann Whitney U test p<0.001).

Table 2

Concerns regarding voluntary work in the COVID-19 healthcare units perceived by the study participants.

Concerns regarding voluntary work in the COVID-19 healthcare units	Number of respondents (%)
possibility of infection and transmission of infection to loved ones	610 (79%)
spending time volunteering instead of studying	533 (69%)
fear of liability and potential consequences for providing help incorrectly	483 (62.6%)
insufficient supply of the personal protective equipment	429 (55.6%)

Medical education in the pandemic era

The most commonly applied method of e-learning was live classes via Internet communicators, as reported by 956 participants (80.6%), other e-learning methods comprised recorded lectures and/or seminars, presentations shared with students, and exercises for their own work. The two main methods of e-learning that were preferred most by respondents were recorded lectures and/or seminars (preferred by 40.3% of students) and live classes via Internet communicators (preferred by 39.2% of students). Practical (i.e., laboratory classes, simulations, practical classes in anatomy) and clinical classes (classes in in-patient or out-patient settings) in the first semester of the academic year 2020/2021 were completed on a limited basis.

The vast majority of students expressed concerns over their practical skills (84.3%) and the level of theoretical knowledge (66.6%) after some months of mostly online teaching. 59.9% are worried about their performance at the Final Medical Exam—passing this exam is compulsory in order to receive a medical license, also the result of the exam is the application criterion for residency.

Students’ attitudes to online learning, motivation to learn, and behavior patterns related to novel situations in medical education were also assessed. 806 (68%) respondents confirmed that they delay their tasks and postpone their duties more often in the online teaching era. Reduced motivation to learn was reported by 934 (78.8%) participants. 596 respondents stated that they learn less than before the pandemic, 338—comparably, and 250 learn more. The level of solitude of students was assessed on a 5-point Likert scale with 1 point reflecting no solitude at all and 5 points reflecting overwhelming solitude; the median was 4 (IQR 3).

Social attitude towards healthcare professionals during the pandemic

949 (80.2%) of respondents thought that social aversion and mistrust towards doctors increased during the pandemic, and 43.3% of this group confirmed that this may affect their enthusiasm toward a future medical career. Also, the challenges faced by the national healthcare system (such as a shortage of healthcare professionals, shortage of medical equipment, and the unwillingness of society to undertake precautionary measures against COVID-19) negatively affect attitudes toward working as a doctor, as reported by 43.8% of participants. The above-mentioned issues were related to considerations and plans to practice medicine abroad, confirmed by 39.1% of respondents.

Resilience

A total of 1032 respondents answered all RS-14 questions. The mean resilience score in this group was 65.5±13.6, the lowest score was 25, and the highest—98 (RS-14 scores from 14 to 98). The percentage of respondents presenting a specific level of resilience is shown in Fig 1.

Fig 1

The percentage of respondents presenting particular levels of resilience according to Resilience Scale-14 (N = 1,032).

Worthy of note is that 72% of the study population presented lower levels of resilience (‘very low’, ‘low’, ‘on the lower end’), indicating a decreased ability to adapt to challenging circumstances.

RS-14 scores depending on medical student characteristics gathered in the self-created survey are provided in Table 3.

Table 3

RS-14 scores depending on medical student characteristics gathered in the self-created survey.

	RS-14 scores			p-value
gender	men	women		<0.01
	67.5±13.9	64.6±13.2
diagnosed mental health conditions	yes	no		<0.001
	59.7±13.8	67.3±12.9
more often use of alcohol, cigarettes or other stimulants during the pandemic	yes	no
	62±13.4	66.8±13.4		<0.001
willingness to volunteer in the COVID-19 health-care units	yes	no		0.05
	67.8±12.5	65±13.7
concerns on the impact of the online learning on the level of knowledge	yes	no		<0.01
	64.5±13.7	67.6±12.9
concerns on the impact of the online learning on the result of Final Medical Exam	yes	no
	64.2±13.9	67.3±13.1		<0.01
reduced motivation in the online learning era	yes	no		<0.01
	64.6±13.4	68.7±13.5
increased motivation in the online learning era	yes	no		<0.001
	63.7±13.1	69.3±13.7
susceptibility to the cases of social mistrust	yes	no		0.02
	64.9±13.6	67.9±13.1
low enthusiasm towards future medical career	yes	no		0.07
	63.8±13.2	66.8±13.9
impact of pandemic on the self-esteem	negative	neutral	positive	<0.001
	61.5±13.2	69.4±12.4	71.6±12.6

Resilience was not dependent on age; however, the highest resilience level was found among 4th-year students and the lowest among 1st- and 6th-year students (Fig 2).

Fig 2

Mean RS-14 scores among students of different years of medical school.

* p<0.05; ** p<0.01.

Burnout

A total number of 1311 students answered all MBI-GS(S) questions. Mean scores, which may range from 0 to 6 for each dimension, were 3.9±1.4, 3.5±1.6, and 2.9±1.1 for EE, CY, and AE, respectively. The prevalence of high, moderate, and low levels of burnout in the three dimensions is provided in Table 4. Average scores for the three dimensions of burnout among students of different years of medical school are provided in Fig 3.

Table 4

Prevalence of high, moderate and low levels of burnout in particular dimensions and of the overall burnout according to the two- and three-dimensional criteria (N = 1,311).

Burnout level in particular dimension (reference values)	Number of respondents (%)
Emotional exhaustion
low (0–7)	78 (6%)
moderate (8–15)	281 (21.4%)
high (≥16)	952 (72.6%)
Cynicism
low (0–5)	126 (9.6%)
moderate (6–12)	261 (19.9%)
high (≥13)	924 (70.5%)
Academic efficacy
low (0–23)	1,084 (82.7%)
moderate (24–29)	183 (13.9%)
high (≥30)	44 (3.4%)
Two—dimensional burnouta	Number of respondents (%)
Yes	786 (59.9%)
No	525 (40.1%)
Three—dimensional burnoutb	Number of respondents (%)
Yes	711 (54.2%)
No	(45.8%)

a. High emotional exhaustion + high cynicism.

b. High emotional exhaustion + high cynicism + low academic efficacy.

Fig 3

Mean burnout scores in each dimension among students of different years of medical school.

According to the two-dimensional (high EE + high CY) and three-dimensional (high EE + high CY + low AE) criteria, the presence of the overall burnout was determined (Table 4).

Participants who reported diagnosed mental conditions presented more severe burnout in all three dimensions (4.2±1.9 vs. 3.8±1.1; p<0.001 for EE; 3.7±1.6 vs. 3.4±1.1; p<0.001 for CY; 2.8±1.1 vs. 2.9±1; p = 0.02 for AE). Burned-out students (three-dimensional criterion) used stimulants more often than those who did not present burnout (Chi2 Pearson p = 0.01). The willingness to volunteer was declared by students with significantly lower burnout in all dimensions.

The students diagnosed with burnout reported reduced motivation to learn significantly more often (Chi-square Pearson p<0.001) and increased procrastination (Chi-square Pearson p<0.001) in the online learning arena. There is also a significant negative correlation between burnout and resilience (r = -0.38, p<0.05). Mean RS-14 scores for participants presenting burnout in particular dimensions at low, moderate, and high levels as well as for those presenting three-dimensional burnout are provided in Fig 4.

Fig 4

Mean RS-14 scores for participants presenting burnout in particular dimensions at low, moderate and high levels (ANOVA) and mean RS-14 scores for participant demonstrated three-dimensional burnout’.

** p < 0.01; *** p < 0.001.

Well-being

A total number of 1359 students answered all MSWBI questions And the median MSWBI value was 5 points. 79 (5.8%) respondents scored 7 MSWBI points, while the median MSWBI score for students of years 1–3 and 6 was 5 points, and for students of years 4 and 5–4 points. Correlations between MSWBI and burnout and resilience scores are provided in Table 5. Median MSWBI was 5 points for the group with three-dimensional burnout and 4 points for the group in which three-dimensional burnout was not found.

Table 5

Correlations between Medical Students Well-Being Index (MSWBI) and burnout and resilience scores.

MSWBI correlations	Correlation coefficient (r)	P value
Burnout
Mean emotional exhaustion score	0.59	<0.01
Mean cynicism score	0.48	<0.01
Mean academic efficacy score	-0.30	<0.001
Resilience
RS-14 score	-0.35	<0.01

Discussion

Our study addressed the ability of medical students to cope with challenges during the COVID-19 pandemic via assessing their resilience level. Additionally, we took burnout and well-being into account as reliable measures of general and education-related welfare. While medical students were already experiencing high levels of distress before the pandemic [20], these new challenges showed the priority of providing support and building resilience in this vulnerable population, with the aim being to have a workforce that will be able to combat the long-lasting consequences of the COVID-19 pandemic and who can effectively face similar crises in the future. The strict limitations on students’ clinical practice and work placements imposed due to the pandemic caused decreased motivation and concerns of inappropriate levels of knowledge as well as questioning their abilities to pass final examinations and work as doctors [21], something that was also reported in our study. Almost two-thirds of the respondents presented low levels of resilience, indicating a problem with their ability to maintain or regain mental health while experiencing adversity [22] such as a global pandemic. Low resilience was correlated with more severe burnout, poor well-being, reduced motivation, and higher usage of stimulants during the COVID-19 pandemic. This may support the conclusion that building resilience is one of the components of creating driven, invested, and content healthcare professionals. Interestingly, the lowest resilience was found among the 1st- and 6th-year medical students, which may indicate that programs for building resilience should be adjusted and changed over time. The need to prioritize healthy coping methods was reported in several other studies [23-25], and previous research has shown that medical students were eager to learn about healthy ways of coping with stress and to find out about tools that may help them with building resilience [26]. Jensen et al. identified many ways of building resilience in physicians—maintaining an interest in their role, acceptance of personal limitations, setting limits, or group practice [27]. Zwack et al. reported that leisure-time activity to reduce stress, cultivation of relations with family and friends, self-organization, and spiritual practices were among the methods that helped physicians to maintain high resilience [28]. These coping strategies could also be adapted to the population of medical students—courses in stress management and maintaining mental health, held by both professional psychologists as well as more experienced colleagues, could have a positive influence on building their resilience. Studies have pointed to self-efficacy, described as confidence in one’s [own] abilities to successfully perform a particular behavior, influence events, and affect other lives, as a possible focus for building resilience in students [29-31].

Due to the combination of COVID-19 restrictions and online learning, researchers were forced to distribute questionnaires online, without direct contact with responders, which may have resulted in bias typical for online surveys. Sampling bias, defined as bias in which a sample is collected in such a way that some members of the intended population have a lower or higher sampling probability than others, must, therefore, be considered in our population—students who were more active on the social media had higher sampling probability, and some characteristics of this group may influence the results. Besides, desirability bias, which reflects the human tendency to appear and behave desirably and avoid undesirable traits, could influence our data, especially with regard to questions on volunteer work or learning habits. Nevertheless, this kind of data collection enabled reaching out to many medical students from different universities; however, survey questions other than validated questionnaires were created by the authors who, being members of the academic community, might allow their own experiences to lead to author bias. Additionally, due to the scarcity of data on resilience, burnout, and well-being in the population of Polish medical students, our data only reflect the current situation, and we could not assess if there was any deterioration of the studied parameters. Nevertheless, some similar research projects were performed in Europe; a study from Cyprus, which also used the MBI-SS questionnaire, revealed that burnout prevalence did not differ significantly before and after the pandemic in the population as a whole. However, it did increase in the group of final-year medical students. In the group of fourth-year medical students, burnout prevalence decreased, we also reported lowest burnout among fourth-year medical students in our study. Emotional exhaustion also decreased in this group, while cynicism increased in all groups [32]. Research on burnout and study satisfaction conducted in Croatia did not reveal the influence of the first lockdown and the switch to online learning on burnout in medical students, or their perception of study satisfaction [33]. Interestingly, a similar study from Kazakhstan showed that burnout syndrome, depression, anxiety, and somatic symptoms decreased after switching to online learning. However, the prevalence of colleague-related burnout during online learning increased in that time [34]. Based on reports from other European countries that examined the level of mental health, cynicism, and burnout in medical students before and during the pandemic, it was concluded that digital learning carries significant risks. It has been found that not only does mental health deteriorate but the level of cynicism also increases. Emotional exhaustion has been found to increase especially in final year students who struggle with a lack of clinical experience just prior to joining qualified junior physicians [32]. In our study, the median MSWBI value was 5 points out of a maximum 7 (greatest distress). This entails less than average performance in psychological and physical domains of life mixed with a lack of awareness of students’ own abilities, fatigue, and an inability to cope with stress. It has been reported that anxiety levels among medical students are substantially higher than in the general population [33]. Other research showed that medical students have a high prevalence of distress and depression, especially among 1st-year students, due to issues of adjusting to a new environment and increased workload [34]. In our study, we report the lowest resilience levels in 1st- and 6th-year medical students. It may be hypothesized, therefore, that these subpopulations may suffer most from new environment adjustments (1st-year students) and increased workload combined with new challenges (6th-year students). It was reported that depression and depressive symptoms are common among physicians [35], and their suicide rates are higher than in the general population [36]. So, future doctors with poor well-being joining the workforce during and after the pandemic may have an elevated risk of mental health problems as well. It was confirmed that depression among medical students in Poland is common [37], and due to the lack of central regulations, psychological support is provided by medical schools individually. Those solutions focus on short-term, temporary therapy [38]. The majority of respondents (80.2%) reported feeling that social aversion and mistrust towards doctors increased during the pandemic, and many of them (43.3%) claimed that it may affect their enthusiasm about their future job. Although there is very little research about mistrust among patients in Poland fueled by the COVID-19 pandemic, scientists from other countries reported that many people endorse conspiracy theories about the origins of the pandemic [39], and some are hesitant to be vaccinated because of their distrust of political and medical institutions, “anti-establishment” sentiments, and conspiratorial and paranoid beliefs [40, 41] and, because of the shortage of healthcare professionals [42-44], the need to care for COVID-19 patients and prevent further spread of the virus, the “non-COVID” patients are often left waiting in long queues for telehealth that may not be enough, especially for those with lower socioeconomic backgrounds, who can’t afford easy access to the devices needed for telemedicine [45]. All these problems have also been present in Poland and may have contributed to the growth of medical mistrust among polish patients.

The conclusions from our study should encourage both faculty and student organizations to develop proper resilience-building strategies. Besides, there is a strong need to support students’ mental health and to monitor students’ well-being during the time of recovery from the pandemic. Today’s students are the physicians of tomorrow and their ability to adapt to challenges is crucial for effective and efficient patient care in the future.

Self-created part of the study survey.

(DOCX)

Click here for additional data file.

The study database.

(XLSX)

Click here for additional data file.

6 Oct 2021

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Reviewer #1: Partly

Reviewer #2: Partly

**********

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Reviewer #1: I Don't Know

Reviewer #2: Yes

**********

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Reviewer #2: Yes

**********

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Reviewer #2: No

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Reviewer #1: The manuscript titled “Medical students facing the pandemic – assessment of resilience, well-being and burnout in the COVID-19 era” assessed resilience, well-being and burnout using validated tools as well as self-created questionnaire administered through Facebook and other online students’ platforms over a one-month period. The majority of medical students had lower levels of resilience and higher burnout with corresponding well-being. Lower resilience and higher burnout was associated with diagnosed mental health conditions, increased use of stimulants, negative self-esteem, and reduced motivation to learn, while higher resilience and less burnout was associated with willingness to work voluntarily in the COVID-19 units.

This is an interesting manuscript that may help fill the gap in information regarding resilience, burnout and well-being in Polish medical students. As the authors suggest, their data only reflects the situation with COVID-19 at the time of collection, and future studies should monitor the situation as the country recovers or changes in the future. It also may provide points for institutions outside of Poland to consider. Listed below are suggestions and comments to help clarify some points and to potentially improve the utility of this manuscript:

General:

• Strongly suggest editing for English grammar and spelling.

Title:

• Line 1: Suggest adding “Polish” to the beginning of the title so it reads: “Polish medical students facing the pandemic – assessment of resilience, well-being and burnout in the COVID-19 era” to be an accurate reflection of the manuscript

Abstract:

• Line 24: Introduction: Suggest replacing “MSs” with “Polish medical students”

• Line 27: Methods: the self-made survey is not mentioned

• Line 34: Results: add “friends and” in front of “relatives”

• General: Mental health was a large component of this manuscript, but it is not mentioned in the abstract. Neither is use of stimulants or views on mistrust towards healthcare professionals.

Introduction:

• There should be reference after every statement – for example, at the end of line 52, it mentions many past studies, but there is no reference(s) at the end of that statement.

• Lines 67-69 is a statement that says “might have taken a toll” – the authors may be able to find a reference that can change the statement to “have taken a toll”. Or if unable to find one, then can state that and bring up the study.

• Would be helpful to understand what the restrictions in Poland were for COVID-19.

• There is a statement defining resilience (lines 95-97) in the methods that may be better placed in the last paragraph of the introduction.

• The last sentence of the introduction doesn’t mention the other factors in the self-created questionnaire about mental health, use of stimulants, presence of COVID-19 infections in respondents and their friends/family, COVID-19 related volunteer or paid work, medical education and views on mistrust towards healthcare professionals.

Methods:

• Line 82: How were the various Facebook groups and studygrams chosen? Was it general medical student group or certain clubs that may introduce a bias in the respondents? Was it possible to determine the response rate, validate that it was medical students who responded, and eliminate duplicates in response (same student answering more than once)?

• Line 83: Were there reminders/multiple posts within the one-month period? How many?

• Line 94: Are the RS-14 levels as seen in Figure 1 defined by the use of the survey? Could you add an label for the x-axis and the score range for each category in the methods section or in the figure?

• Line 101: What are the scores that would indicate poor well-being vs good well-being?

• Line 105: Should specify that the Maslach Burnout Inventory – General Survey for Students was designed for college and university students. Also, the reference is from the 1980s and this particular survey was designed later.

• Line 111: Should add see Table 2 for reference values of low, moderate and high

• Line 112: There should be a statement if two-dimensional burnout for this survey is defined by the survey or by the authors.

• Line 117: How was the self-created part of the survey designed? Did it go through a pilot with students and faculty and refined? Was it a pull down menu of choices or open answer? It would be extremely helpful for the self-created questionnaire to be an appendix of this manuscript. And the data should be provided in accordance to PLOS policy.

• Line 124: It would be helpful if volunteer or paid work was better defined or explained, and why they were combined as they would have different motivating factors. Is volunteer or paid work part of the curriculum?

• Line 141: Please add number of Polish medical schools and whether they all have similar Year 1- Year 6 formats of curriculum. It would also be helpful to have a brief description of the curriculum for those readers who are not familiar with the curriculum.

• Line 144: Is there an estimate of the total number of Polish medical students (and perhaps gender/age/year of study breakdown) to determine an estimated response rate and whether the respondents and their demographics are a representative sample?

Results:

• Lines 162-163: What is the overlap of those two groups? Is there an article about the pre-pandemic levels of mental health issues in this age group?

• Line 168: Is there information regarding how many students were newly diagnosed with psychiatric conditions?

• Line 175-176: Is there information regarding how many students started using stimulants?

• Line 182: In the abstract, it states that “The SARS-CoV-2 infection both among respondents and their relatives did not influence the results”, but this is not stated anywhere else in the manuscript. It could go here. Also, the abstract and methods only mention respondents and family, but Line 180 mentions friends – they should all be consistent. It may also be helpful to understand the context – what was the infection rate and death rate due to COVID-19 in Poland?

• Line 184: Would it be possible to separate out the participants who worked, those who currently work and those who plan to work and those participants who volunteered, those who currently volunteer and those to plan to volunteer? These categories may be different.

• Line 186: What are examples for potential consequences?

• Lines 189-194: Were these choices in the survey or an open answer? It looks like a list that students chose from – what if students had a potential concern that was not listed? The choices and number of respondents could be more clear in table form.

• Line 209: What is the Final Medical Exam? Is this for graduation? Ability to practice? Both?

• Line 220: It is interesting that 80.2% of respondents through that social aversion and mistrust towards doctors increased during the pandemic – this should be discussed in the next section with possible reasons and an explanation of public perceptions in Poland. Can also give examples of challenges faced by the national healthcare system mentioned in line 222.

• Line 266: Replace “particular” with “the three”

Discussion:

• Line 324: Why do the authors think that the lowest resilience in among 1st and 6th year students? Are there articles to support similar findings or are these unique?

• Line 344: Although there is scarce data on resilience, burnout and well-being in the population of Polish medical students, are there reports from nearby countries or those with similar curriculum that were similarly affected by COVID? How are the results similar or unique?

• As mentioned above for Line 220: It is interesting that 80.2% of respondents through that social aversion and mistrust towards doctors increased during the pandemic – this should be discussed in the next section with possible reasons and an explanation of public perceptions in Poland.

• Could add a statement that the study population is outside the validated range of RS-14.

• There is a lot of data presented, but the conclusion is to develop resilience building strategies. What about mental health support?

Tables and Figures:

• Suggest a figure showing average resilience score in Years 1 through 6.

• Suggest a figure showing average scores for the three dimensions of burnout and frequency of two- and three-dimensional burnout in Years 1 through 6.

• Suggest add graph of RS-14 score and two-dimensional burnout and RS-14 score and well-being score in Figure 2.

• Suggest a distribution figure showing well-being scores, similar to resilience, and average well-being scores in Years 1 through 6.

• Could Table 3 be a scatter plot, or a more visual way to show the distribution? Is there a correlation coefficient between burnout and resilience? How similar are these?

Reviewer #2: 1. Standard English should be used for the entire manuscript. Specific sentences that were unclear include Lines 44, 52, 58, 63, 68-69, 111.

2. Lines 52-55 refer to “many past studies”, however there are no citations associated with this statement.

3. Lines 59-60 of the introduction states findings “reported in our study”, however this would be more appropriate in the discussion. Additionally, the sentence regarding “decreased motivation and concerns of inappropriate levels of knowledge, etc.” should be supported by a reference.

4. Resilience is defined in two areas- lines 70 and again in line 95-96, which is redundant.

5. In the Methods section, Lines 117-135 when explaining the self-created part of the survey, it may be better to summarize the five question domains in the text, then provide the actual questions on the survey in supplement material.

6. Line 142- Is it supposed to be “medical facilities” instead of “medical faculties”?

7. Lines 144-146 and Table 1 present survey results and should be moved to the Results section.

8. Lines 157 and 286- chi-square should be written out explicitly

9. What is the response rate to the survey? The data presented in Line 144 describes that 1864 respondents entered the survey, however, how many total medical students are there in Poland who could have completed the survey?

10. Results section- Lines 162-225 describe all of the results of the self-created survey. These results may be better presented in a table and the key findings highlighted in the text of the results section.

11. Figure 1 should have a label on the X-axis

12. It is unclear how the “resilience score” correlates with the 6 categories of resilience in Figure 1 (very low, low, on the low end, moderate, moderately high, high). Placing a legend in the figure may help clarify this.

13. Results section- Lines 236-262 describe the correlation between the resilience score and medical student characteristics gathered in the self-created survey. These results may be better presented in a table and the highlights discussed in the results section.

14. Results section- Lines 280-287 describe the correlation between burnout and medical student characteristics gathered in the self-created survey. These results may be better presented in a table and the highlights discussed in the results section.

15. Figure 2- the meaning of the 2 or 3 stars/dots in the figure is unclear. Please explain

16. Line 296-297- The description of the MSWBI score range and meaning should be in the methods section.

17. Lines 319-321- This was a one-time survey completed during the pandemic, therefore, you don’t have a baseline measure of resilience, burn out and well-being before the pandemic. Therefore, the statement that “2/3 of the respondents presented lower levels of resilience indicated a problem with ability to maintain or regain mental health while experience adversity such as a global pandemic” is not possible because you don’t know what their baseline level of resilience was before the pandemic.

18. Lines 324-326- What are potential reasons the 1st and 6th year students had the lowest resilience?

19. The Discussion is limited to a discussion about resilience and suggestions to improve education about resilience in medical education. Please expand the discussion to also comment on burnout and well-being.

20. Please expand on other limitations of the study aside from the survey being online and the author bias of the self-created survey questions.

**********

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Reviewer #1: No

Reviewer #2: No

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4 Dec 2021

Responses to Reviewer’s 1 comments

General

#1 Comment:

Strongly suggest editing for English grammar and spelling.

#1 Response:

Thank you for this remark. The manuscript was carefully edited for grammar and spelling by English native speaker.

Title

#1 Comment:

Line 1: Suggest adding “Polish” to the beginning of the title so it reads: “Polish medical students facing the pandemic – assessment of resilience, well-being and burnout in the COVID-19 era” to be an accurate reflection of the manuscript

#1 Response:

Thank you for this remark. The suggested change of the title has been applied for more accurate reflection of the scope of the manuscript.

Abstract

#1 Comment:

Line 24: Introduction: Suggest replacing “MSs” with “Polish medical students”

#1 Response:

Thank you for this remark. The suggested change has been applied in Introduction.

#2 Comment:

Line 27: Methods: the self-made survey is not mentioned.

#2 Response:

Thank you for this comment. The Information about self-created part of the survey has been added in the abstract.

#3 Comment:

Line 34: Results: add “friends and” in front of “relatives”

#3 Response:

Thank you for this correction, the change has been applied as suggested.

#4 Comment:

General: Mental health was a large component of this manuscript, but it is not mentioned in the abstract. Neither is use of stimulants or views on mistrust towards healthcare professionals.

#4 Response:

Thank you for this remark, information on the above mentioned issues has been added in the Results section of the abstract.

Introduction

#1 Comment:

There should be reference after every statement – for example, at the end of line 52, it mentions many past studies, but there is no reference(s) at the end of that statement.

#1 Response:

Thank you for this valuable comment, the appropriate references have been added.

#2 Comment:

Lines 67-69 is a statement that says “might have taken a toll” – the authors may be able to find a reference that can change the statement to “have taken a toll”. Or if unable to find one, then can state that and bring up the study.

#2 Response:

Unfortunately, we were not able to find such reference. We have changed the sentence, so now it reads: “It may be hypothesized, that these extraordinary actions such as social distancing and closing schools, offices and entertainment venues might have taken a toll especially on more susceptible to stress and less resilient individuals.” Hopefully, it can be accepted in that form.

#3 Comment:

Would be helpful to understand what the restrictions in Poland were for COVID-19.

#3 Response:

Thank you for this suggestion. The information about COVID-19-related restrictions in Poland has been added.

#4 Comment:

There is a statement defining resilience (lines 95-97) in the methods that may be better placed in the last paragraph of the introduction.

#4 Response:

Thank you very much for this remark. Indeed, definitions of all studied parameters fit better in the Introduction section. The correction has been applied – the definition is deleted from the Methods.

#5 Comment:

The last sentence of the introduction doesn’t mention the other factors in the self-created questionnaire about mental health, use of stimulants, presence of COVID-19 infections in respondents and their friends/family, COVID-19 related volunteer or paid work, medical education and views on mistrust towards healthcare professionals.

#5 Response:

Thank you for this suggestion. The lacking information has been added.

Methods

#1 Comment:

Line 82: How were the various Facebook groups and studygrams chosen? Was it general medical student group or certain clubs that may introduce a bias in the respondents? Was it possible to determine the response rate, validate that it was medical students who responded, and eliminate duplicates in response (same student answering more than once)?

#1 Response:

Thank you for these questions. The survey was posted on national or local Facebook groups for medical students, all of them were open for all polish medical students or students from the particular institution. Also, we contacted student influencers running the nationwide Instagram profiles focused on studying medicine and asked them to share our survey. Via this channel survey was available for all subscribers of the particular profile. Unfortunately, due to character of the survey (online survey) it was not possible to estimate the response rate, since we did not monitor number of subscribers of particular profiles at the time when the survey was open. Also, during this month, these numbers could change. Due to the character of data collection (100% anonymous, no computer IP number collection) we could not prevent the same person filling out the questionnaire twice. Answers to these questions are now added in the Methods section.

#2 Comment:

Line 83: Were there reminders/multiple posts within the one-month period? How many?

#2 Response:

No, the survey was posted once at all of the above-mentioned groups. This information is now added in the Methods section.

#3 Comment:

Line 94: Are the RS-14 levels as seen in Figure 1 defined by the use of the survey? Could you add an label for the x-axis and the score range for each category in the methods section or in the figure?

#3 Response:

Thank you for this suggestion. The x-axis label was added in Figure 1. Yes, resilience levels are defined by the survey authors and we used these levels in the study. The score range for each category has been added in the Methods section.

#4 Comment:

Line 101: What are the scores that would indicate poor well-being vs good well-being?

#4 Response:

Thank you for this question. There is no such clear specification of poor and good well-being according to this survey. It said in the survey manual that MSWBI score ranges from 0 to 7, and 7 points indicate the greatest distress. This clarification is now added in the Methods section and deleted from the Results section.

#5 Comment:

Line 105: Should specify that the Maslach Burnout Inventory – General Survey for Students was designed for college and university students. Also, the reference is from the 1980s and this particular survey was designed later.

#5 Response:

Thank you for this remark. The specification has been added. Indeed, the reference referred to burnout itself, and the proper citation should refer to the survey, which was proposed in the 4th version of the manual by Maslach et al. in 2017 (Maslach, C., Jackson, S. E., and Leiter, M. P. (2017). Maslach Burnout Inventory Manual, 4th Edn. Menlo Park, CA: Mind Garden). The citation is now added accordingly.

#6 Comment:

Line 111: Should add see Table 2 for reference values of low, moderate and high

#6 Response:

Thank you for this remark. The correction has been applied in line with the suggestion.

#7 Comment:

Line 112: There should be a statement if two-dimensional burnout for this survey is defined by the survey or by the authors.

#7 Response:

The two-dimensional burnout (high cynicism + high emotional exhaustion) has been already described in previous studies in the field. However, three-dimensional criterion is most frequently adopted in studies. It is now explained in the Methods section.

#8 Comment:

Line 117: How was the self-created part of the survey designed? Did it go through a pilot with students and faculty and refined? Was it a pull down menu of choices or open answer? It would be extremely helpful for the self-created questionnaire to be an appendix of this manuscript. And the data should be provided in accordance to PLOS policy.

#8 Response:

Thank you for this remark. As it is suggested we have added the self-created part of the survey as the supplementary material. Yes, the pilot was performed in the group of 25 students of different years and their remarks on the questions quality were applied in the final version of the survey, this information is now added in the Methods section.

#9 Comment:

Line 124: It would be helpful if volunteer or paid work was better defined or explained, and why they were combined as they would have different motivating factors. Is volunteer or paid work part of the curriculum?

#9 Response:

Thank you for this remark. The extracurricular volunteer and paid work at the time of COVID-19 pandemic is now explained in more detail in the Methods section.

#10 Comment:

Line 141: Please add number of Polish medical schools and whether they all have similar Year 1- Year 6 formats of curriculum. It would also be helpful to have a brief description of the curriculum for those readers who are not familiar with the curriculum.

#10 Response:

Thank you for this suggestion. The number of Polish medical schools has been added. Also, a brief description of the curriculum, which is the same at all Polish medical schools, is provided.

#11 Comment:

Line 144: Is there an estimate of the total number of Polish medical students (and perhaps gender/age/year of study breakdown) to determine an estimated response rate and whether the respondents and their demographics are a representative sample?

#11 Response:

Thank you for this question. The estimate of the total number of Polish medical students of all years in academic year 2019/2020 was around 32 thousands. Unfortunately, there are no open access data on demographics of this group and determination whether the respondents are a representative sample is not possible.

Results

#1 Comment:

Lines 162-163: What is the overlap of those two groups? Is there an article about the pre-pandemic levels of mental health issues in this age group?

#1 Response:

Thank you for this valuable question. There were 203 students who did not seek psychological help in the past, but felt such need at the time of pandemic, this information is now added in the Results section. Indeed, we found two paper on mental health issues in the population of polish medical students in the pre-pandemic era, both are now cited in the Discussion section.

#2 Comment:

Line 168: Is there information regarding how many students were newly diagnosed with psychiatric conditions?

#2 Response:

Thank you for this question. No, our survey did not include the question of how many students were newly diagnosed with psychiatric conditions.

#3 Comment:

Line 175-176: Is there information regarding how many students started using stimulants?

#3 Response:

Thank you for this question. No, we did not ask in the survey about start of using stimulants during the pandemic.

#4 Comment:

Line 182: In the abstract, it states that “The SARS-CoV-2 infection both among respondents and their relatives did not influence the results”, but this is not stated anywhere else in the manuscript. It could go here. Also, the abstract and methods only mention respondents and family, but Line 180 mentions friends – they should all be consistent. It may also be helpful to understand the context – what was the infection rate and death rate due to COVID-19 in Poland?

#4 Response:

Thank you for this valuable comment. Now all the parts are consistent with regard to this issue. Also, the information about infection and death rates due to COVID-19 in Poland has been added.

#5 Comment:

Line 184: Would it be possible to separate out the participants who worked, those who currently work and those who plan to work and those participants who volunteered, those who currently volunteer and those to plan to volunteer? These categories may be different.

#5 Response:

Thank you for this remark, the correction has been applied.

#6 Comment:

Line 186: What are examples for potential consequences?

#6 Response:

The potential consequences are now added in Results section.

#7 Comment:

Lines 189-194: Were these choices in the survey or an open answer? It looks like a list that students chose from – what if students had a potential concern that was not listed? The choices and number of respondents could be more clear in table form.

#7 Response:

Thank you for this remark. There were choices in the survey and the list of potential answers was based on the discussions with the participants of the pilot period of the study. Due to huge estimated number of participants we decided not to introduce open answers in this questions, because of potential problems with further analysis. In line with the Reviewer’s suggestion it is now presented in the Table form (Table 2).

#8 Comment:

Line 209: What is the Final Medical Exam? Is this for graduation? Ability to practice? Both?

#8 Response:

Thank you for these questions. The explanation about the Exam is now provided.

#9 Comment:

Line 220: It is interesting that 80.2% of respondents through that social aversion and mistrust towards doctors increased during the pandemic – this should be discussed in the next section with possible reasons and an explanation of public perceptions in Poland. Can also give examples of challenges faced by the national healthcare system mentioned in line 222.

#9 Response:

Thank you for this comment. Both possible explanation of the high rate of mistrust towards doctors and examples of challenges faced by Polish healthcare system are now provided accordingly.

#10 Comment:

Line 266: Replace “particular” with “the three”

#10 Response:

Thank you for this correction. It has been applied in the manuscript.

Discussion

#1 Comment:

Line 324: Why do the authors think that the lowest resilience in among 1st and 6th year students? Are there articles to support similar findings or are these unique?

#1 Response:

Thank you for this remark. The lowest resilience levels were found in 1st and 6th year students of our study group and we described this in the Results section – “Resilience was not dependent on age; however, the highest resilience level was found among 4th year students (68.3±12.9 points), and the lowest among 1st (62.9±12.9) and 6th year students (62.6±14.4); p<0.01.” Now, it is replaced with the Figure 2. in line with the Reviewer’s suggestion. We did not find any other studies particularly addressing resilience in Years 1 through 6. However, there is a study indicating that medical students have a high prevalence of distress and depression, especially the 1st year students due to issues of adjustment to new environment and increased workload. This citation has been added in the Discussion section.

#2 Comment:

Line 344: Although there is scarce data on resilience, burnout and well-being in the population of Polish medical students, are there reports from nearby countries or those with similar curriculum that were similarly affected by COVID? How are the results similar or unique?

#2 Response:

Thank you for this suggestion. The studies from Cyprus, Croatia and Kazakhstan are now cited and discussed in the Discussion section.

#3 Comment:

As mentioned above for Line 220: It is interesting that 80.2% of respondents through that social aversion and mistrust towards doctors increased during the pandemic – this should be discussed in the next section with possible reasons and an explanation of public perceptions in Poland.

#3 Response:

Thank you for that remark. As mentioned above, the suggested explanation is now provided in the Discussion section.

#4 Comment:

Could add a statement that the study population is outside the validated range of RS-14.

#4 Response:

Thank you for this remark. As it is mentioned in the Methods section, The RS-14 is validated in the population of young Polish adults (aged 19-27). In our opinion, the population of Polish medical students can be treated as a part of the “population of young Polish adults”. In our study group there were only 52 respondents (2.8%) who reported there age as “older than 26 years”.

#5 Comment:

There is a lot of data presented, but the conclusion is to develop resilience building strategies. What about mental health support?

#5 Response:

Thank your very much for this valuable remark. We have corrected the conclusion in line with the suggestion.

Tables and Figures

#1 Comment:

Suggest a figure showing average resilience score in Years 1 through 6.

#1 Response:

Thank you for this suggestion. We have prepared the figure showing average resilience score in Years 1 through 6 (Figure 2).

#2 Comment:

Suggest a figure showing average scores for the three dimensions of burnout and frequency of two- and three-dimensional burnout in Years 1 through 6.

#2 Response:

Thank you for this suggestion. The figure has been added.

#3 Comment:

Suggest add graph of RS-14 score and two-dimensional burnout and RS-14 score and well-being score in Figure 2.

#3 Response:

Thank you for the suggestion. Figure 2. was meant to show relation between burnout and resilience. We did not intend to show two-dimensional burnout there as parameter less frequently used in the literature. Relation between resilience and well-being is presented in the text in the Results section.

#4 Comment:

Suggest a distribution figure showing well-being scores, similar to resilience, and average well-being scores in Years 1 through 6.

#4 Response:

Thank you for this suggestion. Median MSWBI score for years 1-3 and 6 is 5, and for years 4 and 5 – 4, no significant differences were found with regard to it. This information has been added in the Results section.

#5 Comment:

Could Table 3 be a scatter plot, or a more visual way to show the distribution? Is there a correlation coefficient between burnout and resilience? How similar are these?

#5 Response:

Thank you for this remark. Indeed, there is a significant negative correlation between burnout and resilience (r=-0.38, p<0.05), this information is added in the Results section. The scatter plot for MSWBI which takes integer values from 0 to 7 would not be very informative, that is way we decided to show these data in the table.

Responses to Reviewer’s 2 comments

#1 Comment:

Standard English should be used for the entire manuscript. Specific sentences that were unclear include Lines 44, 52, 58, 63, 68-69, 111.

#1 Response:

Thank you for this remark. The manuscript was edited for grammar and spelling by English native speaker.

#2 Comment:

Lines 52-55 refer to “many past studies”, however there are no citations associated with this statement.

#2 Response:

Thank you very much for this remark. The reference to the review article has been added in line with the suggestion.

#3 Comment:

Lines 59-60 of the introduction states findings “reported in our study”, however this would be more appropriate in the discussion. Additionally, the sentence regarding “decreased motivation and concerns of inappropriate levels of knowledge, etc.” should be supported by a reference.

#3 Response:

Thank you for this remark. The sentence has been deleted from the Introduction.

#4 Comment:

Resilience is defined in two areas- lines 70 and again in line 95-96, which is redundant.

#4 Response:

Thank you very much for this suggestion. The definition of resilience was deleted from the Methods section.

#5 Comment:

In the Methods section, Lines 117-135 when explaining the self-created part of the survey, it may be better to summarize the five question domains in the text, then provide the actual questions on the survey in supplement material.

#5 Response:

Thank you for this suggestion. For the better understanding of all parameters that we studied we would like to leave the description of this part of the survey in the text but additionally we have prepared the self-created part of the survey as the supplemental material.

#6 Comment:

Line 142- Is it supposed to be “medical facilities” instead of “medical faculties”?

#6 Response:

Thank you for this remark. The term “medical faculties” is a term used to describe the faculty of medicine, which is a part of a “non-medical” University. Medicine is taught as an undergraduate, 6-year degree in Poland and it is possible to study medicine at the medical university (such as Medical University of Lodz) which offers only medicine and other medical sciences degrees. The other option is to study at the medical faculty of an university that also offers a variety of courses besides medical ones such as law, economy, engineering, management etc. Such examples are the Faculty of Medicine of the Jagiellonian University in Krakow or the Faculty of Medical Sciences and Health Sciences of the Kazimierz Pulawski University of Technology and Humanities in Radom. This is why we used the term “medical faculties” and we believe no changes or correction are necessary with that regard.

#7 Comment:

Lines 144-146 and Table 1 present survey results and should be moved to the Results section.

#7 Response:

Thank you for this remark. Since both information on the percent of participant who answered all questions and study group characteristics (Table 1.) describe the study group we would like to ask to consider leaving these in the Methods and participants section of the manuscript.

#8 Comment:

Lines 157 and 286- chi-square should be written out explicitly

#8 Response:

Thank you, the correction has been applied.

#9 Comment:

What is the response rate to the survey? The data presented in Line 144 describes that 1864 respondents entered the survey, however, how many total medical students are there in Poland who could have completed the survey?

#9 Response:

Thank you for this question. The estimate of the total number of Polish medical students of all years in academic year 2019/2020 was around 32 thousands. Unfortunately, due to character of the survey (online survey) it was not possible to estimate the response rate, since we did not monitor number of subscribers of particular profiles (Instagram) and members of particular Facebook groups at the time when the survey was open. Also, during this month, these numbers could change.

#10 Comment:

Results section- Lines 162-225 describe all of the results of the self-created survey. These results may be better presented in a table and the key findings highlighted in the text of the results section.

#10 Response:

Thank you for this comment. Indeed, there is much data in the text. We tried to present it in the table but there are totally different issues raised in particular part of the text referring to the factors that we assessed in the survey, so one table would not be possible. This could lead to plenty small tables. At the same time, we believe that presenting all this data gives better background for the reader and better describes the studied population. We have added the table on potential concerns of students regarding the voluntary work in the COVID-19 health-care units.

#11 Comment:

Figure 1 should have a label on the X-axis

#11 Response:

Thank you for this remark. The x-axis label has been added in Figure 1.

#12 Comment:

It is unclear how the “resilience score” correlates with the 6 categories of resilience in Figure 1 (very low, low, on the low end, moderate, moderately high, high). Placing a legend in the figure may help clarify this.

#12 Response:

Thank you for this suggestion. The score ranges for each resilience level have been added in the Methods section.

#13 Comment:

Results section- Lines 236-262 describe the correlation between the resilience score and medical student characteristics gathered in the self-created survey. These results may be better presented in a table and the highlights discussed in the results section.

#13 Response:

Thank you very much for this remark. Some of these results are presented in the figure (Figure 2), the rest is presented in the table (Table 3).

#14 Comment:

Results section- Lines 280-287 describe the correlation between burnout and medical student characteristics gathered in the self-created survey. These results may be better presented in a table and the highlights discussed in the results section.

#14 Response:

Thank you for this remark. Due to different types of variables we had to use different tests to compare these parameters (Chi-square and t-test). This could lead to confusion if we present these two types of variables in one table.

#15 Comment:

Figure 2- the meaning of the 2 or 3 stars/dots in the figure is unclear. Please explain

#15 Response:

Thank you for this remark. The stars refer to the p values. The clarification has been added in the legend of the figure.

#16 Comment:

Line 296-297- The description of the MSWBI score range and meaning should be in the methods section.

#16 Response:

Thank you for this remark. The correction has been applied.

#17 Comment:

Lines 319-321- This was a one-time survey completed during the pandemic, therefore, you don’t have a baseline measure of resilience, burn out and well-being before the pandemic. Therefore, the statement that “2/3 of the respondents presented lower levels of resilience indicated a problem with ability to maintain or regain mental health while experience adversity such as a global pandemic” is not possible because you don’t know what their baseline level of resilience was before the pandemic.

#17 Response:

Thank you for this remark. By using “lower levels” we did not mean “lower than before the pandemic” but “on the lower end of the scale” (‘very low’, ‘low’, ‘on the lower end’) what may be confusing. We have corrected the sentence so now it reads: “2/3 of the respondents presented low levels of resilience indicating a problem with ability to maintain or regain mental health while experience adversity such as a global pandemic”.

#18 Comment:

Lines 324-326- What are potential reasons the 1st and 6th year students had the lowest resilience?

#18 Response:

Thank you for this question. Potential reasons the 1st and 6th year students had the lowest resilience are now provided in the Discussion section.

#19 Comment:

The Discussion is limited to a discussion about resilience and suggestions to improve education about resilience in medical education. Please expand the discussion to also comment on burnout and well-being.

#19 Response:

Thank you for this suggestion. The discussion has been expanded as suggested.

#20 Comment:

Please expand on other limitations of the study aside from the survey being online and the author bias of the self-created survey questions.

#20 Response:

Thank you for the suggestion. The most important limitation is no possibility to compare our results with the pre-pandemic landscape, what is enumerated in the Discussion section. Besides, sampling and desirability biases are explained in more detail with regard to our study.

Submitted filename: Resilience Responses to Reviewers.docx

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9 Dec 2021

Polish medical students facing the pandemic – assessment of resilience, well-being and burnout in the COVID-19 era

PONE-D-21-26801R1

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Reviewers' comments:

14 Jan 2022

PONE-D-21-26801R1

Polish medical students facing the pandemic – assessment of resilience, well-being and burnout in the COVID-19 era

Dear Dr. Nowicki:

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