Motivation for Volunteering
Our study found that a particular medical student’s motivation for volunteering during the COVID-19 pandemic is a combination of altruism, available time, self-serving nature, and external pressures. In our study, 67.6% of medical students volunteered of their own volition without school-required participation in such efforts. Generally, medical school recruitment is contingent upon prospective students demonstrating altruism.13 Similarly, our findings suggest that altruism is a key motivator in students who volunteered, with 31.38% indicating serving the community as one of the three primary factors in their decision to volunteer (Figure 2). Additionally, students who volunteered had statistically higher interest in serving the community than those who did not volunteer.
A sense of obligation to community is not the only motivation for students to volunteer. Self-serving motivators, including additional research opportunities, networking, and benefit to residency applications, account for almost one fifth of the key factors that influence a student’s decision to volunteer. Interestingly, these motivations may explain the drastic difference in volunteering participation between third-year medical students, who experience the added pressure of residency applications, and fourth-year medical students, who have already secured residency positions: 80.7% of third-year medical students in the study cohort volunteered while only 53.4% of fourth-year medical students volunteered (Supplemental Table 2). While both cohorts have substantial clinical training compared to their first- or second-year counterparts, their priorities may vary: the COVID-19 pandemic serves as an extraordinary opportunity for students to boost their curriculum vitae before applying to residency.
Extrinsic pressures to volunteer may result from fellow medical students, faculty, hospital staff, friends, and family members. These pressures were the least influential in a student’s decision to volunteer (Figure 1); however, pressure from other medical students had a higher impact than from friends, family, faculty, or hospital staff. At most medical schools, volunteering efforts during COVID-19 were spearheaded by medical students.5 Thus, medical students may feel the greatest pressure to volunteer from their peers.
Time commitment is an important, yet often overlooked, aspect of volunteering. Interestingly, we found that 11.1% of students who volunteered and 17.11% of students who did not volunteer indicated that this was among the top 3 primary factors in their decision (Figure 2). In this survey, the time commitment variable could be understood as either having enough time or not having enough time for volunteer activities. With educational and clinical obligations, medical students are often limited on time for extracurricular activities and must consider opportunity costs in volunteering. Hours spent volunteering are fewer hours spent on academic development, including studying, research, and extracurricular activities. However, some students may view the time commitment as a necessary cost if they prioritize service or the potential leadership opportunities involved.
A student’s self-selected specialty may reflect their obligation to serve and moral agency. Other studies have found that medical students with a lower degree of altruism are significantly more likely to choose high-income specialties.14 When looking at a student’s self-selected specialty in our study, primary care specialties agreed to a greater extent that physicians have a duty to serve in low risk settings and remote settings than radiology/pathology and other specialties respectively (Figure 4). Overall, altruism may be the main motivation behind student participation in COVID-19 relief efforts, but self-serving motivations are an important secondary consideration.
Assumption of Risk by Students
The AAMC released multiple guidance documents recommending that, where feasible, medical students should be excluded from direct patient care activities for a period of time while medical schools developed plans to safely re-integrate medical students into the clinical space.15 However, even voluntary COVID-19 pandemic relief efforts that do not require interface with patients ask participants to assume some risk. In our study, students who chose not to volunteer considered risk of exposure to themselves or others as significantly more important factors in their decision than students who did volunteer (Figure 1). The AAMC identified the following as barriers to reintegrating students in clinical settings: health insurance status, testing availability, and inadequate personal protective equipment (PPE). These same barriers may also deter students from volunteering in non-clinical settings. For example, medical trainees in the United States have an expectation that appropriate PPE will be available. A primary concern at the onset of the pandemic was PPE scarcity in all settings, as inadequate PPE exposes medical students to heightened risk of exposure to a range of infectious diseases. Similarly, the lack of appropriate masks when delivering groceries or collecting PPE may have also been influences on students’ decisions not to volunteer.
Even with appropriate PPE, there is still a risk of serious illness or death. In April 2020, the Centers for Disease Control estimated that approximately 55% of healthcare workers who developed COVID-19 contracted the virus at the hospital. The median age of our cohort is 25.94 (Table 1), which falls within an age group that carries up to 6.4% risk of hospitalization and up to 3% risk of death related to COVID-19.16 In addition to the risk of significant bodily harm students may assume in volunteering in patient-facing roles during the pandemic, hospitalization or other exclusion from the clinical environment due to COVID-19 may delay a student’s ability to enter clinical rotations, obtain licensure, or even graduate from medical school.
Guidelines for Future Student Involvement
Regardless of whether or not students volunteered in COVID-19 pandemic relief efforts, this cohort of medical students largely believe that clinical students should have the opportunity to volunteer in such efforts. Institutions may utilize the data collected through this study to integrate student perspectives into future medical trainee involvement in pandemic response initiatives. Initiatives which require student presence in the hospital and regular contact with SARS-CoV-2 positive patients should consider balancing educational benefit with trainee risk exposure. Such initiatives should acknowledge the real and perceived pressures felt by medical students in both voluntary and required clinical experiences. Efforts should be made to identify risk mitigation strategies, reinforce institutional non-retaliation policies to protect trainees, and support trainees who require testing, medical care, or extended medical leave due to SARS-CoV-2 infection.
Future Directions
Our survey was distributed to students primarily in May 2020, when medical students were not in the clinical environment. By the end of July 2020, 68% of medical schools returned students to clinical clerkships.17 Now that students are required to return to clinical spaces during a pandemic, their attitudes around serving patients, either in patient-facing or virtual roles, may be shifting and warrant further study. In addition, this survey left the interpretation of “risk” up to the student. Exploring further what trainees and institutions deem “acceptable” risk assumption in the course of medical training is important when considering a student’s duty to serve. As large areas of the United States continue to experience dramatic increases in COVID-19 cases,18 this study is important for directing future involvement of medical trainees in COVID-19 response initiatives.
Limitations
The limitations of this study include the small sample of medical schools to whom our survey was distributed: 23 of the 154 accredited US medical schools received our survey.19 Only 18 students who responded to the survey indicated that they had no opportunities available to volunteer in COVID-19 pandemic relief efforts, which likely does not represent the true proportion of students with this limitation. A few survey responders listed more than three factors in their indication of the top three factors that influenced their decision to volunteer or to not volunteer, and these answers were omitted from our final data analysis.