COVID-19 is considered a global pandemic and has been raging since March 11, 2020 (1), seriously threatening the health of people worldwide. In many countries, there was a serious shortage of medical workers because of the increased demand for professionals to help; consequently, retired doctors were recalled, and medical students were sent to help in the fight against the pandemic. In China, more than 42,600 medical workers went to the most seriously affected areas to help (2). In this sudden public health crisis, doctors renewed their sense of value and honor in the profession. Medical students are a major component of medical reserve forces and must also participate in ensuring the health and safety of the population (3). Therefore, it is important to assess their professional identity and psychological state during the pandemic.

Under stressful situations, individuals have different emotional, cognitive, and behavioral responses. An individual's cognitive evaluation also affects their stress responses (4). The COVID-19 pandemic has had profound mental health consequences for many people (5), especially college students (6). A previous study indicated that medical University students experienced poor mental states during the COVID-19 outbreak (7).

One's professional identity is an individual's professional self-concept based on their beliefs, values, motives, attributes, and experiences (8) and is derived from and perceived in terms of the role that individuals assume in their work. Professional identity is a factor affecting job satisfaction (9). It is an important part of nurturing professionalism among medical students (10, 11) and is related to how strongly individuals identify with their careers. Some scholars also pay attention to the formation and factors that influence medical students' professional identity (12–15). For physicians-in-training, preliminary data suggest that good virtues in medical practice are associated with a strong sense of professional identity (16). Further, career attitude refers to the tendency of medical students to pursue the medical profession in the future; It depends upon different interlinked factors (17) and formed by a matching of perceptions of specialty characteristics with personal needs (18), such as expected salary, intellectual satisfaction, workload, experience during the medical schools, the student values and professional attitude, and so on. Professional identity is an important predictor of continuing to do the job (9). Previous studies have also shown that students' career attitude would be affected by their mental health state (19), depressive symptoms were considered predictors for professional exhaustion which would affected career attitude (20).

Recently, the professional identities of medical students have gradually studied. During the COVID-19 pandemic, some scholars paid attention to the career attitudes (21, 22) and willing to volunteer (23) in medical students; medical students are motivated by a sense of purpose or duty, altruism, perception of good performance and values of professionalism. Previous studies also have focused on the tense physician-patient relationship and violent injuries in China, which may have affected medical students' professional identity (24). To the best of our knowledge, the professional identity and career attitude of medical students in China during the COVID-19 pandemic have yet to be investigated. Therefore, this study has attempted to investigate the changes in medical students' professional identity and career attitude during the COVID-19 pandemic, evaluate their mental health and social support system under stress, and explore the relationship between their career attitude and correlated factors.

A total of 6,226 full-time medical undergraduates aged 18–27 years completed the questionnaires. The median age of the participants was 21 years, of which 60.1% were female. The students came from all provinces of China, except Macau, and 98.6% took the survey at home. A total of 79.0% of the respondents revealed that they would like to participate in the frontline. And 92.0% of them has no 2019-nCoV exposure.

As shown in Table 1, the number of participants who did not change their career attitude was 4,989 (80.1%), while enhanced career attitudes accounted for 741 (11.9%) of the respondents. Students whose career attitude was weakened totaled 496 (8.0%). There were statistical differences among students from different academic years (P < 0.05) and hometowns (P < 0.05).

We then investigated why medical students were willing and unwilling to become doctors. As shown in Figure 1, the top three reasons for willingness to become a doctor were: (1) “Doctors are valuable.” (2) “Being a doctor is my dream.” (3) “Doctors are respected.” The top three reasons for not being willing to become a doctor were: (1) “Doctor-patient relations are strained.” (2) “The workload of doctors is too heavy.” (3) “Being a doctor is stressful.” (Figure 2).

Table 2 includes the results that were obtained using the non-parametric Wilcoxon signed-rank test. In the enhanced group, there was no significant difference in professional achievement before and after the pandemic (P = 0.494); however, the difference was statistically significant for the rest of the groups. In the weakened group, there were significant differences in professional cognition, commitment, achievement, and value.

Scores (cutoff score 5) from GAD-7 and PHQ-9 tests were used to divide respondents into the “anxiety group” and the “depression group,” Based on the GAD-7 and PHQ-9, the prevalence of depression and anxiety among medical students was 22.86 and 35.43%, respectively. A chi-square test showed that there were significant differences in anxiety, depression, and social support among the three groups of medical students with different career attitude (summarized in Table 3).

We set the dependent variable of weakened, unchanged, and enhanced groups to 0, 1, and 2, respectively, and then performed an ordered multivariate logistic regression analysis. The parallel line hypothesis test showed P < 0.05, which indicated that the data could not be analyzed using this method. Therefore, we conducted a disordered multivariate logistic regression analysis. The resultant chi-square value of the model was 139.49 (P < 0.001), which indicated its statistical significance. The pseudo-R2 of Nagelkerke was 0.031, which indicated that the model corresponded, to a certain degree, with the dependent variables (Table 4).

Compared to subjects in the unchanged group, students in junior academic classes of medical school were more likely to enhance their career attitudes, whereas the attitude of freshmen was 1.374 times higher than that of fifth-year students. Subjects whose family members strongly supported them in their fight against the pandemic were more likely to enhance their career attitude than those who were strongly opposed by their family members. The number of subjects who were strongly supported by their families was 2.755 times higher than those whose family members were strongly opposed (Table 4).

Compared to subjects in the unchanged group, males were more likely to weaken their career attitude than females, and medical students with depression were more likely to weaken their attitudes than those with high social support. Students who lived in cities were 1.248 times less likely to practice medicine than those living in rural areas. The results are summarized in Table 5.

The career attitude formed by a matching of perceptions of specialty characteristics with personal needs (18) and the characteristics of students such as age, gender, geography and study year (17). In this study, there were statistical differences among students from different academic years and hometowns. Previous studies have shown that the professional identity of medical students decreases over time (32, 33). At the time of our survey, medical students were staying in their home towns on winter vacation. And medical students from urban resident or rural resident are different, this could be explained by imbalances between economy, culture, and different publicity efforts relating to pandemic prevention knowledge between urban and rural areas (21).

In this study, most (80.8%) of the participants did not change their career attitude, and 741 (11.9%) of the total respondents enhanced their career attitude. This shows that the majority of medical students have a strong desire to become doctors, indicating that they have a strong professional identity. Professional identity is an important factor in the development of medical education and practice, and the transformation of medical students' professional identity is at the core of medical education (11). Those who possess a strong professional identity are more likely to be connected to their line of work and find a greater sense of purpose in life through it (34). In addition, medical students' career attitudes are influenced by their cognition about, attitude toward, and evaluation of their future careers. The formation and evolution of a professional identity is a dynamic process. Before and after the pandemic, most dimensions of professional identity of medical students changed. These findings revealed that COVID-19 pandemic could affect the professional identities of medical students. This finding was similar to that of a previous study, which concluded that nursing students' professional identity was enhanced after the outbreak of SARS in Hong Kong, China (35). After the outbreak of COVID-19 pandemic, one study (36) found that about one-fifth of surveyed medical students currently believe that the COVID-19 pandemic will affect their choice of specialty. Another study found that the percentage of middle-school students who wanted to study medicine increased to 55.1%, and 29.8% of middle-school students had changed from unwilling to study medicine to willing to study medicine, which indicated that middle-school students had changed their attitude toward medical work after the outbreak of COVID-19 (37). Another study (23) showed that 48.7% of Indonesian medical students were willing to volunteer, shortage of medical personnel and sense of duty were the main reasons increasing the students' willingness to volunteer. The professionalism of medical staff during the epidemic may also have been an inspiration. Some scholars (38, 39) found that the role of models and mentors had a significant impact on the professional identity of medical students. Passi and Johnson (40) also indicated that positive role modeling by doctors effectively enhanced the transformation of a student into a doctor. In this study, 79.0% of the students were likely to engage in the “battle” against the virus. This could be regarded as their “post-traumatic growth,” which suggests that exposure to critical events could lead to opportunities for growth (41). According to the survey in this study, “being a doctor is valuable,” “being a doctor is my dream,” and “being a doctor is respected” are the most popular reasons medical students choose to become a doctor. The sense of value and achievement of doctors is still the main reason medical students choose to become doctors.

This study also found that medical students with depression were more likely to weaken their attitude toward medicine, which might be due to a sense of uncertainty about themselves. Previous studies (42, 43) have shown that depression is one of the most common health problems among University students, especially among medical students who endured heavy financial burdens and study-induced stress (44). After the outbreak of COVID-19, 37.0% of Chinese University students experienced depressive symptoms and 24.9% experienced anxiety symptoms (37). The mental health of these medical students could be a predisposing factor for burnout during residency or postgraduate training (45). This might also affect their choice of future career.

Similarly, it was found that strong social support enhanced medical students' career attitudes. This study also established that the attitude of medical students' family members toward fighting the pandemic also affected students' attitudes toward medical practice. Generally speaking, people with high social support had better resources; they received more support and help coping with their working environment and were more likely to solve problems and difficulties. As a resource available to individuals, social support played an intermediary role in coping with stress, and those with good social support could cope better with it (46). The availability of social support reduced the odds of mental distress for those who experienced it (47). Degree of social support was found to be negatively correlated with anxiety and depression among residents (44). In the current COVID-19 outbreak, high social support can effectively reduce anxiety and improve self-efficacy and sleep quality in COVID-19 patients' caregivers (48). Students who lived alone or had poor relationships with their partners, classmates, or friends scored higher on the depression and anxiety scales. Thus, for medical students under stress due to the public health emergency, good social support was conducive to a positive psychological state and encouraged them to continue to engage in the medical profession.

In addition, freshmen, sophomores, juniors, and senior medical students were more likely to strengthen their career attitudes than fifth-year medical students. Previous studies have shown that the professional identity of medical students decreases over time (32, 33). Iqbal et al. (49) also indicated that higher-grade University students were more depressed and had poorer mental health. The reason might be that the higher-grade students have higher levels of stress (50), and they were affected by a heavy academic load and encountered setbacks in clinical internship. On the other hand, the lower-grade medical students had just entered medical colleges and had not yet completely started the study of clinical medicine; thus, they expected much from themselves.

Males were more likely to weaken their attitudes toward medicine. Some previous studies (32, 33, 51) concluded that females reported stronger identification than males. This might be related to the fact that males bore more social responsibilities and economic pressure (52, 53) which bring more pressure or their less seeking help and coping strategies.

The most significant advancement of this study was that it conducted the largest survey of professional identity and career attitude of medical students during the COVID-19 pandemic. Simultaneously, this study discussed the demographic factors of people with different career attitudes in depth and assessed factors related to mental health status. Further research in the field should focus on ways to improve medical students' mental health and enhance their professional identity.

However, this study has several limitations. First, the cases were recruited using snowball sampling. We could not weigh this sample to increase representativeness because statistics on national medical students were not available. Second, medical students reported their professional identity before the outbreak, and the retrospective nature of the study might have caused recall bias. Finally, although the data collection process was anonymous, online surveys could not verify the identity of respondents, and self-reporting might have been accompanied by personal biases.

The COVID-19 pandemic not only effected a crisis but reconstructed the professional identity of medical students. After such a crisis, some medical students' professional identity was enhanced, and they were proud of the profession they had chosen to pursue. However, as illustrated above, this was not the case for all medical students. We should pay more attention to medical students with depressive symptoms, low social support, and higher grades. The utilization of social support by medical students could be strengthened through group coaching, which is an effective method of support (54).

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

The studies involving human participants were reviewed and approved by Ethics Committee of Beijing HuiLongGuan Hospital. The patients/participants provided their written informed consent to participate in this study.

JXC and XJY designed the study, revised the manuscript, and wrote the final version. XJY and LG completed the design of the questionnaire. LBZ and JXC analyzed the data. SYZ, LGZ, and MQ have contributed to data collection. SJZ participated in the revising of the manuscript. JXC received funding support for the research. All authors contributed to the final draft of the manuscript.

This work was supported by Capital Foundation of Medicine Research and Development (Grant Number: 2018-3-2132) and the Special Foundation of Beijing Municipal Science and Technology Commission (Grant Number: Z171100001017001).

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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