Keywords
COVID-19; medical students; Latin America; critical scientific literature appraisal
This article is included in the Sociology of Health gateway.
COVID-19; medical students; Latin America; critical scientific literature appraisal
In December 2019, a cluster of cases of pneumonia of unknown origin was reported in Wuhan, China and since then, the virus has spread globally. On March 11, 2020, the World Health Organization (WHO) declared coronavirus disease 19 (COVID-19) as a pandemic.1 Researchers throughout the globe have worked arduously to rapidly fill in the gaps of knowledge on this novel disease and this has resulted in an unprecedented surge in scientific production.2 However, the pressure of produce science quickly can cause an overproduction of low-quality research. Notably, before the pandemic, it was estimated that approximately 85% of research was wasted due to flaws in design, methodology or interpretation of the data, and these challenges have been augmented due to the time constraints and poor research infrastructure during the COVID-19 pandemic.3,4
The role of medical students has been diverse throughout history, from being participatory agents in the evolution of medical curricula to being agents of promotion, prevention and treatment of diseases.5,6 Medical students have helped during previous disasters and emergencies such as the Spanish flu outbreak of 1918 and the 1952 polio epidemic in Denmark; and they might have an important role during the COVID-19 pandemic through essential tasks such as assistance in clinical care, telemedicine, and fighting against misinformation.7,8
To provide high-quality healthcare services, future physicians should develop abilities to critically assess research to inform evidence-based decisions during their career, including critical appraisal of scientific literature within the curriculum of medical schools and promoting involvement in research opportunities could help students develop these skills.9–12 Notably, the percentage of student authorship in published articles has increased importantly throughout the years.13
Due to their role, and the unprecedent low quality scientific information, it is indispensable that medical students have enough skills to analyse scientific data. In this study, we intend to identify preferred resources used by medical students in Spanish speaking countries in Latin America to obtain information about COVID-19 and evaluate basic critical appraisal skills through a self-report online survey.
This study was approved by the Independent Review Board at Universidad San Francisco de Quito (2020-033M). Although data was anonymous and did not include identifying information, electronic informed consent was requested before the survey was collected. Participation was voluntary, and medical students were informed that data from the survey would be used for analysis and scientific publication. Participants did not receive any compensation from participating in the study.
This was a multinational cross-sectional study based on a self-report online survey. Participants were medical students currently enrolled in a medical school in a Spanish-speaking country in Latin America. The inclusion criteria required for participation were that they were aged 18 or older, with active student status in a medical school based in a Spanish-speaking country in Latin America, and with Spanish language fluency. Exclusion criteria were non-active student status, medical students from a country where Spanish is not the primary language, and previous participation in the survey.
As we intended to include participants from multiple countries and achieve significant variation in characteristics within our purposive sample, a link to the survey and an accompanying standardized text explaining the purpose of the survey was sent via e-mail from the authors to the initial “point of contact” in each country for further distribution following a snowballing approach. The link to the survey was then shared through different social networks by authors to medical students from their own and other medical schools, and authors instructed participants to share the link with their peers. The survey was distributed to students from different academic years to gather a diverse sample in terms of progress in medical school. We also actively tried to contact students from as many countries in Latin America as possible through e-mails sent to the medical students’ organizations publicly available to ask them to distribute the survey to their members. Data collection took place from October 22 to November 6, 2020. During the first week after the survey was released we obtained a huge amount of the answers, but then there was a very low number of new responses daily, therefore we decided to shorten the period for data gathering.
We designed an electronic survey using the Google Forms web application. The survey consisted of fifteen closed-ended questions to gather basic demographic information and evaluate resources used to obtain information on the COVID-19 and explore knowledge and attitudes that medical students had in terms of scientific information appraisal. The survey was designed specifically for this study by the authors; they included active students, alumni, and faculty with vast experience in medical education and research.
The survey was developed in Spanish and reviewed in a telematic session by all authors to provide feedback about the questionnaire and also to ensure that was appropriate despite regional language variations. In addition, two independent academic advisors reviewed the survey for clarity. At this stage, no changes were required. Then, the survey was piloted in medical students from Ecuador (n=5), Mexico (n=3), and Argentina (n=2), who were mainly friends of the authors, to get their input. Those surveys were not included in the analysis. The pilot suggested very few changes, most related to grammar and punctuation After incorporating the feedback, we deployed the survey. As the survey was originally in Spanish, for readers to understand it, a translation to English was performed by an author (BN) with certified proficiency and then by a native speaker who did not participate in the study (The original version in Spanish and a translated version to English are available as extended data).14
Data captured through the Google Forms web application was exported directly to Microsoft Excel (v. 16.58). An initial descriptive analysis of the responses to the survey to determine demographic characteristics and preferred resources used to gather COVID-19 related information was performed. All variables obtained in the results of the survey were analyzed. There was no missing data as the setting in the online survey did not allow for the submission of incomplete forms. We analyzed the difference in the proportion of correct identification of the concept of a preprint and predatory journals when comparing students based on their self-reported level of knowledge, progress in medical school, public vs. private status of medical school, and inclusion of a scientific literature critical appraisal subject during their curriculum. For data analysis, we decided to group low-medium and advanced-experts’ responses in the self-reported level of knowledge and first-second quarter and third-fourth quarter in progress in medical school responses to create dichotomized variables. Due to the categorical nature of our data, we decided to use Chi-squared tests. A one-tailed alpha value of 0.05 was set. All our statistical analyses were conducted on IBM SPSS version 25 (IBM. Corp., Armonk, N.Y., USA).
By incorporating different stakeholders in medical education (active junior and senior students, alumni, and faculty), and researchers from different countries, we could design a study that contained different valuable perspectives on critical appraisal of scientific information.
Although ET is a professor in one of the medical schools where the survey was conducted, participants were not aware of his role in the research. No economic or academic incentive was offered by any of the authors to the participants.
After data gathering, BN and DA performed an initial statistical analysis and shared the results with the other authors. A researcher not involved in this study was invited to validate the statistical analysis. Additionally, all authors had access to the database and agreed with the final data analysis and processing.
There were 770 valid responses to the survey (Underlying data: Survey results-Scientific literacy and preferred resources used by Latin American medical students during COVID-19 pandemic).14 Almost two-thirds of the participants were females (n=487, 63.2%). Most of the participants were from Mexico (n=283, 36.8%) and Ecuador (n=229, 29.7%). Students equally attended private (n=388, 50.4%) or public universities (n=382, 49.6%). We also found a similar distribution in terms of completed progress in medical school: 24.0% (n=185) in the first quarter, 24.3% (n=187) in the second quarter, 24.9% (n=192) in the third quarter, and the remaining 26.8% (n=206) in the final quarter of medical school. Distribution by gender and country is shown in Table 1.
Most medical students considered that they had a low or medium level of knowledge about COVID-19 (n=539, 70.0%), while 231 participants reported an advanced or expert level (30.0%).
Overall, medical students preferred using evidence-based clinical resources (EBCRs), such as UpToDate or Medscape, to learn more about COVID-19 (n=182, 23.6%), followed by academic journals (n=171, 22.2%), and open access courses provided by entities such as the World Health Organisation (WHO) (n=141, 18.3%). Our survey responses were grouped according to the different sub-regions of Latin America (Table 2).
Regarding the type of article, medical students preferred using case reports or case series (n=218, 28.1%) to learn more about COVID-19, followed by review articles (n=168, 21.8%) (Figure 1).
The critical factor that medical students considered when reading a scientific article was most frequently the affiliation of the authors (n=366, 47.5%), followed by the journal of publication (n=176, 22.85%), the type of study (n=138, 17.92%), and the publication status (preprint vs. published) (n=44, 5.71%).
In terms of receiving news related to the COVID-19 pandemic, medical students preferred official websites of organizations such as the WHO (n=221, 28.7%), followed by scientific journals (n=185, 24.0%), and medical platforms (n=128, 16.6%) (Table 3).
We found that approximately a third of the participants correctly identified the concept of a preprint (n=265, 34.4%), while 243 students (31.6%) correctly identified the characteristic of a predatory journal. On the other hand, 553 students (71.8%) correctly identified the concept of an open-access journal.
Two-thirds of the participants (n=526, 68.3%) had a subject focused on scientific literature critical appraisal as a part of their curriculum during medical school.
We conducted chi-squared tests to identify factors that were associated with a significant difference in the proportion of students that correctly identified the concept of a preprint or predatory journals (Extended data: Frequencies of answers and results of Chi-squares performed).14 We did not find a significant difference when comparing participants in terms of self-reported level of knowledge (low/medium vs advanced/expert) in the chance of correctly identifying the concept of a preprint (df=1, χ2=0.632, P=0.456) or a predatory journal (df=1, χ2=0.435, P=0.554).
Participants from public schools correctly identified the concept of predatory journals (n=142, 37.1%) more frequently than students that attended a private medical school (n=101, 26.0%) (df=1, χ2=11.063, P<0.01); however, there was not a significant difference while identifying the concept of a preprint (df=1, χ2=2.805, P=0.094).
Additionally, we did not find significant differences in the correct identification of preprint (df=1, χ2=0.502, P=0.514) or predatory journal (df=1, χ2=0.694, P=0.406) concepts regardless of the inclusion of a scientific literature critical appraisal subject during medical school. Finally, the proportion of participants that answered correctly was not significantly different for preprints (df=3, χ2=7.124, P=0.068) and predatory journals (df=3, χ2=5.741, P=0.125) despite the progress in medical school (first-second quarter vs third-four quarter).
Overall, most medical students perceived that their knowledge about COVID-19 was either low or medium independently of the current academic year they belonged. This differs from what could be expected in previous studies in which students from superior years were more knowledgeable on COVID-19.15 Medical students preferred using evidence-based clinical resources as their main source for learning about COVID-19. This result is consistent with previous research that shows the popularity of these resources within the medical community.16,17 The use of evidence-based electronic resources has been associated with reduced lengths of stay and mortality rates, and it has resulted in improved performances in standardized examinations.18,19
Most of participants preferred getting news related to the pandemic on official websites by entities such as the WHO and the Centre for Disease Control (CDC), which could be a way to combat the current misinformation outbreak (infodemic). Social media platforms provide users with immediate access to massive amounts of content and are the perfect medium to spread questionable information easily.20 A study showed that fake news is easily spread through Latin American countries through social media platforms, and fact-checking could be a potential solution to fight back against the infodemic.21
Notably, participants mentioned a preference for case series/reports to learn more about COVID-19, followed by narrative reviews and case-control studies. Only 112 participants (15%) preferred systematic literature reviews (SLRs) or metanalyses. The importance of addressing this trend relies on the level of evidence that well-conducted SLRs and metanalysis have compared to case series/reports, which has traditionally been portrayed on the top and the bottom of the evidence pyramid, respectively.22,23 It would be expected that medical students who had exposure to a subject focused on critical appraisal skills during their formation would choose study designs higher among the evidence pyramid, however, our results did not show a significant difference. These could be partially attributed to the fact that during the start of the pandemic most of the articles published were retrospective studies or case reports focusing on patients’ characteristics.2 Remarkably, we found that regardless of the progress in medical school, self-perceived level of knowledge about COVID-19, and the inclusion of a critical appraisal subject in the curriculum, most of the participants could not correctly identify the concept of a preprint or a predatory journal, in spite of the enormous surge in preprint production during this pandemic.24 As well, in our study, only 44 participants (5.71%) chose the publication status (preprint vs published article) as a critical factor when reading an article. This is concerning as medical students might fail to recognize that preprints are preliminary reports that have not been peer-reviewed and might contain faulty or low-quality information.25
Additionally, as medical students are more frequently involved in research, they could be potential targets for predatory journals that promise easy and rapid pathways to publish, through unethical practices, which could further contribute to the infodemic.13 As expected, predatory journals have exploited the uncertainty and prolonged reviewing and editing processes by multiple scholarly journals due to the pandemic to increase their profits.26–28 A previous study conducted in the Kingdom of Saudi Arabia and New Zealand also revealed a poor understanding of medical students regarding predatory journals.29
The main limitation to our study is the sample size, particularly in some of the Spanish-speaking countries in Latin America, which could be related to the short time that the survey was available or ineffective sampling strategies for some specific countries. The chain-referral sampling method employed, despite its pragmatism, is a significant limitation, as the sampling is non-random due to the referral process, in which the sample is dependent on the researchers’ contacts, which is reflected by the significantly higher proportion of participants from Mexico and Ecuador. As well, there is uncertainty of whether the sample is representative of the target population. Furthermore, participants could be susceptible to subject bias and might have elected responses that seemed more appropriate for a medical student.
This study is novel in its approach to identify sources used by Latin American medical students to learn about COVID-19 and to evaluate critical appraisal skills used to interpret new scientific information. Additionally, even though we had difficulties in sampling medical students from certain nationalities, we did recruit an equative number of medical students representing different stages of medical degree completion. Our results support the need to reinforce training in critical appraisal of scientific literature during medical school.30,31
Throughout history medical students have an important role, and the COVID-19 crisis is not an exception. Our study found that most of medical students have good behaviours regarding acquire new information related to COVID-19 such as using evidence-based clinical resources to learn about COVID-19 and official websites of recognised organizations to receive news. However, they have problems in terms of correctly identifying predatory journals or preprint articles independently of the region, self-perceived level of knowledge, progress in medical school, or literature critical appraisal classes. Besides, these students prefer a study design that is not at the top of the evidence pyramid. Our findings could provide insights into the need to reinforce training in critical appraisal of scientific literature during medical school in Latin America.
Open Science Framework (OSF). Scientific literacy and preferred resources used by Latin American medical students during COVID-19 pandemic. https://doi.org/10.17605/OSF.IO/7MS64.14
This project contains the following underlying data:
• Survey results-Scientific literacy and preferred resources used by Latin American medical students during COVID-19 pandemic. (These data contain the answers obtained from the surveys that were applied in medical students about scientific literacy and preferred resources).
• Frequencies of answers and results of Chi-squares performed. (These data include how data was analysed)
Data are available under the terms of the Creative Commons Zero “No rights reserved” data waiver (CC0 1.0 Public domain dedication).
Open Science Framework (OSF). Scientific literacy and preferred resources used by Latin American medical students during COVID-19 pandemic. https://doi.org/10.17605/OSF.IO/7MS64.14
This project contains the following extended data:
• Infodemic survey English version. (These data include the English version of the survey that was applied to medical students from Latin American Countries)
• Infodemic survey Spanish version. (These data include the original Spanish version of the study that was used in medical students from Latin American Countries)
Data are available under the terms of the Creative Commons Zero “No rights reserved” data waiver (CC0 1.0 Public domain dedication).
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Is the work clearly and accurately presented and does it cite the current literature?
Yes
Is the study design appropriate and is the work technically sound?
Yes
Are sufficient details of methods and analysis provided to allow replication by others?
Yes
If applicable, is the statistical analysis and its interpretation appropriate?
Yes
Are all the source data underlying the results available to ensure full reproducibility?
Yes
Are the conclusions drawn adequately supported by the results?
Yes
Competing Interests: No competing interests were disclosed.
Reviewer Expertise: Virology, infectious diseases
Is the work clearly and accurately presented and does it cite the current literature?
Yes
Is the study design appropriate and is the work technically sound?
Yes
Are sufficient details of methods and analysis provided to allow replication by others?
Partly
If applicable, is the statistical analysis and its interpretation appropriate?
Partly
Are all the source data underlying the results available to ensure full reproducibility?
Yes
Are the conclusions drawn adequately supported by the results?
Partly
Competing Interests: No competing interests were disclosed.
Reviewer Expertise: psychosocial
Alongside their report, reviewers assign a status to the article:
Invited Reviewers | ||
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Version 1 21 Mar 22 |
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Provide sufficient details of any financial or non-financial competing interests to enable users to assess whether your comments might lead a reasonable person to question your impartiality. Consider the following examples, but note that this is not an exhaustive list:
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