**3. Lack of pandemic preparedness: an identified gap in medical education**

While pushing fresh medical graduates to enter into health care system may be beneficial to handle the pandemic, the risks needs to be recognized.

Due to uncertainty and the absence of defined roles in this calamity, the role of students varied across different institutions around the world. While some universities did not allow contact with patients, others deployed final year students or fresh graduates as frontline workers in COVID ICUs and emergencies [10, 11]. In a conventional medical education system, the graduates are gradually introduced to clinical practice in a controlled and supervised learning environment. During clinical rotations their work is mostly passive, shadowing consultants during ward rounds, taking history and observation of clinical procedures. This structure creates a stable learning environment, but it does not necessarily prepare students to function with appropriate level of confidence and skills in a system under crisis. A study conducted among medical students in Ireland found that majority of students (75%) were not confident about their skills for working in an emergency setting [12]. Pre-assessment for an elective on disaster preparedness found 70% participants unprepared to work in an emergency however, this number reduced to 11% after training [13].

Inclusion of students in the health care system without necessary preparation or training can be a serious risk for patients, other colleagues and for themselves. This has been explored in various researches in which students did not have sufficient information to make appropriate clinical decisions in their work setting [14].

The presence of such student volunteers or physician assistants can actually overburden the system capacity and compromise quality of patient care. They can act as vector for virus transmission, deplete resources like personal protective equipment and overstrain teaching faculty or clinicians whose resilience was already at stake in this extraordinary situation [15]. However the balance would still be fluctuating between the duality of providing adequate manpower to the health care system and risk of managing the system with unprepared workforce. A careful and ongoing risk benefit analysis as per situation country wise would lead to practical solutions to overcome this challenge.

## **4. Vulnerability of medical students and trainees to mental health problems**

Implementation of unaccustomed public health interventions like social distancing and lockdown, fear and stigma due to COVID-19, closures of medical colleges, anxiety

from suspension of clinical training and rotations, apprehension about well-being of older relatives and the abrupt switch to the 'New normal' life had a negative impact on psychological health of medical students [16].

The complexity of this challenge is thoroughly evaluated by researchers all over the world. Available evidence suggest that even in pre-COVID times, the mental health of medical students was at a greater risk as compared to the general population [17]. Moreover, graduates and medical students are recognized as vulnerable strata with a high frequency of suicidal ideation and death by suicide. The results of a recent meta-analysis found suicidal ideation to be more prevalent among medical students as compared to qualified doctors [18].

Data from Turkey, Iran, India and European countries like Malta suggest a high prevalence of depression and anxiety in medical students during COVID-19 pandemic [19–23]. However prevalence of anxiety in medical students is found to be similar to pre-pandemic era according to the results of a recent meta-analysis. Sleep deterioration and decreased appetite was commonly reported symptoms [22, 23].

In contrast to stay at home orders, rapid inclusion of recent graduates or final year students in health care system put an additional challenge, the effect of which is yet to be evaluated [24]. Though many students showed great motivation to volunteer their services, however for many the experience was dreadful and altruism alone cannot justify this rapid transition to work**.** A recent research conducted on post-graduate trainees identified anxiety, stress and feeling of helplessness while working in a pandemic [25]. Moreover, disruption of training caused by cancelation of elective rotations, procedures or teaching sessions by supervising faculty could be strong predictors of evoking uncertainty regarding their future career.
