and avoid over burning the nation's health system as much of the virus remains unknown and obscured [1] . Fortunately, the 3-month-MCO has shown promising success with steady reduction of local cases and 48 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
The copyright holder for this preprint this version posted July 8, 2020. . https://doi.org/10.1101/2020.07.07.20147918 doi: medRxiv preprint introduction of recovery MCO which is part of the exit strategy that allows resumption of most economic 49 sectors. Despite Malaysia is currently under recovery stage, there is no doubt that the COVID-19 50 pandemic has not only affected the global health and economy, but also the world of education. Up to 140 51 country-wide closures of schools and universities affecting more than 1 billion students were reported by 52 the United Nations Education, Scientific and Cultural Organization (UNESCO). There is no exception to 53 Malaysia as all learning is forced to move onto online space since the commencement of MCO.
Regardless of the reopening of economic sectors, the Ministry of Higher Education Malaysia has 55 announced that online learning will be continued in all universities until 31st of December 2020. The 56 sudden shift away from conventional medical education into solely virtual learning possesses a great 57 challenge for both medical educators and medical students as medicine is well-known to be an evidence-58 based field that involves internships or clerkships to learn from real patients [2] . Apart from that, issues 59 concerning internet connection and unavailability of clinical equipment among medical students further 60 increase the pressure and challenge in delivering medical education. Nevertheless, looking at the bright 61 side, the COVID-19 pandemic has actually created a platform for medical educators to be more creative 62 and innovative, exploring new learning designs or pedagogies to provide medical students with the best 63 possible learning experiences [3] . Learning has also become more student-centered, encouraging self- CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)
The copyright holder for this preprint this version posted July 8, 2020. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)
The copyright holder for this preprint this version posted July 8, 2020. was used, and respondents were asked to rate their agreement for each statement as follows: 1=strongly 114 disagree, 2=disagree, 3=no opinion, 4=agree, and 5=strongly agree. Out of a total of 35 questions, there 115 were nine that were reverse items (Question 2, 4, 5, 6, 7, 21, 22, 23, 24). The questionnaire has been 116 modified for medical students and minor adjustments in grammar were made to avoid confusion among 117 the medical students (S1 Appendix). A pilot study was done on 35 UKM medical students (Cronbach's 118 Alpha; =0.91). Demographic data and education background of samples were collected including age of 119 the respondents, year of study, and phase of study. Respondents were also required to rank their 120 preferred choices of digital learning source and choose their frequency of digital learning usage. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)
The copyright holder for this preprint this version posted July 8, 2020. . https://doi.org/10.1101/2020.07.07.20147918 doi: medRxiv preprint p<0.05. A summary of social demographic, education background variables, and frequency of digital 130 learning usage was done using descriptive analysis of frequency. The relationship between total score as 131 dependent variable and education background as independent variables was analyzed using cross 132 tabulation analysis. All the variables were transformed by labelling into categorical variables. Descriptive 133 analyses were included for frequencies and percentages of digital learning usage while Student's t-test 134 and Chi-Square analysis were utilized to determine the difference between groups for selected variables. Table   141 1. 
The frequency of digital learning usage was being divided into 5 groups; does not use, use less 145 than 1 time per week, 1 to 2 times per week, 3 to 4 times and more than 5 times per week. Respondents 146 rated the frequency based on their usage other than regular classes purposes. During the pre-COVID 147 period, most of the respondents (50%) used digital learning more than 5 times per week and there was a 148 small proportion (6%) of respondents never used digital learning. However, during the COVID-19 period, 149 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)
The copyright holder for this preprint this version posted July 8, 2020. . https://doi.org/10.1101/2020.07.07.20147918 doi: medRxiv preprint as medical education has fully transformed to entirely online teaching and learning, all respondents have 150 employed digital learning in their studies with an increased number of respondents using more than 5 151 times per week (58.55%) as compared to 50% prior to the COVID-19 outbreak ( Fig 1A) . As most of the 152 UKM medical students had an average of 2 to 3 teachings, group discussions or lab sessions per week, 153 hence the frequency of digital learning usage was further divided into high usage (use at least 3 times 154 and above per week) and low usage (use less than 3 times per week). Overall, most of the respondents 155 had high usage before and during COVID-19 period and there was a rise in high usage during COVID-19 156 period (86.8%) as compared to pre-COVID-19 period (76.7%) (Fig 1B) . Difference in digital learning 157 usage between pre-COVID-19 and COVID-19 period was assessed using Chi-Square analysis ( Fig 1C) 158 which showed a significant difference (p<0.05) as students during the COVID-19 period had a higher 159 frequency of digital learning usage as compared to prior COVID-19 period. Among all the respondents 160 who use digital learning, e-books were the most preferred choice for the source of digital learning 161 (40.67%) while audiotapes (6.00%) was the least preferred one before the COVID-19 period. However, 162 videos (38.16%) were the most preferred choice during COVID-19 period. A reduction in preference for e-163 books (36.84%) and online research articles (11.84%) with an increase in preference for videos (38.16%), 164 online courses (21.05%), games (16.45%), simulation software (11.84%) and audiotapes (9.97%) were 165 noted during this pandemic period ( Fig 1D) . 
Descriptive statistics were used to provide an overall picture of the learning motivation of this 169 study. Based on the total motivation score, the students can be grouped into 3 levels of motivation; "Low", 170 "Moderate", and "High" as previously mentioned [21] . As for prior to COVID-19 period, the samples were CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
The copyright holder for this preprint this version posted July 8, 2020. . https://doi.org/10.1101/2020.07.07.20147918 doi: medRxiv preprint percentage of respondents with high learning motivation (67.80%) (Fig 2A) . Difference in level of learning 178 motivation among different variables was analyzed using the Student's t test. Results showed that the 179 level of learning motivation was significantly different (p<0.01) across the frequency of digital learning 180 usage during the COVID-19 period as higher total scores were obtained with higher frequency of digital 181 learning usage ( Fig 2B) . Nevertheless, the level of learning motivation between before and during 182 COVID-19 period (Fig 2A) , and level of learning motivation across frequency of digital learning usage 183 prior to COVID-19 period showed no significant difference ( Fig 2B) . We have gathered feedback and reflections and further collated them into 11 emerging themes 201 that featured the learning motivation of UKM medical students during COVID-19 period (Table 2) , which 202 were further summarized into 2 main themes; intrinsic and extrinsic motivations (Fig 4) . Intrinsic 203 motivation in learning refers to the action of self-learning because of inherent interest or satisfaction, 204 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
The copyright holder for this preprint this version posted July 8, 2020. . https://doi.org/10.1101/2020.07.07.20147918 doi: medRxiv preprint whereas extrinsic learning motivation pertains to learning to attain some other outcomes that are 205 unrelated to the action. We labelled respondents as "R" in our transcripts.
206 Table 2 . Quotes from respondents to highlight main themes of learning motivation.
Emerging theme Main theme "I set up a to-do list every day and focus on things I want to study in small sessions." (R2)
Intrinsic motivation "Regardless whether we're in difficult times, learning is a continuous journey, the one that can only stop you from learning new knowledge is your own self." (R12)
Self-discipline "Very badly. No motivation most of the day" (R29) Self-adaptation "To pass the year and move on" (R139) Feeling indifferent "Weekly teaching and lecture motivate me to understand things better" (R1)
Online teaching Extrinsic motivation "My supervisor is the main reason why I am able to cope with this kind of learning method." (R4)
Lecturer "I watch videos to understand better." (R54) Digital learning using different resources "Always remind myself about the pro exam." (R14) Examination "Ask motivation from friends and family" (R11) Family "By continuously keeping in touch with my friends, making a checklist of the subjects that I need to cover, having a conducive study area, online group study with friends." (R31) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
The copyright holder for this preprint this version posted July 8, 2020. 
For example, one remark was, "Ask motivation from friends and family." (R11) 257 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
The copyright holder for this preprint this version posted July 8, 2020. (Table 3) , consisting of a total of 18 emerging themes, which were further summarized into 5 main themes (Fig 5) . "We need virtual reality; it will make it a lot more fun but then again not realistic at all" (R51)
Virtual reality "Hope University expands and adds more resources to online medical courses (subscribe e.g. UpToDate)."
Learning apps . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
The copyright holder for this preprint this version posted July 8, 2020. 278 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
The copyright holder for this preprint this version posted July 8, 2020. History taking can be carried out by doing video conferencing with patients whose condition was stable to 296 be interviewed as suggested by two students. Learning via simulation software was also mentioned by 23 students.
. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
The copyright holder for this preprint this version posted July 8, 2020. . https://doi.org/10.1101/2020.07.07.20147918 doi: medRxiv preprint skills" (R14) 304 Three responses suggested virtual reality to replace the clinical exposure learning for medical students.
"We need virtual reality; it will make it a lot more fun but then again not realistic at all" (R51) 306 There were two students who wished to subscribe to more learning apps during this COVID-19 period. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
The copyright holder for this preprint this version posted July 8, 2020. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
The copyright holder for this preprint this version posted July 8, 2020. Previously, it has also been reported that there was no 400 significant difference in the level of intrinsic motivation among medical students who participated in high-401 fidelity mannequin simulation, as the medical students were found to be originally highly intrinsically 402 motivated [37] . This was well reflected by our medical students who portrayed intrinsic motivation, mainly 403 self-motivation, and self-discipline in coping with this tough time. For instance, some of them will motivate 404 themselves to keep on learning by recalling the actual intention of the onset of medical pursuit while some 405 laid out an organized study plan with daily learning objectives and they would adhere to it to ensure that 406 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
The copyright holder for this preprint this version posted July 8, 2020. . https://doi.org/10.1101/2020.07.07.20147918 doi: medRxiv preprint they learn something every day. However, the significantly higher learning motivation with high digital 407 learning usage during the pandemic period could be explained as online learning being the only source of 408 learning during COVID-19. Thus, medical students with pre-existing high intrinsic motivation will use all 409 available resources for their study and lean towards digital sources. times. This may be due to the sudden change in learning environment and methodology thus the need to 426 adapt with such changes. Reflections from our medical students stated that the unconducive learning 427 environment at home was a discouraging factor. This could be due to inaccessibility of certain learning 428 materials such as online research articles or certain online learning platforms that are only accessible at 429 the university area. Hence, we propose that more online learning platforms like UpToDate and full text 430 journals should be subscribed by the university and more importantly, these should be accessible without 431 any time and place restrictions. Besides, as suggested by our students, an ideal LMS that enables 432 students to access all learning materials while encouraging discussions between lecturers and students 433 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)
The copyright holder for this preprint this version posted July 8, 2020. . https://doi.org/10.1101/2020.07.07.20147918 doi: medRxiv preprint via online assessments such as quizzes and viva sessions are required if the university were to embark 434 on a successful digital learning experience.
This study was conducted with a few potential limitations. Since this was a cross-sectional study, 
. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)
The copyright holder for this preprint this version posted July 8, 2020. . https://doi.org/10.1101/2020.07.07.20147918 doi: medRxiv preprint