This study aimed to evaluate the relationship between spirituality, empathy, and resilience in medical students. Medical students with higher spirituality were found to have higher scores in both resilience and empathy. Furthermore, female medical students were found to have higher levels of both spirituality and empathy, but not resilience, than male medical students. In contrast, no significant differences were found in spirituality, empathy, or resilience across years of medical school.
Medical school in Brazil is a 6-year medical program. The first 4 years are basic and clinical studies, and the last 2 years are clinical training (“internship”). The medical schools studied have a curriculum that integrates basic research, clinical research, and social sciences from the first to the fourth year of the medical program. Medical students have early contact with patients and the community from the first semester under the supervision of preceptors and faculty. The last 2 years of medical school are called “internships” and include rotations in which medical students are responsible for the direct treatment of patients under the supervision of medical staff. This study only assessed students in the first 4 years of the medical program. As we aimed to evaluate students in the basic/clinical years, i.e. before they are responsible for the direct treatment of patients, we decided to study medical students before their “internship”. The sample was composed of 63.3% female students, reflecting the current profile of medical schools in Brazil.
In Brazil, medical school is accessible immediately after completing the equivalent of high school. However, more and more people are deciding to continue medical school at an older age. In our study, 341 medical students (24.9% of the total) were over 30 years old. We compared the values of resilience, empathy, and spirituality of these medical students with those of younger medical students and found no significant differences (data not shown).
Although there is a relationship between religiosity and spirituality, when asking medical students to indicate different levels of spirituality, we decided to adopt the non-religious definition of König et al. [1, 19]There were no significant differences in the level of spirituality among students according to their year of medical school (Table 2). However, female medical students were more likely to consider themselves very spiritual (36.3% female vs. 25.6% male). P< 0.001).
Previous studies have shown that higher levels of spirituality are associated with better prognosis, adherence to treatment, easier decision-making, and more ethical values. [1, 7, 19]Understanding the suffering of others brings compassion to patient relationships in all situations and also informs clinical care. [26]During medical school, spirituality may protect against burnout and psychological distress. [27] Lucchetti and colleagues observed that students with higher levels of spiritual well-being and daily spiritual experiences rated themselves as more satisfied with their lives in general, whereas students with lower scores reported higher levels of psychological distress and burnout. [28] We conclude that many medical students believe that spirituality influences patient health and would like to address this issue in clinical practice; however, the majority feel ill-prepared to do so and that their medical school does not provide them with the necessary training. These results suggest a gap between students’ attitudes and needs in this area and the training they are receiving. We suggest that spirituality should be an important part of medical curricula and that medical students should be prepared to consider the important influence of spirituality on patients’ health and responses to medical care.
Resilience refers to the ability to cope with life events, see problems as opportunities for personal growth, recognize limitations as well as individual and collective resources, organize strategies through self-reflection, creativity, optimism and humour, and be flexible, responsible and ethical in all that we do. [9, 10]In recent years, resilience has been gaining attention from a psychological perspective, as explained by Howe et al. [12]has been incorporated into health science and has been shown to lead to improved health, well-being and quality of life. [11, 29]In this context, resilience may lead to improved academic and professional performance. A recent study of a large number of medical students from 22 medical schools showed that medical students with higher resilience scores had a better quality of life and better perceptions of the academic environment. [11].
We hypothesized that spirituality may play a role in resilience. This hypothesis prompted our group to study the relationship between spirituality and resilience. With a reported high prevalence of anxiety and depression among medical students as a result of academic pressure, workload, financial difficulties, lack of sleep, and other stressors, identifying coping strategies becomes important. [30]Spirituality is seen as an important resource throughout the training, providing support and coping skills to students who experience situations involving emotional stress or interpersonal conflict, and facilitating a better balance between personal and professional life. [6]However, this topic has not been adequately explored in the curriculum, appearing mainly in discussions of ethics, palliative and intensive care, end-of-life care, and chronic diseases with poor prognosis. [3, 28, 31, 32]There are already some efforts to incorporate an understanding of spiritual history into the first year of courses as part of communication skills. [32, 33].
Empathy is a key component of the medical profession and is frequently associated with improved health outcomes and quality of care in clinical practice. [34,35,36,37]Empathy is the ability to share, understand, and respond compassionately to the experiences of others. [5, 36, 37]Empathy involves a cognitive and emotional response of actively listening, identifying, understanding, and communicating that understanding of the concerns and feelings of others.
Our results did not show any significant differences between empathy scores and years of course. Systematic reviews have not shown conclusive results regarding changes in levels of empathy through years of study. [38]Some studies suggest a decline in empathy, while others suggest no change. Previous studies have suggested that the changes in empathy observed during medical school vary depending on the region of the world studied. [39]A possible reason for the lack of change in empathy among medical students is that in the medical schools studied, contact with patients and the community occurs early on under the supervision of supervisors and faculty, and professional values are an important aspect of the curriculum from the very beginning of the medical program.
We decided to use the two most commonly used questionnaires to assess empathy in medical students: the Jefferson Scale and the Davis Scale. The Davis Scale contains questions about empathy in general, while the Jefferson Scale contains questions about the medical profession. We adopted a framework that considers empathy as a multidimensional construct consisting of cognitive and affective components. [21]Female medical students scored significantly higher than male medical students in all domains of the Davis scale (Table 1), and empathic concern and perspective taking were at higher levels in medical students with higher spirituality (Table 3). One possible factor explaining the relationship between spirituality and empathy is that these concepts may overlap, as they relate to connecting with others and the practice of helping people. Furthermore, many questions in the Resilience Inventory explore beliefs that can be associated with the concept of spirituality. To explore this hypothesis, we compared each item between students with high spirituality and those with low or no spirituality (Table 4). Items with greater differences between the two groups were related to meaning and purpose in life, which are characteristic of the concepts of resilience and spirituality.
The development of educational activities that encourage reflection on spirituality, empathy, and resilience during the medical course is considered crucial to the development of ethical professional identity for medical students and physicians-in-training.In the United States, osteopathic medical schools have always considered the spiritual dimension of medicine. [40]In medical education, discussing spirituality in relation to people (classmates, teachers, patients) and the world can be a good strategy to promote respect for equity, diversity, and inclusion in medical schools and health care systems. [3, 9, 12, 16, 41,42,43,44,45].
Our study has several strengths: it was a multicenter study, involving medical schools in different parts of the country, with a large group of students in their first year and during their clinical training. To ensure that a long questionnaire could be completed, only students in the classroom were invited to participate in the study. One of the limitations of this study is the cross-sectional design and the lack of follow-up of the participants involved.
