This study aimed to evaluate the relationships among spirituality, empathy, and resilience in medical students. We observed that medical students with high spirituality had higher scores for both resilience and empathy. In addition, we observed higher levels of both spirituality and empathy, but not resilience, in female medical students than in male medical students. In contrast, we did not detect significant differences in spirituality, empathy, or resilience among students in different years of medical school. Medical school is a six-year medical program in Brazil. The first four years are basic and clinical studies, and the last two years are clerkships (internships). In this study, we evaluated only students in the first four years of the medical course. The sample was composed of 63.3% female students, reflecting the current profile of Brazilian medical schools.
Spirituality is a complex concept that varies considerably depending on cultural, religious and academic influences. In recent decades, spirituality has become increasingly important in health care and health profession education since it has been found to be related to less substance use, a lower incidence of depression, better ability to cope with disease and treatment adherence, and lower mortality rates (20–22). Although there is a relationship between religiosity and spirituality, we decided to adopt the nonreligious definition of Koenig et al. when asking medical students indicate their different levels of spirituality (1, 19). We did not observe any significant differences in the level of spirituality among students in different years of medical school (Table 2), suggesting no change in spirituality during medical school. However, more female medical students considered themselves highly spiritual (36.3 women vs. 25.6% men, P < 0.001).
Previous studies have shown that high levels of spirituality are related to a better prognosis, greater adherence to treatment, easier decision-making, and more ethical values (1, 19, 22). Supporting the understanding of other people's suffering also favors clinical care by bringing compassion to relationships with patients in all types of scenarios (23). During medical school, spirituality may be protective against burnout and psychological suffering. Wachholtz and Rogoff (24) observed that students with higher levels of spiritual well-being and daily spiritual experiences described themselves as more satisfied with their life in general, while students with low scores had higher levels of psychological distress and burnout. Lucchetti et al. (25) concluded that many medical students believe that spirituality has an influence on patients’ health and want to address this in clinical practice. Nevertheless, the majority feel they are unprepared to do so and that medical school does not provide the necessary training. These results suggest that there is a gap between students’ attitudes/needs in this area and the training they are receiving.
The concept of resilience was imported from physics and is used to designate the capacity of a material or body to suffer stress or the imposition of external pressure and return to its original state without becoming deformed after the stimulus of the stressor is withdrawn. In a transdisciplinary context, this term is used in physiology and psychology to refer to a person’s capacity to resist adversity without developing physical, psychological, or social disabilities (6). Resilience is an emotional competence and can be considered a behavior that can be acquired and improved. It has been suggested that resilience involves cognitive processes that encompass at least four dimensions: self-efficacy, planning, self-control, and commitment and perseverance (26). Resilience refers to the ability to deal with life events, view problems as opportunities for personal growth, and recognize limitations as well as personal and collective resources. It also means being able to organize strategies through self-reflection, creativity, optimism and humor and being flexible and able to act with responsibility and ethical awareness (6, 26). In recent years, resilience (from the psychological perspective mentioned by Howe et al.) has been assimilated by health sciences and is associated with better outcomes in health promotion, well-being and quality of life (7, 27). In this context, resilience may be linked to improved academic and professional performance. In a recent study involving a large number of medical students from twenty-two medical schools, we showed that medical students with higher resilience scores have better quality of life and better perceptions of the academic environment (7).
We reasoned that spirituality may play a role in resilience. This hypothesis prompted our group to study the relationship between spirituality and resilience. Because a high prevalence of anxiety and depression among medical students has been reported as a result of academic pressure, workload, financial hardship, sleep deprivation and other stressors, it is important to identify coping strategies (28). Spirituality can be considered an important resource throughout training that provides support and coping skills for students who experience situations involving emotional stress and relational conflicts in addition to facilitating a better balance between personal life and work. (21). However, this topic has not been well explored in the curriculum and is present mainly in discussions about ethics, palliative and critical care, end-of-life care and some chronic diseases with poor prognoses (3, 25, 29). By observing the statistically significant associations between spirituality and higher resilience and empathy scores, the importance of safe spaces to approach spirituality in both medical training and practice becomes clear. There are already some initiatives to include spiritual history taking in the initial years of courses as a component of communication skills (29, 30).
Empathy is an important component of medical professionalism and has frequently been associated with improvements in health outcomes and quality of care in clinical practice (31–33). Empathy is the ability to share, understand and respond with care to the experiences of others (14, 34, 35). Empathy involves cognitive and emotional reactions, such as actively listening to, identifying, and understanding the concerns and emotions of others and conveying this understanding.
Our results did not show an association between scores for empathy and course years, suggesting that empathy does not vary substantially during the medical course. A systematic review showed inconclusive results regarding changes in the level of empathy throughout years of study (36). It has been suggested that the changes in empathy during medical school observed in previous studies depend on the region of the world studied (37).
Aspects related to the hidden curriculum are also strongly related to levels of empathy among students, and formal empathy training and activities should be stimulated (38, 39). One notable issue is that some behaviors capable of mitigating psychological stress, such as choices that can improve quality of life, may interfere with the level of empathy; openness to spirituality may be one of these behaviors (5).
We decided to use the two most commonly used questionnaires, the Jefferson and Davis Scales, to evaluate empathy in medical students. We adopted a framework that considers empathy to be a multidimensional construct that consists of cognitive and affective components (15). All domains of the Davis Scale showed significantly higher scores for female medical students than for male medical students (Table 1), and empathetic concern and perspective taking were at a higher level for medical students with high levels of spirituality (Table 3). One possible factor that explains the association between spirituality and empathy is that these concepts may overlap since they are associated with connection to others or the practice of helping people. In addition, many questions in the resilience inventory explore beliefs that can be connected to 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). The items with greater differences between the two groups are related to the meaning or purpose of life and are characteristic of the concepts of resilience and spirituality.
The development of educational activities to stimulate reflection about spirituality, empathy and resilience during medical courses is considered pivotal for the development of an ethical professional identity for medical students and physicians in training. In medical education, discussing spirituality as connected to people (classmates, teachers and patients) and the world can be a good strategy for stimulating respect for equity, diversity and inclusion in medical schools and in the health system (3, 6, 8, 10, 40, 41).
Our study has several strengths. It was multicentric, included medical schools in different regions of the country and included a large group of students who were in their first and clinical years. To ensure completion of the long questionnaire, only students present in the classroom were invited to participate in the study. One limitation of the study is its cross-sectional design and lack of follow-up of the participants involved.