Spirituality of medical students: associations with empathy and attitudes in the doctor-patient relationship

Introduction: Currently, the study of the factors that improve interpersonal relationships in patient care and medical education has been considered relevant and necessary. Understanding what precedes empathy and medical interns’ and young doctors’ attitudes is a relevant topic for health professionals’ education and for their academic and professional performance. Although patients and medical students have indicated that spirituality is an important issue, it is not frequently addressed in medical schools. Objective: This study aims to verify the association between (i) well-being related to spirituality, religiosity and the medical interns’ and residents’ personal beliefs and (ii) empathy and attitudes in the doctor-patient relationship. Methods: This was a quantitative, cross-sectional, observational study. A total of 64 undergraduate students in the last years of medical school and 50 residents answered the following self-administered instruments: WHOQOL-SRPB, Jefferson Scale of Empathy, and Patient-Practitioner Orientation Scale. Descriptive statistics, Pearson’s correlation and stepwise linear regressions were used to analyze data. Results: Significant correlations (p<0.05) varying from weak (r=0.10) to moderate (r=0.39) were found. The WHOQOL-SRPB final score affected the global score of empathy (R2 = 0.12; p <0.00; VIF=1.00). The component meaning and purpose in life affected the global score of the patientcentered attitude (R2= 0.14; p <0.00; VIF=1.00). Conclusions: Spirituality, religiosity and personal beliefs are associated with patient-centered attitudes and medical interns’ and residents’ empathy. In general, well-being related to spirituality preceded empathy, and the component meaning and purpose in life preceded patientcentered attitudes. These results imply the need to consider well-being related to spirituality in interns’ and residents’ education for a better doctor-patient relationship.


INTRODUCTION
In the last decades, re-humanizing medicine has received a widespread concern. The influence of the biomedical model, which has been hegemonic for fourteen centuries, promotes a disease-centered approach, instead of a person-centered care 1. Since the 20th century, the psychosocial dimension has reintegrated medical education and health practices. It focuses on the construction of a biopsychosocial model, as opposed to the biomedical model. The biopsychosocial model perspective points out the need for doctors to improve their relational skills 2 . Thus, empathy in the doctor-patient relationship, patientcentered care and humanistic medical care are essential and central professional characteristics and skills for doctors 3 .
Empathy is a multidimensional construct in the cognitive, emotional and behavioral domains [4][5][6][7] . Higher levels of empathy perceived by patients have a positive correlation with their general satisfaction with doctors, interpersonal trust and higher adherence to treatment 8 , including positive clinical results 9 . Also, lower levels of empathy are associated to a higher probability of medical error 10 .
Patient-centered medicine is one of the main methods used to humanize medicine 11 . It has two principles: personcentered care, which recognizes patients' ideas and emotions towards the disease; and shared decision-making and responsibilities between doctors and patients related to the disease 12 . Patient-centered medicine promotes greater patient and doctor satisfaction and reduces (i) adverse effects associated with prescriptions, (ii) complaints about medical care, (iii) volume of complementary exams, (iv) referrals to specialists, and (v) costs to the healthcare system and to the patient [11][12][13] .
Understanding what precedes empathy regarding the interns' and young doctors' attitudes is a relevant topic in the education of health professionals and in their academic and professional performance. Some factors have already been associated to higher levels of empathy and person-centered care, such as the female gender 5,14 , the first years of medical school 15 and the students' psychosocial issues in the beginning of the medical course 16 , working on person-centered medical specialties 17 and primary care 18 . Egalitarianism, global selfesteem and well-being are positively related to empathy and a patient-centered attitude 19 . Two studies with medical students analyzed spirituality and empathy as correlated variables 20,21 . Another study showed a positive association between spirituality, care and empathy 22 . A recent study associated quality of life to spirituality in medical students and showed that the component meaning and purpose in life was related to higher levels of empathy 20 . No studies were found associating spirituality or spirituality-related quality of life to patientcentered attitudes in the doctor-patient relationship.
Thus, many associations can be established regarding doctors' attitudes and behaviors in the doctor-patient relationship. However, the relationship between behavioral and cognitive aspects -such as spirituality, religiosity and personal beliefs -with empathy and attitudes in the doctor-patient relationship needs clarification. Concerning the importance of this issue in medical education, this research assesses how the perception of well-being (quality of life) related to spirituality, religiosity and personal beliefs are associated to medical interns' and residents' empathy and attitudes in the doctorpatient relationship. Our hypothesis is that the perception of well-being (quality of life) related to spirituality, religiosity and personal beliefs precedes empathy and the patient-centered care in the doctor-patient relationship.

Statistical Analysis
Descriptive statistics characterized the sample and determined the measures of central tendency and position of the data (mean, median, standard deviation, frequency and percentage). The normality of the data was verified by the Shapiro-Wilks test and the variables will be analyzed considering a normal distribution, as suggested in the literature 30    Cronbach's alpha. The software SPSS 20.0 analyzed the data.
The alpha level was set at 0.05.

RESULTS
Of the 114 participants, 56.2% are interns attending the fifth and sixth years of medical school and 43.9% are first to fourth-year residents.
The mean age was 25.9 years ± 0.6, with a predominance of female participants (67.5%). Catholicism (44.7%) was the most frequent religion among the participants, as well as high religious involvement (43%) ( Table 1). indicates a number close to the maximum value of 140. Table 3 shows Pearson's coefficient correlations between WHOQOL-SRPB (and its domains S1 to S8), JSE-S and

Spirituality and Empathy
This study found that levels of empathy were positively associated with the perception of well-being related to spirituality, religiosity, and personal beliefs. WHOQOL-SRPB Final Score predicted the global empathy and perspectivetaking. Inner peace predicted the domain compassion of JSE. Other studies have found a positive association between spirituality, care, and empathy 22,42 .
Previous studies have described that burnout is inversely correlated to empathy, while personal well-being and quality of life showed a positive correlation with empathy scores in medical students 7,43 . A recent study with a sample of students has indicated that empathy in the doctor-patient relationship is associated with well-being related to spirituality -Meaning and Purpose in Life 20 . Therefore, some factors such as well- Previous studies have pointed out that religiosity has an association with better mental health results 29,46 , but other studies have shown no association between religious beliefs and empathy 31,22 . Religiosity is defined as how much an individual believes in, follows and practices a religion. It may be organizational (to attend a church or a religious temple or non-organizational (to pray, read books, watch religious TV shows) 32 . Having a religious affiliation or religious involvement was not equally associated with empathy as some domains of spirituality were.
In this sense, when we consider medical education and the empathy approach, we need to broaden the focus and search for other factors that influence students' and young doctors' empathic behavior towards patients. The following ideas may provide essential conditions for professional education 33 and affect their practice -empathic behavior activities during medical training that stimulate the study of spirituality by acknowledging people's subjectivity, resources to understand self-care and self-knowledge, and debates about transcendence, inner peace, mechanisms of resilience, and topics on physicians' well-being. Moreover, such activities may be a mechanism used to face stress, to keep oneself highly resilient and to improve the quality of life 34

Spirituality and Patient-centered Medicine
Our study indicated a positive association between the perception of well-being related to spirituality/religiosity/ beliefs and a more patient-centered medical attitude in a sample

Study Limitations
We used self-administered questionnaires on empathy and doctor-patient orientation, which can be influenced by the bias of social desirability, biasing the responses of interns and residents to what is socially accepted. However, this limitation and subjectivity of responses is inherent to this type of study.
Another limitation concerns the sample restriction to the interns attending the last two years of medical school and residents in the first four years of residency, so the data does not represent the other students. New studies have included students attending the first years, as there are indications that this period in higher education is a significant predictor of higher levels of empathy 20 .
There is also the risk of selection bias -31.3% of eligible individuals participated in the study. The number is appropriate, but there may be a "Healthy entrant effect" which, in this case, may mean that more empathetic, more religious and spiritualized students are more likely to answer the questionnaire than less empathic and religious ones. In this sense, 67.5% of the study participants were women; 90% of medical residents and 50% of medical interns had chosen or intended to choose a "person-centered" specialty. Therefore, the selection bias can be justified by the fact that the majority of the sample consists of women and students and doctors with a choice of "person-centered" specialties, factors that are related to higher levels of empathy, according to previous studies 5, 14,16 .
Although the response rate was satisfactory for the eligible individuals (31.3%) in this study, the research was carried out in a single higher education institution and thus, external validity was not verified. However, the total WHOQOL-SRPB score (74.02) in our study group is similar to the results of other studies20 (ranging from 71.76 to 73.5) in a similar population -medical students in Brazil -which reinforces the appropriateness of the selection method and the sample size.