bmc medical education

• Open access
• Published: 23 November 2024

Medical education challenges during the war crisis in Sudan: a cross-sectional study, 2023–2024

• Alaa T. Omer   ORCID: orcid.org/0000-0002-9814-2052 1 , 2 , 4 ,
• Eithar M. Ali   ORCID: orcid.org/0000-0002-2536-5335 1 , 2 ,
• Mustafa E. Elhassan   ORCID: orcid.org/0009-0006-7958-1646 1 , 2 ,
• Samah A. Ibrahim   ORCID: orcid.org/0000-0002-0789-4102 1 , 3 &
• Yousra S. Ahmed   ORCID: orcid.org/0000-0002-9631-0171 1 , 2  

BMC Medical Education volume  24 , Article number:  1354 ( 2024 ) Cite this article

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The ongoing war crisis in Khartoum, Sudan, has created significant challenges for medical students, impacting their education. A cross-sectional study involving 224 medical students was conducted in Khartoum state to explore the challenges faced by medical students during this crisis, using a structured Google Form questionnaire. The majority of participants were female (65.6%), fourth-year students (36.6%), and aged between 22 and 25 years (66.8%). Notably, 92% of the participants had been displaced from Khartoum. The study found that a majority of participants reported experiencing physiological distress, with study distractions (65.2%), anxiety (51.8%), and depression (49.1%). Significant gender differences were observed, with females reporting higher psychological distress compared to males ( p -value = 0.04). Additionally, 45% of participants noted that the war led to a shortage of experienced teaching staff, and 56.6% raised concerns about the potential decline in the quality standards of their university's curriculum. Nearly 48% of participants expressed a desire to collaborate with international or local universities in stable regions to continue their education. However, 20.2% believed that online learning can effectively maintain the continuity of their education. A significant correlation was found between university type and the ability to resume activities online or outside of Khartoum State ( p -value = 0.01). The study concludes that the war crisis in Khartoum State has had significant, negative consequences for medical students, impacting their mental well-being, access to necessary resources, and overall learning experiences. Immediate interventions, psychological support, and increased coordination and collaboration among international and regional academic institutions are needed.

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Introduction

The foundation of any country's progress is education. The history of medical education in Sudan is extensive and intriguing. It began in 1924 and has undergone several stages and phases since then [ 1 ].

Sudan's medical education system is designed to provide thorough training for future healthcare professionals, emphasizing both academic and practical abilities. In terms of admission criteria to Sudanese medical faculties, applicants are normally required to have finished secondary education with a focus on science disciplines such as biology, chemistry, and physics. Many colleges require students to complete a national or university-specific entrance exam. Many programs are offered in English; therefore, proficiency in the language is frequently required. Bachelor of Medicine, Bachelor of Surgery (MBBS) programs typically last five to six years. The curriculum normally consists of two years of pre-clinical courses followed by four years of clinical training. Tuition rates vary greatly based on the institution. Public universities may have lower tuition fees than private institutions, with tuition often ranging between $500 and $2,000 each year. Students may also be charged for registration, examination fees, textbooks, and other items, which can add several hundred dollars to the overall cost [ 2 ].

The ongoing conflict in Sudan is essentially a power battle between the Sudanese Armed Forces (SAF) and the Rapid Support Forces (RSF), a paramilitary group formed by Janjaweed militias participating in the Darfur crisis. The violence has caused considerable civilian casualties, enormous displacement, and a humanitarian disaster.

The war encompasses several areas: the capital city, Khartoum, has been a major battleground, with severe combat and enormous civilian suffering. The second region is Darfur, which has experienced a revival of violence, with claims of ethnic targeting and atrocities reminiscent of the previous conflict. Fighting has also expanded to neighbouring regions, including Kordofan and Blue Nile, escalating tensions and humanitarian needs [ 3 ].

Recently, 9 million Sudanese people have been displaced by war, facing a rapidly mounting humanitarian emergency after months of serious fighting between the military and a rival paramilitary force [ 4 ].

War and other forms of instability within or between governments influence people's capacity to engage in basic civil activities, including employment, healthcare, and education [ 5 ]. The most significant interruptions to education as a result of the war crisis were the disruption of the curriculum, the devaluation of clinical training in hospitals, and the absence of an internet network to support online study [ 5 ].

Sudan's war has led to disruptions in medical education in several aspects, the most important of which were the interruption of the curriculum, the negative impact on clinical training in hospitals, and the lack of an internet network to continue e-learning. The war crisis has displaced a large number of students to their original rural homes and underprivileged areas [ 6 ]. In this condition, students must attend their classes on different platforms and utilize digital education. One of the main requirements of distance learning is a safe and fast internet connection. For most students, access to the technical requirements of online education is a significant problem in these circumstances. It might be completely or partially inaccessible to medical students in rural areas, which leads to several problems in their education.

The rural homes where most displaced students reside are not desirable locations for studying. The rural home environment is not conducive to education because students may get distracted by other family members [ 7 ].

Population displacement, harm to medical facilities or staff, and infrastructure deterioration that disrupts logistics and supply chains can all exacerbate the impact of war on medical education [ 8 ]. Buildings are destroyed; faculties, schools, and dormitories are utilized for military training or as shelters for displaced families; professors and students are at risk of being murdered, injured, or abducted; and psychological trauma results [ 9 ].

E-learning provides several benefits over traditional education, especially for future medical education programs. Continuing online study in health professions may be an alternative course of action in the event of an emergency. This method seems more suitable for medical education in developed countries rather than in developing countries [ 10 ].

The international influence of war on medical education is profound and diverse, affecting the healthcare environment in conflict-affected areas. This dynamic interplay has long-term ramifications for health systems and medical education in post-conflict cultures, in addition to influencing the immediate provision of healthcare during crisis periods. According to research on the Russian invasion of Ukraine, students in particular have experienced a loss of future skill development and diminished employment opportunities, in addition to the many deaths that have occurred in Ukrainian communities overall [ 11 ]. By stopping medical education in Ukraine, the 2022 conflict has disrupted medical education not just nationally but also globally. It is essential to keep in mind that historically, a large section of Ukraine's population has immigrated from abroad to comprehend this. In Ukrainian medical schools, around 26,000 foreign students are registered, with more than half of them enrolling in healthcare-related professional education. The governments of their own nations have removed the majority of these overseas students. However, given that they won't be able to complete medical school in Ukraine for some time, there are still a lot of concerns [ 11 ].

For instance, the Second World War saw a significant rise in the number of medical graduates in the USA, with a focus placed on course topics like first aid and emergency care [ 12 ]. Sub-Saharan Africa faced political and economic challenges between 1975 and 1990, and medical schools were not immune to these issues. This period was marked by conflict, corruption, rising national debts, and political unrest. It became challenging in many nations to sustain the resources of medical schools, including professors, buildings, labs, and libraries [ 1 ].

In cross-sectional research examining the effects of conflicts on medical education conducted in Iraq, 4 (50%) of the medical schools in the World Directory of Medical Schools believed that war had negatively impacted the quality of training medical schools could provide, while 5 (63%) claimed that medical students' educational achievement had been negatively or significantly impacted [ 13 ]. There were 197 respondents, and 62% of them felt that their safety had been in danger because of violent insecurity. Most medical students (56%) planned to leave Iraq after graduation. Students at various medical colleges shared similar worries about their clinical competence, mental fatigue, and personal safety. When asked about how conflict affects their mental health, students frequently mentioned worry and despair. Other impacts on their student experience included gaps in medical knowledge, often due to missed teaching [ 13 ].

Due to the destruction of college infrastructure and the loss of teaching personnel, the 20-year civil war at Liberia's only accredited medical school resulted in severe delays in medical training [ 14 ]. A recent systematic review in Syria reported that all aspects of medical education have been severely impacted by the ten-year Syrian crisis. Prior to the conflict, the poor quality and resource shortage in medical education and health professionals' training were exacerbated [ 15 ].

This study will focus on key learning challenges faced by undergraduate medical students due to the recent war crisis in Sudan. To our knowledge, there is no study in Sudan fully characterizing the challenges or barriers faced by medical students during the last war and the interventions used to overcome these hardships. This study concludes about the impacts of the ongoing conflict on medical education.

Materials and methods

Study conception.

The present study utilized a semi-structured questionnaire to achieve its conceptualized objectives. Students' perspectives toward the impact of war on their health, university infrastructure, and implementation of the curricula were assessed, along with their future prospects. E-learning as a substitute for traditional learning was evaluated.

Study design and setting

This is a descriptive cross-sectional study conducted during the war crisis among students in Khartoum State, using a web-based questionnaire. Khartoum State is the capital of Sudan and has been affected by the war conflict since 15 April 2023. It has seven localities/districts, in which these medical colleges are distributed, and it is ranked as the first in terms of the number of universities and colleges compared to other states. These colleges vary in terms of their age and are under the Ministry of Higher Education in Khartoum State. Notably, students from other states come to study in Khartoum State. Khartoum State, along with a few other states, has been affected by war since its onset.

Study period

The study was conducted between October 28, 2023, and March 6, 2024. This involved various stages, including proposal writing, acquiring ethical clearance, data collection and management, and manuscript preparation. The web-based questionnaire for data collection was available online from December 9, 2023, to January 4, 2024.

Participants, sample size and sampling technique

This study was conducted during the war crisis in Khartoum State. It included all undergraduate medical students enrolled in the medical faculties of Khartoum State. The sample frame for this study was the medical schools, and undergraduate medical students were considered as the sample unit. To obtain the sample size from the above sample frame, the sample size calculator program was used. As the exact number of students is difficult to obtain, the sample frame is considered unknown. This is due to the difficulty in communicating with relevant authorities during the war to determine the number of students in the medical schools in Khartoum, as most communication channels with the administration have been affected by the conflict. A sample size of at least 225 students is required to achieve a 95% confidence level with a margin of error of ± 6%, assuming the population proportion is 70% and the exact sample frame is unknown. As the sample size was found to be 225 and the number of participants was 224, the response rate was 99.5%. A Google Form was used as a technique for data collection.

Data collection method and instruments

Data were collected through a web-based method to reach undergraduate medical students. The questionnaire (Annex 1), as an instrument, was created by the authors following a thorough analysis of the literature and taking into account the objectives of this study. It was a semi-structured questionnaire designed in English and administered as a self-administered questionnaire. No translation was needed, because it targets an educated audience and the language is simple. It included consent and four sections. It was validated by two medical education experts, one statistician, and one research expert. Each section covers a certain objective and navigates to other sections. The first section included relevant socio-demographic data. The second section looked at the impact of war on the students, regarding income, residency, physical and psychological health. In addition, the actions taken by students to continue their studies and their consideration of a career shift were assessed. The third section emphasized the effect of the war conflict on the university's academic staff and infrastructure. The last section assesses the effect of war crises on curriculum and accessibility to e-learning for continuation of study as an alternative method.

Data management

Data were initially entered and cleaned using a Microsoft Excel sheet, then transferred and analysed using Statistical Package for Social Sciences (SPSS) version 25.0, descriptive statistics used and categorical data presented in form of frequencies (n) and percentages (%), while numeric data presented in form of means and SD. For inferential statistics, Chi-square test was used, P value of ≤ 0 0.05 was considered significant.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Ethical considerations: approval and informed consent

Due to challenges caused by the war crisis and limited connectivity in Khartoum, ethical clearance (serial number 0241103) was obtained from the ethical committee of the Ministry of Health and Social Development at the White Nile State, located outside of Khartoum. Nevertheless, all participants provided written informed consent at the beginning of the web-based questionnaire, confirming their agreement before participating in the study.

Competing of interest

Authors declare no competing of interest that might be perceived to influence the results and/or discussion reported in this paper.

The study's authors state that financing for the research is non-existent. It is entirely self-financed.

This study included a total of 224 undergraduate medical students at Khartoum State with a response rate of 99.5%. Almost two-thirds of students were females (65.6%). Fourth-year students were the largest group (36.6%), followed by 5th year students (21%). The mean age of students was 22.4 years ± 2.6 SD (Standard Deviation), the youngest student aged 17 years while the oldest aged 41 years, the most common age group was 22–25 years (66.8%) (Table  1 ).

In regard to type of university, public universities represented (59.4%), while private ones constituted (40.6%) (Table  2 ). And the largest percentage of these universities located in Khartoum locality (75.9) (Table  3 ).

The ongoing war affected (92%) of students which displaced either internally (38.4%) or externally (53.6%), while (8%) didn’t displaced (still in Khartoum). (Fig.  1 ).

Current residential status of the medical students, considering the ongoing war crisis, ( N  = 224)

Gezira state (39%), River Nile (19.5%) and Red Sea (9.8%) represented the most common states for displacement inside Sudan. (Fig.  2 ).

States to which medical students displaced inside Sudan, ( N  = 82)

While Kingdom of Saudi Arabia (KSA) (50.4%) and Egypt (28.7%) were the most common countries outside Sudan. (Fig.  3 ).

Countries to which medical students travelled outside Sudan during the ongoing war crisis, (115)

A psychological impact due to the ongoing war was experienced by 137 (61.4%) of the medical students. The most popular psychological impacts were: distraction from study (65.2%), anxiety (51.8%), and depression (49.1%) (Table  4 ).

Medical students who considered making a career shift from medicine were (25.4%), while (30.8%) may consider this and (43.8%) didn’t. A total of 66 medical students (29.5%) took steps to continue their learning outside Khartoum state, (46.2%), (43.1%), (10.8) of them continued their learning at the same university but outside Khartoum, same university but outside Sudan and different university outside Sudan, respectively (Table  5 ).

Regarding impact of ongoing war on students’ university infrastructure, (61.1%) of students stated that the war led to loss of clinics/ hospitals for clinical training, and (53.8%) agreed that it led to a loss of lecture theatres and buildings. Regarding the staff, (55.3%) of medical students stated that one or more of the academic staff members at their universities have permanently left the university/college after the war crisis and now work outside Sudan (Table  6 ).

More than half of the medical students (56.6%) agreed that the war affected the implementation of curriculum at their university by Lack of standardization and quality of curriculum, (54.8%) affected by decreased training in primary and preventive care. During the beginning of a war crisis (42.2%) of students were on vacation. Near half of students (48%) suggested collaboration with international or local universities in stable regions to facilitate exchange programs to assist in continuing and improving education. Medical students whose university resumed activities either online or on-site outside Khartoum and currently they are representing (62.5%) (Table  7 ).

In case of resuming activities online, (91.5%) have electronic device, such as a smartphone, tablet, or laptop, that they can use for studying, (64.3%) have a stable internet access with appropriate speed, and (66.1%) have stable electrical power supply (Table  8 ).

Results showed that there is a statistically significant association between the gender of students and the psychological impact of war on them ( P  = 0.04). Also, a significant correlation was found between type of university and resuming activities online or outside Khartoum state ( P  = 0.01) (Table  9 ).

There was no significant association between the consideration of career shift and the gender or the academic level of the medical students (Table  10 ). Also there was no significant association between type of university and taking steps to study outside Khartoum state (Table  11 ).

In light of the ongoing conflict in Sudan that began in April 2023, this study attempts to determine the challenges that medical students at Khartoum State universities must overcome in order to complete their education [ 16 ].

Our study had a female participation rate of 65.6%, which differed from other studies with different gender ratios. For example, the proportion of female respondents was 56.7% in Karachi, Pakistan [ 17 ], while the male-to-female ratio in Taiwan was 3.7:1 [ 18 ]. Additionally, 2.5% of participants in our study were older than 25, which is different from the typical age range of medical students, who are usually in their early twenties. It's possible that some people are entering medicine from other health-related fields. Furthermore, the disruptions that have occurred in Sudan—starting with the Sudanese Revolution in 2018, followed by the COVID-19 pandemic, and the ensuing war crisis in 2023—may have contributed to the delay in medical program enrolment and medical education.

According to our findings, 92% of medical students from Khartoum State were displaced by the conflict; 53.6% of them moved abroad, and 38.4% settled in remote areas of Sudan. In comparison, only 20% of students in Ukraine were forced to flee due to the Russian invasion [ 19 ]. Remarkably, 8% of students chose to remain in the conflict area, probably because of limited options for relocation, family ties, financial limitations, or a duty to provide medical assistance. When formulating plans to maintain medical education, it is critical to keep the needs of these remaining students in mind and strive for a secure, welcoming, and encouraging learning environment.

We also evaluated how the war affected the infrastructure of medical universities and found some notable difficulties. Of the participants, more than half 61.1% reported that university buildings and lecture halls had been damaged, and 53.8% reported that affiliated hospitals and clinics had been destroyed. Similar to what has happened in war-torn countries like Iraq, Liberia, and Ukraine, where similar damage hindered medical education and training, this widespread destruction compromises vital healthcare and educational facilities [ 13 ,  14 ,  19 ].

According to their self-reported diagnoses, 61.4% of students reported psychological effects from the ongoing violence, which has a significant adverse effect on their mental health, according to our results. In addition, 49.1% struggled with what they believed to be depression, 51.8% felt anxious, and 65.2% felt that the war had distracted them from their studies. These results underscore the psychological cost of the conflict and are consistent with similar research conducted in Syria and Iraq, where students also experienced mental health issues that negatively impacted their academic performance and general well-being [ 13 ,  20 ].

In an earlier study, higher levels of stress, anxiety, and depression have been found to be associated with female gender [ 21 ]. In our study, female students reported higher levels of psychological conditions at a rate of 70.8% compared to male students. This is in line with studies by Hisato et al., who discovered a strong correlation between female gender and psychological distress [ 22 ].

According to our survey, 43.8% of medical students in Khartoum are dedicated to their field and have no plans to change careers. This percentage is comparable to results from Iraq, where nearly half of students demonstrated a similar level of commitment [ 13 ]. However, 56.2% of respondents are considering altering their professional path, indicating possible difficulties for Sudan's medical profession. Furthermore, only 29.5% of students have decided to pursue their medical education outside of Khartoum, and even fewer are prepared to transfer schools. This reflects the poor operational status of Sudanese universities, which drives students to look for opportunities in safer, more developed cities abroad.

According to our research, Sudan's medical academic staff may face serious consequences in the future, which could have a significant impact on medical education in the nation. In particular, the incidence of permanent disability, reported at 16.3%, and the loss of medical academic staff due to death from the ongoing war crisis, reported at 43.3%, indicate a significant loss of knowledge and experience. The quality and continuity of the region's medical education and training programs are likely to suffer greatly from this attrition. Furthermore, the fact that 55.3% of employees are leaving the country permanently suggests a significant brain drain, which is weakening international healthcare ties and creating a shortage of trained educators and medical professionals. Staff absences or disabilities can interfere with the continuity of medical education, which can impact students' learning and possibly result in a shortage of qualified practitioners. It will take coordinated efforts to address these problems, including government backing, international cooperation, and infrastructure investments in healthcare and education.

Adapting curricula to wartime conditions and guaranteeing consistent, high-quality instruction are two critical issues that our research highlights, as supported by Dobiesz et al.'s scoping review on wartime healthcare education. One of the biggest obstacles is a scarcity of resources and skilled instructors [ 23 ]. In our survey, 56.6% of students voiced concerns about the quality of the curriculum at their university, and 45.2% named the lack of experienced faculty as a major barrier. This is in line with observations made in other war-torn areas, like Liberia, where a decline in educational quality was caused by faculty departures [ 14 ]. Clinical training is also disrupted by war; according to UNESCO, institutional disruptions from conflicts frequently cause training for health professionals to be delayed or restricted. Limited access to clinical settings and practical training significantly impedes the development of essential clinical skills [ 24 ]. For instance, 61% of medical students reported that the Iraq War had a major negative influence on the quality of their training [ 13 ], and 54.8% of respondents said that there were fewer opportunities for training in Khartoum's medical facilities.

According to a recent study, remote learning and online learning environments may be useful in Sudan's wartime setting, enabling medical education to proceed despite obstacles to physical access. Asynchronous online learning is advantageous in places with limited internet connectivity because it provides flexibility and offline resource access [ 13 ]. Najran University in Saudi Arabia is one successful example of how e-learning works well in emergency situations [ 25 ]. However, according to our survey, medical students may find that having reliable internet and electronic devices alone isn't sufficient in a time of war. Even with over half having reliable internet access and 90% owning devices, only 20.2% think that online learning can effectively continue their education. Adoption of online learning may be hampered by issues like safety concerns, cultural preferences for in-person contact, and limited communication with peers and instructors. These barriers could impede the adoption of online learning even if it could technically be made available [ 26 ]. Furthermore, according to our survey, almost 60% of public universities have resumed activities, either online or outside the state of Khartoum. Public universities may find more support for their reopening efforts because they frequently have stronger ties to local communities, governmental organizations, and public health initiatives. Resuming operations at a university is greatly affected by the local context.

This study concludes that the war crisis in Khartoum State has had significant, negative consequences for medical students, impacting their well-being, access to necessary resources, and overall learning experiences. It highlights potential challenges for education continuation, such as infrastructure devastation, staff shortages, e-learning obstacles, and curriculum quality concerns. Despite these issues, many students wish to continue their education through collaborations with universities in stable regions or via online learning.

The results of this study are not representative, exhibit selection bias and cannot be generalized. Displacement issues for both authors and participants in addition to significant disruption of internet connectivity and electricity affect communication and constitute significant obstacle for data collection. As a result, the authors decided to approach participants without randomization.

Recommendation

Every student needs a good environment to learn that can afford their needs. By default, peace is a core stone in this environment. In war crises, students faced huge challenges regarding their own peace, nutrition, education, etc. The greater psychological impact makes them need help for long-term life. For all of the above, authorities should put a good plan to overcome this problem. The plan included short—and long-term solutions. It must take into consideration all students by their different backgrounds. Incorporate students in this stage is very crucial. Students know their needs as well as the efforts that they can provide. Financial and psychological support plays a great role in encountering such problems. E-learning could help with flexible curriculum.

Some medical schools moved to other states or even to other countries. All these solutions can help. Regarding the curricula, educators and stakeholders can modify the content and duration. Moreover, exams need expertise to be designed. Of note, putting in mind the psychological effect of the war crises during the education process. Collaborative effort between non-governmental organizations and universities will be good during the war crises.

The datasets used and/or analysed during the current study available from the corresponding author on reasonable request.

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Acknowledgements

This study wouldn't be possible without the time, encouragement, and help of a few individuals. First of all, Dr. Elfatih Malik, we really appreciate your kind words, advice, and counsel that helped us finish this study and provide excellent information on the methods.We are really appreciative of Dr. Anfal, our college, for her help. We would also want to sincerely thank Dr. Azhari Abdallah for his guidance on earlier research. Additionally, we would like to thank the medical students who contributed their time and suggestions to help us better our study.

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Authors and affiliations.

Education and Development Centre EDC, University of Khartoum, Khartoum, Sudan

Alaa T. Omer, Eithar M. Ali, Mustafa E. Elhassan, Samah A. Ibrahim & Yousra S. Ahmed

Faculty of Medicine, University of Khartoum, Khartoum, Sudan

Alaa T. Omer, Eithar M. Ali, Mustafa E. Elhassan & Yousra S. Ahmed

Department of Scientific Research, Almugtaribeen University, Khartoum, Sudan

Samah A. Ibrahim

Khartoum, Red Sea State, Sudan

Alaa T. Omer

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Alaa T. Omer is the corresponding author and contributed to conceptualization, data curation, formal analysis, investigation, methodology, project administration, writing - original draft, and writing - review and editing.The following authors have all contributed to the project through various roles: Ethar M. Ali, Mustafa E. Elhassan, Samah A. Ibrahim, and Yousra S. Ahmed. They have each performed data curation, formal analysis, investigation, methodology, project administration, writing - original draft, and writing - review and editing.

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Omer, A.T., Ali, E.M., Elhassan, M.E. et al. Medical education challenges during the war crisis in Sudan: a cross-sectional study, 2023–2024. BMC Med Educ 24 , 1354 (2024). https://doi.org/10.1186/s12909-024-06358-2

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Compassion cultivation training promotes medical student wellness and enhanced clinical care

Laura a weingartner, susan sawning, jon b klein.

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Received 2018 Jan 19; Accepted 2019 Apr 3; Collection date 2019.

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/ ), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated.

Compassionate health care is associated with positive patient outcomes. Educational interventions for medical students that develop compassion may also increase wellness, decrease burnout, and improve provider-patient relationships. Research on compassion training in medical education is needed to determine how students learn and apply these skills. The authors evaluated an elective course for medical students modeled after the Compassion Cultivation Training course developed by the Stanford Center for Compassion and Altruism Research and Education. The elective goals were to strengthen student compassion, kindness, and wellness through compassion training and mindfulness meditation training modeled by a faculty instructor. The research objectives were to understand students’ applications and perceptions of this training.

Over three years, 45 students participated in the elective at the University of Louisville School of Medicine. The course administered a pre/post Kentucky Inventory of Mindfulness Skills that measured observing, describing, acting with awareness, and accepting without judgment. Qualitative analyses of self-reported experiences were used to assess students’ perceptions of compassion training and their application of skills learned through the elective.

The mindfulness inventory showed significant improvements in observing ( t  = 3.62, p  = 0.005) and accepting without judgment skills ( t  = 2.87, p  = 0.017) for some elective cohorts. Qualitative data indicated that students across all cohorts found the elective rewarding, and they used mindfulness, meditation, and compassion skills broadly outside the course. Students described how the training helped them address major stressors associated with personal, academic, and clinical responsibilities. Students also reported that the skills strengthened interpersonal interactions, including with patients.

Conclusions

These outcomes illuminate students’ attitudes toward compassion training and suggest that among receptive students, a brief, student-focused intervention can be enthusiastically received and positively influence students’ compassion toward oneself and others. To underscore the importance of interpersonal and cognitive skills such as compassion and mindfulness, faculty should consider purposefully modeling these skills to students. Modeling compassion cultivation and mindfulness skills in the context of patient interactions may address student empathy erosion more directly than stress management training alone. This pilot study shows compassion training could be an attractive, efficient option to address burnout by simultaneously promoting student wellness and enhanced patient interactions.

Keywords: Burnout, Compassion, Medical students, Mindfulness, Modeling

Healthcare providers must develop personal connections to deliver optimal patient care, and some keys to forming these connections are compassion and empathy [ 1 ]. Compassion is recognizing emotional distress by others (or oneself) and the resulting desire to reduce suffering [ 2 ]. This is contrasted with empathy, or personally experiencing others’ feelings and emotions [ 3 ]. For providers, compassion and empathy contribute broadly to positive patient health outcomes and patient satisfaction [ 4 – 6 ], but repeatedly experiencing patient suffering is precarious for provider wellness. For medical students, empathy erosion notably peaks during clerkship in medical school with the heightened stress of transitioning to patient care [ 7 – 9 ]. Compassion fatigue, a type of burnout experienced by caregivers supporting suffering individuals [ 10 ], is also prevalent in medicine [ 11 , 12 ]. Reduced provider compassion and empathy contribute to suboptimal patient health outcomes [ 13 , 14 ] and to provider burnout (described below), which motivates academic healthcare centers to address provider wellness.

Wellness in medical education

Chronic stress is pervasive in medical occupations and associated with decreased compassion and empathy. Startling levels of depression, suicidal ideation, burnout, and alcohol abuse occur during student and resident training, and debilitating stress continues throughout physicians’ careers according to many US-centered studies [ 15 – 18 ]. Interventions that offer providers practical tools to manage stress during training and throughout their later careers could impede burnout [ 19 ]. Self-care activities such as resilience building and stress-management training have recently gained prominence [ 20 ], and reviews of medical-school interventions suggest that organization-sponsored programs are infrequent but very potentially effective in reducing burnout [ 21 – 24 ]. Self-care can also augment the development of compassion for self and others [ 25 – 29 ], thereby providing benefits to both healthcare providers and patients.

Mindfulness training is one approach to facilitate wellness. Mindfulness is a teachable aspect of awareness in which practitioners pay attention on purpose, in the moment, and without judgment [ 30 ]. This ability to refocus attention and address daily distractions or anxiety can positively influence cognitive appraisal and emotional reactions, alter and lower an individual’s perception of stress, and improve well-being [ 31 – 34 ]. Mindfulness has shown promise to address stress and support empathy with medical students across varied intervention structures and evaluations [ 35 – 38 ], and training can also improve physician-patient communication [ 39 ].

Despite the promise of interventions like mindfulness training [ 24 ], the systematic inclusion of wellness training in undergraduate medical education challenges many programs because of the reallocation of time from traditional content that would be required to adopt this training [ 40 ]. This prompts a need to identify and evaluate wellness programs that are both effective and efficient, and an intervention specifically aimed at improving both patient care and provider self-care is appealing because of competing curricular demands. A promising approach is compassion training, which can cultivate and improve compassion for both others and oneself through structured training [ 41 – 43 ].

Intervention conceptual framework and purpose

Here we report the results of a three-year pilot study of a brief elective course for medical students designed to foster compassion through developing mindfulness skills. Our educational intervention was modeled after the Stanford Center for Compassion and Altruism Research and Education’s (CCARE) Compassion Cultivation Training (CCT). This secular, eight-week educational course aims to strengthen the qualities of compassion, kindness, and well-being. CCT has wide-ranging success in alleviating negative emotional states, increasing compassion, and improving interpersonal skills for healthy adults [ 44 – 46 ]. A University of Louisville School of Medicine (ULSOM) faculty member (author JBK) with ten years of meditation practice completed CCT instructor training with CCARE in 2013. In 2015, ULSOM began offering a two-credit-hour elective following the CCT syllabus available through CCARE [ 47 ] with content adapted to medical students’ experiences, including compassion exercises specifically focusing on patient interactions where appropriate (e.g., exercises to help students understand that compassion is a process that can unfold in response to suffering, practicing compassionate thoughts and actions in response to patient interactions, focusing on making positive differences in the lives of patients, etc.). Weekly, two-hour sessions included pedagogical instruction, guided group meditation, mindfulness training, group discussion, listening and communication exercises, practical exercises related to weekly compassion themes, and 15–30 min of daily home meditation.

ULSOM was one of the first programs to implement and study CCT as an intervention for medical students specifically. Our research was built on a conceptual framework using social learning theory, in which behavior is modified through observation, modeling, and reflection on responses [ 48 ]. Social learning also places importance on the setting where learning takes place and the community of learners that influence the individual learner’s experience [ 49 ]. The CCT faculty instructor modeled compassion cultivation and mindfulness skills, including loving-kindness meditation. This meditation method can increase well-being, connectedness, and compassion through consciously wishing wellness to oneself and others, including for difficult relationships [ 50 , 51 ]. By observing and mirroring the trained instructor, students learned in the group setting to modify their stress and compassionate behavior toward self and others.

The CCT elective objectives were to help students feel more connected to others and to promote wellness strategies early in their medical careers. We predicted that this brief educational intervention would improve students’ mindfulness traits and foster a sense of well-being and heightened compassion. Furthermore, we predicted the reward of positive interactions with others and/or reduced stress, coupled with the group reflection on these experiences, would provide internal and external reinforcement of self-care behaviors.

Study design

The full eight-week CCT course was given in 2015 and 2016, and an abbreviated five-week course was held in 2017. Preclinical second-year (M2) students were eligible to participate in the 2015 course while both M2 and fourth-year (M4) students were eligible to participate in 2016 and 2017. Study participants were recruited via email invitation to CCT-enrolled students.

A mixed-methods design evaluated the impact of the CCT elective on students’ mindfulness skills, stress management, and compassion. All students completed a pre/post-test of the Kentucky Inventory of Mindfulness Skills (KIMS) [ 52 ], which is a validated, 39-item self-assessment instrument with a Likert-type scale ranging from one (never or very rarely true) to five (almost always or always true). This inventory assessed four different mindfulness facets, including: observing, describing, acting with awareness, and accepting without judgment. The KIMS has been validated for internal consistency, retest reliability, and correlation with similar self-assessment tools [ 53 ].

Completing the pre/post-test KIMS was part of the elective curriculum as a self-assessment. However, submitting identified data for research was optional for students, so only matched pre/post data were included in the analyses. Students in the 2015 sessions completed paper-based KIMS for both pre/post-tests in class. Students in the 2016 and 2017 session completed a paper-based KIMS pre-test in class and the post-test electronically, after the final session was complete.

In addition to the KIMS, students were invited to complete a follow-up, open-ended questionnaire through an electronic survey platform in June 2016 (2015/2016 cohorts) and February 2017 (2017 cohort). Students were asked to provide subjective feedback to better understand their course experience, their sustained use of skills learned in the course, and their perceptions of utility, benefits, and transferrable skills from the course.

Data analysis

Individual pre- and post-test KIMS scores were calculated for each of the four mindfulness facets. Responses from 2015/2016 were combined for analysis as the cohorts experienced the same scheduling format. Scores from 2017 were analyzed separately since the course was held over fewer sessions. Two-tailed, paired t-tests were performed in SPSS (IBM SPSS Statistics for Macintosh, Version 24.0. Armonk, NY) to determine whether mean post-test scores were significantly greater than pre-test scores for each mindfulness facet. Completed pre/post-tests without identification for pairing were not included in the analysis.

De-identified qualitative response data from all three years were evaluated independently by two authors (SS, LAW) using a directed approach to content analysis to identify themes among the data [ 54 ]. After an initial review of responses, a priori codes were established by both coders for each question. Responses were consistent across cohorts, so qualitative data were analyzed in aggregate. Emergent codes were incorporated to re-analyze the dataset independently by each coder. No substantial differences emerged between coders. Categorized data were then assigned to and collapsed into themes across questions by the coders jointly, which resulted in a set of final themes for each topic.

Participants

Forty-five students from M2 and M4 participated in the CCT elective over three years (Table 1 ). Twenty-five students completed the full eight-week course and twenty completed the abbreviated five-week course. Respondent sample sizes are noted and indicate that not all students answered all questions because of variation in surveying and the optional nature of the data collection. Demographic breakdowns are not reported to preserve student confidentiality.

CCT enrollment and elective structure showing research participation in the mindfulness inventory and subjective/qualitative feedback

1 An individual’s data from the Kentucky Inventory of Mindfulness Skills (KIMS) were included only if both the pre-test and post-test were identified and thus able to be paired

2 The six students who answered the post-course survey had also completed the non-redundant course evaluation so are not counted in duplicate in the qualitative total of 38 students reported in the text

In the full-length course, 44% of students ( N  = 11/25) completed identified pre- and post-test KIMS that could be matched for paired analysis. In the abbreviated cohort, 80% of students ( N  = 16/20) completed identified pre- and post-test KIMS. Thirty-eight students total provided qualitative feedback on course evaluations and/or the qualitative post-course survey.

Mindfulness inventory

For the full-length 2015/2016 cohorts, post-test mean scores for all KIMS mindfulness facets were higher than the pre-test values, with significant improvements in observing and accepting without judgment (Table 2 ). For the abbreviated 2017 cohort, no significant differences were seen between the pre- and post-test scores. Relatively large standard deviations across all KIMS subscales in both groups suggest that students started with variable baseline mindfulness levels, and among-student differences were generally maintained after the training.

Mindfulness inventory comparing pre/post score means with a paired t-test analysis

1 Categorized by full-length (combined 2015 and 2016, n = 11) and abbreviated (2017, n = 16) elective structure

2 Two-tailed with significantly higher post-test means indicated in bold

Student perceptions

Sources of stress.

Students’ major sources of stress were reported to be academic/clinical responsibilities, interpersonal relationships, debt, and personal self-esteem/mental health struggles ( N  = 16). Students described “feeling inadequate” and that work and family “can be stressful on the best of days.” Students reported difficulty addressing daily stress prior to CCT: they previously addressed stress through physical activity and by taking breaks from academic work, but unhealthy coping strategies included substance abuse and avoidance. One student reflected that, “I tended to ignore [stress] until I became overwhelmed or until the stressor was removed and then I felt useless.” Another student reflected that, “Sometimes I’d have meltdowns.” Only one respondent reported working with a support network during times of stress before CCT, and only 25% of respondents ( N  = 4/16) had had any previous mindfulness experience. Of the students who had previous training, all but one had been provided this opportunity through a structured university program, suggesting that students were not receiving similar training elsewhere.

Applying CCT skills

Students overwhelming described positive experiences from the CCT elective (Table 3 ). Most reported using CCT skills daily or often after the course ( N  = 20/27, 74%), and no student reported “never” practicing CCT skills after the elective. Students continued meditating ( N  = 26/34, 76%), expanding compassion ( N  = 10/34, 29%), using mindfulness ( N  = 6/34, 18%), and breathing for stress management ( N  = 5/34, 15%). Students found that pairing the stress-mitigation, mindfulness, and compassion-building skills with deliberate practice was useful and effective. Many valued the ability to recognize and think through emotions they felt. They benefited from the group dynamic of CCT, the realization that other students have similar issues, and the safe space to discuss common struggles with stress management and patient care.

Qualitative analysis of continued student skill use ( N  = 34), application ( N  = 29), and transfer of skills ( N  = 26)

Likewise, students reported broad use of stress-management and compassion-building skills in academic, clinical, and personal settings (Table 3 ). Students used skills for personal stress management and reported that the course had affected their experiences by allowing them to evaluate sources of stress and take deliberate steps to focus on the present moment (be that studying or interacting with a patient). Several students reported positive applications of skills during patient interactions, such as: using mindfulness skills to refocus and be present with a patient, expanding compassion by consciously wanting patients to be relieved of an ailment, and increasing patience, listening, and empathy during difficult interactions.

Student motivation

Students initially enrolled in CCT to learn stress management skills and to prevent compassion fatigue so that burnout would not compromise their patient care (Table 4 ). They perceived these benefits and indicated that CCT also contributed to their professional identity formation through self-introspection about becoming a physician and caring for patients. One student described how CCT forced them “to reevaluate why [we] are in medical school,” while another gained “perspective on self-care and the importance of taking care of yourself while also taking care of patients.” One student simply described the course as “life changing.”

Qualitative analysis of student enrollment motivation (N = 16) and integrating the course into required curriculum ( N  = 27)

Students were unsure whether CCT training should be part of their required curriculum. Those who supported requiring this content suggested that the experience would be beneficial and low risk, and it would help students focus on the human aspect of medicine. Students who did not support requiring CCT suggested that students need to be open-minded to this type of training. They were concerned that this could create resentment, which along with larger class sizes, could weaken the group dynamics and thus effectiveness of CCT training.

Despite these reservations, 17 of 27 respondents (63%) felt that this intervention should be a required course for all medical students. When asked when the most beneficial time to hold the course would be, responses varied: fourteen (53%) suggested in preclinical years, ten (37%) suggested during clerkships, and three (10%) said anytime. Multiple respondents recommended CCT during preclinical years with follow-up sessions during clerkship rotations “once you’ve realized that patient care can be stressful and you still have [opportunities] to practice the techniques.”

Instructor importance

Finally, a central theme that emerged among respondents was that the instructor was critical for student buy-in and training success (Table 5 ). Students reported that the instructor’s enthusiasm and conscious effort to model CCT skills helped them develop this skill set. The scientific foundation of CCT methods presented by the instructor also initially validated the experience. Few students desired changes to the course. Those who had suggestions requested logistical changes, such afternoon sessions to accommodate clerkship rotations or requesting more comfortable spaces for meditation exercises.

Qualitative analysis of student feedback regarding the faculty instructor (N = 20)

Our study demonstrates that a brief educational intervention can foster compassion and mindfulness skills in medical students participating in the elective. Students reported using CCT skills for personal well-being and stress management and for patient interactions. Students had overwhelmingly positive perceptions of the course and felt CCT was worth their time investment. This intervention ultimately addresses student wellness with threefold benefits: brevity, practical stress-management skills, and potential improvements to clinical care.

Modeling in medical education

Mindfulness is widely accepted as a teachable strategy to self-regulate attention [ 55 – 62 ]. In this study, the faculty instructor modeled meditation and mindfulness, and students applied these in their own lives as supported by social learning theory [ 48 ]. In clinical learning, role modeling is an essential conduit to learn humanistic aspects of care such as compassionate bedside manner and favorable physician-patient interactions [ 63 ]. If we hope to advance systematic efforts to decrease burnout and increase resilience, teaching faculty must purposefully model interpersonal and cognitive skills such as compassion and mindfulness. Social learning theory further proposes that imitation more likely occurs when the model is perceived as like oneself. Some student comments that the faculty instructor was “relatable” accordingly suggest that students benefited from a professional role model who was similar. This supports other studies of successful mindfulness instructors in which “embodiment, empowerment, non-reactivity and peer support” defined the instructor-student role ([ 64 ], p., 172). Without dedicated, professional role models, students may not view these qualities as legitimate, necessary clinical skills.

Wellness training

Our study aligns with previous research in mindfulness education showing that brief interventions have reported pre/post increases on mindfulness, with different interventions showing variable effects [ 38 ]. A mindfulness intervention looking specifically at the intervention’s brevity (4 weeks) of an adapted Mind Body Medicine (MBM) course found that students’ mindfulness increased and stress decreased [ 36 ], and thus short interventions can be effective. Another recent study that also looked at CCT with various healthcare providers found improvements in self-compassion and mindfulness scores [ 65 ], which aligns with the KIMS results and student feedback in our study. Their study did not find a reduction in interpersonal conflict or burnout with the instruments used, which contrasts the self-reported feedback from medical students in our study. Qualitative data may capture a more comprehensive understanding of how training effects participants. Other wellness programs for medical students have also used multiple-skill approaches for medical students, such as a combined reflective writing and MBM workshop [ 66 ]. This experience focused on building practical skills to address stress while using these strategies to better understand the source of stress and its effects on individual wellness and patient care, which is paralleled with CCT’s multiple-strategy approach to mindfulness, well-being, and compassion.

The CCT program is a valuable self-care training option because of its focus on expanding compassion. Previous studies using loving-kindness meditation with providers also found improvements in well-being and feelings of connection [ 43 , 67 ]. In this study, students reported various ways that they expanded compassion with themselves, patients, and others. The specific improvements of the “observing” and “accepting without judgment” mindfulness facets could be linked to students’ reported applications of compassion. Students practiced patience during difficult interactions with family, friends, and relationships, and they deliberately focused on others and not just themselves and their troubles. The ability to withhold judgments about patients and to be aware of others’ thoughts and feelings may help improve patient interactions, and it could also help reduce some of the unidentified stress that students feel.

Patients want their providers to be compassionate [ 68 ], and patients who perceive their provider as person-focused also perceive their care to be higher quality and are more satisfied [ 69 ]. A lack self-compassion in healthcare providers may be linked to higher burnout and/or less compassion for others [ 27 – 29 ]. The erosion of empathy that students often feel when they get to the clinic can be addressed with compassion training in a way that is different than stress management alone by teaching students the importance of cultivating compassion skills with each patient interaction [ 70 ]. Furthermore, recent research examining multiple properties of empathy found that aspects of cognitive and affective empathy (aspects which, similar to compassion, comprise understanding others’ emotions and pain) actually increased as students progressed through medical school [ 71 ]. These outcomes highlight the complexity of reported medical student empathy decline [ 8 ], reveal an intervention opportunity for academic healthcare centers to develop provider compassion, and also reinforce the importance of assessing students with multiple instruments, such as in this study. Qualitative analysis is especially useful to gain insight into the complexity of compassion and medical students’ relationship with this construct.

Practical implications

Even as academic medical programs attempt to reduce systemic sources of stress for providers, it is unrealistic for all stressors to be alleviated from variable sources. Thus, the practical solution for providers is learning skills to cope with inevitable stress. The positive perceptions of CCT and its utility suggest that students who had opted into the elective found this type of training worthwhile, which supports other qualitative studies of stress management with medical students [ 72 ]. CCT students reported various benefits to deliberate practice, and these rewards prompted students to continue using the skills. The follow-up with the 2015 cohort occurred over one year later, and this longer-term (although not long-term) insight suggested that these perceptions were maintained. Students also discussed using skills they learned with patients, which emphasized clinical applications of CCT and potentially enhancing patient interactions.

Differences between KIMS results for the 2015/2016 and 2017 cohorts suggest that course structure could be crucial to developing mindfulness skills. The 2017 cohort experienced an accelerated course to accommodate scheduling constraints, which may have limited students’ ability to improve mindfulness skills over the elective duration, especially for students experiencing additional pressures and responsibilities as they progress through their training. However, positive qualitative feedback and perceptions of the course were consistent across cohorts despite differences in course duration and also sampling time (one year out versus immediately following the course). Furthermore, although KIMS scores did not change significantly across all mindfulness facets, individuals report deliberately practicing other skills in qualitative feedback (e.g., demonstrating acting with awareness by focusing on one patient at a time). For students who were uninterested in mindfulness, developing self-compassion and other self-care techniques may have also provided alternative benefits to CCT students. Thus, CCT may have meaningful impact that scales do not capture, reinforcing the importance of qualitative assessment.

Role modeling was an important component of CCT success. A practical consequence is that medical schools must ensure instructors are well trained, genuine, and relatable to medical students. Formal training to teach mindfulness and compassion provides instructors with a scientific foundation and ensures that instructors can translate their experiences to students. Representation from top faculty leadership in a program like CCT also develops these skills among campus leaders and demonstrates institutional support for well-being and compassion.

Students struggled with some of the same concerns as medical educators, such as whether wellness training should be integrated into required curriculum for all students [ 38 ]. Broad implementation of CCT for all medical students could be limited by several factors. Faculty interest and funds to train with CCARE for CCT may be limited, and instructors with the appropriate skillset and background may not be available to meet the number of students. Increasing the size of the class could reduce the intimacy and safe-space dynamics created by limiting enrollment size. Forcing students who are uninterested in mindfulness training could also lead to resentment, and thus negatively change the experience of all students in the course. Although some students expressed that they had not realized how helpful the course would be until they were in it, there was a serious concern that an influx of resistant students could adversely affect mindfulness training and compassion cultivation. However, undergraduate medical education likely provides a more practical, comprehensive setting for teaching these skills to all students versus more diverse and potentially stressful residencies, which perhaps requires medical educators to validate compassion training’s relevance and worth to students.

Limitations

This study was limited by its small sample size and short-term analysis, although these were inherent in the design to create a brief, intimate CCT experience. Not all students participated in the study, similar to other studies of compassion development in health professions with low response rates [ 73 , 74 ]. This study was also limited by variation in data-collection approaches across cohorts that did not include comparison groups. Students’ perceptions of application and compassion were derived from self-report data without scale measures, and pre-clerkship students had limited patient interactions. Students self-selected into the elective and therefore may have been more likely to find benefit in this training. Alternatively, as students suggested, some students who would not opt in to this training could be immensely helped by it.

Future directions

We intend to expand CCT to a larger group of students, ideally through multiple course sections to maintain small enrollment size. Long-term follow-ups that include more formal burnout and compassion measures to improve robustness will suggest if skills from this brief intervention are retained, particularly in comparison to control groups who have not had similar wellness interventions. Comparison groups that receive similar amounts of interaction with an attending in a different setting could also help determine whether CCT itself or personalized attention from an attending is particularly effective. Because students do not receive training to expand compassion elsewhere, institutions must provide similar training opportunities to students and foster a climate of well-being. In their foundational report on burnout interventions, West et al. [ 24 ] charged the medical education community with understanding how individual interventions can be combined with organizational solutions, which have been shown to be more beneficial [ 75 ]. We are addressing this call by offering CCT and similar organization-directed programs to students, residents, and faculty physicians through Being Well , a comprehensive, institutional-led initiative at ULSOM to increase health, resilience, and compassion across the continuum.

CCT was well received by medical students who opted into this elective and subsequently described positive impacts on academic and clinical stress. During the elective, some students increased their mindfulness skills and many reported improved interpersonal and patient interactions. Incorporating a brief educational intervention like CCT to simultaneously improve self-care and expand compassion could help academic medical centers address competing challenges of supporting student wellness and patient care.

Acknowledgements

The authors would like to thank the Center for Compassion and Altruism Research and Education (CCARE) at the Stanford School of Medicine for their support. The authors would also like to thank the Dean of the School of Medicine, Dr. Toni Ganzel, who has helped to make wellness and compassion a priority at ULSOM, and the UME Medical Education Research Unit staff for providing substantial research support.

No funding was obtained for this study.

Availability of data and materials

All data from this study are summarized in the results section. Raw data from this study cannot be shared in accordance with the confidentiality agreement for consented participants.

Abbreviations

Center for Compassion and Altruisms Research and Education

Compassion Cultivation Training

Kentucky Inventory of Mindfulness Skills

Mind Body Medicine

University of Louisville School of Medicine

Authors’ contributions

LAW contributed to study design, the collection, interpretation, and analysis of data, and drafting of this article. SS contributed to study conception and design, the collection, interpretation, and analysis of data, and drafting of this article. MAS contributed to the conception of the study and article revision. JBK contributed to instruction, the conception of the study, data collection, and article revision. All authors gave final approval of the submission.

Authors’ information

LAW - PhD, MS, is Research Manager of Undergraduate Medical Education Research, University of Louisville School of Medicine, Louisville, Kentucky, USA.

SS - MSSW, is Director of Undergraduate Medical Education Research, University of Louisville School of Medicine, Louisville, Kentucky, USA.

MAS - MD, MA, is Professor of Medicine and Vice Dean for Undergraduate Medical Education, University of Louisville School of Medicine, Louisville, Kentucky, USA.

JBK - MD, PhD, is Professor of Medicine and Vice Dean for Research; University of Louisville School of Medicine, and Robley Rex VA Medical Center, Louisville, Kentucky, USA.

Ethics approval and consent to participate

This study was approved by the University of Louisville Institutional Review Board (#15.0835). Study participants were given a preamble with information regarding study aim, data confidentiality, and voluntary nature. Submission of identified inventory data and completion of optional surveys were regarded as informed consent and voluntary participation.

Consent for publication

Not Applicable.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Contributor Information

Laura A. Weingartner, Phone: (502) 852-0771, Email: [email protected]

Susan Sawning, Email: [email protected].

M. Ann Shaw, Email: [email protected].

Jon B. Klein, Email: [email protected]

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Evaluation of pain knowledge and attitudes and beliefs from a pre-licensure physical therapy curriculum and a stand-alone pain elective

Affiliations.

• 1 Department of Physical Therapy, School of Movement and Rehabilitation Sciences at Bellarmine University, Nolen C. Allen Building, 2001 Newburg Rd. Room 471, Louisville, KY, 40205, USA. [email protected].
• 2 Department of Neurological Surgery, University of Louisville, Louisville, USA. [email protected].
• 3 Department of Physical Therapy, School of Movement and Rehabilitation Sciences at Bellarmine University, Nolen C. Allen Building, 2001 Newburg Rd. Room 471, Louisville, KY, 40205, USA.
• 4 Select Medical, Mechanicsburg, PA, USA.
• PMID: 31619237
• PMCID: PMC6796383
• DOI: 10.1186/s12909-019-1820-7

Background: Adequate pain education of health professionals is fundamental in the management of pain. Although an interprofessional consensus of core competencies for health professional pre-licensure education in pain have been established, the degree of their incorporation into physical therapy curriculum varies greatly. The purpose of this study was to 1. Assess students' pain knowledge and their attitudes and beliefs in a pre-licensure physical therapy curriculum using a cross sectional comparison, and 2. Using a sub-sample of this population, we evaluated if an elective course on pain based on International Association for the Study of Pain (IASP) guidelines had an effect on students' knowledge and beliefs.

Methods: The Neurophysiology of Pain Questionnaire (NPQ) and the Pain Attitudes and Beliefs Scale for Physiotherapists (PABS-PT) was completed by first semester (n = 72) and final (n = 56) semester doctor of physical therapy (DPT) students. Final semester students completed surveys before and after participation in an elective course of their choosing (pain elective (PE) or other electives (OE)).

Results: Participation rate was > 90% (n = 128/140). We found mean differences in NPQ scores between final semester (3rd year) students (76.9%) compared to first semester students (64%), p < 0.001. Third year students showed a mean difference on PABS-PT subscales, showing decreased biomedical (p < 0.001) and increased biopsychosocial (p = 0.005) scores compared to first semester students. Only final semester students that participated in the PE improved their NPQ scores (from 79 to 86%, p < 0.001) and demonstrated a significant change in the expected direction on PABS-PT subscales with increased biopsychosocial (p = 0.003) and decreased biological scores (p < 0.001).

Conclusions: We suggest that although core pre-licensure DPT education improves students' pain knowledge and changes their attitudes towards pain, taking a IASP based pain elective continues to improve their pain neurobiology knowledge and also further changes their attitudes and beliefs towards pain. Therefore, a stand-alone course on pain in addition to pain concepts threaded throughout the curriculum may help ensure that entry-level DPT students are better prepared to effectively work with patients with pain.

Keywords: Education; Pain; Pain knowledge; Physical therapy curriculum.

• Cross-Sectional Studies
• Curriculum*
• Health Knowledge, Attitudes, Practice*
• Pain Management / methods*
• Physical Therapists / education*
• Physical Therapy Modalities / education*