Discussion:
Today’s medical students are tomorrow’s doctors, and strong foundations in both intellectual and emotional intelligence are paramount for fostering a skillful doctor who is capable of maintaining efficacious doctor-patient relationships, which would improve therapy by increasing trust and satisfaction on both sides. (7) (18) Intellectual and emotional intelligence can both be improved throughout the educational stages of university life. High EI is believed to be of importance to the doctor’s practical life, enabling them to better deal with patients by using emotions to investigate and reach a correct diagnosis. EI may also enable doctors to understand different points of view concurrently, understand their own reactions, and handle stress in an appropriate manner; newer research additionally focuses on EI as an indicator of a doctor’s academic and professional success. (7) (19) (20) (21)
This study assessed emotional intelligence among medical students and identified some factors that affect it. Changes and interventions with which to improve EI were considered. Finally, we established a base for further studies, e.g. measuring methods to improve EI, identifying its relationship with physical and mental health, and determining if it is connected to career success. Moreover, the findings may direct medical education to emphasize EI learning and to incorporate special technical courses for improving EI in medical students and doctors.
The results showed a significant difference in EI between basic and clinical medical students, with EI declining significantly in the second period. This indicates that as medical students progress from basic to clinical stage, their awareness of their own feelings and emotions decreases. This is consistent with the results established in an exploratory study conducted by the University of Kentucky College of Medicine, which also found that some subscales of emotional intelligence (empathic concern and attention to feelings) decreased as students proceeded through their study. (4) This decline may be attributed to many factors, including:
  1. High expectations : In medical training, the divide between reality and prior expectations of the student is sometimes profound and disappointing. (22) During their basic years, many students have high expectations of clinical training that stem from movies or medical series (such as The Good Doctor andHouse ). However, as soon as they start their clinical period, they realize the difference between what they expected and what is practically applied in hospitals. For example: The unethical behaviors of some doctors are a huge letdown for students. One study of 3rd and 4th years found that 61% of students observed unethical behaviors toward patients, and 40% of students reported feeling guilty for participating in that behavior in order to please their doctors and get good evaluations. (4)
  2. Low self-esteem : Decreased self-esteem among clinical-stage medical students in clinical stage stems from embarrassment and self-doubt caused by some of their doctors, including occasional gender discrimination and disrespectful treatment, which could be exaggerated and augmented when students realize that there is a deficit in the rights that protect students and health care professionals against violence. (4) Moreover, students may encounter differences between what they learned about the signs and symptoms of diseases from books during their basic years and how patients present in the hospital; many times, not all symptoms can be seen on a patient. This difference may weaken student self-confidence and their confidence in what they learned, which may affect their EI. (23)
  3. Social environment : As EI is associated with pro-social behavior, the change in a student’s social environment between basic and clinical periods is a potential cause for the decline in their emotional intelligence. Clinical training includes several rotations, each one in a different hospital, which usually separates students from their families and peers. This may create a feeling of loneliness, which may affect their empathy. The need to adapt at every rotation to a new environment with different requirements also causes immense stress. (4)
  4. Medical challenges : Medical studies are hard, and the medical environment is a stressful one. The medical world is rapidly changing, with more demanding patients and families and increased workloads on doctors (24) (9) In addition, the number of students entering medical school increases every year, which means that getting a satisfying job or residency program is becoming harder. This puts medical students in a constant state of fear for their future, especially when they see that the highly competitive nature of medicine leads many graduates to end up receiving unpaid residency programs. This constant fear of the future combines with immense responsibilities and the high expectations of family members to create a very stressful circumstance for the student. (4) In addition, the challenge of balancing medical life, social life, responsibilities, and personal happiness causes some stress to medical students, which would potentially decrease their EI. Finally, fear of catching illness or of facing people in suffering is also overwhelming to some medical students. (9)
  5. Humanity vs objectivity : The conflict between humanity and objectivity that occurs inside medical students throughout their clinical training would decrease their productivity. These students encounter patients, witness them suffering, and may see some die. As they progress through medical school and continue to face these scenarios, they may become more cynical and desensitized, potentially starting to see patients as objects rather than people. This decrease in humanism may be an important factor in decreasing EI, especially through its effect on empathy. (4) (25)
There could be additional factors that might explain the observed results, which is why we recommend more research be carried out to address these factors. It is also relevant to note that some studies have showed that EI does not change throughout the course of medical studies. (9)
One of the interesting results in the present study is that among medical students who regret studying medicine, EI scores were lower than for their peers who do not. This may be attributed to the following:
  1. Some medical students are forced to study medicine by the desire of their parents, making them less interested, confident, and productive and more depressed. Even without that, studying medicine is a hard decision on its own, and pre-college students are not prepared to choose properly. (7)
  2. Generally, medical students initially enjoy studying medicine due to the similarity of early years with school subjects and to enthusiasm for college life. As they advance, radical changes in the educational system make it harder and more difficult to tolerate— i.e. self-study, the enormous amount of subjects and material, and increased difficulty. (22)
  3. From a social point of view, a medical student’s time is fully consumed by their studies; their social life, time with friends, and even favorite hobbies become sharply limited, affecting the student’s emotions. These feelings become exaggerated and augmented when they realize that they are still stuck in the educational phase of life while their peers move on to new experiences, such as getting married and becoming independent and financially autonomous through gaining access to the labor market. (4) (22)
  4. Students may feel guilty about the high installments their parents pay yearly to fund their education, which may forbid other family members from pursuing college education or require their parents to hold two or three jobs.
  5. Students who are satisfied in studying medicine have higher EI. (26) Moreover, studies emphasize that students who enjoy studying medicine have higher EI scores. (27)
We also observed that the mean EI score for students having hobbies and extracurricular activities is higher than that for students who do not. A similar finding was reported in another study, demonstrating that emotional intelligence is influenced positively by performing leisure activities. (24) Generally speaking, medical students who have hobbies would also have outstanding skill in time management. Furthermore, the social interactions they take part in while performing these hobbies and extracurricular activities enable these students to better deal with patients in their professional career. (28) (29)
Our finding that the overall emotional intelligence scores of men and women were almost equal is consistent with the literature. (30) (5) This would rebut the idea that women are more emotional. However, another study stated that “women may be better at translating their EI into clinical care delivery compared to men,” in which light this finding could be interpreted as women being better in specific aspects of emotional intelligence and men in other aspects, with the overall scores being equal. (5) Some literature has reported that females have higher EI scores than males (6) (24) (26) (18) (7) (27) (31); to the best of our knowledge, none has found that males have higher EI.
Our observations that financial and marital status, birth order, place of residency, hometown, and university attended do not affect student EI are consistent with the literature. (24) (5) (27) Notably, the two universities that participated in the study have different educational systems. For instance, Al-Quds University follows the integrated medical curriculum, while Al-Najah University follows the regional approach. In addition, third-year basic students in Al-Najah University have a weekly clinical rotation, which is not applied in Al-Quds University. Nonetheless, students’ EI scores were not significantly different.
Unexpectedly, having an older brother or sister who is studying medicine appears not to significantly influence the EI of students. The expectation was that having an older family member studying medicine—i.e. one with similar experience—may prepare the student for the reality of medical school by managing expectations and providing hints and advice based on experience. (6) Also surprising was that living with the family and not in student housing had no significant effect. (7) Both of these factors were expected to improve EI and prevent its deterioration during medical studies by providing a supportive environment to the student both physically and mentally, thereby helping tolerance of the stressful medical environment. (27)
In addition, academic performance appears to have no significant correlation with EI. This may be interpreted as the students being more aware of the fact that their performance is not necessarily representative of their capacities. This result supports that having high IQ does not necessarily go hand in hand with having high EQ. (17) (18) However, some studies have reported that academic performance is significantly affected by EI. (32) (24) (18) (7); furthermore, since studying is the only parameter for success in their schools, concentration on studies causes students to neglect their social lives. (9) Hopefully, medical students still have opportunity to improve their EI; it has been pointed out that physicians achieve higher EI as they age and gain experience. (6)
Despite the interesting results of this study, it has some limitations. First, the study is restricted to the West Bank. Second, it is cross-sectional and not a cohort study due to limitations of time and financial support. Our cross-sectional design limits studying causality of the factors identified as affecting EI, thus prospective follow-up studies are needed to investigate this causality. Third, the sample was collected online and consisted of self-reports over a limited duration of time. Self-ratings of EI may provide an indication of the respondent’s beliefs about their EI (perceived EI) rather than reflecting their actual capacity, and tend to be positively biased. (33) Fourth, the sample size within each academic year was small, especially for residency (n=18) and internship (n=35). Fifth is common method variance, which is attributable to the measurement method rather than to the constructs the measures represent; this is especially encountered in questionnaire-based cross-sectional studies on attitude/behavioral constructs, such as the present study. (34)