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Performing a literature review

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• Gulraj S Matharu , academic foundation doctor ,
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• 1 Institute of Biomedical Research, College of Medical and Dental Sciences, School of Immunity and Infection, University of Birmingham, UK

A necessary skill for any doctor

What causes disease, which drug is best, does this patient need surgery, and what is the prognosis? Although experience helps in answering these questions, ultimately they are best answered by evidence based medicine. But how do you assess the evidence? As a medical student, and throughout your career as a doctor, critical appraisal of published literature is an important skill to develop and refine. At medical school you will repeatedly appraise published literature and write literature reviews. These activities are commonly part of a special study module, research project for an intercalated degree, or another type of essay based assignment.

Formulating a question

Literature reviews are most commonly performed to help answer a particular question. While you are at medical school, there will usually be some choice regarding the area you are going to review.

Once you have identified a subject area for review, the next step is to formulate a specific research question. This is arguably the most important step because a clear question needs to be defined from the outset, which you aim to answer by doing the review. The clearer the question, the more likely it is that the answer will be clear too. It is important to have discussions with your supervisor when formulating a research question as his or her input will be invaluable. The research question must be objective and concise because it is easier to search through the evidence with a clear question. The question also needs to be feasible. What is the point in having a question for which no published evidence exists? Your supervisor’s input will ensure you are not trying to answer an unrealistic question. Finally, is the research question clinically important? There are many research questions that may be answered, but not all of them will be relevant to clinical practice. The research question we will use as an example to work through in this article is, “What is the evidence for using angiotensin converting enzyme (ACE) inhibitors in patients with hypertension?”

Collecting the evidence

After formulating a specific research question for your literature review, the next step is to collect the evidence. Your supervisor will initially point you in the right direction by highlighting some of the more relevant papers published. Before doing the literature search it is important to agree a list of keywords with your supervisor. A source of useful keywords can be obtained by reading Cochrane reviews or other systematic reviews, such as those published in the BMJ . 1 2 A relevant Cochrane review for our research question on ACE inhibitors in hypertension is that by Heran and colleagues. 3 Appropriate keywords to search for the evidence include the words used in your research question (“angiotensin converting enzyme inhibitor,” “hypertension,” “blood pressure”), details of the types of study you are looking for (“randomised controlled trial,” “case control,” “cohort”), and the specific drugs you are interested in (that is, the various ACE inhibitors such as “ramipril,” “perindopril,” and “lisinopril”).

Once keywords have been agreed it is time to search for the evidence using the various electronic medical databases (such as PubMed, Medline, and EMBASE). PubMed is the largest of these databases and contains online information and tutorials on how to do literature searches with worked examples. Searching the databases and obtaining the articles are usually free of charge through the subscription that your university pays. Early consultation with a medical librarian is important as it will help you perform your literature search in an impartial manner, and librarians can train you to do these searches for yourself.

Literature searches can be broad or tailored to be more specific. With our example, a broad search would entail searching all articles that contain the words “blood pressure” or “ACE inhibitor.” This provides a comprehensive list of all the literature, but there are likely to be thousands of articles to review subsequently (fig 1). ⇓ In contrast, various search restrictions can be applied on the electronic databases to filter out papers that may not be relevant to your review. Figure 2 gives an example of a specific search. ⇓ The search terms used in this case were “angiotensin converting enzyme inhibitor” and “hypertension.” The limits applied to this search were all randomised controlled trials carried out in humans, published in the English language over the last 10 years, with the search terms appearing in the title of the study only. Thus the more specific the search strategy, the more manageable the number of articles to review (fig 3), and this will save you time. ⇓ However, this method risks your not identifying all the evidence in the particular field. Striking a balance between a broad and a specific search strategy is therefore important. This will come with experience and consultation with your supervisor. It is important to note that evidence is continually becoming available on these electronic databases and therefore repeating the same search at a later date can provide new evidence relevant to your review.

Fig 1 Results from a broad literature search using the term “angiotensin converting enzyme inhibitor”

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Fig 2 Example of a specific literature search. The search terms used were “angiotensin converting enzyme inhibitor” and “hypertension.” The limits applied to this search were all randomised controlled trials carried out in humans, published in English over the past 10 years, with the search terms appearing in the title of the study only

Fig 3 Results from a specific literature search (using the search terms and limits from figure 2)

Reading the abstracts (study summary) of the articles identified in your search may help you decide whether the study is applicable for your review—for example, the work may have been carried out using an animal model rather than in humans. After excluding any inappropriate articles, you need to obtain the full articles of studies you have identified. Additional relevant articles that may not have come up in your original search can also be found by searching the reference lists of the articles you have already obtained. Once again, you may find that some articles are still not applicable for your review, and these can also be excluded at this stage. It is important to explain in your final review what criteria you used to exclude articles as well as those criteria used for inclusion.

The National Institute for Health and Clinical Excellence (NICE) publishes evidence based guidelines for the United Kingdom and therefore provides an additional resource for identifying the relevant literature in a particular field. 4 NICE critically appraises the published literature with recommendations for best clinical practice proposed and graded based on the quality of evidence available. Similarly, there are internationally published evidence based guidelines, such as those produced by the European Society of Cardiology and the American College of Chest Physicians, which can be useful when collecting the literature in a particular field. 5 6

Appraising the evidence

Once you have collected the evidence, you need to critically appraise the published material. Box 1 gives definitions of terms you will encounter when reading the literature. A brief guide of how to critically appraise a study is presented; however, it is advisable to consult the references cited for further details.

Box 1: Definitions of common terms in the literature 7

Prospective—collecting data in real time after the study is designed

Retrospective—analysis of data that have already been collected to determine associations between exposure and outcome

Hypothesis—proposed association between exposure and outcome. If presented in the negative it is called the null hypothesis

Variable—a quantity or quality that changes during the study and can be measured

Single blind—subjects are unaware of their treatment, but clinicians are aware

Double blind—both subjects and clinicians are unaware of treatment given

Placebo—a simulated medical intervention, with subjects not receiving the specific intervention or treatment being studied

Outcome measure/endpoint—clinical variable or variables measured in a study subsequently used to make conclusions about the original interventions or treatments administered

Bias—difference between reported results and true results. Many types exist (such as selection, allocation, and reporting biases)

Probability (P) value—number between 0 and 1 providing the likelihood the reported results occurred by chance. A P value of 0.05 means there is a 5% likelihood that the reported result occurred by chance

Confidence intervals—provides a range between two numbers within which one can be certain the results lie. A confidence interval of 95% means one can be 95% certain the actual results lie within the reported range

The study authors should clearly define their research question and ideally the hypothesis to be tested. If the hypothesis is presented in the negative, it is called the null hypothesis. An example of a null hypothesis is smoking does not cause lung cancer. The study is then performed to assess the significance of the exposure (smoking) on outcome (lung cancer).

A major part of the critical appraisal process is to focus on study methodology, with your key task being an assessment of the extent to which a study was susceptible to bias (the discrepancy between the reported results and the true results). It should be clear from the methods what type of study was performed (box 2).

Box 2: Different study types 7

Systematic review/meta-analysis—comprehensive review of published literature using predefined methodology. Meta-analyses combine results from various studies to give numerical data for the overall association between variables

Randomised controlled trial—random allocation of patients to one of two or more groups. Used to test a new drug or procedure

Cohort study—two or more groups followed up over a long period, with one group exposed to a certain agent (drug or environmental agent) and the other not exposed, with various outcomes compared. An example would be following up a group of smokers and a group of non-smokers with the outcome measure being the development of lung cancer

Case-control study—cases (those with a particular outcome) are matched as closely as possible (for age, sex, ethnicity) with controls (those without the particular outcome). Retrospective data analysis is performed to determine any factors associated with developing the particular outcomes

Cross sectional study—looks at a specific group of patients at a single point in time. Effectively a survey. An example is asking a group of people how many of them drink alcohol

Case report—detailed reports concerning single patients. Useful in highlighting adverse drug reactions

There are many different types of bias, which depend on the particular type of study performed, and it is important to look for these biases. Several published checklists are available that provide excellent resources to help you work through the various studies and identify sources of bias. The CONSORT statement (which stands for CONsolidated Standards Of Reporting Trials) provides a minimum set of recommendations for reporting randomised controlled trials and comprises a rigorous 25 item checklist, with variations available for other study types. 8 9 As would be expected, most (17 of 25) of the items focus on questions relating to the methods and results of the randomised trial. The remaining items relate to the title, abstract, introduction, and discussion of the study, in addition to questions on trial registration, protocol, and funding.

Jadad scoring provides a simple and validated system to assess the methodological quality of a randomised clinical trial using three questions. 10 The score ranges from zero to five, with one point given for a “yes” in each of the following questions. (1) Was the study described as randomised? (2) Was the study described as double blind? (3) Were there details of subject withdrawals, exclusions, and dropouts? A further point is given if (1) the method of randomisation was appropriate, and (2) the method of blinding was appropriate.

In addition, the Critical Appraisal Skills Programme provides excellent tools for assessing the evidence in all study types (box 2). 11 The Oxford Centre for Evidence-Based Medicine levels of evidence is yet another useful resource for assessing the methodological quality of all studies. 12

Ensure all patients have been accounted for and any exclusions, for whatever reason, are reported. Knowing the baseline demographic (age, sex, ethnicity) and clinical characteristics of the population is important. Results are usually reported as probability values or confidence intervals (box 1).

This should explain the major study findings, put the results in the context of the published literature, and attempt to account for any variations from previous work. Study limitations and sources of bias should be discussed. Authors’ conclusions should be supported by the study results and not unnecessarily extrapolated. For example, a treatment shown to be effective in animals does not necessarily mean it will work in humans.

The format for writing up the literature review usually consists of an abstract (short structured summary of the review), the introduction or background, methods, results, and discussion with conclusions. There are a number of good examples of how to structure a literature review and these can be used as an outline when writing your review. 13 14

The introduction should identify the specific research question you intend to address and briefly put this into the context of the published literature. As you have now probably realised, the methods used for the review must be clear to the reader and provide the necessary detail for someone to be able to reproduce the search. The search strategy needs to include a list of keywords used, which databases were searched, and the specific search limits or filters applied. Any grading of methodological quality, such as the CONSORT statement or Jadad scoring, must be explained in addition to any study inclusion or exclusion criteria. 6 7 8 The methods also need to include a section on the data collected from each of the studies, the specific outcomes of interest, and any statistical analysis used. The latter point is usually relevant only when performing meta-analyses.

The results section must clearly show the process of filtering down from the articles obtained from the original search to the final studies included in the review—that is, accounting for all excluded studies. A flowchart is usually best to illustrate this. Next should follow a brief description of what was done in the main studies, the number of participants, the relevant results, and any potential sources of bias. It is useful to group similar studies together as it allows comparisons to be made by the reader and saves repetition in your write-up. Boxes and figures should be used appropriately to illustrate important findings from the various studies.

Finally, in the discussion you need to consider the study findings in light of the methodological quality—that is, the extent of potential bias in each study that may have affected the study results. Using the evidence, you need to make conclusions in your review, and highlight any important gaps in the evidence base, which need to be dealt with in future studies. Working through drafts of the literature review with your supervisor will help refine your critical appraisal skills and the ability to present information concisely in a structured review article. Remember, if the work is good it may get published.

Originally published as: Student BMJ 2012;20:e404

Competing interests: None declared.

Provenance and peer review: Not commissioned; externally peer reviewed.

• ↵ The Cochrane Library. www3.interscience.wiley.com/cgibin/mrwhome/106568753/HOME?CRETRY=1&SRETRY=0 .
• ↵ British Medical Journal . www.bmj.com/ .
• ↵ Heran BS, Wong MMY, Heran IK, Wright JM. Blood pressure lowering efficacy of angiotensin converting enzyme (ACE) inhibitors for primary hypertension. Cochrane Database Syst Rev 2008 ; 4 : CD003823 , doi: 10.1002/14651858.CD003823.pub2. OpenUrl PubMed
• ↵ National Institute for Health and Clinical Excellence. www.nice.org.uk .
• ↵ European Society of Cardiology. www.escardio.org/guidelines .
• ↵ Geerts WH, Bergqvist D, Pineo GF, Heit JA, Samama CM, Lassen MR, et al. Prevention of venous thromboembolism: American College of Chest Physicians evidence-based clinical practice guidelines (8th ed). Chest 2008 ; 133 : 381 -453S. OpenUrl CrossRef
• ↵ Wikipedia. http://en.wikipedia.org/wiki .
• ↵ Moher D, Schulz KF, Altman DG, Egger M, Davidoff F, Elbourne D, et al. The CONSORT statement: revised recommendations for improving the quality of reports of parallel-group randomised trials. Lancet 2001 ; 357 : 1191 -4. OpenUrl CrossRef PubMed Web of Science
• ↵ The CONSORT statement. www.consort-statement.org/ .
• ↵ Jadad AR, Moore RA, Carroll D, Jenkinson C, Reynolds DJ, Gavaghan DJ, et al. Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control Clin Trials 1996 ; 17 : 1 -12. OpenUrl CrossRef PubMed Web of Science
• ↵ Critical Appraisal Skills Programme (CASP). www.sph.nhs.uk/what-we-do/public-health-workforce/resources/critical-appraisals-skills-programme .
• ↵ Oxford Centre for Evidence-based Medicine—Levels of Evidence. www.cebm.net .
• ↵ Van den Bruel A, Thompson MJ, Haj-Hassan T, Stevens R, Moll H, Lakhanpaul M, et al . Diagnostic value of laboratory tests in identifying serious infections in febrile children: systematic review. BMJ 2011 ; 342 : d3082 . OpenUrl Abstract / FREE Full Text
• ↵ Awopetu AI, Moxey P, Hinchliffe RJ, Jones KG, Thompson MM, Holt PJ. Systematic review and meta-analysis of the relationship between hospital volume and outcome for lower limb arterial surgery. Br J Surg 2010 ; 97 : 797 -803. OpenUrl CrossRef PubMed

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What is a literature review?

Systematic reviews vs literature reviews, literature reviews - articles, writing literature reviews, frequently used journal article databases.

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The literature review is the qualitative summary of evidence on a topic using informal or subjective methods to collect and interpret studies.The literature review can inform a particular research project or can result in a review article publication.

• Aaron L. Writing a literature review article. Radiol Technol. 2008 Nov-Dec; 80(12): 185-6.
• Gasparyan AY, Ayvazyan L, Blackmore H, Kitas GD. Writing a narrative biomedical review: considerations for authors, peer reviewers, and editors. Rheumatol Int. 2011 Nov; 31(11): 1409-17.
• Matharu GS, Buckley CD. Performing a literature review: a necessary skill for any doctor. Student BMJ. 2012; 20:e404. Requires FREE site registration
• Literature Reviews The Writing Center at University of North Carolina at Chapel Hill has created a succinct handout that explains what a literature review is and offer insights into the form and construction of a literature review in the humanities, social sciences, and sciences.
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• The Pandora's Box of Evidence Synthesis and the case for a living Evidence Synthesis Taxonomy | BMJ Evidence-Based Medicine, 2023
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Home » Office of Curriculum » Medical Student Scholarship » III Scholarship Start Here » Scholarship of Integration » Key Steps in a Literature Review

Key Steps in a Literature Review

The 5 key steps  below are most relevant to narrative reviews. Systematic reviews include the additional step of using a standardized scoring system to assess the quality of each article. More information on  Step 1 can be found  here  and Step 5  here .

• Consider the purpose and rationale of a review
• Clearly articulate the components of the question
• The research question and purpose of your review should guide the development of your search strategy (i.e. which databases to search and which search terms to use)
• Justify any limitations you create for your search,
• Determine inclusion and exclusion criteria.
• Start by reviewing abstracts for relevant articles. Once this is complete, then begin a full text review of the remaining articles.
• Develop a data-charting form to extract data from each article. Update this form as needed if you find there is more information worth collecting.
• The resulting forms will serve as a summary of each article that will facilitate the process of synthesizing your results (i.e. the selected articles).
• In your analysis, include a numerical summary of studies included, an evidence table summarizing included articles, and a qualitative summary of the results.
• Report the results in the context of the overall purpose or research question.
• Consider the meaning of your results. Discuss limitations and implications for future research, practice, and/or policy.

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Literature review

Literature reviews are a way of identifying what is already known about a research area and what the gaps are. To do a literature review, you will need to identify relevant literature, often through searching academic databases, and then review existing literature. Most often, you will do the literature review at the beginning of your research project, but it is iterative, so you may choose to change the literature review as you move through your project.

Searching the literature

The University of Melbourne Library has some resources about searching the literature. Leonie spoke about how she met with a librarian about searching the literature. You may also want to meet face-to-face with a librarian or attend a class at the library to learn more about literature searching. When you search the literature, you may find journal articles, reports, books and other materials.

Filing, categorising and managing literature

In order to manage the literature you have identified through searches, you may choose to use a reference manager. The University of Melbourne has access to RefWorks and Endnote. Further information about accessing this software is available through the University of Melbourne Library .

Writing a literature review

The purpose of the literature review is to identify what is already known about a particular research area and critically analyse prior studies. It will also help you to identify any gaps in the research and situate your research in what is already known about a particular topic.

• Aveyard, H. (2010). Doing a literature review in health and social care: A practical guide . London, UK: McGraw-Hill Education. Retrieved from Proquest https://ebookcentral.proquest.com/lib/unimelb/detail.action?docID=771406
• Reeves, S., Koppel, I., Barr, H., Freeth, D., Hammick, M. (2002). Twelve tips for undertaking a systematic review. Medical Teacher . 24(4), 358-363 .
• Grant, M.J. and Booth, A. (2009). A typology of reviews: an analysis of 14 review types and associated methodologies. Health Information & Libraries Journal .
• Jesson, J., & Lacey, F. (2006). How to do (or not to do) a critical literature review. Pharmacy Education , 6(2), 139-148 .
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The use of drugs and medical students: a literature review

Affiliations.

• 1 4Th-year Medical Students fo the State University of Ponta Grossa (PR), Brazil.
• 2 Master in Science and Technology Teaching; Associate Professor of the Medical Program of the State University of Ponta Grossa (PR), Brazil.
• 3 PhD in Internal Medicine; Adjunct Professor of Medicine at the Ponta Grossa State University (UEPG), Ponta Grossa (PR), Brazil.
• PMID: 30304147
• DOI: 10.1590/1806-9282.64.05.462

Introduction: The consumption and abuse of alcohol and other drugs are increasingly present in the lives of university students and may already be considered a public health problem because of the direct impacts on the physical and mental health of these individuals. The requirements of the medical program play a vital role in the increasing rate of drug users.

Objectives: To carry out a systematic review of the literature on the use of drugs, licit or not, in Brazilian medical students.

Methods: A descriptive-exploratory study, in which the SciELO and MEDLINE databases were used. A total of 99 articles were found, of which 16 were selected for this review.

Results: Alcohol and tobacco were the most frequently used licit drugs among medical students. The most consumed illicit drugs were marijuana, solvents, "lança-perfume" (ether spray), and anxiolytics. The male genre presented a tendency of consuming more significant amounts of all kinds of drugs, with the exception of tranquilizers. It was found an increasing prevalence of drug consumption in medical students, as the program progressed, which may result from the intrinsic stress from medical school activities. Students who do not use psychoactive drugs are more likely to live with their parents, to disapprove drugs consumption, to practice religious beliefs and to be employed.

Conclusion: The prevalence of licit and illicit drug use among medical students is high, even though they understand the injuries it may cause.

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• Systematic Review
• Alcohol Drinking / epidemiology
• Brazil / epidemiology
• Illicit Drugs
• Marijuana Smoking / epidemiology
• Sex Factors
• Smoking / epidemiology
• Students, Medical / psychology*
• Substance-Related Disorders / epidemiology*

Test Anxiety Among US Medical Students: A Review of the Current Literature

• Published: 14 February 2024

Cite this article

• Clark Williamson   ORCID: orcid.org/0000-0003-4702-9567 1 ,
• Sarah T. Wright   ORCID: orcid.org/0000-0003-2076-8343 2 &
• Gary L. Beck Dallaghan   ORCID: orcid.org/0000-0002-8539-6969 3  

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Medical students experience anxiety at higher rates than the general public and many are uniquely affected by additional test anxiety throughout their medical education. Although test anxiety has been studied for decades, little evidence has been published suggesting interventions improve examination performance in medical education. Therefore, we set out to review the current literature to elucidate efforts so far and establish trends in research.

Databases searched included PubMed, EMBASE, PsychINFO, ERIC, SCOPUS, and CINAHL. English language articles published between 2010 and 2021 were loaded into a reference manager to screen out duplicate articles. During the full-text screen and data extraction phase, reference lists were also inspected to identify additional articles for inclusion in the study.

Of 883 studies identified, 860 were excluded resulting in 22 studies for extraction and analysis. First-year ( n  = 15) and second-year ( n  = 12) students were primarily tested. Less than 10 included third- or fourth-year students. Self-help and wellness interventions were employed, though interventions ranged from dog therapy to deep breathing techniques to fish oil supplementation. Test anxiety was evaluated using self-report questionnaires, such as the Westside Test Anxiety Scale, Beck Anxiety Inventory, and State-Trait Anxiety Inventory. None of the studies reported improved examination scores.

This review identifies a variety of measurement tools and interventions attempting to mitigate test anxiety. As far as improving examination performance, none of the interventions reported was successful. Further research addressing test anxiety that results in improved medical student academic performance should be conducted and also use established assessment tools.

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Williamson, C., Wright, S.T. & Beck Dallaghan, G.L. Test Anxiety Among US Medical Students: A Review of the Current Literature. Med.Sci.Educ. (2024). https://doi.org/10.1007/s40670-024-01999-w

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Implementing spiritual care education into the teaching of palliative medicine: an outcome evaluation

• Yann-Nicolas Batzler 1 ,
• Nicola Stricker 2 , 3 ,
• Simone Bakus 4 ,
• Manuela Schallenburger 1 , 6 ,
• Jacqueline Schwartz 1 &
• Martin Neukirchen 1 , 5  

BMC Medical Education volume  24 , Article number:  411 ( 2024 ) Cite this article

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The concept of “total pain” plays an important role in palliative care; it means that pain is not solely experienced on a physical level, but also within a psychological, social and spiritual dimension. Understanding what spirituality entails, however, is a challenge for health care professionals, as is screening for the spiritual needs of patients.

This is a novel, interprofessional approach in teaching undergraduate medical students about spiritual care in the format of a seminar. The aim of this study is to assess if an increase in knowledge about spiritual care in the clinical context is achievable with this format.

In a mandatory seminar within the palliative care curriculum at our university, both a physician and a hospital chaplain teach strategies in symptom control from different perspectives (somatic domain – spiritual domain). For evaluation purposes of the content taught on the spiritual domain, we conducted a questionnaire consisting of two parts: specific outcome evaluation making use of the comparative self-assessment (CSA) gain and overall perception of the seminar using Likert scale.

In total, 52 students participated. Regarding specific outcome evaluation, the greatest gain was achieved in the ability to define total pain (84.8%) and in realizing its relevance in clinical settings (77.4%). The lowest, but still fairly high improvement was achieved in the ability to identify patients who might benefit from spiritual counselling (60.9%). The learning benefits were all significant as confirmed by confidence intervals. Overall, students were satisfied with the structure of the seminar. The content was delivered clearly and comprehensibly reaching a mean score of 4.3 on Likert scale (4 = agree). The content was perceived as overall relevant to the later work in medicine (mean 4.3). Most students do not opt for a seminar solely revolving around spiritual care (mean 2.6).

Conclusions

We conclude that implementing spiritual care education following an interprofessional approach into existing medical curricula, e.g. palliative medicine, is feasible and well perceived among medical students. Students do not wish for a seminar which solely revolves around spiritual care but prefer a close link to clinical practice and strategies.

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Introduction

Education in palliative care was introduced in 2009 as a compulsory subject in German medical curricula. In the 1960s, Dame Cicely Saunders established palliative medicine and hospices as we know them today. Back then, Cicely Saunders propagated the concept of “total pain”, which means that pain or suffering in general is not solely experienced on a physical level, but also within a psychological, social and spiritual dimension (see. Fig.  1 ) [ 1 , 2 , 3 , 4 ]. Understanding the importance of spirituality in everyday clinical practice and what it entails, however, is a challenge for health care professionals (HCP) in all medical disciplines across the world [ 5 , 6 ]. Palliative care is a relatively young medical discipline which oftentimes is not sufficiently taught in medical curricula [ 1 , 7 ] and, therefore, knowledge regarding the importance of spirituality, which at many faculties is integrated into palliative care education, is scarce [ 1 , 7 ]. As a result, HCP tend to neglect the spiritual needs of patients [ 7 , 8 ]. But, if there is no fundamental knowledge in regards of spirituality and spiritual care among physicians, how can they target total pain adequately?

The European Association of palliative care (EAPC) describes spirituality as following:

“Spirituality is the dynamic dimension of human life that relates to the way persons (individual and community) experience, express and/or seek meaning, purpose and transcendence, and the way they connect to the moment, to self, to others, to nature, to the significant and/or the sacred.” [ 1 , 9 ].

It must be clear to all HCP that spirituality is a unique and subjective phenomenon that differs substantially from patient to patient [ 2 , 10 ]. Furthermore, to fully address the spiritual needs of patients, self-reflection, thorough consideration of one’s own attitude towards death, and finding meaning in life, are essential [ 8 , 9 ]. Several studies have shown the impact which the addressing of spiritual needs in the context of total pain can have on ameliorating the symptoms of patients, leading to a better quality of life and care [ 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 ]. Thus, once spiritual needs become imminent, it is necessary to engage in an interdisciplinary and multi-professional collaboration with specially trained professionals in the field of spiritual care [ 8 , 10 , 14 , 15 , 19 ]. Summing up, it is very important to raise awareness about the positive impact of spiritual care among HCPs [ 8 , 15 ]. To increase such knowledge and accrue such skills, the teaching of spiritual care in medical curricula is essential [ 20 ]. Throughout different regions in the world, in-person didactic teaching on spiritual care is the most commonly used technique [ 5 ]. Usually, the teaching is based on case studies and many include screening strategies assessing spiritual needs [ 5 ]. Often, education on spirituality and spiritual care is part of curricula in palliative care [ 5 , 21 ]. In German medical curricula, there is no compulsory subject solely revolving around spiritual care [ 22 ]. However, regarding the concept of total pain, implementing spiritual care into palliative care teaching, however, seems like a plausible proposition.

This study was conducted in order to assess the way medical students perceive the concept of implementing spiritual care into the teaching on symptom control in palliative care. Furthermore, we aimed to determine whether an actual increase of knowledge about spiritual care in the clinical context was achievable within this seminar.

Material and methods

This study is a single-centre prospective study conducted at University Hospital Duesseldorf, Germany. Ethical approval was obtained by the local ethics committee (reference number 2022–2274).

Curricular structure

At our facility, palliative care education is structured as followed: Five lectures (somatic symptoms, psychological symptoms, social symptoms and advance care planning, spiritual symptoms and end-of-life care and care for relatives, clinical ethics) and four seminars (symptom control, breaking bad news, clinical ethics I and II). Since 2022, the lecture on spiritual symptoms and end-of-life-care is held by both a physician and a hospital chaplain within the palliative care curriculum at Düsseldorf medical faculty. Beforehand, this lecture was solely held by a hospital chaplain. As internal evaluations implied, this concept was not well perceived by medical students as the relevance to daily clinical work was not apparent to them. They did not understand how spiritual care can support somatic strategies of symptom control and how both approaches are intertwined. Furthermore, they were unsure of how to assess patients’ spiritual needs. We therefore opted for the above-mentioned approach which allows lecturing relevant medical implications alongside spiritual care. As evaluations showed, this embeds spiritual care in a more clinical and tangible manner and students seem to better realize the relevance that spiritual care has in daily clinical practice. For example, students repeatedly stated that they were now able to understand the importance of ongoing collaborations for patients’ comfort care, e.g., in more sufficiently relieving anxiety or social distress.

Since this novel concept was perceived positively by medical students, we transposed it to our seminar titled “symptom control” which is now also held by a hospital chaplain and a physician. In the seminars, content from the lectures is further deepened and there is more room for discussions, e.g. concerning assessment of spiritual needs, possibilities of spiritual care, and inter-professional collaboration. There is also an emphasis on determining which patients might benefit from spiritual care making use of the SPIR tool (patient’s self-description as a S piritual person— P lace of spirituality in patient’s life – patient’s I ntegration in a spiritual community – R ole of health care professional in the domain of spirituality), which tackles different dimensions of spirituality [ 23 ].

In the seminar, a 33-year-old fictitious patient (inspired by a real patient) served as an example case. Her situation is used to address strategies for symptom control on both somatic and spiritual domains. To achieve this, a reflective question is discussed with the students followed by a joint development of possible therapeutic strategies on both the somatic and spiritual domain (see Fig.  2 ).

Case discussion in the seminar

Our approach can be described as novel, since training in spiritual care often involves the mere shadowing of chaplains [ 5 , 24 , 25 , 26 ]. An interprofessional, educational approach was mainly used with physicians or nurses in training [ 5 , 27 , 28 , 29 ], but not with medical students.

Evaluation methods

A structured, paper-based questionnaire was developed in repeated interdisciplinary and multi-professional discussions in the Interdisciplinary Centre for Palliative Care Medicine, University Hospital Düsseldorf, Germany. The basis for the questionnaire were the learning goals that are to be achieved within the seminar, as well as a didactic evaluation. The questionnaire was pretested among medical students, and unclear statements were altered. The questionnaire consists of two parts. The first part is made up of five statements regarding knowledge about total pain, assessing spiritual needs, and defining spiritual care (see Table  1 ) on both the knowledge and skills level. These statements cover the field of specific outcome evaluation. Making use of the comparative self-assessment (CSA) method to determine if a gain in knowledge was achieved, each student evaluated their knowledge before and after the seminar using the German school grading system (1 = “excellent” to 6 = “unsatisfactory”). The CSA gain is a well described and implemented method in evaluating actual knowledge gains in education [ 30 , 31 , 32 , 33 , 34 ]. This evaluation tool has the benefit of not taking into account experiences made beforehand as they are not contributing to the effect size [ 31 ]. CSA gain is calculated as followed:

Furthermore, CSA gain was calculated with a 95% confidence interval and standard error using individual learning gain (ILG) values. These values were calculated using the following formulas:

ILG = 0 if pre = post and

ILG = (pre − post)/(pre − 1) × 100 if pre > post [ 31 ].

The second part of the questionnaire consists of four questions regarding the perception of the seminar (structure, teaching spiritual care alongside symptom control in palliative care). A 5-Point-Likert scale was used for evaluation (1 = strongly disagree, 2 = disagree, 3 = neither, 4 = agree, 5 = strongly agree).

Study participation and analysis

Participation in the study was anonymous, voluntary, and could be withdrawn at any time without explanation. Eligible participants were undergraduate medical students at the beginning of their fifth year of medical education (Germany: total of min. six years), who completed the mandatory palliative care course. The purpose and content of the study were presented orally, and, furthermore, written information and consent documents were handed out. After completion of the seminar, the questionnaire was handed out making use of a post-then design in which the students were asked to retrospectively rate their knowledge before and after the seminar. There were no exclusion criteria other than refusing to participate. Due to the small number of students per seminar ( n  = 15–20), no demographic characteristics besides sex were assessed.

Data analysis was performed using Microsoft Excel 2020 (version 16.42, Microsoft Corp., Redmond, WA, USA) and IBM SPSS Statistic version 28.0.1.1 (IBM, Armonk, NY, USA).

Throughout the course of one semester in 2023, the questionnaires were rolled out in each of six separate seminars. Out of 108 eligible attending students, 52 students participated in total (48.1%). 25% ( n  = 13) of the participants were of female, 75% ( n  = 39) of male sex. Within the answered questionnaires, there was no missing data.

Regarding the specific outcome evaluation, CSA gains showed a relevant increase especially in the field of knowledge (see Table  2 and Fig.  3 ). The greatest improvement (84.8%) was achieved in the ability of defining total pain and realizing its importance in clinical settings (77.4%). After the seminar, medical students were increasingly able to name tools such as SPIR in order to engage in spiritual needs assessment (CSA gain 68,8%). A lower increase in knowledge was achieved in realizing how spiritual care itself can benefit patients’ needs (66.7%). The lowest gain was detected in actually identifying patients who might benefit from spiritual care (60.9%), which represents a skill to be learned rather than knowledge to be gained.

CSA gains for each item

Statistical analysis using 95% confidence intervals confirmed the gains in knowledge, which were significant for all items (Table  2 ).

In regard to the second part of the questionnaire, students were overall satisfied with the new structure of the seminar (Table  3 and Fig.  4 ). The content was comprehensible and delivered clearly gaining a mean score of 4.3 (median 4, SD 0.6, min. 2, max. 5). The content was perceived as overall relevant to the later work in medicine (mean 4.3, median 4, SD 0.6, min. 3, max. 5). It seems as if medical students regard the implementation of spiritual care education into the seminar “symptom control”, which focuses on alleviating symptoms on multidimensional levels, as expedient. They feel that implementing education on spiritual care into this seminar makes sense (mean 4.2, median 4, SD 0.8, min. 1, max. 5). Furthermore, most students do not opt for a seminar solely revolving around spiritual care (mean 2.6, median 2, SD 1.3, min. 1, max. 5).

Perception of the seminar, Likert scale (1 = strongly disagree, 2 = disagree, 3 = neither, 4 = agree, 5 = strongly agree)

Our data show that implementing spiritual care education into existing medical curricula, in our example palliative care, is feasible and well perceived among medical students. The timing of our seminar is in accordance to other studies that found that spiritual care should be implemented in mandatory undergraduate courses [ 6 ]. Students do not wish for a seminar solely revolving around spiritual care but prefer a connection to clinical practice and strategies in symptom management. This enables them to understand the relevance of spiritual care in a daily clinical setting.

To evaluate training programs, Kirkpatrick proposed a four-level approach (level 1: reaction, level 2: learning, level 3: behaviour, level 4: results) [ 35 ]. We followed levels 1 (reaction—satisfaction) and 2 (learning—gains in knowledge) making use of the conducted questionnaire. Level 3 (change in behaviour – acquired skills) was briefly addressed with item 5 in the first part of the questionnaire. As level 4 is an indicator of direct results of the training at an organizational level, we were not able to incorporate items on this level. A different study among undergraduate nursing students assessed the effectiveness of teaching spiritual care in mandatory classes: There was an increase in knowledge, e.g., in defining spirituality, compared to students who obtained no information on spiritual care [ 36 ]. This is comparable to our study, as there were gains in knowledge after completing the mandatory seminar. We reached higher individual learning gains on the knowledge level than on the skills level, as was also the case in a number of other studies we conducted [ 31 ]. This is mainly because, due to the format of the seminar, no bedside teaching takes place and scenarios that might occur in everyday clinical practice can only be discussed and serve as examples.

The concept of total pain is essential in palliative care; however, it should not only be taken into consideration in a palliative setting, but whenever patients experience high burdens on various dimensions such as pain, anxiety, grief or existential distress [ 2 , 4 , 17 , 37 , 38 ]. We were able to thoroughly educate students on total pain and its relevance in clinical settings. Spirituality plays an important role in a holistic approach. However, literature shows that HCP often don’t know how to implement spiritual assessments and how to deal with spiritual needs [ 1 , 5 , 6 , 8 ]. A systematic review on teaching methods found the usage of practical tools and the involvement of chaplains to be effective facilitators in the teaching of spiritual care [ 5 ]. A scoping review found that spiritual care should be taught in both mono- and multi-disciplinary educational settings [ 6 ]. With our multi-professional approach, we were able to introduce students to tools in assessing spiritual needs, such as SPIR [ 23 ]. Within this item, there was a definite gain in knowledge of these tools which make assessing spiritual needs of patients more feasible. This is in accordance with findings of a number other studies [ 5 ]. In our study, however, students are still unsure if they are fully able to determine which patients might actually benefit from spiritual care, even though this item still reached a learning gain of 60.9%. As concluded by other authors, there is need for ongoing education [ 5 ].

Even though our seminar entails many different aspects of the total pain concept (somatic symptom management, spirituality, and spiritual care) medical students found the content to be clearly structured and comprehensible. More importantly, they understood the relevance of spirituality for their future clinical work and perceived the multi-professional teaching as highly satisfactory. In sensitizing them in this, we hope that they keep in mind the importance of ongoing collaborations between different professions.

Our study has some limitations. Even though the questionnaire was pretested among medical students before the actual study, no validated questionnaire was used. The response rate of almost 50% is relatively low and it can be assumed that those who participated were mostly students who were interested in the topic. This might have led to bias as positive effects might have been overestimated. Due to the small study population and to protect the privacy of participating students, no demographic data besides sex was collected. Demographic data, however, might contribute to a better understanding of spirituality or palliative medicine beforehand such as age, professional expertise, or own spiritual resources. This also meant that adjusting for confounding factors was not possible. This study solely dealt with medical students and no patients were involved. It would be of interest to assess as to whether the content taught in this seminar ultimately impacts the wellbeing or stress levels of patients in everyday clinical practice. A study focusing on patients would complement the findings of this study, as suggested by other researchers [ 5 ]. Furthermore, the study was only performed in one centre; therefore, it can only serve as an example on how spiritual care education might be successfully implemented into medical curricula.

Spirituality plays an important role for many people and should always be taken into consideration when treating patients. This especially applies to palliative care where the addressing of spiritual needs is of crucial importance [ 18 ]. However, many HCP don’t know how to address topics revolving around spirituality which makes it hard to determine which patients might benefit from spiritual care. Therefore, education on the nature of spiritual care, on what it entails and on how it can support patients in everyday clinical practice should be thoroughly integrated into medical curricula. We opted to implement spirituality and spiritual care into an existing seminar and lecture within the medical curriculum at our faculty. This was well received among students. As a result, we found a clear increase in knowledge about total pain and about the tools one might use to assess spiritual needs. This knowledge needs to be further strengthened in practical clinical scenarios.

Availability of data and materials

All data and materials are available within this publication.

Abbreviations

Health care professional

European Association of palliative care

• Spiritual care

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We thank Dr Jessica JT Fischer for excellent English language editing.

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Yann-Nicolas Batzler, Manuela Schallenburger, Jacqueline Schwartz & Martin Neukirchen

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Nicola Stricker

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Simone Bakus

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Martin Neukirchen

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YB, NS, MS, JS, MN designed the study. YB analysed and interpreted the data. YB drafted the first version of the manuscript, which was critically revised by NS, MS, JS, and MN in several rounds of feedback. All authors have approved the submitted version and have agreed to be accountable for their contributions as well as for accuracy and integrity for any part of the work.

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Batzler, YN., Stricker, N., Bakus, S. et al. Implementing spiritual care education into the teaching of palliative medicine: an outcome evaluation. BMC Med Educ 24 , 411 (2024). https://doi.org/10.1186/s12909-024-05415-0

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REVIEW article

Factors influencing death attitudes of medical students: a scoping review.

• 1 Department of Postgraduate Students, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, China
• 2 Innovation Center of Nursing Research and Nursing Key Laboratory of Sichuan Province, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, China
• 3 West China School of Nursing, Sichuan University, Chengdu, China
• 4 Department of Biotherapy, Cancer Center, West China Hospital, Sichuan University, Chengdu, China

Aim: To summarize factors influencing death attitudes of medical students, help identify intervention targets, and design precision interventions for improving death attitudes of medical students.

Methods: Web of Science, PubMed, Embase, OVID, China National Knowledge Infrastructure, and Wanfang databases were searched. Retrieval time was from January 2012 to September 2023. Studies on factors influencing death attitudes of medical students were included.

Results: Thirty-five studies were included in the final review. A total of 28 factors influencing death attitudes of medical students were summarized and divided into three categories comprising personal factors, social factors, and psychological factors. More than 15 studies confirmed that gender, religion, and discussing death with families were factors that influenced medical students’ death attitudes.

Conclusion: Results indicate that there are many types of factors that influence death attitudes of medical students. It is necessary for universities to implement death education based individual characteristics and guide medical students to cultivate generally optimistic death attitudes and appropriate life values.

1 Introduction

The number of medical students is quickly rising within the global health care system ( 1 ). However, a number of physical and mental health issues that have emerged during the medical students’ growth process have attracted considerable attention in recent years. Medical students belong to a group of individuals that experience relatively high pressure. Violence, homicide, suicide, and other malignant episodes have recently increased, which is indicative feelings of meaninglessness in the lives of medical students ( 2 ). Individual emotional and psychological feedback about their own death or the death of others has been researched for decades, with these attributes the subject of a 1936 study of death attitudes. As future medical professionals, medical students constantly come into contact with death. As a result, their outlooks on life and attitudes toward death influences their future employment potential and their ability to cope with death ( 3 ). It has been shown that medical students’ attitudes toward death have a dramatic impact on almost every aspect of their development, particularly their mental health and cognitive abilities ( 4 ), death education can assist medical students better comprehend the purpose and worth of life as well as help them have a positive outlook on death ( 5 ). Medical students, as future medical workers, will encounter death on a regular basis, and their attitudes toward death will have a direct impact on their personal growth as well as their attitudes and behaviors in the later stages of complex clinical work. Furthermore, medical students who receive death education can develop a stronger sense of social duty as well as become more adept at spreading the word about death education, which will benefit society as a whole ( 6 , 7 ).

There is an urgent need for colleges to develop guidance for medical students in adopting appropriate views of death, to help them build a mature education guidance system, and to develop distinct education programs with different attributes that match individual characteristics. This paper summarizes the latest research progress on the factors that influence medical students’ death attitudes, and makes a reasonable analysis of these factors, aiming to provide new ideas and references for universities to set up death education systems.

2 Article types

The current article is a review. Specifically, the Joanna Briggs Institute methodology for scoping reviews ( 8 ) guided the current methodology. The primary review issue concerned the factors that influence medical students’ death attitudes.

3.1 Literature search strategy

We searched six electronic databases, namely Web of Science, PubMed, Embase, OVID, China National Knowledge Infrastructure, and Wanfang databases. Retrieval time was from January 2012 to September 2023. Boolean operators were used, with two librarians helping to develop the search strategy. The Boolean search combined subject and free words, including “medical student,” “nursing student,” “death attitude,” and “attitude toward death.”

3.2 Study selection

The following inclusion criteria for studies was applied: (1) research subjects were medical students, including clinical medicine students and nursing students; (2) study of factors influencing death attitudes of medical students; (3) full text available; and (4) articles published in Chinese or English. Exclusion criteria included: (1) intervention research on death attitudes of medical students and (2) books, editorials, letters, or conference abstracts. Searched studies were imported into NoteExpress to remove duplicate studies. Two reviewers independently selected the remaining studies by screening the title and abstract. If studies met inclusion criteria, the full text was screened, and studies that continued to meet inclusion criteria were explored further. Selection results were cross-checked, and a third reviewer was invited to discuss and make a final decision when there were differences.

3.3 Data extraction

Two reviewers independently screened the full text of each included article. Extracted data included authors, country, publication year, sex ratio, samples, and questionnaire used to investigate death attitudes. To ensure validity, two reviewers cross-checked the extracted data.

3.4 Data analysis

The extracted data were discussed by the team. We summarized the factors influencing death attitudes of medical students and divided the influencing factors into three categories comprising personal factors, social factors, and psychological factors.

4.1 Characteristics of included studies

As shown in Figure 1 , a total of 2,257 articles were initially retrieved, and 1,732 duplicates were removed. After screening the titles and abstracts, 452 records were removed because study type did not meet inclusion criteria (e.g., conference abstracts, letters, protocols, and intervention research). After screening 73 full texts, 38 studies were further excluded, of which 16 were intervention studies, 18 were not published in Chinese or English, and 18 did not have full text available. After all screening, a total of 35 studies were included in the current scoping review ( 9 – 44 ). As shown in Table 1 , most of the included studies came from China, while seven studies came from Iran, Spain, Korea, Bolivia, Poland, and Palestine. Student majors included medicine, nursing, physiotherapy, pharmacy, rehabilitation, midwifery, medical laboratory technology, and preventive medicine. Additionally, most of the included studies used the Death Attitude Profile-Revised questionnaire to measure the death attitudes of medical students.

Figure 1 . Flow diagram of study selections.

Table 1 . General information of included studies.

4.2 Personal factors related to death attitudes

4.2.1 gender.

A total of 19 studies explored the relationship between gender and death attitudes of medical students ( 9 , 10 , 12 , 14 , 15 , 17 , 19 – 22 , 24 – 26 , 32 , 34 , 38 , 39 , 41 , 42 ). As shown in Table 2 , four studies indicated that females generally displayed higher scores on fear of death assessments in comparison to males ( 9 , 12 , 34 , 39 ). Three studies showed that males exhibited greater scores on the death avoidance dimension when compared to females ( 15 , 19 , 25 ). In contrast, other studies arrived at different conclusions ( 26 , 32 ). Furthermore, there were different findings in the approach acceptance dimension. Some scholars found that males exhibited greater scores than females on this particular dimension ( 25 , 39 ), whereas Ke et al. and Chen et al. reported that females demonstrated higher scores on the acceptance dimension ( 17 , 26 ). However, another study indicated that gender differences did not yield any noteworthy impact on the views of medical students toward death ( 22 ).

Table 2 . Personal factors related to death attitudes of medical students.

Eight studies explored the relationship between age and death attitudes of medical students ( 12 , 14 , 19 , 31 , 37 , 38 , 42 , 44 ). In Table 2 , Asadpour et al. ( 12 ) found an inverse relationship between age and the level of fear of death, indicating that individuals’ fear of death tends to diminish as they grow older. Zahran et al. ( 38 ) observed that age had no significant statistical impact on death attitudes, which was similar to the conclusion drawn by Xu et al. ( 19 ).

4.2.3 Grade

A total of 14 studies explored the relationship between grade and death attitudes of medical students ( 9 , 12 , 14 , 15 , 18 , 20 – 22 , 26 , 30 – 32 , 34 , 35 , 38 ). As shown in Table 1 , Kim et al. ( 20 ) observed that nursing students exhibited increasingly positive death attitudes as they progressed through higher grade levels. Similarly, another study discovered that students in advanced grades experienced higher levels of anxiety and fear of death than their lower-grade counterparts ( 18 ). Additionally, the results of a study conducted by Nong et al. ( 15 ) were similar, indicating that second-year college students scored significantly lower on the fear of death dimension in comparison to first-year college students. However, two studies found that grade was not an influencing factor of the death attitudes of medical students ( 21 , 22 ).

4.2.4 Religion

Sixteen studies have been conducted to assess the influence of religion on medical students’ death attitudes ( 10 , 11 , 14 , 17 , 19 , 21 , 22 , 25 , 27 , 28 , 34 , 37 , 39 , 41 , 44 ). As shown in Table 2 , three studies observed a statistically significant distinction between scores of the approach acceptance dimension with and without religion ( 21 , 25 , 28 ). Medical students who held religious beliefs exhibited higher scores on the natural acceptance dimension ( 14 , 22 ). Conversely, other studies found that religion did not have a significant impact on death attitudes among medical students ( 10 , 11 , 34 ).

4.2.5 Origin

Seven studies looked at the impact of students’ origin on their attitudes toward death ( 10 , 17 , 21 , 23 , 32 , 34 , 41 ). Some studies from China have focused on differences in death attitudes among medical students from different origins, finding that urban medical students had a relatively more positive view of death than those from rural areas ( 10 , 17 , 21 , 32 , 34 , 41 ). Additionally, Niu et al. ( 34 ) found that medical students from rural areas exhibited higher scores on the fear of death dimension, which was similar to another study ( 21 ). In contrast, Xie et al. ( 32 ) found opposite results. One study found that there were no significant differences between the two origins ( 23 ).

4.2.6 Profession

Eight studies explored the relationship between profession and death attitudes of medical students ( 11 , 13 – 16 , 26 , 30 , 34 ). The findings of two studies indicated that nursing students exhibited a higher level of fear of death ( 11 , 26 ). Nursing and midwifery majors exhibited a higher propensity than pharmacy and rehabilitation majors in terms of both approach acceptance and escape acceptance ( 26 ). In the realm of the natural acceptance dimension, one study reported that individuals pursuing clinical majors demonstrated higher scores ( 13 ), whereas another study arrived at a contrasting conclusion ( 34 ).

4.2.7 Family status

As shown in Table 2 , eight studies explored the relationship between family status and death attitudes of medical students ( 11 , 12 , 17 , 19 , 21 , 25 , 26 , 28 ). Ke et al. ( 26 ) discovered that medical students with a large family size, including parents and three or more generations, showed lower scores in terms of acceptance methods and avoidance of acceptance. There was a significant difference in scores of the avoiding death dimension between medical students who were only children and medical students who had brothers and sisters ( 17 , 25 ).

4.2.8 Other personal factors

As shown in Table 2 , there were some other personal factors related to death attitudes. Five studies explored the relationship between physical condition and death attitudes of medical students ( 13 , 15 , 25 , 26 , 32 ). Medical students who perceived themselves to be in better physical shape, or were actually in better physical shape, exhibited lower levels of fear of death and death avoidance ( 13 , 26 ). Some studies have explored the correlation between average monthly expenditure ( 28 , 41 ), university ( 22 , 38 ), education level ( 12 , 29 , 32 ), and death attitudes of medical students; however, the results of these studies differed. Comprehensive education has been shown to be more likely to foster reasonably positive views toward death among medical students ( 12 , 32 ). Only one study examined the effects of character ( 10 ) and race ( 36 ).

4.3 Social factors related to death attitudes

4.3.1 death education.

As shown in Table 3 , nine studies explored the relationship between death education and death attitudes in medical students. All of these, studies suggested that medical students who received death education demonstrated more positive views toward death ( 14 , 20 – 22 , 27 – 29 , 31 , 41 ). In particular, there was a significant decrease in scores on the dimension of fear of death ( 22 , 27 , 29 , 31 ). In addition, Xu et al. ( 19 ) discovered that medical students who received death education showed a greater propensity for natural acceptance of death.

Table 3 . Social factors related to death attitudes of medical students.

4.3.2 Discussing death with families

As shown in Table 3 , 15 studies explored the relationship between talking about death with families and the death attitudes of medical students ( 9 , 11 , 13 – 15 , 22 , 24 – 29 , 34 , 39 , 42 ), and various family death discussion styles significantly influenced medical students’ death attitudes. Xie et al. ( 9 ) discovered that this kind of conversation considerably decreased the fear of death in medical students, which was similar to the findings of three other studies ( 11 , 26 , 39 ). Some studies found that engaging in this particular form of discourse had a notable impact on diminishing scores related to the dimension of death avoidance ( 11 , 26 , 27 ). Furthermore, whether the family engaged in conversations about death may also have an impact on the scores of medical students in relation to the dimension of natural acceptance ( 42 ).

4.3.3 Funeral experiences

As shown in Table 3 , 12 studies explored the relationship between funeral experiences and the death attitudes of medical students ( 10 – 12 , 14 , 15 , 21 , 22 , 25 , 28 , 34 , 39 , 44 ). Six studies found that these experiences did not significantly affect attitudes toward death ( 10 , 12 , 25 , 28 , 34 ). Two studies revealed that students who participated in funeral ceremonies exhibited more positive attitudes toward death ( 21 , 44 ). In contrast, Hu et al. ( 22 ) discovered that medical students who had participated in funerals exhibited lower scores on the natural acceptance component than those who had not attended funerals.

4.3.4 Experience of losing friends or family

As shown in Table 3 , five studies explored the relationship between the experience of losing friends or family and their death attitudes ( 17 , 18 , 26 – 28 ). Ke et al. ( 26 ) discovered that the death of family members had a notable impact on medical students’ scores in the natural acceptance dimension, leading to a significant decrease. Two studies suggested that this situation caused an increase in medical students’ scores in the death avoidance dimension ( 27 , 28 ).

4.3.5 Other social factors

As shown in Table 3 , there were some other social factors related to death attitudes. Reading death-related books ( 14 , 24 , 25 ), seeing death-related media reports ( 25 ), and having first-hand experience in caring for end-of-life ( 14 , 17 , 19 , 26 ) or suicidal patients ( 10 , 27 ) were factors that influenced death attitudes among medical students.

4.4 Psychological factors of death attitudes

As shown in Table 4 , psychological well-being ( 20 ), sense of meaning in life ( 29 , 40 ), suicidal thoughts ( 9 ), powerful emotional reaction to death ( 42 ), professional recognition ( 26 , 32 ), and Internet addiction ( 33 , 41 ) were factors that influenced death attitudes of medical students. Students who possessed a heightened feeling of spiritual well-being and a deep understanding of the meaning of life tended to exhibit a more distinct purpose in life and a greater appreciation for the worth of their own existence ( 20 , 29 , 40 ). Xie et al. ( 32 ) discovered a correlation between medical students’ level of professional recognition and their anxiety about death, which was similar to the results of another study ( 26 ). Additionally, two studies ( 33 , 41 ) found that the degree of Internet addiction could influence medical students’ death attitudes.

Table 4 . Psychological factors of death attitudes of medical students.

5 Discussion

Through the examination of the current studies, we determined that medical students’ attitudes toward death are influenced, to some degree, by individual characteristics, social interactions, and mental status. Colleges and institutions should consider the unique circumstances of medical students to implement death education in a focused and tailored manner.

5.1 Personal factors

Research examining the impact of gender on death attitudes revealed that females exhibit more fear of death than males, which is similar to the results of a previous review ( 43 ). This is likely due to the female tendency to engage in more emotional thinking and experience higher levels of anxiety, which consequently intensifies their fear of death ( 12 , 39 ). Moreover, the contrasting attitudes toward death in clinical and nursing professions can be attributed to the higher number of females in the nursing field. This finding is similar to a previous study, which suggested that the nursing interns had statistically significantly higher scores in death attitudes compared to the norms ( 19 ). In addition, the nursing profession directly engages in patient care, which suggests that its curriculum and clinical experiences may influence its perspectives on death. However, additional comparative research is needed to confirm these findings.

Diverse researchers have reached varying conclusions regarding the disparities in death attitudes among medical students of different ages. This discrepancy can be attributed to the fact that the medical student population consists of individuals who are relatively similar in age, thereby limiting the ability to accurately assess the distinct impact of age on death attitudes. Study findings indicated that those with a longer duration of medical education, namely, those who were in higher grades, tend to exhibit more positive death attitudes compared to individuals in lower grades ( 18 , 20 ). The hypothesis suggests that the primary factor behind this phenomenon is the progressive development of more positive attitudes toward death as individuals advance in grade level, which can be attributed to their exposure to clinical training in hospice care or education connected to death ( 20 ).

The perspectives of family members toward death, as well as familial backgrounds, exert a certain degree of influence on the perceptions of medical students regarding death. This finding is similar to the results of a previous review ( 43 ). The presence of a familial environment that encourages open acknowledgment and discourse about death, along with a strong sense of kinship, has the potential to assist medical students in mitigating their fear of death to a certain degree and fostering a more optimistic outlook on the subject of death ( 11 , 21 , 29 , 39 ). If there are older adults within the family, the younger generation will inevitably encounter disease and death at a younger age, thus gradually forming a more accurate perception of death ( 26 ).

Various religions hold distinct notions regarding life and death, and it may be argued that religious convictions will influence individuals’ perspectives on death to some degree ( 21 , 34 ). These results are similar to the previous study ( 43 ). Based on the analyzed studies, it is evident that the presence or absence of religious beliefs does not significantly influence medical students’ attitudes toward death. It is worth noting that some of these studies had limited sample sizes and lacked precise screening regarding the definition of, and loyalty toward, religious beliefs, which may have impacted the results. Further research is needed to thoroughly investigate this factor ( 34 , 44 ).

Various countries exhibit distinct societies and cultures. However, this study lacks sufficient literature pertaining to race or country of origin, necessitating further investigation. Chinese scholars have conducted studies examining disparities in death attitudes between medical students from urban and rural backgrounds. The research suggests that an urban upbringing and higher levels of parental education may contribute to greater emphasis on the psychological development of children, resulting in a relatively positive outlook on death ( 10 , 34 ).

In summary, while implementing death education, colleges and universities should tailor their approach based on several factors, including gender, location of origin, and family background. For instance, when targeting women, the emphasis should be on alleviating their apprehension toward death. Medical students hailing from rural areas should receive intentional guidance to approach death with a positive mindset. Death education should be conducted promptly and efficiently. Furthermore, it has been discovered that both family and society exert significant effects on the attitudes of medical students regarding death. Consequently, death education for medical students should extend beyond the confines of the school classroom. Schools should actively collaborate with families and communities of medical students to implement death education, aimed at assisting medical students in developing a positive attitude toward death through subtle impacts.

5.2 Social factors

The results of this study found that receiving death education can also improve medical students’ attitudes toward death. This is similar to results of previous studies ( 45 , 46 ). It is evident that current universities are actively broadening their methods of death education and constructing effective death education classrooms, which can assist medical students in developing a more optimistic perspective on death. However, there are currently a limited number of universities that have truly integrated death education into their academic programs ( 20 ).

Based on the current findings, the impact of funeral experiences on medical students’ perspectives regarding death remains uncertain. It is necessary to conduct additional research to determine whether funerals, as a temporary situation involving direct confrontation with death, can aid medical students in developing favorable attitudes toward death. Experiencing the death of family members in life can result in medical students having negative attitudes toward death for a certain period of time.

In summary, death education can extend beyond conventional lecture formats, and confronting death can prove effective in enhancing medical students’ disposition toward death. Universities should actively engage in the exploration and discovery of comprehensive and varied approaches to death education. Simultaneous attention should be paid to the social experiences of medical students. This includes providing immediate support to students who have recently lost a family member to assist them to quickly adjust their physical and mental condition during critical moments. Further, universities should offer guidance to help students develop a constructive mindset and approach toward death through real-life encounters.

5.3 Psychological factors

Psychological well-being among medical students is a significant indicator of attitudes toward death. Students with relatively sound mental states tended to have more positive attitudes toward death. Psychological well-being is essential for medical students to effectively cope with the demanding circumstances they encounter, including the emotional toll of witnessing deaths in their professional setting and clinical training ( 20 ). Therefore, when implementing death education, universities should promptly consider the mental well-being of medical students and conduct customized death education based on their mental health. Additionally, there is a need to enhance the management system of universities to prevent medical students from developing Internet addiction, which consequently impacts their physical and mental well-being, as well as their attitudes toward death.

Furthermore, considering the distinctive characteristics of medical students, it is imperative to include professionalism education in conjunction with death instruction. By doing so, these two components can mutually reinforce each other, fostering the development of medical professionals who possess a scientific and professional approach toward death and who are also inclined to volunteer.

6 Limitations

In the current review, only six databases were searched, making it possible that some relevant studies may not have been included. Additionally, several studies written in languages other than Chinese and English. Furthermore, the studies identified primarily concentrated within Asia and surrounding regions, more pertinent studies have been conducted in China, necessitating greater investigation into the determinants that impact the attitudes of medical students toward mortality in other locations. Subsequent research will examine the global context in more detail.

7 Conclusion

Medical students’ perspectives on mortality are shaped by individual aspects, social experiences, mental status, and various other elements. Alterations in their perspectives about death can similarly impact their approach to patient care and end-of-life support. Universities should prioritize this issue and consider individual characteristics. They should implement focused death education programs to guide medical students in developing positive attitudes toward death and accurate life values. Additionally, they should ensure that students understand the psychological and physiological conditions and needs of dying individuals. Together, these interventions will improve the standard of care given to individuals with terminal illnesses and their families.

Author contributions

JT: Conceptualization, Data curation, Methodology, Writing – original draft. QL: Data curation, Writing – review & editing. YL: Data curation, Writing – review & editing. JL: Writing – review & editing. QZ: Resources, Supervision, Writing – review & editing. HS: Supervision, Writing – review & editing.

The author(s) declare that financial support was received for the research, authorship, and/or publication of this article. This work was funded by the Chengdu Bureau of Science and Technology (grant number: 2023-YF09-00039-SN).

Conflict of interest

The authors declare that the current study was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

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Keywords: medical students, death attitude, death education, scoping review, mental health

Citation: Tong J, Liu Q, Liu Y, Li J, Zhang Q and Shi H (2024) Factors influencing death attitudes of medical students: a scoping review. Front. Public Health . 12:1342800. doi: 10.3389/fpubh.2024.1342800

Received: 22 November 2023; Accepted: 25 March 2024; Published: 08 April 2024.

Reviewed by:

Copyright © 2024 Tong, Liu, Liu, Li, Zhang and Shi. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Qin Zhang, [email protected] ; Huashan Shi, [email protected]

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

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High schoolers get a taste of medical practice at special UW event in Spokane

Dozens of Spokane-area high school students gathered at the UW School of Medicine Friday afternoon to learn what it means to have a career in health care.

As part of Greater Spokane Incorporated’s Business AfterSchool program, the after-school session allowed students to examine heart and lung specimens, perform physical exams and attend a panel made up of medical students, professors and current residents at local hospitals.

First-year medical students and event organizers Cate Marken and Maxey Cherel hope the hands-on experience gives students the ability to see themselves in health care.

“For me, this was a cool event to kind of give back to my own community that I come from. I come from a family that no one’s ever been in health care. So I want to kind of be an ally in a way for students to just kind of learn more in high school and get exposed,” Cherel said.

Because of her background, Cherel has often felt an “imposter syndrome” when pursuing her medical education. She doesn’t want any of these students to feel the same.

“If I had had that opportunity like this, I think I would have just felt like I belonged,” she said.

A sophomore at Mead High School, Owen Cahill said he is fascinated by how the human body works and hopes to learn more about it through a career in surgery.

“I just want to know how stuff works, honestly,” Cahill said when asked what he hopes to learn at the event.

Recently, he dissected a cow’s eye in a high school class and had “not gotten queasy,” he said proudly.

“I just like to learn about how the mechanics of the body work. Like this does this to that make this happen,” he said.

More students need to be encouraged to work in health care, Business AfterSchool career pathway manager Matthew Himlie said.

“Health care is a huge field in Spokane. And it’s a big driver of our economy. There are a lot of jobs there we want young people to be aware of,” he said.

Valley Christian Sophomore Cloie Isley got to give her family a physical exam with the help of several medical students.

“I really liked getting to see in real time. Not only getting education but experiencing how it feels,” she said.

It is physical experience even first-year medical students do not get, Marken said.

“We don’t even get to do really until we’ve been in school for a little bit. So I think learning a little bit about how the heart works and what doctors do in a regular office visit is great for them to get a taste of what it might be like,” she said.

Marken recommends high schoolers interested in health care try to reach out to medical students or health care workers.

“We are very happy to help and encourage. Just be willing to be curious, ask questions and know that they do belong,” she said.

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Technology is redefining health care and it’s not only cutting-edge surgical treatments and advances in important routine screenings like mammograms.

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What motivates medical students to select medical studies: a systematic literature review

1 School of Public Health, PGIMER, Sector-12, Chandigarh, 160012 India

Federica Angeli

2 Department of Health Services Research, Care and Public Health Research Institute, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands

3 Department of Organization Studies, School of Social and Behavioural Sciences, Tilburg University, Tilburg, the Netherlands

Nonita Dhirar

Neetu singla, dirk ruwaard.

4 Department of Health Services Research, Care and Public Health Research Institute, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands

Associated Data

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

There is a significant shortage of health workers across and within countries. It is of utmost importance to determine the factors that motivate students to opt for medical studies. The objective of this study is to group and review all the studies that investigated the motivational factors that underpin students’ selection of medical study in recent years.

The literature search was carried out by two researchers independently in PubMed, Google Scholar, Wiley and IndMED databases for articles published from year 2006 till 2016. A total of 38 combinations of MeSH words were used for search purpose. Studies related to medical students and interns have been included. The application of inclusion and exclusion criteria and PRISMA guidelines for reporting systematic review led to the final selection of 24 articles.

The majority of the studies ( n  = 16; 66.6%) were from high-income countries followed by an equal number from upper-middle and lower-middle income countries ( n  = 4,16.7%). None of the studies were from low-income countries. All of the studies were cross-sectional in nature. The main motivating factors that emerged were scientific (interest in science / medicine, social interest and academia, flexible work hours and work independence), societal (prestige, job security, financial security) and humanitarian (serving the poor and under priviledged) in high-, upper-middle and lower-middle income countries, respectively. The findings were comparable to Maslow’s hierarchy of needs theory of motivation.

This systematic review identifies the motivational factors influencing students to join medical studies in different parts of the globe. These factors vary per country depending on the level of income. This study offers cues to policy makers and educators to formulate policy in order to tackle the shortage of health workers, i.e. medical doctors. However, more research is needed to translate health policy into concrete and effective measures.

The world is currently facing a dual problem of shortage and inequitable distribution of health workers, especially in middle- and low-income countries [ 1 ]. The World Health Organization (WHO) estimated a need for an additional 4.3 million health workers in 57 countries to fulfill the Millennium Development Goals [ 2 ]. In addition, 83 countries (44.6%) do not currently meet the 2006 World Health Report threshold of 22.8 skilled health professionals per 10,000 population [ 3 ]. Among many, the main reasons cited for shortage of health workers in rural areas include poor working conditions, lack of accommodation, lack of transport, poor pay structure, overburden with additional administrative responsibility and political interference [ 4 ]. In middle- and low-income countries, the situation is more critical because of migration of doctors to high-income (developed) countries whereas inequitable distribution of health workers between urban and rural areas is primarily due to poor motivation of health workers to work in rural areas [ 5 ].

The choice of medical study depends upon various factors such as interest in the medical field, good job opportunities, a desire to serve others, medical background of the parents and many more [ 6 , 7 ]. In literature, no review has been conducted in the last ten years about motivation factors of students to select medical studies. The existing reviews have either been conducted before ten years or with different objectives [ 8 , 9 ]. One review by Puertas et al. [ 8 ] published in 2013 was conducted to review the factors influencing medical student’s choice in primary care while another one by Brissette and Howes [ 9 ] published in 2010 was conducted on the articles available till 2008. Brisstte and Howes identified that motivation to take up medical studies lies in addressing learner’s needs for competence, autonomy, and relatedness. Providing optimal challenge and positive performance feedback, choice and opportunity for self-direction, and a sense of belongingness and connection to the medical profession can all be focused on to address the above mentioned motivators [ 9 ]. The review has given points for educators to act upon.The lacunae left by the previous review studies need to be addressed in a finer manner in context with the current challenge of the global workforce.

In last few years, human resources for health has attracted substantial scholarly attention. Over the last decade, there have been advancement in different fields of medical sciences, from prevention, patient care to laboratory workup and management of severe diseases and palliation. With the growing population and improving health care owing to better technologies, it is gravely important to improve the medical workforce, mostly doctors.

Globally, several health-related goals and programs are giving priority to human resource development in the health sector. The major health related initiatives like Sustainable Development Goals [ 10 ] and WHO’s six building blocks [ 11 ] focus on human resource development for achieving universal health coverage. The National health programs, like the National Health Mission in India, focuses on increasing human resources to upbring the health care services in the country.

The prospective medical students form a significant pool of health care workers that can help overcome the shortage globally. Therefore, understanding the current common motivational factors is essential and a summary of the factors through a review of these studies would derive a clearer picture. A strong predictor for any student to take up a career in any field is the motivation or drive from within. Motivation is defined as the process that initiates, guides, and maintains goal-oriented behaviors. It involves the biological, emotional, social, and cognitive forces that activate behavior. Fulfillment of needs results in some type of behavior, which can be either intrinsic or extrinsic [ 7 ]. Understanding motivation is very important in the medical sector because a motivated individual is willing to exert and maintain an effort to provide good-quality health services.

The objective of this study is to group and review all the studies that investigated the motivational factors that underpin students’ selection of medical study in recent years.

Search strategy

The literature search was carried out with the purpose to identify the perceptions of medical students to enter medical studies. The search was carried out by two researchers (NS and ND) independently in PubMed, Google Scholar, Wiley and IndMED databases for original studies conducted from 2006 to 2016. This time frame was chosen as many studies were done during this period to identify the motivational factors. MeSH and free-text terms “(Motivat*) AND (select* OR choice OR choose) AND (medical student* OR medical school* OR interns) have been used. Internship in the period of practical application of theoretical (mostly) knowledge of the previous medical school years, hence interns were also made a part of the search strategy. Search terms and keywords were altered as per specification of individual databases. A total of 38 combinations were used for search purpose.

An initial search identified thousands of related records from the Google scholar, PubMed, Ind Med and Wiley online library databases. The articles which were not related to motivation were excluded at the first step. Then search results were imported to Microsoft Excel and duplications were removed by sorting the titles of articles. The selected studies were then screened by reading the title and abstract resulting in shortlisting 91 articles. Of these, 62 articles were excluded based on eligibility criteria. The remaining 29 full-text articles were further assessed, and five were excluded because the articles were in Korean, Spanish and Chinese. A total of 24 studies were selected. Any differences of opinion were debated and consensus was reached. Further differences were resolved by the third researcher (SG). PRISMA guidelines were strictly followed during the study. Figure  1 represents the flow chart leading to sample selection.

Flow chart of selection and exclusion of studies for the systematic review

Selection criteria and sample

All studies carried out and published from year 2006 till 2016 were included in the review. Inclusion criteria were studies describing motivation to study medicine, conducted among medical students and interns and available in English language. Exclusion criteria were those studies done before 2006, published in languages other than English, and those not related to motivation or medical students and interns.

Data analysis

A thematic analysis of selected papers was performed, wherein two research assistants coded the papers independently and reached consensus on relevant themes [ 12 ]. They also extracted details of the final articles using a standardized abstraction form that collected information on: the author, the journal, the year of publication, location, study objectives, study design, major findings, limitations, and observations. In this paper, we systematically review the literature related to medical education with the goal of identifying the motivating factors influencing the medical students to join medical studies.

The results of the studies’ review were categorized under different heads viz. scientific factors, social factors and humanitarian factors based upon criteria devised by Goel S et al. in their study on development and validation of the motivations for selection of medical study in India [ 13 ]. In this study a ‘Motivation of Selection of Medical Study (MSMS)’ tool was developed using extensive literature review followed by Delphi technique. The three domains and the issues that emerged are shown in Table  1 .

Domains and issues that emerge as main motivational factors

Ethical considerations

The study was granted ethical approval from the Institute’s Ethical Committee, PGIMER, Chandigarh (PGI/IEC/2012/810–1 P-154). Since the study is a systematic review of studies and individual level data is neither obtained nor presented, the consent.

The characteristics of the studies included in the systematic review are shown in Table  2 . The assessment of factors of motivations for medical students to select medical studies was based on the World Bank categorization of low-, middle- and high-income countries [ 14 ].The low-income, lower middle-income, upper middle-income and high-income economies are defined as those with a Gross National Income (GNI) per capita of $1005 or less, between $1006 and $3955, between $3956 and $12,235 and $12,236 or more, respectively in the year 2016. The majority of the studies ( n  = 16, 66.6%) were from high-income countries followed by an equal number from upper middle and lower middle income countries ( n  = 4,16.7%). None of the studies were from low-income countries. All of the studies were cross sectional in nature ( n  = 24). Figure  2 shows the geographic distribution of the different studies.

Characteristics of the studies included in the systematic review ( n  = 24)

Geographical distribution of the different studies across the globe (used a web page https://mapchart.net which is free of cost and specifically designed for making customised maps)

Predominance of motivating factors according to income group

Results reported for motivation to select medicine by medical students changes in the context of place (see Fig.  3 and Table  3 ). The choice of medical study among students differs between students in high-income countries, and those in upper-middle and lower–middle-income countries. The individual motivation factors that emerged are presented in Table  4 .

Categorization of motivation factors across different income country groups

Factors affecting motivations of medical students to select medicine across different country income groups

Most commonly cited motivational factors among all the studies analyzed ( N  = 24)

High-income countries

In most of the high-income counties, scientific and humanitarian factors were described as the main motivators to select medicine by medical students [ 15 – 29 ]. Most of the high income countries including Spain, Croatia, Poland, UK, Hungary, Germany and South Korea reported similar type of motivators to motivate the medical students for choosing medicine: interest in science/medicine, social interest, flexible work hours and work independence. Results reported by Kim et al.(2016) [ 16 ], Becker et al. (2015) [ 29 ], Wouters (2014) [ 19 ] emphasized on the scientific factors. Societal factors were also reported in most of these studies but fell lower in hierarchy.

Uppermiddle income countries

The main motivators to select medicine by medical students of upper-middle income countries include the societal and scientific factors [ 30 – 33 ]. A study by Kavousipour et al. (2015) [ 30 ] conducted in Iran explains that the factors which were most significant to motivate the students were family attitudes, getting good jobs in future, respect for themselves, the ability to learn, believing their role in victory and defeat and the tendency toward optimism about themselves. Pagnin et al. (2013) [ 32 ] also concluded similar findings. Social and professional status of the job, healthcare-people factor, others’ recommendation and advices, personal interest and nature of occupation, occupational experience and personal life had been identified as main factors of motivation. The findings reported by Korkmaz et al. (2013) [ 31 ] also found societal and scientific factors to be more significant motivators.

Lower-middle -income

In low-middle income countries, students have mixed responses for the choice of medical studies. [ 34 – 37 ]. Humanitarian and societal factors had been reported as main influences to join medicine.

Few studies conducted in various parts of India had reported almost similar results. A study conducted in Madhya Pradesh, India by Diwan et al. (2013) [ 35 ] concluded that reasons for entering medical education included personal ambition, parental desire, prestigious profession, altruistic reasons and pecuniary incentives. Similar to these findings were those reported by Kuriakose (2015) [ 34 ], Seetharaman et al. (2012) [ 36 ] and Lal et al. in 2007 [ 37 ]. The main reasons that motivate the medical students were to serve the sick and society and having a high status in society.

To our knowledge, this is the first systematic review of motivational factors for choosing medical studies by medical students globally. Earlier reviews were related to factors influencing student rating in undergraduate medical education course evaluations and factors that influence a career choice in primary care among medical students from high-, middle- and low-income countries [ 8 ]. The present systematic review, which has analyzed 24 studies in detail, is important as it identifies the motivational factors influencing the medical students to join medical studies in different parts of the globe along with the variations among the factors in lower-middle, upper-middle and high-income countries. As such, it provides essential insights into how students could be motivated, and how this varies across countries. No study was found from low-income countries. The limited research on this topic in low-income countries could be related to the lack of interest in this particular area, or to an overall deficit in research in developing nations, or both. These countries could identify the issues and intervene according to the research done in lower-middle and upper-middle income countries.

Several theories of motivation have been described in relation to career choice among student including intrinsic and extrinsic factors as described by Brissette and Howe [ 9 ] and by Maslow [ 38 ],. Taylor, McClelland and Herzberg [ 39 ]. However, Maslow’s theory remains to be the most detailed and frequently used theory [ 38 ]. The Maslow’s hierarchy of needs describes motivational factors under five broad segments: the physiological needs, the needs for safety and security, the needs for love and belonging, the needs for esteem, and the need to actualize the self, in that order [ 38 ]. Physiological needs are the basic needs required by an individual, such as food, water, sleep, etc. Once these needs are met, the second segment of needs comes into picture making safety, stability, protection the prime concerns. Following these factors the third segment consists of desires to marry, have a family, become a part of their community etc. The fourth segment of esteem has two versions as described by Maslow. The need for respect, prestige, prominence, magnificence, appreciation, attention, status, self-esteem, and dominance forms the lower version while the higher form involves the need for self-respect which includes feelings as self-confidence, capability, accomplishment, mastery, and freedom. The last segment is the phase of self-actualization which is a desire for self-fulfillment [ 38 ].

In low-middle income countries, students are still striving to fulfill primary basic needs and safety and security of employment, family, health. They fall under the first two segments of the pyramid comprising of basic needs, safety stability and protection and hence the predominant motivational factors are humanitarian in this group. In some areas where these needs are fulfilled, the higher segment of self-esteem also come into picture, hence societal factors are also seen in lower-middle income countries. The prime reasons for selecting medical studies among students in low-income countries were parental desire, respected profession and economic incentives, respect in society, high societal status and to serve the sick. The desire to serve the poor is deeply ingrained in this society. Most of the students belong to lower or middle socio-economic groups and understand the miseries of poor well and these factors lead them to serve the humanity and poor people. Here medical students are more sensitive to the social needs of population. The very reasons identified to take up medical career in these countries can be used to encourage students to take up medical studies. Mainly, the respect and feeling of altruism, followed by the monetary and social benefits are a driving force that can be used to attract the students into medical profession, hence improving the workforce. As the motivational factors are mostly innate, their further interest in medical studies and serving the nation will remain significant.

In the upper-middle income countries the factors as described by the middle zone in the Maslow’s hierarchy of needs pyramid were identified. The majority of studies identified societal factors as better predictors as compared to humanitarian and scientific factors. The main motivators to select medicine by medical students of upper-middle income countries are job security, social status, and parental wish. The reason behind this is that, to become a doctor is one of the highest ambition of many school-going students and their parents in middle- and low-income countries, along with the fact that the medical profession is preferred by the students due to its high prospect of financial security and high social status. Being a respected profession with high social status and higher salaries has been found to be motivating factor for students. The students in these countries have mostly met their basic needs and are more attracted towards a better lifestyle and income. Security in all fronts is a strong predictor for picking medical studies, and this can help enroll more students into this career. Excelling in their medical education may act as a strong target as their competition decides their future prospects.

The motivational factors commonly reported by most of the studies in high-income countries were the third and fourth segments of the Maslow’s hierarchy of needs pyramid. The scientific factors were the main motivators to select medicine by students. This may be due to the fact that the students in high-income countries chose medicine or science, who have prime interest in these subjects. The interest in science is usually developed during their school times to become medical school academics in a well-developed education system and with advanced technologies (modern laboratory facilities). The availability of good technologies and advanced education helps in developing specialized skills through the medical school years and beyond. In addition, the ability to earn well, pay their debts and live comfortably are strong motivators as well.

There are various strengths of the study. Firstly, the review was done on a sizeable number of 24 studies across the globe, hence generating stronger evidence. Secondly, the study relates the motivational factors across different countries with the Maslow’s hierarchy of needs theory [ 38 ]. This helps to understand the motivational factors of medical students to work in rural areas with respect to the innate motivational factors of a human being.

This review has a few limitations. Despite our efforts to identify all relevant studies by searching four different databases and using a fairly large number of search terms, we might have missed relevant studies. Additionally, unpublished studies from low- and middle-income countries were not represented (publication bias). The exclusion of articles published before 2006 may have omitted literature that could have provided valuable information. However, our review supplement two existing reviews published earlier [ 8 , 9 ].

In conclusion, this systematic review investigated the reasons that affect students’ decisions to join medical profession. The motivational factors are being classified in scientific factors (e.g. ‘interest in medicine’), societal factors (e.g. ‘respect/prestige’) and humanitarian factors (e.g.‘desire to help others’). The predominance of factors varied among students in high-, upper-middle and lower-middle income countries. Hence, this study offers cues to policy makers and educators in different countries to understand the motivational factors as a first step to formulate policy in order to tackle the shortage of health workers to improve the status of human resources across nations. However, more research on the subject would assist in promoting as well as translating health policy into concrete and effective measures at the local, national, regional and global levels in low- and middle- income countries.

Acknowledgements

This study did not receive any funding.

Availability of data and materials

Abbreviations, authors’ contributions.

Conceptualization: SG FA. Data curation: SG ND NS. Formal analysis: SG ND NS. Funding acquisition: SG. Investigation: SG. Methodology: SG FA DR. Project administration: SG. Resources: SG. Software: NS, ND. Supervision: SG. Validation: SG ND. Writing original draft: ND NS. Writing review & editing: SG FA DR. All authors have read and approved the final version of the manuscript.

Ethics approval and consent to participate

The study was granted ethical approval from the Institute’s Ethical Committee, PGIMER, Chandigarh (PGI/IEC/2012/810–1 P-154). The anonymity and confidentiality of participants in the studies were ensured. Since the study is a systematic review of studies and individual level data is not obtained, the consent was not required.

Consent for publication

Since individual level data is not presented, the consent for publication of data was not required.

Competing interests

The authors declare that they have no competing interests.

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