Sustained Impact of an Emotional Intelligence and Resilience Curriculum for Medical Students

Introduction

Over the past decade, there has been a notable surge in attention towards creating and sustaining wellness programs for medical trainees.^1,2 Emphasis on emotional intelligence (EI), resilience, professionalism and communication skills remain at the forefront of these initiatives.^3–6

Emotional intelligence encompasses the ability to recognize, understand, and interpret personal and interpersonal emotions.^7–10 Key facets of EI include self-perception, self-expression, interpersonal relations, decision-making and stress management.^9,11,12 Notably, resilience skills are intertwined with EI, and improvements in resilience skills have been linked to improvements in overall wellness.³ Resilience may protect professionals from stressors that could lead to burnout.⁵ Medical students can benefit from resilience training to allow them to better cope with the stressors of medical education and future clinical practice.

Several studies demonstrate the impact of robust EI and resilience skills on mitigating burnout, improving the quality and satisfaction of patient care, and fostering greater job satisfaction among medical students and residents.^13–23 This recognition of EI’s significance is reflected in the incorporation of such competencies in medical school admissions criteria and integration of EI initiatives into residency training programs.^4,13,16–18 Governing bodies in medical education, including the Liaison Committee on Medical Education (LCME) and American Council for Graduate Medical Education (ACGME), underscore the importance of EI proficiency for medical trainees.^24,25

Empirical evidence demonstrates the feasibility and efficacy of interventions aimed at teaching and enhancing EI skills, with studies suggesting that interventions conducted prior to the third year of medical school may represent an ideal opportunity for skills cultivation.^26–29 Despite these advances, longitudinal studies assessing the impact of EI interventions are sparse. Minimal existing research does indicate a positive association between administration of an EI intervention and sustained increases in EI skills, patient satisfaction and application of EI skills among surgical residents.¹⁷ In relation to medical students, little information pertaining to the longitudinal effects exists, signaling an essential area for further study. A recent study by Versel et al showed an EI curriculum targeting second year medical students was well received and demonstrated an increase in their EI scores and resilience immediately following completion of the course.²⁶ Currently, no other studies in the literature explore the longitudinal effect of an EI intervention in medical students. Our study aims to evaluate the longitudinal impact of this EI curriculum by assessing EI scores one year following course completion in medical students.

Methods

An elective program entitled Emotional Intelligence-Resilience Elective was implemented for second-year medical students over the 2021–2022 and 2022–2023 school year at a US allopathic medical school. Participation in the elective was open to all second-year students on a voluntary basis. The program consisted of six in-person sessions conducted by an expert faculty member, with each session spanning approximately two hours. Each elective session focused on specific topics relevant to EI and resilience, including positive thinking, reframing, optimism, gratitude, reflection, altruism, service, finding meaning and purpose, social support, relationships, mentorship, self-care skills, mindfulness, and self-compassion. In addition to attendance at these sessions, students completed pre- and post-session readings and lectures, engaged in self-care and resilience-building exercises, and provided written reflections. The six sessions were conducted longitudinally over the academic year.

To gauge the efficacy of the curriculum, two surveys were administered to students at three time points: beginning of the course, end of the course, and one-year following the course. Prior to group analyses, responses were de-identified by a third-party representative to ensure anonymity and confidentiality. One survey used was the Bar-On Emotional Quotient Inventory 2.0 (EQ-i 2.0^®) assessment tool, a validated tool assessing the Bar-On model of emotional-social intelligence.¹¹ This EI survey encompassed 133 self-reported items utilized to compute one cumulative EI score, five composite scores, and 15 content subscale scores. Item scoring consists of a 5-point Likert scale (1=never; 5=always) and scores are standardized to a national mean of 100 with a standard deviation of 15.¹¹ Since resilience is the ability of an individual to respond to stress, resilience skills were assessed based on the stress management composite score and the subscales contributing to stress management.²² EI skills were evaluated using all sections and subsections. Students received their personalized EI reports to facilitate reflection and growth as part of the course curriculum. The second survey consisted of 10 items that evaluated students’ understanding and utilization of EI skills, scored with a 5-point Likert scale (1=strongly disagree; 5=strongly agree). This internally designed survey also included a free-text comment section as part of the post-course evaluation. Prior to group analysis, responses were de-identified by a third-party representative to ensure anonymity and confidentiality.

This study met the criteria for exemption from the Loyola University Chicago Health Sciences Division Institutional Review Boards approval; therefore, the requirement for informed consent was waived.

Statistical Methods

Survey responses from pre-, post-, and 1-year post-course were compared to assess estimated mean changes in the cumulative EI score, the five composite scores, and the 15 content subscale scores. Generalized estimated equations (GEE) were used to compare pre- to post-course, pre- to 1-year post-course, and post- to 1-year post-course. Models were specified with a normal distribution and identity link for each EQI construct, with an unstructured correlation matrix to account for participant’s dependent (paired) responses and adjusted for respondent’s sex. Additionally, mixed ordinal logistic models were used to estimate the log odds of higher response (greater agreement) among the 10 items that evaluated students’ understanding and utilization of EI skills pre- versus post-course, pre- versus 1-year post-course, and post- versus 1-year post-course, adjusted for respondent’s sex. Mixed ordinal logistic models were specified with robust standard errors and an unstructured covariance matrix to account for respondent’s dependent (paired) responses. All analyses were conducted via Stata v.18, are two-sided, and have a threshold for significance of p<0.05.

Results

A total of 70 students participated in the EI-Resilience elective over the two years. 30 of these seventy students completed all of the surveys at the three time points (response rate = 43%, 30/70). An additional five students completed the one-year postintervention internal survey but did not complete the EI survey at that time point.

Mean EI scores at baseline, post-intervention, and one-year post-intervention are detailed in Tables 1–3. In Table 1, a comparison of mean EI scores pre- and post-intervention showed a significant increase in all components of EI (all p<0.05), except Independence (p=0.253), Impulse Control (p=0.057), and Optimism (p=0.101). Table 2 demonstrates all EI measures had significantly higher scores at the one-year post-intervention follow-up compared to pre-intervention responses (all p<0.05), except for independence (p = 0.159) and stress tolerance (p = 0.065).

Table 1 Comparison of Mean Emotional Intelligence Between Pre- and Post-Intervention

Table 2 Comparison of Mean Emotional Intelligence Between Pre- and 1-Year Post-Intervention

Table 3 Comparison of Mean Emotional Intelligence Between Post- and 1-Year Post-Intervention

As seen in Table 3, no significant changes were observed in EI components between the immediate post-intervention assessments and the one-year follow-up assessments, except for a noteworthy increase in the mean Interpersonal Relationship score. Students reported a mean increase in their Interpersonal Relationship skills of 5.7 points (95% CI: 3.0, 8.4, p<0.001) at one-year post-intervention assessment compared to the immediate post-intervention evaluation.

Responses to the internally developed survey assessing familiarity with and utility of EI skills are reported in Table 4. In comparison to baseline, students expressed significantly greater agreement with all survey items at both immediate post-intervention and one-year post-intervention assessments. Comparing student responses between the immediate post-intervention and one-year post-intervention, no significant changes are detected, with exception of students reporting significantly higher agreement on the item “I regularly think about my EI skills when I interact with others” (p<0.001), and students reporting decreased agreement on items “I recognize how EI skills can promote resilience” and “I am familiar with specific EI-Resilience strategies” (p = 0.011, and 0.004, respectively).

Table 4 Change in Internally Developed Survey Responses at Various Follow-Up Times

In the one-year post-intervention survey (Table 5), 91% of students agreed or strongly agreed that they used what they had learned in the EI-Resilience Elective during their third year. Additionally, all students agreed or strongly agreed that they found the EI-Resilience elective to be applicable during their third year and that the EI-Resilience elective should be continued.

Table 5 One-Year Post Intervention Evaluation Questions

In the free-text comment section of the curriculum evaluation, students found the skills taught in the course to be beneficial one year afterwards during their third year of medical school. One student commented,

During certain aspects of setbacks in my third year, I often reflected on this course in order to help navigate and provide encouragement to keep going even in the setting of obstacles.

Another student wrote,

It is easy to fall into a mindset of ingratitude and frustration with the heavy workload of third year. This course taught me gratitude and coping mechanisms.

Discussion

An Emotional-Intelligence Resilience curriculum was implemented as a voluntary elective for second-year medical students. The curriculum comprised six sessions aimed at enhancing EI skills supplemented with assignments designed to bolster EI skills. Subsequently, students progressed throughout the third year of medical school in a predominantly clinical curriculum, as is standard for allopathic medical schools. Students did not receive any further EI interventions in the third year.

The overall EI score, most EI subcomponents, and Well-Being scores significantly increased immediately following completion of the course. This is consistent with a previous study using this EI curriculum.²⁶ When examining the longitudinal outcomes of the curriculum, no significant changes were detected in most of the EI components between the immediate post-test and 1-year post-test time periods. This suggests that the EI and resilience skills gained through the educational intervention were maintained longitudinally as students progressed through their third year of medical school. Interestingly, a significant increase in the Interpersonal Relationship component was detected, suggesting this area of EI continued to improve beyond the intervention. Since the clinical year integrates a student into a patient care team and develops patient communication skills, the increase in interpersonal relationships may be related to these interactions.

The reported findings demonstrate that one-year post intervention, students regularly think about their EI skills when interacting with others. Regularly considering EI skills can allow students to interact and communicate with others in a professional manner.^3–6 Interestingly, students did have a decrease in their ability to recognize how EI skills can promote resilience and a decreased familiarity with EI and resilience strategies. These findings highlight the need for doing a brief reminder educational session during the third of year medical school in order to sustain the maximal benefits of the initial intervention.

Overall, results demonstrate the intervention continued to be well-received by students, even after completing third year of medical school. The comments from students suggest teaching EI and resilience prior to clinical years can be crucial to their success in the clinical setting. Students applied the skills they had learned in the elective during their third year and would like to see the elective be available for other students in the future.

Currently, no other studies in the literature explore the longitudinal effect of an EI intervention in medical students. Few studies demonstrate varying effects of an EI intervention in medical education, though such studies differ in design, implementation, population, and outcome measures.^{13,16–18,26,30–38}

The third year of medical school marks a unique transition for medical students, in which students enter the clinical setting and are faced with challenging clinical scenarios, dynamic team interactions, career planning pressures, and time management demands.^{35–37,39,40} Students routinely demonstrate decreased comfort and preparedness for these challenges.^39,40 Previous research demonstrates successful implementation of an EI-Resilience curriculum to improve EI and resilience skills prior to the start of the third-year.^26,37,38 Our findings indicate no significant changes immediately following the EI-Resilience intervention compared to assessments at the end of the third year. Given the unique challenges of the third year, these results highlight the longitudinal and sustained effects of an EI-intervention prior to the third-year.

The success of the intervention may be attributed to a variety of factors. Since students self-enrolled in the curriculum, these students may have had prior interest or experiences related to EI. Self-selection may have contributed to a more engaged and receptive cohort. Student reception may translate into more frequent implementation of learned EI skills following the intervention in the third year of medical school. Given the growing interest in EI and resilience in undergraduate and graduate medical education, faculty involved in teaching medical students in the third year may be more aware of EI skills and may more readily engage students in these discussions and strategies.

Limitations

Several limitations to this study exist. This study consists of a single-arm design without a control group, therefore limiting the generalizability and validity of the longitudinal effects. Furthermore, the study was conducted at a single institution with a relatively small sample size, further restricting generalizability to other undergraduate medical students or graduate medical residents. Our relatively low response rate at the 1-year post course follow-up may limit our generalizability, especially if those who did not respond would have had responses that vary from those who did. As discussed previously, students self-selected to voluntarily participate in the elective intervention. This self-selection possibly introduces selection bias, which may be mitigated by mandatory enrollment or mandatory assessment of EI and resilience skills. Finally, several students failed to complete the one-year post-intervention assessment, resulting in a decreased sample size and possible attrition bias.

Future research should center upon the studying these outlined effects in a larger sample size. Implementation of an EI-Resilience curriculum on a larger scale may afford opportunities to tailor EI interventions to the unique challenges of undergraduate medical students. The ongoing longitudinal effects of an EI intervention should be continuously assessed as students progress through the fourth year and onto graduate medical education. This ongoing assessment may reveal unique time points for refreshing EI and resilience strategies. Additionally, future research could include a control group so there may be a comparison between students who do and do not enroll in the EI course.

Conclusion

In conclusion, the implementation of an Emotional Intelligence-Resilience curriculum as a voluntary elective for second-year medical students demonstrated promising results in enhancing EI and resilience skills over a sustained period. This study contributes to the minimal literature examining the longitudinal and sustained effects of EI interventions in medical education, highlighting the potential for interventions to teach essential skills for navigating the clinical and interpersonal challenges faced in medical training. EI and resilience training for early medical students could help them maintain well-being and reduce burnout as they transition into the stressors of a clinical setting. Future research should expand on these findings to further elucidate the impacts and optimal timing of EI interventions in medical education.