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JAOA/AACOM Medical Education  |   April 2019
Longitudinal Assessment of Medical Student Emotional Intelligence Over Preclinical Training
Author Notes
  • From the College of Osteopathic Medicine at Liberty University in Lynchburg, Virginia (Dr Mintle and Student Doctor Russo) and the School of Communication and Creative Arts at Liberty University in Lynchburg, Virginia (Dr Greer). 
  • Financial Disclosures: None reported. 
  • Support: A grant was obtained from Six Seconds to cover the costs of computer scoring of the Six Seconds Emotional Intelligence Assessment for the longitudinal data collection and study. Funding conditions attached to the grant were the submission of quarterly reports to ensure we were collecting data, a summary of the study to be submitted to Six Seconds, a commitment to publish in a research journal and to present at conferences, if applicable, and written credit to Six Seconds for their grant assistance. 
  •  *Address correspondence to Linda S. Mintle, MSW, PhD, Liberty University College of Osteopathic Medicine, 306 Liberty View Ln, Lynchburg, VA 24502-2291. Email: lsmintle@liberty.edu
     
Article Information
Medical Education
JAOA/AACOM Medical Education   |   April 2019
Longitudinal Assessment of Medical Student Emotional Intelligence Over Preclinical Training
The Journal of the American Osteopathic Association, April 2019, Vol. 119, 236-242. doi:https://doi.org/10.7556/jaoa.2019.039
The Journal of the American Osteopathic Association, April 2019, Vol. 119, 236-242. doi:https://doi.org/10.7556/jaoa.2019.039
Web of Science® Times Cited: 1
Abstract

Context: Given the importance of emotional intelligence (EI) in physician leadership and success, the possible decline of EI over the course of training is a concern in medical education.

Objectives: To assess the EI of osteopathic medical students as they progress through the preclinical years of medical school, to discover the course of EI over time, and to identify specific core EI competencies to be enhanced or coached.

Methods: This exploratory, longitudinal study used survey data to assess the course and competencies of EI in the incoming 2019 class of medical students at a college of osteopathic medicine. Changes in EI overall scores and the 8 core competency scale scores were assessed, and additional demographic data were collected for use in analysis. Methods of analysis included paired samples t test, independent samples t test, Pearson product moment correlation, and multiple regression analysis. Statistical significance was defined as P<.05.

Results: Sixty-two participants completed the Six Seconds Emotional Intelligence Assessment survey at orientation and again after their second year. Overall EI scores declined over the course of the preclinical training for men and women (t61=4.24, P<.001), although no differences were noted by gender when independent-samples t tests were run. However, 2 of the 8 competency scales of the composite EI scores did not decline over time—Enhanced Emotional Literacy and Pursue Noble Goals. A weak negative correlation was found between Medical College Admission Test scores and the scale of Apply Consequential Thinking (r=−0.3, P<.05). A weak positive correlation was found between grade point average and intrinsic motivation (r=0.3, P<.05) and optimism (r=0.3, P<.05), and a moderate positive correlation existed between preboard examination scores and intrinsic motivation (r=0.5, P<.001) and optimism (r=0.4, P<.01). None of the chosen independent variables (academic grades, test scores, age, or gender) contributed to overall EI scores.

Conclusions: During the preclinical training, osteopathic medical students’ overall EI scores, as well as 6 of the 8 core competency scales, declined. Therefore, EI coaching is warranted to address specific core competencies needed to build, enhance, and prevent the decline of EI through preclinical training.

The road to becoming a physician involves more than technical competencies and biomedical knowledge. While both are bedrocks of teaching during preclinical training in medical school, success as a physician also includes the development of leadership and interpersonal skills. In the words of Darrell G. Kirch, MD, president and chief executive officer of the American Association of Medical Colleges, “Being a good doctor is about more than scientific knowledge. It also requires an understanding of people.”1 
Goleman2 popularized the term emotional intelligence (EI) by applying it to organizations, leadership, and team building.2 He describes EI as an underlying characteristic that would cause a person to recognize, understand, and use emotional information in a way that results in or causes superior or effective performance.2 In medicine, a physician's EI is important to assess because it may affect his or her ability to cope with stress and organizational demands, motivate patients to change, and perform well on patient satisfaction measures. For example, a 3-year study analyzing patients with diabetes showed better clinical outcomes when the physician was empathetic, which is a component of EI.3 Higher EI positively contributes to the patient-physician relationship, increased empathy, teamwork, communication skills, stress management, organizational commitment, and leadership.4 Learning and enhancing emotional and communication skills during medical training is believed to positively affect both patient outcomes and empathy.5 Each of these areas is involved in the changing landscape of health care delivery and requires attention to systemic and relationship dynamics. 
In terms of academic performance, Chew et al6 found that students who were more emotionally intelligent performed better on continuous assessments and final professional examinations than students who were not. The conclusion was that emotional skills development may enhance medical students’ academic performances. 
Empathy is one component of EI and has been shown to erode over the course of medical training.7 To remedy this decline in empathy, Satterfield and Hughes8 noted that empathy skills training could successfully enhance empathy through medical school. Thus, training on EI may be a tool to assist medical students toward remaining empathetic while developing additional EI competencies, such as applying consequential thinking and navigating emotions. 
A systematic review of physician leadership and EI found that a range of physicians, from critical care to community practice physicians, medical students, and other health care workers in medical settings such as academic medicine, residencies, and physician practices endorsed EI as a leadership development strategy and considered it relevant to medical training.9 Occasionally, EI is also recognized as part of the curricula for medical students because of the role it may play in enhancing leadership skills as future physicians. In one study, a positive association between public health–specific competencies and attributes of EI was found to be essential for leadership and organizational success.10 
Another desired quality for leadership and organizational success is the ability to apply knowledge and skills with emotional sensitivity. A physician who can master logical reasoning skills in the traditional academic sense, but who also understands the role emotions play in learning and consolidation of knowledge, will be better attuned to patients.11 It is important for physicians to learn to use their cognitive abilities informed by emotional states and then manage those states in terms of behavior and decision-making.12 Overall, the more EI is bolstered, the more interpersonally effective physicians become. Therefore, assessing the trajectory of EI throughout medical school could provide valuable information as to the course of EI development in emerging physicians. The purpose of this study was to assess the EI of a medical student cohort as they progressed through preclinical training at a college of osteopathic medicine. We wanted to discover the trajectory of EI over time and to identify specific competencies that could be enhanced or trained. 
Methods
Approval for the study was granted by the Institutional Review Board of Liberty University on June 10, 2015. This longitudinal exploratory study used a sample of undergraduate medical students from the 2019 incoming class at an eastern US college of osteopathic medicine. Students were informed of the voluntary study at orientation prior to the launch of the academic year. Those students who agreed to participate and signed the informed consent were administered the Six Seconds Emotional Intelligence (SEI) assessment at 2 different points in their preclinical training. Demographic data (age and gender) were collected online and assigned to the identification number given to each participant by the research manager to ensure anonymity. The initial EI assessment (EI pretest) was taken via computer link on the college of osteopathic medicine student-issued computers at orientation before the first academic year began. The final EI assessment (EI posttest) was taken at the end of the second year, and students were sent a link to the assessment to their college email addresses. 
In addition to our interest in the course of overall EI during preclinical training, we wanted to know whether a correlation existed between academic success and EI. Previous studies have reported mixed results1; thus, data collected were used to correlate EI competencies with academic factors to see whether such correlations existed. Academic factors included preadmission Medical College Admission Test (MCAT) scores, final preclinical grade point average (GPA) on a 100-point scale, and Comprehensive Osteopathic Medical Self-Assessment Examination (COMSAE) scores. 
Assessment: The Instrument
The SEI12 assessment was selected for this study because of its potential to develop coaching and training tools. The assessment frames EI in the context of life and work outcomes, thus lending to practical application. The scales of measure lend well to core competencies associated with EI. 
The SEI is a self-assessment measure delivered online and computer scored that takes an average of 16 minutes to complete.13 The assessment has been validated internationally for persons aged 18 years or older and is available in several languages. The SEI measures personal perceptions and impressions at a given time in a person's life, and it provides an overall EI rating that represents a composite of 8 specific competency scales. The 8 competency scales that comprised the overall EI score were defined as follows: 
  • 1. Enhanced Emotional Literacy to accurately identify and interpret both simple and compound feelings
  • 2. Recognize Patterns to acknowledge frequently recurring reactions and behaviors
  • 3. Apply Consequential Thinking to evaluate the costs and benefits of your choices
  • 4. Navigate Emotions to assess, harness, and transform emotions as a strategic resource
  • 5. Engage Intrinsic Motivation to gain energy from personal values and commitments vs being driven by external sources
  • 6. Exercise Optimism to take a proactive perspective of hope and possibility
  • 7. Increase Empathy to recognize and appropriately respond to another's emotions
  • 8. Pursue Noble Goals to connect your daily choices with your overarching sense of purpose
According to the technical manual, the instrument has undergone 3 validation analyses through factor analysis with the 8 EI scales rendering fair construct validity and good concurrent validity. 
Statistical Analysis
The gathered data were used to explore the relationship between self-reported EI scores and student demographics, academic performance, and the stability of EI scores over time. Methods of analysis included paired samples t test, independent samples t test, Pearson product moment correlation, and multiple regression analysis. Statistical significance was defined as P<.05. Data were analyzed using SPSS version 23 (IBM). 
Results
Of 160 students eligible to participate, 62 (38.7%) were included in the study (33 men and 29 women). Table 1 presents descriptive data. A paired samples t test was conducted to compare scores on the EI pre- and posttest. A difference was found between mean (SD) pretest and posttest scores (100.3 [10.5] and 96.0 [12.1], respectively; t61=4.2, P<.001). The scores showed a decline in overall EI from the start of medical school to the end of year 2. 
Table 1.
Assessment of First- and Second-Year Osteopathhic Medical Students’ Emotional Intelligence: Characteristics of Final Population Sample (N=62)
Characteristic Mean (SD) Median Range
Age, y 25.0 (3.6) 24 21-44
MCAT 26.7 (3.6) 26 18-35
GPAa 83.7 (4.8) 84 71-93
COMSAEb 479.5 (94.6) 471 281-812

a Grade point average (GPA) calculated on a 100-point scale.

b n=59 (3 participant scores were not available at the time of the data collection).

Abbreviations: COMSAE, Comprehensive Osteopathic Medical Self-Assessment Examination; MCAT, Medical College Admission Test.

Table 1.
Assessment of First- and Second-Year Osteopathhic Medical Students’ Emotional Intelligence: Characteristics of Final Population Sample (N=62)
Characteristic Mean (SD) Median Range
Age, y 25.0 (3.6) 24 21-44
MCAT 26.7 (3.6) 26 18-35
GPAa 83.7 (4.8) 84 71-93
COMSAEb 479.5 (94.6) 471 281-812

a Grade point average (GPA) calculated on a 100-point scale.

b n=59 (3 participant scores were not available at the time of the data collection).

Abbreviations: COMSAE, Comprehensive Osteopathic Medical Self-Assessment Examination; MCAT, Medical College Admission Test.

×
An independent samples t test showed no differences between men and women in EI as indicated by pre- and posttest scores. However, paired samples t tests indicated a difference within genders on pre- and posttest scores (Table 2). Both men and women had lower EI scores on the posttest compared with the pretest, indicating a decline in EI over the course of preclinical training; however, there were no differences between the 2 genders in terms of overall EI scores. The medical students’ baseline scores for 2 of the 8 competency scales, Enhanced Emotional Literacy and Pursuit of Noble Goals, did not change over the 2 years of the study. All other competency scales declined over time. 
Table 2.
Overall Emotional Intelligence Scores of First- and Second-Year Osteopathhic Medical Students According to Gender (N=62)
Mean (SD)
Gender Pretest Posttest df t P Valuea
Men 100.7 (10.0) 96.5 (11.7) 32 2.8 .01
Women 99.9 (11.2) 95.5 (12.6) 28 3.2 .01

a Significant at P<.05.

Table 2.
Overall Emotional Intelligence Scores of First- and Second-Year Osteopathhic Medical Students According to Gender (N=62)
Mean (SD)
Gender Pretest Posttest df t P Valuea
Men 100.7 (10.0) 96.5 (11.7) 32 2.8 .01
Women 99.9 (11.2) 95.5 (12.6) 28 3.2 .01

a Significant at P<.05.

×
Using the Pearson product moment correlations, age demonstrated no statistically significant relationship. However, MCAT scores were negatively correlated with the Apply Consequential Thinking scale (r=−0.3, P<.05), which indicated that the higher the MCAT score, the lower the score on this scale. A weak positive correlation was found between GPA (r=0.3, P<.05) and the Engage Intrinsic Motivation scale using the Pearson product moment correlation. The positive correlation indicates that the higher the GPA, the higher students scored on Engage Intrinsic Motivation. Grade point average was also shown to have a weak positive correlation with the Exercise Optimism scale (r=0.3, P<.05). Students who took the COMSAE demonstrated a moderate correlation with the Engage Intrinsic Motivation (r=0.5, P<.001) and Exercise Optimism (r=0.4, P<.01) scales, indicating the higher the board score, the more students were intrinsically motivated and optimistic (Table 3). A multiple regression model was used to examine associations between respondent characteristics and overall EI scores. Independent variables included age, gender, MCAT scores, and cumulative GPA. None of these factors contributed to the overall EI score. 
Table 3.
Significant Pearson Correlations Between GPA and COMSAE Scores of First- and Second-Year Osteopathic Medical Students With Emotional Intelligence Competencies (N=62)
GPA COMSAE
Competency r P Value r P Value
Engage Intrinsic Motivation 0.3 .05 0.5 .001
Exercise Optimism 0.3 .05 0.4 .01

Abbreviations: COMSAE, Comprehensive Osteopathic Medical Self-Assessment Examination; GPA, grade point average.

Table 3.
Significant Pearson Correlations Between GPA and COMSAE Scores of First- and Second-Year Osteopathic Medical Students With Emotional Intelligence Competencies (N=62)
GPA COMSAE
Competency r P Value r P Value
Engage Intrinsic Motivation 0.3 .05 0.5 .001
Exercise Optimism 0.3 .05 0.4 .01

Abbreviations: COMSAE, Comprehensive Osteopathic Medical Self-Assessment Examination; GPA, grade point average.

×
Discussion
Our intent was to use the data related to the competency scales to target necessary areas of EI training to help better prepare students for future practice. Any of the 8 competency scales that declined over time would be targeted for coaching. In this study, EI scores significantly decreased as medical students progressed through their preclinical training. Emotional intelligence is important for physician leadership, performance, and success, and, therefore, it is important to stabilize and enhance EI throughout medical school. We found that 6 of the 8 competencies declined over time and only 2 remained stable. 
The Enhance Emotional Literacy scale scores remained stable, indicating that students entered medical school with the perception that they were able to accurately identify and interpret both simple and compound feelings. The data indicated that students did not lose ground with this skill throughout their preclinical training. However, scores declined on other competencies related to their ability to read and navigate emotions and use emotions in consequential thinking. Whether their perceptions translate to actual behavior could be assessed in future studies if this finding holds true with other student cohorts. 
Moreover, the students’ overall sense of purpose (Pursue Noble Goals) did not significantly change and was also linked to doing well on the pre–board examination. Perhaps students who felt a deep sense of purpose in practicing medicine were better able to stay their academic course in medical school. Connecting daily choices with an overarching sense of purpose appeared to help academically. 
We found no EI differences between gender or age, which differed from other studies that have shown women5 and older people14 to have a higher EI. A negative relationship was noted between MCAT scores and the Apply Consequential Thinking scale. When applying consequential thinking, one evaluates the costs and benefits of a choice. The MCAT tests critical thinking, problem solving, and medical knowledge from an academic vs intrapersonal or interpersonal perspective. 
Grade point average and COMSAE scores were both positively correlated with the Engage Intrinsic Motivation and Exercise Optimism scales, which implies that confidence and self-assurance would be associated with success in achieving good grades. Although GPA and COMSAE scores did not show a relationship to overall EI, the 2 scales could help explain why a previous study6 found that students with higher EI performed better on academic assessments. Being intrinsically motivated and optimistic likely enhances both confidence and grade performance. 
The main reason the SEI assessment was selected was to have a tool that would not only provide a baseline of EI but also help identify specific components of EI that could be enhanced or targeted for intervention. For example, if students perceive themselves to be emotionally literate, they may be able to read a patient's emotions but unable to apply consequential thinking to patient-physician situations. A coaching intervention for applied consequential thinking might be to ask the student questions, such as, “Have you considered what might happen if this problem is not addressed? What are the long-term consequences? What are the emotional costs? Who else might be affected?” Or, if it holds true that sustaining a sense of optimism contributes to better pre–board examination scores, then interventions focused on developing and retaining a sense of optimism, for example, asking students, “What is visibly not working and what parts of that could you change?” could be designed. These preliminary data allow us to know where to put our training efforts and possibly prevent overall EI decline. Furthermore, students with technical skills who may advance the field of medicine but may have difficulty with EI could be identified early and coached in EI development. 
Several issues may have influenced the data and limited the study findings. The admissions department of this particular institution may have been looking for students with high EI because of the mission and vision of the school, which emphasizes service and whole person treatment. Students' goals had to align with the noble goal of the college of osteopathic medicine to be admitted. In addition, students who chose to participate in the study were self-selecting based on their own perceptions of EI. The voluntary nature of participation may also have introduced bias. Students who were uncomfortable with a study assessing their EI may not have participated. In addition, a larger representation from the class would have made the study more robust. In the future, this study could be replicated with additional cohorts and include all 4 years of medical school to see if the declining trend of EI holds true throughout undergraduate medical education. 
Another limitation of the study was that only 1 measure of EI was used. While SEI was purposeful toward developing the action step of coaching, other studies have used different measurements of EI. Future studies could look at other EI measures as an additional way to see whether students scored similarly using a different measure and add to the overall validity of their EI scores. 
It would also be important to reassess students’ EI into their third and fourth years to investigate if the EI decline stabilizes, worsens, or improves. Furthermore, EI scores could be used to determine whether a link between EI and specialty selection exists, which could affect career counseling of students before residency matching. Future studies could assess whether a coaching intervention would help preserve baseline EI scores and also enhance EI in preclinical training. If students strive to be well-rounded, empathetic osteopathic physicians, interventions should be put into place early on during medical school to promote EI. Sustaining or strengthening EI is consistent with the osteopathic philosophy of developing a caring, holistic physician who attends to the emotional states of his or her patients. 
In terms of independent variables selected for the multiple regression analysis, it is possible that variables not selected could have had a significant effect on EI. For example, one study found that medical students who had a background in humanities had higher EI scores than students who did not have such a background.15 Other independent variables that may have contributed to the variance, such as ethnicity or religion, were not analyzed in this study. Additionally, the responses were self-reported, which reflects only perceptions of emotional abilities, not actual measurement of those abilities. Consequently, the measure can reflect self-presentation bias. An application of the competency scales to an observable measurement of EI to see whether perception and behavior correlated would be helpful in future studies. Furthermore, this study had constraints on generalizability. It was conducted at a single new osteopathic medical school that was faith-based in terms of its mission and vision. Those factors could have affected the type of students admitted and thus resulted in data not generalizable to the larger population of medical students. This study needs to be replicated in both osteopathic and allopathic medical schools. 
Conclusion
Given the concern of declining EI among medical students, this exploratory study set out to determine the trend of EI in medical students during their preclinical training. Results indicated that overall EI does decline during the course of preclinical training for both genders, although no gender differences were noted. Two of the 8 competency scales (Enhanced Emotional Literacy and Pursue Noble Goals) that composed the overall EI score did not decline over time, which indicates that there are 6 scales to target for possible intervention in this sample. Given the need to prepare students for leadership and physician success, coaching EI skills early on in medical education could contribute to future physician success. 
Acknowledgments
We thank Six Seconds for supporting this research. We also thank research manager Barbara Lutz, MA, for managing the data sets and Shannan Zilles for providing technical manuscript assistance. 
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Table 1.
Assessment of First- and Second-Year Osteopathhic Medical Students’ Emotional Intelligence: Characteristics of Final Population Sample (N=62)
Characteristic Mean (SD) Median Range
Age, y 25.0 (3.6) 24 21-44
MCAT 26.7 (3.6) 26 18-35
GPAa 83.7 (4.8) 84 71-93
COMSAEb 479.5 (94.6) 471 281-812

a Grade point average (GPA) calculated on a 100-point scale.

b n=59 (3 participant scores were not available at the time of the data collection).

Abbreviations: COMSAE, Comprehensive Osteopathic Medical Self-Assessment Examination; MCAT, Medical College Admission Test.

Table 1.
Assessment of First- and Second-Year Osteopathhic Medical Students’ Emotional Intelligence: Characteristics of Final Population Sample (N=62)
Characteristic Mean (SD) Median Range
Age, y 25.0 (3.6) 24 21-44
MCAT 26.7 (3.6) 26 18-35
GPAa 83.7 (4.8) 84 71-93
COMSAEb 479.5 (94.6) 471 281-812

a Grade point average (GPA) calculated on a 100-point scale.

b n=59 (3 participant scores were not available at the time of the data collection).

Abbreviations: COMSAE, Comprehensive Osteopathic Medical Self-Assessment Examination; MCAT, Medical College Admission Test.

×
Table 2.
Overall Emotional Intelligence Scores of First- and Second-Year Osteopathhic Medical Students According to Gender (N=62)
Mean (SD)
Gender Pretest Posttest df t P Valuea
Men 100.7 (10.0) 96.5 (11.7) 32 2.8 .01
Women 99.9 (11.2) 95.5 (12.6) 28 3.2 .01

a Significant at P<.05.

Table 2.
Overall Emotional Intelligence Scores of First- and Second-Year Osteopathhic Medical Students According to Gender (N=62)
Mean (SD)
Gender Pretest Posttest df t P Valuea
Men 100.7 (10.0) 96.5 (11.7) 32 2.8 .01
Women 99.9 (11.2) 95.5 (12.6) 28 3.2 .01

a Significant at P<.05.

×
Table 3.
Significant Pearson Correlations Between GPA and COMSAE Scores of First- and Second-Year Osteopathic Medical Students With Emotional Intelligence Competencies (N=62)
GPA COMSAE
Competency r P Value r P Value
Engage Intrinsic Motivation 0.3 .05 0.5 .001
Exercise Optimism 0.3 .05 0.4 .01

Abbreviations: COMSAE, Comprehensive Osteopathic Medical Self-Assessment Examination; GPA, grade point average.

Table 3.
Significant Pearson Correlations Between GPA and COMSAE Scores of First- and Second-Year Osteopathic Medical Students With Emotional Intelligence Competencies (N=62)
GPA COMSAE
Competency r P Value r P Value
Engage Intrinsic Motivation 0.3 .05 0.5 .001
Exercise Optimism 0.3 .05 0.4 .01

Abbreviations: COMSAE, Comprehensive Osteopathic Medical Self-Assessment Examination; GPA, grade point average.

×