Mentoring as a part of Integral Training in Medicine: A pilot study involving a control group aimed at improving attitudes toward suffering and death.

doi:10.21203/rs.3.rs-1398476/v1

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Mentoring as a part of Integral Training in Medicine: A pilot study involving a control group aimed at improving attitudes toward suffering and death.

https://doi.org/10.21203/rs.3.rs-1398476/v1

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Background

Medical degree students often express great satisfaction toward their mentoring experience and share the impression that it has contributed significantly to their personal and professional development. Mentoring can contribute to a more comprehensive and integral preparation of the student for professional life, promoting critical reflection, but studies are needed which focus on effectiveness in achieving educational objectives by means of an appropriate methodology.

Methods

This pilot study aims to evaluate the formative impact on students' attitudes towards suffering and death and their perception of the role of mentors in an innovative mentoring program for undergraduate students through a quasi-experimental design.

Between October 2019 and March 2020, 2nd-year medical students were invited to participate in a mentoring program made up of 5 mentors, randomly assigned to each student by Microsoft Excel's randomization function. A validated and adapted scale was used to measure students' perception of their mentors (CECA Scale) and the mentoring program, while another two validated scales were used to measure attitudes toward suffering (Brief Humanising Scale) and death (Bugen Scale).

Results

Of the 109 students invited to participate (79% female and 21% male), 20 agreed to participate in the intervention group and 24 in the control group. CECA was scored with medians of 6 (the highest score). The Brief Humanising Scale returned no statistically significant differences between the groups. The Bugen Scale showed significant differences after intervention in 80% of the items directly related to the educational objectives.

Conclusions

Students' perception of mentors and mentoring has been optimal. Students' attitude toward suffering was not improved, although attitudes toward death were. Long-term, mixed studies are needed to obtain a higher degree of evidence.

Death

Medical students

Mentor

Mentoring

Suffering

Mentoring is understood in this study as integral formative education, along with other registered in medical literature [1, 2]. It is considered as a formal or informal process of meetings, open to the mutual personal development of mentor and mentorees, in which the accompanying person (mentor) offers an environment of trust, cordiality, understanding and encouragement so that those who are accompanied (mentorees), so that they may better discover and realize their professional and personal possibilities and commitments.

Numerous studies have shown that medical degree students often express great satisfaction toward their mentoring experience and share the impression that it has contributed significantly to their personal and professional development [3]. Furthermore, mentoring improved the students' confidence, ability to enjoy the career, sense of belonging, and emotional well-being [4, 5, 6]. It has also proved successful as a predictor of professional success [7] and a positive factor in worldwide promotion and academic productivity, facilitating alumni recruitment for teaching medicine [3, 4, 8, 9].

Some mentoring programs tried to meet students' needs for integral education. They contained moments in which the student could express their various concerns in confidence, choose among various projects, advance in promotion processes once their studies have been completed, and, in general, facilitate the resolution of specific problems concerning personal and professional growth [3].

As was the case for the group of students in this study, the initiation of clinical rotations, mainly performed in palliative care units, raises the need for work-oriented training on attitudes towards suffering and death. In a cultural context such as that of Western societies, where well-being is highly valued, addressing the issue of suffering and death with medical students is as tricky as necessary [10].

Sooner or later, each student will face "extreme situations" [11] when dealing with their patients and even in their personal lives. It is not easy to consider the value that, paradoxically, the terrible suffering associated with such situations may harbour. For example, it is not evident that suffering can provide an opportunity for personal growth and maturing [12].

A survey on four US medical schools found that only 38% of students indicated that teaching about suffering was occurring in their schools and that most of what they learned about dealing with suffering patients is taught by role modelling. They gave minor support to statements that their education prepares them to deal with their reactions to the suffering of patients personally [13]. Work engagement has been negatively correlated with burnout and perceived stress [14]. Although burnout is a students' frequent problem, only a third seek help [15], and they had a significant unmet need for health care [16].

Students and residents in the United States felt unprepared to provide good care for the dying [17]. Students experienced substantial emotional stress coping with patient deaths, and common coping mechanisms included talking through their emotions, thrusting themselves into continuing their rounds or crying [18]. Emotional reactions differ as a function of the setting: surprise and shock in the Emergency Department versus sadness and grief in an inpatient setting [19]. Experiencing the death of a patient led to students feeling emotionally diminished and a decrease in empathy to cope with the emotional pain [20]. Spanish students reported that the thing that would most help them to die peacefully would know that their life would not be prolonged artificially, and what worries them most is pain and suffering [21].

Medicine has the challenge of incorporating comprehensive training to teaching what suffering is and how to avoid or relieve it through a "systematic and disciplined approach to knowledge that arises from the experience" [22]. To this end, the experience of health professionals working in palliative care gives rise to some exciting clinical approaches [23, 24]. Formative mentoring can contribute to a more comprehensive and integral preparation of the student for professional life, promoting critical reflection. It may be gained through educational interventions of an experiential character and oriented to work motivation, professionalism and correct attitudes in the face of extreme situations.

Various studies carried out have attempted to find an ideal framework for mentoring [25], to better understand the different models and types of mentoring [26], to identify keys to the success of an mentoring plan [27] and to assess the effects of these programs [2]. However, most of the studies selected in various reviews are satisfaction surveys, interviews, or focus groups aimed at exploring student perception [28]. These are usually cross-sectional studies without comparative control groups [3]. Presently, studies are needed which focus on effectiveness in achieving educational objectives by means of an appropriate methodology [2].

Study setting and participants

The study was conducted at the Universidad Francisco de Vitoria Medical School, during the academic year 2019–2020, between October 2019 and March 2020.

In the 2nd year of Medicine, those enrolled in the year-long subject of Medical Humanities II receive training in fundamental bioethics and carry out a 2-day rotation in palliative care. It entails a report in which they analyse the organisational characteristics of the centre they are appointed to, the values of professionals and patients, and the perceived training needs identified following this rotation.

In addition, the intervention group carried out a structured mentoring program, focusing on attitudes toward suffering and death. It consisted of 5 one-hour mentoring sessions: 3 individual and 2 group meetings. Group sessions took place in the second and fifth meetings. Although it was a structured training objective, it also contemplated the possibility of addressing any other matter of concern to the student that may arise.

Each student and group was accompanied by a mentor, the same person throughout the academic year. There were six mentors (3 men and 3 women) who had undergone a 50-hour training course and, in addition, a training co-creation meeting to share best practices before each of the mentoring sessions. The training aimed to equip the mentors with the necessary skills to subsequently mentor the students in an open and non-judgmental manner and generate a relationship of trust to encourage students' involvement and participation. The training also aided the mentors in detecting the students' latent training needs - especially regarding attitudes toward suffering and death.

The mentoring sessions had the following objectives: 1st session: Presentation on the experience and concept of suffering [22]; 2nd session: Exploration of attitudes toward suffering and the possibility of the paradox of suffering. This concept means that, although suffering is generally experienced as something undesirable and, in some way, absurd, paradoxically, it may also provide an opportunity for the discovering of values, and possible personal development; 3rd session: identification, interpretation and management of emotions which arise during a situation of suffering; 4th session: dealing with one's death and that of the patients; 5th: reflection on what has been learned and its use and application in the future.

In the mentoring sessions, a mainly experiential methodology was employed. It was based on the critical incidents arising from the students' experiences of suffering or from coping with the idea of their own death. Such incidents may have arisen during the medical rotations or through other personal experiences. From here on, a Socratic debate was initiated, aimed at fostering reflective learning. After considering the students' input, mentors could share their own experiences and the basic concepts linked to the teaching objectives.

The methodologies used in the 2nd and 4th sessions were entirely focused, respectively, on the consideration of attitudes towards suffering and death.

In the 2nd group mentoring session, the following dynamics were proposed: Firstly, sharing personal positions on a Likert scale upon three sentences related to suffering; secondly, reflecting on what their usual attitude to suffering was, choosing between rejection, accepting it with resignation, and accepting it as an opportunity or challenge; finally, the group reflected on the possibility of suffering as something absurd but, paradoxically, sometimes with a meaning to be gained from it.

In the 4th (individual) mentoring session, 3 group dynamics were performed. In the first, an imaginary scenario was proposed in which each student was diagnosed with a terminal disease. From there, they were asked to reflect individually and then in a group on the unfinished phrase "When my time comes to die, I want…". In the second session, a 10-minute video of the film Wit was shown (Nichols 2001) in which a nurse (Susie, played by Audra MacDonald) attends a patient with terminal-stage ovarian cancer (Vivian Bearin, played by Emma Thompson). Following this reflection, the students were then asked to discuss what a professional should do when accompanying a terminal patient. In the third session, the students, who had not yet received training in clinical communication, were presented with the hypothetical situation of having to help patients in extreme situations. They talked about how they might manage with the skills they had at hand. The objective here was to help them discover the importance of maintaining an attitude of being present despite the feeling of personal shortage in the face of such suffering and hardship.

Study design

It was a prospective, quasi-experimental study comparing an intervention group and a control group before and after the mentoring program activities.

The study subjects were students enrolled for the first time in the subject of Medical Humanities II, scheduled in the second year of studies at the School of Medicine. There was an intervention group (with the mentoring program described above) and a control group, which received the same training as the intervention group, except for the mentoring program.

All study subjects who volunteered were randomly assigned to either the intervention or the control group. Written informed consent was obtained from those who joined both groups.

The main effect measures were: Age, sex, average academic performance in 2018-19 and 2019-20, and three scales: The Brief Humanising Scale oriented toward the identification of attitudes to suffering, the Bugen Scale oriented toward the identification of attitudes to death and an adaptation of the CECA Scale aimed at identifying students' appreciation of mentoring and mentors.

On the Brief Humanising Scale, validated in our field (Villacieros et al. 2019) to assess the attitude to suffering, each item was answered on a Likert scale, with a score of 0 to 5, with the following sections: 0 = totally disagree; 1 = disagree; 2 = slightly disagree; 3 = slightly agree; 4 = agree;5 = totally agree. It comprised 15 items, 9 of which explore whether suffering is understood as "change" (9 items, possible total score from 0 to 45) or as "burden" (6 items, possible total score from 0 to 30 points). Items were categorised according to whether the attitude toward suffering was considered an opportunity for change or a burden. In order to respect its structure, no adaptation was made; however, only the Change Factor category items directly related to the training objectives were considered. The higher the score here, the easier it is to find or make sense of suffering. These items were directly related to the program's educational objectives (Table 1).

Table 1

Suffering as a Change Factor
1. Suffering can be something transcendental which may even lead to a new life
2. The human being can make sense of suffering
3. Suffering is necessary to learn
4. Suffering is an obstacle to overcoming and thus to achieving inner peace
5. Suffering is a sign that one should change something
6. Suffering is intimately linked to love
7. Suffering is due to the non-acceptance of pain, to internal struggle
8. The experience of suffering serves to change the way we see life
9. Suffering is a source of energy, compelling us to seek what we lack
1. It is caused by ancestors who have offended through the crimes they committed or their moral misdeeds
2. Since there is a lot of suffering, if one accepts his or her share, there remains less left

The Bugen scale of coping with death was also validated in Spanish geographic and cultural context [29]. Each item was answered on a Likert scale, with a score of 1 to 7 and with the following sections: 1 = strongly disagree, 4 = no opinion, 7 = strongly agree. It consists of 30 items with a possible score between 30 and 210.

No adaptation was also made to this scale to avoid any distortion, although, of the 30 items it contained, only 10 were directly related to the educational objectives (Table 2).

Table 2

Bugen Scale: Items related to the program’s educational objectives.
1. Thinking about death is a waste of time
2. I have a positive outlook on death and the process of dying
3. I am aware of all the emotions that characterise human grieving
4. I feel ready to face my death
5. I feel ready to face my process of dying
6. I can express my fears about death
7. I can put words to my instincts about death and the process of dying
8. I can spend time with the dying if I need to
9. I can help people with their thoughts and feelings about death and the process of dying
10. I can lessen the anxiety of those around me when the subject of death and the process of dying arises

Items related to communicative skills or knowledge of the management of the deceased were discarded, as they did not fall within the program's educational objectives.

The CECA scale used is an adaptation of the original scale, which has been validated in Spanish geographic and cultural context [30] to understand the students' perception of the quality of teaching. It was adapted to the perception of mentoring and mentors. Each item was answered on a Likert scale, with a score of 1 to 6, with the following sections: 1 = totally disagree; 2 = disagree; 3 = slightly disagree; 4 = slightly agree, 5 = agree;6 = totally agree. It consists of 10 items evaluating the role of the mentor and 14 evaluating the mentoring sessions (Table 3).

Table 3

The CECA scale, adapted for the evaluation of mentors and mentoring
PERCEPTION OF MENTOR QUALITY
1. The explanations of the content matter are clear to me
2. The questions raised are resolved for me
3. I feel respected in my opinions
4. I felt accompanied by my mentor
5. I have felt correctly motivated and challenged by my mentor
6. I receive meaningful feedback that allows me to improve
7. My mentor is punctual in his commitments (mentoring attendance, marking and feedback)
8. My mentor is easily accessible
9. From a general perspective, evaluate the teaching work of this mentor globally as a facilitator of your learning and development
10. To what extent would you sign up for other mentoring programs taught by this mentor?
PERCEPTION OF THE MENTORING SESSIONS
1. The organisation of the mentoring program (activities, evaluation criteria, etc.) is clear to me
2. The teaching methodology employed in the mentoring sessions favours my learning
3. I can relate the mentoring to real-life situations
4. My desire to learn is answered and encouraged
5. The activities developed encourage me to become more involved with others (colleagues, friends, family, etc.)
6. The topics covered give rise to important questions for me
7. The assessment method allows for reflection on what has been learned
8. I learn in the mentoring sessions
9. The teaching-learning methodology of face-to-face sessions favours my personal development
10. The issues dealt with in the mentoring sessions favour my personal development
11. The evaluation methodology adequately covers all important aspects of mentoring
12. Mentoring has helped me get to know myself better and propose actions for self-improvement
13. Mentoring has helped me get through my second-year studies better
14. From a general consideration, give a global evaluation of the effectiveness of mentoring as a learning space for personal development

Both academic results and scale results were measured at the beginning and end of the intervention in both groups.

Data analysis

A descriptive statistical analysis of the data was carried out, comparing the intervention and control groups before and after the intervention. The intervals were calculated with a 95% confidence interval (CI) for the mean of continuous variables. For variables related to the response scores in the scales used, the medians were calculated, and the percentiles 25 and 74 - parameters that are most useful for smaller samples. To identify statistically significant differences, p was calculated using the Man Whitney U test.

Ethical considerations

All procedures performed were in accordance with the ethical standards of the institutional and national research and the study was approved by the Bioethics Committee of the School of Medical at Universidad Francisco de Vitoria.

Of the 112 second-year students of the School of Medicine invited to participate in the study, 44 accepted: 20 in the intervention group and 23 in the control group. Demographic and academic records data are shown in Table 4.

Table 4

Demographic and academic records data.
	INTERVENTION (N = 20)	CONTROL (N = 23)	p-value difference*
Female sex	70.0%	95.8%	0.035
Mean age in years (95% CI)	20.3 (20.0-20.5)	20.9 (20.2–21.8)	0.090
Average academic grade BEFORE	7.5 (7.1–7.9)	7.0 (6.6–7.5)	0.134
Average academic grade AFTER	8.0 (7.7–8.4)	7.7 (7.4–8.1)	0.403
* Mann Whitney U test

Results before mentoring program: intervention group versus control group

On the Brief Humanizing Scale, at baseline there were no statistically significant differences in the measurement of the change factor (p = 0.940) with a median (percentile 25–75) of the total score (over a maximum of 45 points) in the intervention group of 29 (26–32) and in the control group, 28.5 (23.5–32.5). Regarding the Bugen Scale, there were also no significant differences in total scores or by item at baseline. Total results (possible range between 30 and 210 points) between the two groups were: intervention group median (percentile 25–75): 129 (107.5-141.5); control group: 120 (108.5- 135.25) (p = 0.605).

Results after mentoring program: intervention group versus control group

On the Brief Humanizing Scale, similar results to those of before the intervention were returned following the intervention. There was a slight increase in the medians, with no statistically significant differences in the measurement of the change factor (p = 0.843).

On the Bugen scale, following the intervention, a statistically significant difference was found in 6 of the 10 items linked to the educational objectives (Table 5).

Table 5

Bugen Scale: Items with significant differences between intervention and control groups following intervention.
		INTERV G. (N = 20) Median (P25-P75)	CONTR G. (N = 17) median (P25-P75)		p*
Total Score (Range 30–210)		143 (128.5-152.2)	123 (109.5-140.5)		0.012
Score by statement (Range 1–7)	Code	INTERV G. (N = 20) Median (P25-P75)		CONTR G. (N = 17) Median (P25-P75)	p*
I have a positive outlook on death and the process of dying	2	5 (4-5.7)		3 (2–5)	0.038
I am aware of all the emotions that characterise human grieving	3	6 (5–6)		5 (4–5)	0.009
I feel prepared to face my own death	4	4 (3–5)		2 (1.5-3)	0.012
I feel prepared to face my own process of dying	5	3.5 (2-4.7)		< 2 (1-3.5)	0.048
I can put words to my instincts about death and the process of dying	7	< 6 (5–6)		< 4 (3–5)	0.011
I can help people express their thoughts and feelings regarding death and the process of dying	9	< 5 (5-6.7)		< 5 (3.5-5)	0.029
* Mann Whitney U test

Pre and post intervention comparison of the intervention group

In the total Brief Humanizing Scale score, the intervention group did not show significant differences between before and after the intervention.

Regarding the Bugen Scale, a statistically significant difference was found in 6 of the 10 items linked to the educational objectives (Table 6).

Table 6

Bugen scale in the intervention group: Comparing before and after.
		BEFORE (N = 20) Median (P25-P75)	AFTER (N = 20) Median (P25-P75)	p*
Total Score (Range 30–210)		129 (17.5-141.5)	143 (128.5-152.2)	0.605
Score by statement (Range 1–7)	Code	BEFORE (N = 20) Median (P25-P75)	AFTER (N = 22) Median (P25-P75)	p*
I am aware of all the emotions that characterise human grieving	3	4 (2.25-5)	6 (5–6)	0.000
I feel prepared to face my own death	4	2 (1–4)	4 (3–5)	0.016
I feel prepared to face my own process of dying	5	2.5 (1–3)	3.5 (2-4.75)	0.042
I can express my fears regarding death	6	5 (3.25-5)	6 (5-6.75)	0.016
I can put words to my instincts about death and the process of dying	7	4 (4–5)	6 (5–6)	0.013
I can lessen the anxiety of those around me when the subject of death and the process of dying arises	10	4.5 (3-5.75)	5 (4.25–6.75)	0.045
* Mann.Whitney U test

CECA scale.

The results of the CECA scale are reflected in Table 7.

Table 7. Students' perception of the quality of mentoring and mentors.
PERCEPTION OF MENTOR QUALITY
STATEMENT (Range 1–6)	Median P25-P75
The explanations of the content matter are clear to me	6 (6–6)
The questions raised are resolved for me	6 (5–6)
I feel respected in my opinions	6 (6–6)
I felt accompanied by my mentor	6 (6–6)
I have felt correctly motivated and challenged by my mentor	6 (6–6)
I receive meaningful feedback that allows me to improve	6 (6–6)
My mentor is punctual in his commitments (mentoring attendance, marking and feedback)	6 (6–6)
My mentor is easily accessible	6 (6–6)
From a generall perspective, evaluate the teaching work of this mentor globally as a facilitator of your learning and development	6 (6–6)
To what extent would you sign up for other mentoring programs taught by this mentor?	6 (6–6)
PERCEPTION OF MENTORING
The organisation of the mentoring program (activities, evaluation criteria, etc.) is clear to me	6 (5–6)
The teaching methodology employed in the mentoring sessions favours my learning	6 (5.25-6)
I can relate the mentoring to real-life situations	6 (6–6)
My desire to learn is answered and encouraged	6 (6–6)
The activities developed encourage me to become more involved with others (colleagues, friends, family, etc.)	6 (5–6)
The topics covered give rise to important questions for me	6 (5–6)
The assessment method allows one to reflect on what has been learned	6 (5–6)
I learn in the mentoring sessions	6 (6–6)
The teaching-learning methodology of face-to-face sessions favours my personal development	6 (6–6)
The issues dealt with in the mentoring sessions favour my personal development	6 (6–6)
The evaluation methodology adequately covers all important aspects of mentoring	6 (5.25-6)
Mentoring has helped me get to know myself better and propose actions for self improvement	6 (6–6)
Mentoring has helped me get through my second year studies better	6 (5–6)
From a general consideration, give a global evaluation of: The effectiveness of mentoring as a learning space for personal development	6 (5.25-6)

Both the items pertaining to the students' perception of the mentors, as well as those related to the perception of the quality of the mentoring sessions have received high scores. The data suggest that the mentors and mentoring sessions have met the expectations held both by the students and the objectives behind the training model itself.

These results are similar to reported positive experiences enjoyed in other mentoring programs run in various schools of medicine throughout the world [3]. They are also in line with a required multicomponent (introductory lectures, tours of the dissection hall and clinical wards, online diaries, and reflection groups) elective course developed over three semesters at the Medical School of Duesseldorf. Students rated the course positively [31]. Educational goals (improving attitudes towards suffering and dying) and methodology approach (mentoring) both components have been well received by students. The research showed the demand for support and insight into medical students' experiences, emotions, and attitudes toward death and suffering [32].

Our study comprised of two main teaching objectives: To help improve attitudes toward suffering and to improve attitudes toward death.

The authors of this studio assumed Cassel's concept of suffering: "the state of severe distress associated with an event that threatens the intactness of person" [22]. Adjustment to medical school, student abuse, exposure to death and suffering, intolerance of uncertainty, the incongruity between students' expectations and the realities of medical training and practice [33], or moral distress [34] are possible sources of students' severe stress and suffering. There are various barriers to help-seeking, particularly self-awareness about the problem and prioritising well-being [35]. The mentoring program at the Universidad Francisco de Vitoria Medicine School addressed situation awareness when training students to identify their emotions in suffering settings. According to program goals, the Brief Humanising Scale explored the outlook on a people's sense of purpose to discover or give to suffering.

Mindfulness-based interventions have been accomplished to prevent o relieve medical students' stress [36], founding some of them improving subjective well-being [37]. Internet-based cognitive behavioural therapy has also been a program to make a more acceptable option for medical students to help them manage stress [38].

However, the Universidad Francisco de Vitoria mentoring program was not oriented to relieve stress because the Medicine School has resources to prevent and treat it. The program pursued helping students manage their current and often unavoidable own suffering, reflecting on their attitudes towards it and helping them know that sometimes this absurd and undesirable experience may have a sense, helping them discover values or become more resilient.

Other training experiences have been focused on practising various mind-body skills, such as several forms of meditation and using drawings and written exercises for self-awareness and self-expression. These program results were not connected to insight into a possible purpose of suffering [39, 40]. Another program focused on providing students with the opportunity to explore humanism in medicine and self-care. The authors of this report found learning outcomes connected to attitudes and insight on suffering purpose improvement, but they did not explicitly assess them [41].

The total score of the Humanising Scale was taken, with a relatively high starting point regarding the change factor, entailing a particular educational challenge for improvement. The data obtained after the intervention suggest that it did not have the desired effect on the students.

These results have likely been because intervention did not delve sufficiently into the notion of the paradox of suffering. This idea was crucial in the 2nd (group) mentoring session. It devoted most of its time to discovering and exploring attitudes, and only the possibility of the paradox of suffering was pointed out. Consequently, in future editions, more time will be allocated for students to reflect and share their own experiences of suffering as an opportunity for change or as a challenge. It will be carried out in a Socratic manner through questions that help explore their personal experiences of this paradox.

Concerning death confrontation attitude, the overall Bugen Scale data before the intervention suggest that no significant differences between the two groups were found to make them incomparable (median intervention and control group: 129 and 120 respectively). These data are similar to those recorded on a sample of 916 undergraduate students from Cuba and Spain (median: 120) to validate this scale. The author considered that the confrontation to the death was bad below 110 points, neutral from 111 to 128 and good from 129 points [29].

Another study explored the perceptions and attitudes of Spanish students regarding specific issues related to death and end of life using the modified Bugen Scale. The sample (411 students) presented a moderate level of perceived competency in the ability to face death [42]. Four items were shared with the present study. Their mean (± SD) results were the following: "I feel prepared to face my own process of dying" 3.58 (± 2.020); "I feel prepared to face my own death" had a mean of 3.44 (± 2.049); "I can express my fears regarding death" 4.64 (± 1.710); "I can help people express their thoughts and feelings regarding death and the process of dying" 3.56 (± 1.611). Unfortunately, it is impossible to compare their study means and the reported medians here, and although our means (± SD) are known, it is uneasy to obtain meaningful conclusions.

From 10 items related to the teaching objectives, whether in the comparison between groups or the pre-post comparison of the intervention group, 8 significantly improved attitudes toward death. This 80% success rate gives reasonable cause for optimism for the outcome of the intervention. It is attributable to the program, especially the fourth mentoring session previously described in the methodology section. The intervention group total Bugen Scale score progression from a median of 129 before intervention (relatively high) to 143 shown a good placement on the "good" confrontation range.

This result is in line to other initiatives such as specific courses. For instance, a 7-week course, one-and-one-half-hour per week with 30 participants on Death and Dying focused on measuring the pre- and post-course fears about death and dying with Collett-Lester Death Anxiety Scale. It showed a decrease in anxiety about death and dying when the post-test was compared with the pre-test on the anxiety scales [43]. These results were confirmed later with a sample of 71 medical students [44]. Another research evaluated the effects of courses for health care workers and medical students in care at the end of life. 41 undergraduate medical students completed the Multidimensional Fear of Death Scale on the first and last day of the course. Overall, fear of death scores were reduced, and the attitudes to dying patients improved [45].

Although Kaye's and Hegedus et al.'s interventions and this mentoring program seem to converge improving intervention results, our report did not measure anxiety or fear. It was focused on some educational outcomes very oriented to improve attitudes towards own and others death. Improving anxiety and fear is relevant, but educational goals go beyond relieving negative emotions. Moreover, mentoring has some educational objectives, such as a particular personal commitment between mentor and student, not needed in standard courses.

On the contrary, a national survey in sixteen Japanese medical schools examined how programs teach end-of-life care to medical students in the fifth or sixth year. Students who took a program had greater death anxiety, significantly higher than those who took no program, suggesting that improving end-of-life care education is needed to improve the attitude of medical students to death [46].

The present study has limitations, such as having a small sample carried out in a solitary teaching centre. Another limitation has been that the measurement tools used were not tailor-made to the needs of the study's educational objectives. It instigated the need to define which items were related to the teaching objectives and which were not. Although the CECA scale has been validated, its adaptation has not been formally validated in our field. Selection bias has also been possible, given the significant gender differences between the intervention and control groups and that most medical students declined to participate in the study, probably due to the intense academic pressure they are subjected. On another note, it has proved difficult to assess the importance of the intervention's pedagogical impact through strictly quantitative and short-term measures such as those used here. Long-term and mixed studies are required, allowing the effectiveness of this type of intervention in an integral mentoring training program to be revealed through more proficient measuring procedures that provide more reliable and higher-quality evidence.

Our pilot study about the effectiveness of a mentoring program comprised of two main teaching objectives: To help improve attitudes toward suffering and to improve attitudes toward death.

The total score of the Humanising Scale to detect attitudes towards suffering showed a relatively high starting point regarding the change factor, entailing a particular educational challenge for improvement. The data obtained after the intervention suggest that it did not have the desired effect on the students.

Concerning death confrontation attitude, the overall Bugen Scale data suggests that the mentoring program improved students' attitudes toward death.

The limitations of this pilot study make future mixed and long-term studies necessary.

Abbreviations

Not Applicable.

Ethics Approval and Consent to Participate

This study was approved by Comité de Ética de la Investigación de la Universidad Francisco de Vitoria ethics committee and written informed consent was obtained from all participants.

Consent for publication

Not applicable because no identifying images or other personal or clinical details of participants compromise anonymity.

Availability of Data and Materials

Authors share their raw data by providing it in a supplementary file to BMC Medical Education. The data that support the findings of this study are available from BMC Medical Education, but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are however available from the authors upon reasonable request and with permission of BMC Medical Education.

Competing Interests

The authors declare no competing interests.

Funding

No funding was obtained for this study.

Authors' contributions

SAM, MPRG, RAM, BHS, FLV and FVO contributed to the conception; SAM to the design of the work, SAM and IHP to the acquisition, analysis, SAM to interpretation of data; SAM have drafted the work and MPRG, RAM, BHS, FLV, FVO substantively revised it. All authors have approved the submitted version and have agreed both to be personally accountable for the author's own contributions; they ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature.

Acknowledgements

The authors are grateful for the collaboration of the students who volunteered to participate in this study.

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Mentoring as a part of Integral Training in Medicine: A pilot study involving a control group aimed at improving attitudes toward suffering and death.

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Abstract

Background

Methods

Study setting and participants

Study design

Data analysis

Ethical considerations

Results

Results before mentoring program: intervention group versus control group

Results after mentoring program: intervention group versus control group

Pre and post intervention comparison of the intervention group

Discussion

Conclusions

Declarations

References

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