Unveiling the Spirituality of Encounter Through Exploration of Meaning in Real Life Patient Interactions Among University Senior Medical Clerks

Introduction

Clinical medical clerkship, simply referred to as "clerkship," is a phase of medical education that serves as a bridge between theoretical knowledge acquired in earlier years of medical school and practical skills required for medical practice. It provides a comprehensive introduction to diverse aspects of patient care and helps students develop appropriate clinical skills, diagnostic reasoning and patient management abilities as they encounter real patients. 

The literature uncovered various specific topics related to real-life patient encounters and medical clerkship. Topics such as religion and spirituality as cultural assets for coping and ethical decision-making,[1,2] the practice of patient-centered care in providing positive changes on the medical clerks’ attitudes, knowledge and skills,[3-5] personal reflections on palliative care,[6-8] and developing professional identity,[9,10] emerged as the more frequent subject matters highlighted during patient encounters in clerkship. 

However, the diverse exposure to various medical specialties, coupled with the multitude of patient encounters and academic, physical, psychological and emotional challenges inherent in clerkship, serve as rich sources of meaning more than what has previously been studied. Meaning refers to the subjective significance, interpretation, insight or personal understanding that senior medical clerks attribute to their experiences during real-life patient encounters. Thus, this opportunity to study the significance embedded in lived experiences of medical clerks during actual patient interactions may serve as a catalyst for more transformative self-reflections, personal development and a comprehensive understanding of patient care. 

Qualitative phenomenological inquiry is a suitable method to uncover the deeper, lived experiences of medical clerks during real-life patient encounters. By understanding subjective interpretations, emotions and transformative elements inherent in these experiences, the essence of what it means to engage with patients in a real-world medical setting can be validated. To direct our investigation, we were guided by the following research questions: 1) How may senior medical students’ real patient encounters during their clinical rotations be described and reflectively analyzed? 2) What meanings and insights can be derived from their lived experiences? and 3) What implications and possibilities can be drawn from the study that are relevant to medical students’ formation and patients’ care vis-à-vis the role of various stakeholders and programs in the medical curriculum? 

The theoretical orientation of this study may be rooted in the philosophical underpinnings of the Theology of Migration. Medical clerkship is depicted as a transformative journey, drawing parallels with migration. A phenomenological understanding within the paradigm of the Theology of Migration was given by Gabriel Marcel, a prominent French philosopher and Christian phenomenologist, who delved into the human condition in his work Homo Viator.[11] Presenting a profound perspective on the nature of man as an eternal traveler, the understanding of human constitution as a migrant provides a unique lens for the journey of medical clerks during their real-life patient encounters. 

Methodology

Context of the Study 

The Clinical Clerkship program in the medical university where this study was conducted lasts 12 months, involving mandatory and elective rotations at various medical services, including affiliated hospitals. During this period, students enhance their clinical skills, focusing on history-taking, physical examination and data integration for clinical impressions. As active members of medical teams, they participate in diagnosing and managing patients in the hospital and other affiliated institutions. This period is a tough yet rewarding phase of medical school, characterized by physical rigors of careful monitoring, exhausting duty days, lack of sleep, long rounds, frequent hunger, handling numerous admission and discharge papers, and scrubbing in surgical procedures. It also presents with mental challenges that include remembering patient histories and engaging with consultants, as well as emotional difficulties such as dealing with harsh realities of death, loss and unsuccessful treatments. 

Given these challenges, this paper explores whether medical clerks find deeper meaning in their experiences during actual patient encounters. This inquiry aims to capture the subtleties of challenges and rewards inherent in patient interactions throughout clerkship, fostering a more empathetic and nuanced viewpoint. Ultimately, the aspiration is to cultivate an environment that not only supports and reflects on the experiences, but also appreciates the profound meaning real patient encounters bring to the forefront. 

Role of the Researchers 

This research study is a collaborative effort between a research methodology professor and a Master's student in Theology, who is also a medical doctor eager to embark on qualitative research methods in medicine. In a mentoring role, the authors worked together to develop research questions, design the study, organize data and make decisions for interpretation and thematic analysis. The professor brings extensive expertise in teaching research methodology, while the student, a medical doctor and professor of medicine, contributes her firsthand experience in exploring the relationship between patient encounters and deeper meaning derived from these interactions. 

Design and Development of Specific Questions 

A qualitative design with a phenomenology approach was used to explore the senior medical students’ lived experiences during their patient encounters. Phenomenology is the study of “phenomena”: appearances of things, or things as they appear in our experience, or the ways we experience things, thus they are meanings that things have from the subjective or first-person point of view.[12] This design was therefore well-suited to explore the essence of medical students’ real-life patient encounters during their clinical rotations. 

The questions were developed by the authors. Specifically, the following areas were discussed during the interview: motive/s for pursuing a career in medicine, strategies in preparing for patient encounters and their initial approaches when facing patients, encounters that left a lasting impact or resonated as pathways towards a vocation that connects them to something or someone greater, circumstances that seemed to evoke reflective insights or experiences during their patient interactions, and lessons or insights that they could carry forward into their future medical practice based on their profound experiences. 

Setting and Study Participants 

This study was done at a local medical university and its sister tertiary hospital in Manila, Philippines. Using a purposive or selective sampling method, three female medical clerks who had attended clerkship rotations in different specialties for at least three months, and who consented to join the study by willingly sharing their experiences during patient encounters were included. Pseudonyms were assigned to each medical clerk to safeguard their identities. 

Data Collection and Analysis 

The data collection process was initiated through face-to-face in-depth interviews that adopted a semi-structured approach, featuring open-ended guiding questions designed to delve into students' experiences during patient encounters. Throughout the interviews, the researcher employed mobile phone voice recorders to capture all discussions accurately. 

Following the interviews, the researcher meticulously transcribed the recordings and cross-checked them for accuracy to ensure the fidelity of data. The clean narratives were then sent back to the medical clerks for verification. The analysis employed in this study was adapted from Colaizzi's descriptive phenomenological method.[13] The raw narratives were first translated and edited. Subsequently, significant statements related to the investigated phenomenon (real patient encounters) were identified. Initial reflections by evaluating their meanings were then derived from the statements. The identified meanings were then organized into themes. The themes were then summarized and consequently condensed into an eidetic insight—a concise statement capturing aspects that were deemed essential for the phenomenon. 

Ethical Considerations 

All methods were performed in accordance with the Declaration of Helsinki and followed the standards of the institutional research committee. Before commencing the face-to-face interviews, they were given the freedom to ask questions before signing the consent form. Their permission was likewise asked prior to audio recordings. It was emphasized that the study guaranteed their anonymity, confidentiality, freedom to participate voluntarily and the right to withdraw at any time without repercussions. 

Results

The three participants were all Filipino Roman Catholic female medical students who were in their fourth year of medical school at the medical university. Their ages were 25, 26 and 24 years old, respectively. They are anonymized in the results below as Medical Clerk 1, 2 and 3 (MC1, MC2, MC3). The insights extracted from the narratives were translated into reflections and then organized into themes. This process revealed the emergence of 10 significant major themes stemming from patient encounters (Table 1). 

Theme 1: Taking up medicine is the fulfillment of life’s blessed calling that is imbued with profound responsibility 

By unwaveringly pursuing their shared calling, medical clerks have unearthed the profound sense of purpose that resides within them. MC1 encountered an initial setback when she was denied admission to the medical university. Yet, driven by her unyielding determination to realize her dream of becoming a doctor, she courageously sought reconsideration and eventually achieved her goal. MC2’s aspiration to become a doctor was deeply ingrained within her due to the early exposure she had as a child. For her, this path represented her way of selflessly serving others as she stated: “Observing my parents' dedication and the way they view their work as a vocation, I was drawn to medicine not just as a profession, but as a means of serving and making a positive impact on people's lives.” MC3 was inspired by the dedicated doctors who provided care for her grandmother during their regular visits to the hospital. She chose to follow in their footsteps, becoming the doctor she once depended on for her grandmother's well-being. 

To uphold the sacredness of the calling, commitment to responsibility is attached to this vocation. MC1 encountered ethical and moral dilemmas while tending to a dying patient, yet she was resolute in continuing with her duties. She shared this experience: “The first encounter with death as a clerk is unforgettable, particularly when witnessing the profound impact on the family, but as a doctor, I have to remain composed, not showing my emotions, while providing the care they need”. MC2 came to understand that being a doctor carries both privilege and responsibility, compelling her to persevere in the face of self-doubt, inadequacies and inevitable mistakes as a trainee. Similarly, MC3 grappled with lingering doubts about her abilities, but recognized that being a doctor is a solemn commitment. She expressed: “The weight of responsibility rests squarely on your shoulders as you guide your patients, holding their overall well-being in your hands. Providing care is an arduous task, and it's in moments like these that I recognize the paramount importance of having a genuine passion for medicine”. In addition, she further said: “What fuels my determination to persevere, despite these uncertainties, is my calling. I firmly believe that the Lord intends to utilize me as an instrument for healing”. 

Theme 2: Fostering personal and spiritual bonds in patient encounters 

Interacting with patients forges a profound spiritual connection, motivating medical clerks to provide care with the same compassion they would offer to their own families. MC2 shared a deep spiritual bond with a female patient who reminded her of her late mother. For her, healing extends beyond mere physical treatment: “This experience impressed on me that being a doctor isn't solely about medical knowledge from textbooks but also about the human connection you establish with your patients, which is integral to the healing process”. Meanwhile, MC3 was deeply moved by patients of the same age as her parents. She voiced that: “The prospect of my parents requiring hospitalization weighs heavily on my mind. This contemplation of life's fragility motivates me to strive towards becoming the best doctor I can be”. 

Theme 3: Confronting human mortality is a deeply sobering experience that reinforces the significance of holding onto faith. 

Facing mortality as a doctor serves as a strong reminder that life's path is often beyond our control, even when we exert our utmost efforts to sustain it. MC1’s first encounter with a dying patient deeply stirred her emotions, making her acutely aware of life's fragility and the constraints of medical practice. She articulated: “While we have the power to offer medical intervention, we lack the ultimate say in a person's life, which resides with a higher power. It reinforced the complexity of healing, moving beyond the physical recovery to the acceptance of life's uncertainties”. Similarly, MC3, when confronted with mortality, found herself equally struck by the transient nature of life. She commented: “While I once considered 70 or 80 to be the threshold of old age and believed that 60 was still a time of strength, this perspective has shifted as I witness younger individuals facing serious illnesses”. 

Theme 4: Challenges serve as catalyst for growth and resilience in the journey of becoming a doctor 

The daily challenges faced during clerkship are more than mere hurdles; they represent opportunities for personal and professional growth. MC1, for instance, discovered that despite the inevitable mistakes made along the way, her confidence steadily increased as her experience accumulated. Furthermore, MC3 initially grappled with disparities between what textbooks conveyed and realities she encountered in her patients. She stated: “Communicating with challenging or disorganized patients can be particularly demanding. Nonetheless, these experiences have served as valuable lessons, equipping me to approach future patients with greater confidence”. 

Theme 5: The power of faith and prayer in challenging moments 

Faith serves as the medical clerks’ paramount wellspring of resilience, endowing them with inner fortitude and optimism needed to endure daily adversities. MC1 found solace and strength in prayer: “While I may not be religious, I do believe in a higher power. I've witnessed the transformative power of prayer. Patients and relatives often turn to the Lord as their last resort, their ultimate source of hope, even when facing the darkest of times”. She further recognized the pivotal role of faith in her journey. She conveyed: “Whenever I feel my strength waning, I turn to the Lord and ask, "Can I do this?" My prayers are casual, unstructured conversations with Him, seeking help and guidance”. Similarly, MC2 consistently incorporated her faith into the daily challenges: “I prepare for my daily interaction with patients by engaging in spiritual practices such as journaling and reading books. I consider it a privilege to be involved in the healing process, a role that echoes what Jesus did”. 

Theme 6: Weaving personal growth and academic and practical wisdom from a strong community of mentors, family, friends and patients 

Collaborative knowledge sharing enriches the holistic learning journey of any physician across all stages of their training. MC1 shared: “In the midst of the demanding challenges that occasionally threaten to overwhelm me, I find solace in the nurturing environment surrounding me. I've learned to appreciate quality in my relationships over quantity, selecting friends who comprehend the intricate journey, and engaging in enlightening conversations that revolve around our shared experiences with patients”. MC2 expressed her gratitude for the collaborative environment fostered by her peers: “To elevate yourself, you must uplift others. An essential part of medicine is supporting one another. Fostering this type of thinking and environment is crucial because if you keep the knowledge to yourself, not only will you stagnate, but you also won't receive blessings for growth”. Additionally, she emphasized the importance of fostering self-care practices and cultivating a culture of kindness within the hospital environment to enhance the mental well-being of healthcare staff. Similarly, MC3 affirmed: “Moreover, I find it incredibly inspiring when professors candidly share their personal journeys and challenges, particularly during their own time in medical school. These narratives serve as a source of motivation, reinforcing the understanding that I'm not alone in facing these hurdles. These stories remind me that struggle is part of the journey, and they provide an additional layer of inspiration”. 

Theme 7: A lifelong odyssey of learning and adaptation 

With the ever-changing landscape of medicine, doctors must maintain their unwavering dedication to keeping themselves informed about the latest research, technologies and treatment methodologies. MC1 exemplified this commitment through her diligent research of each case she encountered: “Amidst the legitimate concerns of making errors, such as prescribing the wrong medication or facing questions without answers, I've developed a proactive approach. I diligently research the cases I've encountered, deepening my understanding and building a wealth of knowledge”. Similarly, MC3 recognized that medicine is a lifelong learning, making it a priority during patient encounters, refraining from allowing personal emotions to overshadow her focus. 

Theme 8: The vital role of compassion and social awareness in healing 

Addressing the emotional and social well-being of patients is essential for their overall health. MC2 recognized that in cases where cure is not possible, doctors should continue to provide comfort and display compassion. Central to medicine is the concept of patient-centered and whole-person care emphasizing the need to not only administer treatment, but also understand patients' unique socioeconomic circumstances. She conveyed: “I firmly believe that regardless of financial means, patients encounter a range of life challenges that can impede their access to necessary care, making the social aspect of medicine an indispensable component to address”. 

Theme 9: The physician’s vocation: humbled by limits 

Recognizing the limitations as doctors serves as a humbling reminder to dedicate themselves to their patients while seeking divine guidance at every step. MC1, understanding that she could not offer guarantees, was committed to always provide her best care and entrusting the patient's well-being to the will of God. In a similar vein, MC2 found inspiration in a book entitled "Some Days You Can't Save Them All," which shattered her misconception that doctors must be infallible. She acknowledged: “It was a humbling experience for me because I used to think that you had to be perfect to be a doctor. My biggest fears about being a doctor were twofold: first, not being able to do what I needed to do for my patients, and second, becoming desensitized to the reality of their suffering. I didn't want to lose my empathy and sensitivity”. 

Theme 10: Enhancing medical education through increased patient encounters 

Enhancing the frequency of real patient interactions is vital in equipping students with essential skills for their future patient care responsibilities. MC1 firmly believed that early exposure to actual patients can help reflect on their ultimate roles, shifting their focus away from stress and exhaustion. She conveyed: “To enhance our curriculum, I suggest incorporating a day for students to truly witness what transpires in a clerk's life…. I believe this initiative would provide students in their 1st, 2nd, and 3rd year of medical school with a safety net, a spark that can fuel their motivation. If I were a 3rd- or 2nd-year student, I would be genuinely excited knowing that there’s an actual patient whom we will see and learn from and this can allow them to strive even harder as students”. MC3 further emphasized: “I believe that to better prepare for clerkship, incorporating more patient encounters into our learning process is essential. Not only do these experiences enhance our retention of medical knowledge, but they also foster a deeper and more personal connection between us, as aspiring medical professionals, and the patients we serve”. 

Discussion

Medical clerkship is a transformative journey for every medical student. Employing a phenomenological approach, the study revealed ten key major themes. Foremost of which is the unveiling of the profound calling that is inherent in a medical vocation which was verified in the study of Kao and Jager.[14] Students often perceive this calling as an internal summons, passion, a life purpose, or being in the right place.[15] Individuals with a strong sense of calling not only find satisfaction in their work but also demonstrate persistence in their roles despite difficulties.[16,17]

The encounters of medical clerks with patients forged spiritual and personal connections. In the healing process, connection is seen as the establishment of a space that prioritizes confidentiality, empathy, love and compassion. This space, created through mental presence, emotional openness and respect for physical appearance, fosters a safe environment for open sharing. This communion leads to a state of grace, allowing for entry of the divine and facilitating healing, transformation and transcendence.[18]

Another significant theme was the intersection between mortality and faith. In a study that explored how medical students and doctors cope with patient loss, religion and faith served as common coping mechanisms, alleviating feelings of helplessness as well as providing comfort that a patient's fate is ultimately in God's hands and that within the larger existence of universal truth and values, what had occurred could essentially make sense.[19,20]

The study also drew attention to the catalytic role of challenges in fostering growth and resilience. Resilience is positively linked to the well-being of medical students.[21] Cross-sectional studies have found that higher resilience correlates with lower psychological distress, increased life satisfaction, happiness, better quality of life, reduced anxiety symptoms, enhanced subjective well-being among medical students and professional identity formation.[10,22-27]

The potent influence of faith, prayer and support from mentors, family and friends were also pointed out in the study. Prayer and meditative practices contribute significantly to the overall well-being of medical students, reducing anxiety and depression while fostering optimism and hope.[2,28] Support coming from leaders, colleagues and nurse partners, likewise helps in stress management, alleviates burnout symptoms, strengthens professional relationships and mitigates mental health challenges.[29-32]

The study also stressed the enduring journey of learning and adaptation. In the evolving landscape of medical practice, particularly with the rise of "evidence-based medicine," doctors are expected to stay current and apply recent advances in their profession, necessitating self-directed robust learning, self-discovery and lasting enthusiasm.[33]

The findings further emphasized the vital role of compassion and social awareness in healing. Compassion encompasses ethical, professional, communicative, humanistic, religious-spiritual and patient involvement dimensions. It also covers the recognition of social and economic challenges that impact patient's health outcomes, particularly for those with lower socioeconomic status.[34]

The study also underscored the humility arising from acknowledging the limits of the physician's vocation. In clinical practice, humility acts as a relational construct, adapting to various contexts and times, moderating power imbalances and guarding against narcissistic entitlement. Patients perceive humble doctors as trustworthy and inviting, while arrogance creates barriers to approachability and confidence.[35]

Lastly, it is crucial to stress the significance of increasing exposure to patient encounters, the driving force that integrates theory and practice.[36] Early workplace encounters among medical students strengthened their learning and professional identity as evolving doctors.[37] Other emerging themes took the form of developmental outcomes which included the ability to perform the task, modification of attitudes towards the task and development of relationships within the team. The central feature of the experience which influenced all developmental outcomes was making mistakes, contributing towards the development of a professional.[38]

These themes collectively merge into an eidetic insight, which articulates that real patient encounters through medical clerkship are a sacred responsibility. Every encounter offers an opportunity to grow more deeply in faith and one’s social, psycho-emotional and intellectual well-being. It involves entering into profound human and spiritual connections within a caring environment that is imbued with compassion, humility, stewardship, professionalism, collaboration, growth and resilience. 

Within the paradigm of the Theology of Migration, framing medical clerks as beings in constant motion, their journey becomes a meaningful exploration as they transition from classroom learning to the dynamic realm of real patient encounters. This experiential shift resonates with the phenomenological orientation of Gabriel Marcel's "Homo Viator[11]," offering a rich source of parallels. 

As medical clerks move from theoretical knowledge to lived experiences of patient interactions, they embark on an existential journey marked by profound themes of hope, ambiguity and the search for meaning. The encounter with patients, their families and the uncertainties inherent in healthcare settings can lead to a heightened consciousness of one's sense of duty. The fears, anxieties and uncertainties encountered in patient care become pivotal points for personal and spiritual growth, in congruency with Marcel’s key point of brokenness and wholeness. 

In this journey, medical clerks may experience a discernment and realization that, while developing their competencies, there is need to recognize a higher power or intelligence on whose hands ultimately the life and well-being of a person rests. This recognition aligns with Marcel's themes of faith and transcendence, where the pursuit of better opportunities in patient care is seen as a manifestation of the human desire for meaning beyond this world. 

Moving forward in patient encounters, medical clerks become more closely in touch with themselves, with God, with colleagues and with patients and their families. The genuine connectedness formed in these encounters contributes to a sense of continuity and meaning in their journey as medical practitioners. Through the intertwining of Marcel's existential concepts with experiences of medical clerks in real patient encounters, a "spirituality of encounter" emerges—a profound recognition of the sacredness and interconnectedness of human experience in the realm of healthcare. 

Conclusions

In conclusion, the essential intuition drawn from this study emphasizes spirituality that real patient encounters in medical clerkship impart. It represents a sacred responsibility, providing opportunities for profound connections, resilience, deepened faith and comprehensive personal and professional development within a caring and compassionate environment. 

In light of the phenomenological insights derived from the study, several implications emerge. The theoretical implication for medical students is rooted in emphasizing medicine as not merely a profession but a vocation imbued with divine purpose. Understanding themselves as instruments of God's healing ministry fosters humility and encourages selfless giving, viewing patients not as mere transactions but as souls entrusted to their care. It underscores the profound responsibility of restoring not just physical health, but the dignity of each individual, reinforcing spiritual dimensions inherent in the doctor-patient relationship. Such a perspective can be further integrated into medical ethics courses within medical schools, serving to fortify the spiritual foundation of students as they embark on this profession. 

For the medical education system, there is a pressing need for the integration of holistic care within the curriculum. This entails expanding educational offerings to include courses or workshops that transcend clinical realms, focusing on empathetic communication, understanding social dynamics, fostering ethics, promoting cultural sensitivity and delving into the spiritual dimensions of health and illness. 

The establishment of mentorship programs and structured reflection sessions is also important. Encouraging students to engage in mentorship relationships with seasoned healthcare providers facilitates the transfer of experiential wisdom and contributes significantly to personal and professional growth of medical students. 

Another implication revolves around the promotion of patient-centered care. The curriculum should emphasize the significance of understanding and respecting patients' values, beliefs and preferences. Tailoring treatment plans accordingly ensures a more personalized and empathetic approach to healthcare. 

Additionally, mental health education must be integrated into the curriculum, incorporating stress management strategies and awareness programs that will familiarize medical students with signs of stress, burnout and compassion fatigue. Medical students should be actively encouraged to proactively manage their well-being by seeking counseling or therapy. This proactive approach aligns with the study's emphasis on resilience and mental health, contributing to a more supportive and sustainable medical education environment. 

Acknowledgments 

We would like to thank the medical clerks G.C., M. S. and Y.Z., whose invaluable time, wisdom and dedication greatly enriched this study. 

Declarations

Funding

The authors declare that no funds, grants, or other support were received during the preparation of this manuscript. 

Competing Interests 

The authors have no relevant financial or non-financial interests to disclose. 

Ethics Approval 

The paper has been exempted from review by the University of Santo Tomas, Faculty of Medicine and Surgery Research Ethics Board. 

Consent to Participate and Publish 

Informed consent for participation and publication were obtained from all the medical clerks. 

Authors’ Contributions 

All authors contributed to the study conception and design. Material preparation, data curation and formal analysis were performed by MDC and RPR. The original draft of the manuscript was written by MDC. The review and editing of the paper were contributed by CCDC. All authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.