Longitudinal Follow-Up of Death Anxiety and Psychophysical-Symptom Experience of Participants in the Silent Mentor Program

Abstract

This study assessed death anxiety (Death Anxiety Questionnaire, DAQ) and psychophysical- (psychological and physical) symptom experience following cadaveric dissection among the Silent Mentor Program (SMP) participants before thawing (T1), after the suturing, dressing and coffining session (T2), and one month post-program (T3). There was a significant decline in the total DAQ score comparing T1 and T2 (t = 7.69, p < 0.001) and T2 and T3 (t = 5.00, p < 0.001) and T1 and T3 (t = 10.80, p < 0.001). There was a significant reduction in total psychological-symptom score comparing T1 and T2 (t = 4.92, p < 0.001) and between T1 and T3 (t = 4.85, p < 0.001). However, for the physical-symptom experience, a significant increase in the physical-symptom score between T1 and T2 (t = –3.25, p = 0.001) was reported but the scores reduced significantly one month after the program (T2–T3; t = 4.12, p < 0.001). The mentoring concept of the SMP program has beneficial effects on improving attitude towards death and psychophysical-symptom experience associated with cadaver dissection.

Keywords

death anxiety psychophysical cadaver dissection

The Silent Mentor Program (SMP, formerly named as “Cadaver Donation and Caring Unit”) was established in 1996 by the Tzu Chi University, Taiwan). SMP is a component of medical education based on either formaldehyde-embalmed or freezing preserved bodies donated by pledgers. Traditional cadaveric training mainly used bodies donated by individuals or were unclaimed bodies from hospitals, where often the identity of the body was unknown. The concept of silent mentor program requires students to address the body donors as their mentors instead of objects for practice or learning (Asia Research News, 2017). It promotes a sense of respect for the sacrifices and contributions of the body donors and their family members. The program aims to cultivate a sense of compassion among medical students and junior doctors towards their patients, to treat the human body with utmost respect, and the practice of altruism in life (Asia Research News, 2017). The SMP is currently being implemented by many medical schools. The University of Malaya initiated the SMP in the year 2012 (Saw, 2018). The SMP in the University of Malaya involves a series of ceremonies: (1) home visits; (2) brief introduction of silent mentors, a day before the cadaveric dissection workshop; (3) initiation ceremony, on the day of the workshop; (4) suturing, dressing and coffining session, after completion of workshop; (5) gratitude ceremony, a day after the workshop; and lastly, (6) sending-off ceremony. For many of the participants, the program provides them their first exposure to performing cadaver dissections.

Undertaking practical dissections on human cadavers can be a stressful and uncomfortable experience for students and may cause post-traumatic stress disorder (Evans & Fitzgibbon, 1992; Getachew, 2014; Hancock et al., 1998; Romo Barrientos et al., 2019; Zubair et al., 2021). The consequences of such negative emotions not only impede the students’ learning process but also potentially daunt their interest and their future clinical career (Greene & Rosen, 2021; Russa & Mligiliche, 2014). It is unknown whether fear and negative emotional reactions are reduced if the students know and feel connected with the donor. In the SMP program, students are assigned to a respective Silent Mentor and interact with the mentor’s family members. They learn about their mentor’s life history through their family, write and present their mentor’s brief biography and pay tribute to their mentors. Since the introduction of the concept of Silent Mentor, much has been reported about the success of the program in improving surgical skills and, in addition, nourishing the value of humanity, empathy, compassion and self-sacrifice (Hong et al., 2017; Santibañez et al., 2016; Saw, 2018). In contrast, little has been investigated regarding the influence of the concept of Silent Mentor on negative emotional reactions associated with cadaveric dissection. A study in Taiwan reported that the programme plays a significant role in soothing negative emotions towards the first contact with cadavers. Moreover, the study also found that attitudes toward death improved after attending the program (Chiou, 2017). Attitude toward death is an important factor that influences the behavior of healthcare professionals, their communication with, and care of patients, especially terminally ill patients (Asadpour et al., 2016; Durand et al., 1990). Hence, it is important to assess students’ attitudes toward death to provide insight to enhance integrated teaching strategies in the medical curriculum to help students reduce anxieties about death.

Since the introduction of the SPM program at the University of Malaya, medical students’ experience of negative emotional or physical reactions as they begin cadaver dissection has not been extensively researched. Given that cadaveric dissection has been the central pillar of anatomy learning, herein this study aimed to explore attitudes toward death and negative emotions towards cadaveric dissection among the medical students who participated in the SMP program. The study also assessed the longitudinal changes in the level of death anxiety and psychophysical-symptom experience associated with cadaver dissection, starting from before the practice of cadaver dissection to a month after the program. This study hopes to explore whether participating in the SMP program can help students reduce their death anxiety and negative emotions with regard to cadaveric dissection.

Methods

Between July 2018 and January 2020 (7 sessions of SMP), all medical students who joined the SMP were invited to participate in this study. We sent them a survey link of questionnaires that consists of four sections. The first section assessed participant demographic background. The second section assessed death anxiety using the Death Anxiety Questionnaire (DAQ) (Conte, 1982). The DAQ is a 15-item multidimensional scale that measures fears related to suffering, loneliness, the unknown and personal extinction. The responses were according to the scale; 0 = not at all, 1 = somewhat, 2 = very much. The total score can range from 0 to 45, and a high score indicates high death anxiety. The third section of the questionnaire assessed the psychophysical-symptom experience associated with exposure to cadavers, which consists of psychological-symptom (10-item) and physical-symptom (8-item) experience. The questionnaires were self-developed from insights of previous studies on reactions of medical students during cadaver dissection (Agnihotri & Sagoo, 2010; Chiou et al., 2017; Getachew, 2014; Lalit et al., 2018). Items were rated on a 4-point response scale ranging from 1 to 4. Four items in the psychological-symptom domain were reverse-scored. The total score can range from 10–40 for psychological-symptom experience items and 8–32 for physical-symptom experience; a high score indicates high negative psychological- and physical-symptom experience.

Three assessments for DAQ and psychophysical-symptom experience were carried out on a three-time-point assessment. The first assessment was conducted before the thawing process – before cadaveric encounter or namely the pre-SMP phase (T1). The second assessment was carried out after the suturing, dressing and coffining session – the completion of cadaveric dissections (T2). The last assessment was a month after the gratitude and sending-off ceremony (T3), namely post-SMP phase. In the gratitude and sending-off ceremony, the SMP participants expressed their gratitude to their mentors and pay their last respects. Figure 1 shows the sequence of the SMP program and the three phases of the assessment.

Ethical Considerations

The University of Malaya Research Ethics Committee approved this study (Approval code: UM.TNC2/UMREC – 353. Students were informed that their participation was voluntary, and consent was implied on the completion of the questionnaire.

Statistical Analysis

All statistical analyses were performed using Statistical Package for the Social Sciences, version 20.0 (IBM Corp., Armonk, NY, USA). The reliability of the items was evaluated by assessing the internal consistency of the items representing the score. The DAQ has reliability (Cronbach’s α) of 0.871, 0.910 and 0.931 for TI, T2 and T3, respectively. The psychological response score has a Cronbach’s α of 0.531, 0.635 and 0.722 for TI, T2 and T3, respectively. The physical response score has a Cronbach’s α of 0.839, 0.905 and 0.916 for TI, T2 and T3, respectively. The changes of the scores over time were analyzed using repeated measures t-tests. The significance level was set at p < 0.05.

Results

Between July 2018 and January 2020 (7 sessions of SMP), a total of 197 complete responses were received. Table 1 shows the demographic of the medical students attending the SMP who completed the three phases of the assessment. The age range of the participants was between 20 and 27 years. The majority were female (64.5%) and of Chinese ethnicity (58.9%).

Table 1.

Participant Characteristics (N = 197).

Socio demographic characteristics	Frequency (%)
Gender
Male	70 (35.5)
Female	127 (64.5)
Ethnicity
Malay	59 (29.9)
Chinese	116 (58.9)
Indian	15 (7.6)
Others	7 (3.6)
Age (years old)
20–23	135 (68.5)
24–27	62 (31.5)
Year of study
Year 2–4th	79 (40.1)
Year 5 and graduated	118 (59.9)

Figure 2 shows the responses of individual items for DAQ for the three assessments. The proportion of anxiety responses was generally high in T1, with over 60% of participants responding somewhat/very much for the domains of fear of the unknown and fear of suffering. Nearly all items show a consistent decline in the proportion of somewhat/very much responses across the T2 and T3 assessments. As also shown in Table 2, the mean (±SD) of the total DAQ score was 24.8(±8.9) during T1, which was higher than the midpoint score of 22.5. There was a significant decline in the total DAQ score comparing T1 and T2 (t = 7.69, p < 0.001) and T2 and T3 (t = 5.00, p < 0.001) and T1 and T3 (t = 10.80, p < 0.001).

Table 2.

Scores of DAQ, Psychophysical Responses and SAST for the Pre-SMP (T1), After Coffining Ceremony (T2) and Post-SMP (T3) Phases.

	Mean (SD)
	Pre-SMP (T1)	After coffining (T2)	Post-SMP (T3)	t(T1–T2)	p-value	t(T2–T3)	p-value	t(T1–T3)	p-value
Death Anxiety Question (DAQ) (score range)
Total DAQ score (0–45)	24.8 (8.9)	19.8 (9.5)	17.3 (9.5)	7.69	p < 0.001	5.00	p < 0.001	10.80	p < 0.001
Fear of an unknown (0–15)	7.9 (3.5)	6.4 (3.4)	5.5 (3.3)
Fear of suffering (0–9)	6.0 (2.2)	5.0 (2.4)	4.3 (2.4)
Fear of loneliness (0–6)	3.8 (1.8)	3.0 (1.8)	2.5 (1.7)
Fear of personal extinction (0–9)	3.5 (2.3)	2.8 (2.1)	2.5 (2.1)
Does the thought bother you that you might lose control of your mind before death? (0–3)	1.5 (1.0)	1.2 (1.0)	1.1 (0.9)
Do you worry that expenses connected with your death will be burden to other people? (0–3)	2.1 (1.0)	1.5 (1.0)	1.4 (1.0)
Psychophysical responses
Psychological (10–40)	18.7 (4.1)	17.1 (4.5)	16.9 (5.0)	4.92	p < 0.001	0.54	0.587	4.85	p < 0.001
Physical (8–32)	8.7 (1.8)	9.4 (3.2)	8.5 (2.0)	–3.25	0.001	4.12	p < 0.001	1.67	0.207

Figure 3 shows the proportion of somewhat/a great extent responses for items in the psychophysical-symptom experience. In the first assessment, a considerably high proportion reported somewhat/a great extent of feeling nervous (33.5%) and worrying about possible misfortunes (18.8%). In contrast, a great proportion reported having great interest in the program (92.9%), feeling calm (86.6%), excited (77.2%), and being self-confident (61.9%). A very low proportion reported physical-symptom experience associated with exposure to cadavers. Fast heart beating (5.1%) and cold sweat (2.5%) were relatively reported more than other physical symptoms. A considerably higher proportion reported nausea or vomiting (7.6%), muscle cramps (6.1%), dizziness (4.6%), and weakness (4.1%) were reported in T2. All physical-symptom experiences were reported in low proportion in T3.

As shown in Table 2, the total score for psychological- and physical-symptom experience was 18.7(±4.1) out of a possible 40, and 8.7 (±1.8) out of a possible 32, respectively in the T1 assessment. There was a significant reduction in the total psychological-symptom score comparing T1 and T2 (t = 4.92, p < 0.001) and between T1 and T3 (t = 4.85, p < 0.001). There was a significant increase in the total physical-symptom score between T1 and T2 (t= –3.25, p = 0.001). In contrast, a significant decrease between T2 and T3 (t = 4.12, p < 0.001) was observed.

Discussion

Few empirical studies have demonstrated the beneficial impact of the SMP ceremonies on their participants. Our findings add to growing evidence of the positive impact of the program in overcoming medical students’ death anxiety and emotional responses to cadaveric dissection.

Death-related subjects have often provoked heightened fear in many people. Confronting one’s own or the death of loved ones is often an unpleasant emotional experience. The DAQ measures a wide range of attitudes towards dying and death related to fear of suffering, loneliness, the unknown and personal extinction (Conte et al., 1982). In the present study, the medical students reported a relatively high level of death anxiety just before their first cadaveric contact. Death anxiety was conducted just before the participants removed the mentors out of the freezer to the anatomy dissection hall for thawing. This perhaps resulted in a high level of death anxiety. However, the mean death anxiety score reported by our study participants is lower than that reported by nursing students in Turkey, who reported a mean death score of 32.98 (Gurdogan et al., 2019). Of note, participating in the SMP is not compulsory for all medical students. All participation is voluntary and selected upon registration. Medical students were requested to provide a short quote on the reason they wished to join the workshop training and were selected based on their enthusiasm for the program. The relatively lower death anxiety score among our study participants is perhaps due to the reason that students who were successfully selected to participate in the program are relatively more emotionally prepared and have better attitudes toward death. As evident, a great proportion of the students in the present study reported great interest in the program, feeling calm, excited, and having self-confidence. Likewise, the finding of the mean score of psychological-symptom experience of 18.7 out of a possible 40 scores also showed that the students in this study were in a good state of psychological well-being.

In the present study, a low proportion of adverse physical symptoms were reported before cadaveric contact. Similarly, as participation is voluntary, this perhaps explains the low symptoms experienced. Nonetheless, an increase in the proportion of physical symptoms was reported after the suturing, dressing and coffining session. The ceremony is conducted on the last day of the five-day training workshop. Students cleanse their mentors, perform suturing and dressing before putting their mentors in the coffin, the processes perhaps heightening feelings of nausea, muscle cramps, fast heartbeat, and dizziness. Consistent with past findings from medical students in many countries, physical symptoms such as dizziness, nausea, palpitations, breathlessness were also commonly reported during cadaveric dissection (Chia et al., 2020; Getachew, 2014). The wide range of psychological as well as physical symptom experiences associated with cadaveric dissection found in our study was equally reported by many medical students in other studies across the globe (Getachew, 2014; Khan & Mirza, 2013). Serious attention should be paid to students who experience unpleasant responses to cadaveric dissections. As noted earlier, such reactions not only impede the learning process but may also have a long-term effect, such as post-traumatic stress disorder and could also potentially daunt their interest and their future clinical career (Curfman et al., 2018; Finkelstein & Mathers, 1990). It has been suggested that before the commencement of cadaver dissection sessions, education to reduce students’ anxiety and to help students mentally prepared is essential (Bati et al., 2013; Getachew, 2014).

The trend analysis shows that the high level of death anxiety shows a continuous decline during the subsequent two-time-point collections. On a positive note, this is perhaps due to the positive implication of the concept of silent mentoring and the series of ceremonies during the program that reduced students’ death anxiety. Similarly reported in Taiwan, a continuous reduction in students’ negative attitudes towards death during the program was recorded (Chiou et al., 2017). It has been suggested that the noble and selfless acts of silent mentors in donating their bodies to science have touched the students’ hearts and changed their perception of death, and no longer viewing it as a horrible thing (Chiou et al., 2017). The program and its ceremonies have allowed most students who lacked experiences of facing death to reflect on this issue (Chiou et al., 2017). There has been a suggestion that the basic concepts of death and dying should be included in medical school curricula (Durand et al., 1990). Physicians feeling uncomfortable with death and awkward in responding to or dealing with dying patients are not uncommon and warrant considerable attention (Dickinson et al., 1999). It is imperative for physicians to have a positive attitude toward death. Having a positive mindset about death not only enables the physician to deal better with terminally ill patients but also helps the patient to confront death in as positive a manner as possible. Further, close contact with a silent mentor’s family members is another important aspect of the program that is extremely beneficial for students to equip them with the skill to communicate with the families of terminally ill patients on issues concerning death and dying.

Similarly, the negative psychological-symptom experience toward cadaveric dissection also showed continuous reduction over time. Nevertheless, as for the finding on physical-symptom experience, although an increase of total physical-symptom scores was reported after the suturing, dressing and coffining session, a significant reduction in symptoms was observed a month after the program. This finding implies that the heightened physical symptoms during suturing, dressing and coffining session were temporary. Following this session, students attended the gratitude ceremony and sending off mentors for cremation along with mentors’ family members. This perhaps resulted in reduced negative feelings. In essence, the important highlight of the temporal assessment of death anxiety and psychophysical-symptom experience a month after the program generally showed a significantly lower level compared to the baseline level. This implies the sustainability of the reductions or the potentially long-term positive influence that the program had on the participants.

This study has several limitations that could have influenced our results. Firstly, death anxiety and assessment of psychophysical-symptom experience were obtained by self-report measures, therefore may be vulnerable to response bias. The second limitation pertains to the method used in this study whereby we did not have a control group of students who did not join the SMP program. Future studies, such as case-control studies or randomized control trials, are mandatory to confirm these findings

Conclusions

This study adds to evidence suggesting the benefits of the Silent Mentor program, which is not solely a medical program to train surgical skills and cultivate humanistic attributes, such as compassion and self-sacrifice, but has been shown to result in significant reductions in death anxiety and negative emotions associated with cadaver dissection. Our findings also revealed that, even though cadaveric dissection is undeniably stressful to a minority of students, on the whole the students were resilient and did not exhibit evidence of post-traumatic stress. This potentially suggests the sustainable benefit the program had on its participants. The philosophy of silent mentoring and the altruistic teachings of the Silent Mentor should be introduced in medical teaching.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Li-Ping Wong

Author Biographies

Li Ping Wong is a professor at the Department of Social and Preventive Medicine, Faculty of Medicine, University of Malaya, Malaysia. She graduated with a PhD in Epidemiology in 2004 from the University of Malaya. Her areas of expertise include social determinants and health behaviors, social epidemiology, and community health. She is a board member in the Unit of Silent Mentor Program (SMP).

Sik Loo Tan is currently a senior lecturer in the Department of Orthopaedic Surgery, Faculty of Medicine, University of Malaya. She graduated with PhD in Medical Biotechnology and Stem Cells. She is a Board Member in the Unit of Silent Mentor Program (SMP). Her area of expertise is mesenchymal stem cells applications in tendon repair, in in vitro and in vivo models; Streptozotocin (STZ)-induced rat model for musculoskeletal diseases (i.e. osteoarthritis and tendon degeneration) related studies. Her work is related to musculoskeletal cellular and molecular research, with fresh clinical samples and frozen samples from SMP.

Haridah Alias is currently a PhD candidate at University of Malaya. She has been involved in various research on behavioral medicine, social epidemiology and community preventive medicine. She graduated from the University of Malaya with a Master in Medical Science and Bachelor of Biomedical Science.

Thiam Eng Sia is currently the manager of Unit of Silent Mentor Program, Faculty of Medicine, University of Malaya, overseeing the administration and operations of the Silent Mentor Program in the country since the year 2012. He has committed himself to social and charitable projects in most of his career for the last 30 years.

Aik Saw is a professor of Orthopaedic Surgery at the University of Malaya Medical Center. His area professor Saw’s area of expertise is in corrective and reconstructive surgery of upper and lower limbs deformities. He is a member of various national and international professional bodies including being the council member of the Asean Orthopaedic Association. He is presently the director of the University Malaya Silent Mentor Program and also also the Chief Editor of the Malaysian Orthopaedic Journal.

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