Insight from a novel humanities-based education intervention to teach empathy to internal medicine residents locally

Abstract

The medical humanities have the potential to develop empathy in junior doctors through perspective taking and critique of deep-seated beliefs. An education intervention to develop empathy was integrated into an internal medicine residency curriculum in Singapore. All junior residents currently in the programme were invited to participate in individual interviews after the humanities sessions. Data collected was analysed qualitatively using thematic analysis. A total of three sessions were conducted over one year from April 2020. Two participants were recruited successfully for the study. A total of 4 interviews were completed and themes relating to the role of the humanities in empathy education, barriers to its implementation, and cynicism to the sessions were elicited. The results provided insight about how residents experienced a novel humanities-based postgraduate medical education program. However, the low recruitment is a major limitation in this study and data collected may not be confidently interpreted. There is still significant work needed to create greater awareness about the role of the humanities in medical education and research. Improvement in the pandemic situation may also improve participation in future studies.

Professionalism is a core competency for residency training according to the Accreditation Council for Graduate Medical Education (ACGME) guidelines and is characterised by humanistic clinical practice demonstrated through empathetic practices. ¹ Empathy, defined as a predominantly cognitive attribute that involves an understanding of patients’ experiences, concerns and perspectives combined with a capacity to communicate this understanding ² is thus an important competency. In a scoping review by Zhou et al., a myriad of teaching practices for empathy was noted but studies have been criticised to be of poor quality. ³ Nonetheless, the medical humanities, defined as an interdisciplinary field where concepts, content and methods from art, history and literature are used to investigate the experience of illness and to understand the professional identity of healthcare providers have frequently been employed in pilot studies published in the literature.^3,4 Through reflective practice and self-awareness, the humanities facilitate perspective-taking and challenge existing biases and stigma, allowing learners to break through common barriers in developing empathy. ⁵

While there have been pilot studies and commentaries on the state of the medical humanities in China, Hong Kong, and Taiwan, the field is just starting to develop in Singapore. ⁶ There is a gap of knowledge in how the medical fraternity in Singapore may benefit from the medical humanities in medical education although pilot studies have demonstrated the acceptability and feasibility of such programmes. ⁷ In view of a strong desire to support our residents in a core competency and the recognition that the humanities play an important role in medical education, ⁸ a humanities-based education intervention was developed and integrated into the Singhealth Internal Medicine (IM) Residency curriculum. This study seeks to investigate the experiences of the junior IM residents participating in a novel humanities-based programme to teach empathy.

The sessions were conducted in April 2020, August 2020 and February 2021. Each session lasted 1 hour and residents participated in large-group interactive discussions. A medical consultant specialist from respiratory medicine and intensive care, palliative medicine, and gastroenterology took turns to be the lone facilitator of each session. In the first session, the participants were introduced to the medical humanities and its relevance to professional development and clinical practice. This was illustrated through the interpretation of artistic representations including paintings, literature, and music. In the second session, a more in-depth exploration of the concept of empathy was undertaken through negative role-modelling illustrated via video clips from the movie Wit, a movie featuring a literature professor suffering from ovarian cancer. ⁹ In the third session, participants were introduced to narrative medicine and the traditional checklist framework of medical history-taking was critiqued. All facilitators were guided by Gagne’s instructional model of teaching, using different modalities of the humanities to gain attention and stimulate recall and reflection. ¹⁰ Each session was attended by about 100 residents. The first two sessions were conducted over an online platform while the third was conducted in person. The same group of residents attended all three sessions.

All junior residents in the residency programme were invited to participate in the study but only 2 participants provided consent for enrolment. A total of 4 individual interviews were conducted by an independent research coordinator (RC) after each session using a semi-structured interview guide. The data collected was transcribed and analysed using thematic analysis. ¹¹ The 2 participants were aged between 28–35 and in their second and third year of residency training. Participant 1 (P1) attended all three sessions and completed three interviews while participant 2 (P2) only attended the second session and completed one interview. All the interviews were conducted within 2 months after each humanities session. Results are summarised in Table 1.

Table 1.

Themes and quotes of participants.

Theme	Quotes
1. The function of the medical humanities in professional development in the aspects of empathy and clinical communication was recognised. This was achieved through meaning-making and reflections.	“…it triggered memories I could relate with in the book that the writer had faced and reminds me, motivates me on why we are doing this and continue to work hard and my job.”
	“…the doctor-patient relationship is one of most important things. I think even some of the more senior physicians actually go to the extent of saying that it's something that is sacred, that you should really protect that as much as we can.”
2. Barriers to the success of the program include time constraints and online learning platforms.	“…sometimes, during the mid-day, you get phone calls and that certainly may be a bit distracting”
	“… humanities is best done face to face on a more personal setting. So, sort of convey emotions and feelings, through the personal touch rather than online.”
3. There was cynicism towards the program. This was because of the hidden curriculum and a perceived lack of empathy towards other colleagues and negative role-modelling. This led to discontent and moral distress.	“It has to come down from the top. It cannot be thinking against the grind of the team. Of course, on call, when there are no seniors around I can bring it but then you have to take into account on call I don’t have the time. I don’t have the luxury of time sometimes.”
	“Rather than actually making the environment where it is easier to do things… our hospital is a hierarchal thing, you can't expect a junior to be empathetic when the senior is not.”
	“it's very sad that in front of the patients, we are not even empathetic towards our colleagues. So, how can we then say that we want to bring empathy towards the patient when we can't even be empathetic towards our own kind?”

The data collected suggests that residents recognised the importance and relevance of empathy when reminded by representations in art, drama, and narrative medicine. The impact of the hidden curriculum in the learning and teaching of empathy was however concerning. The hidden curriculum is defined as a set of influences that function at the level of organisational structure and culture, including implicit rules to survive the institution such as customs, rituals, and taken for granted aspects. ¹² It can be transmitted through human behaviours, as well as structural and organizational practices. Through policies, resources allocation and role-modelling, learners receive implicit messages about what is valued and how they should behave in alignment with these values. ¹³ The narrative experiences of the participants highlighted how one may experience the hidden curriculum, particularly the associated moral distress in junior doctors. Moral distress may be defined as the negative feelings that arise when one knows the morally correct thing to do but they feel compelled to act in a way that contradicts with their values. ¹⁴ Overall, our data suggests that the humanities sessions may be ineffective as the disconnect between what was taught and what was observed in practice was not addressed.

We recognise that the low number of participants for this study is a major limitation to how the data can be interpretated and generalised. We faced similar challenges as other humanities programs that struggled to gain acceptability and integration into the formal curriculum. ⁴ Barriers included competing needs for clinical work, distractions during the sessions and a lack of awareness of the humanities. These were also likely exacerbated by inherent stressors due to the pandemic. Greater efforts are needed to increase awareness about the medical humanities and engage multiple stakeholders for future programs. However, we also hope that our experience will motivate like-minded educators to conduct and investigate similar humanities educational interventions.