This study aimed to assess the impact of narrative medicine for 5th year Western and Chinese medical students using a purposively developed questionnaire. Three factors were extracted from the 9 questionnaire items: personal attitude, self-development/reflection and emotional benefit. Overall, students were significantly more likely to agree that the course facilitated their self-development and reflection than it facilitating personal attitudes about narrative medicine and emotional benefits. This finding that students’ empathy, reflection and interpersonal relationships all benefit from their engagement with the narrative medicine course resonates with previous research analysing writing content during courses. Through these narratives students described how their engagement in narrative writing, they received a greater understanding of themselves, patients’ and families’ feelings, reflection, humanistic situations, and motivation to improve [12,13,14, 16].
The current study is unique in that we examined two different groups of medical students: Western (MSs) and Chinese (TCMSs) medicine students. We found perceptions of narrative medicine to be significantly higher in TCMSs than MSs for each of the 9 items in the questionnaire and therefore for the 3 extracted factors. Such a finding leads us to wonder why this might be so. As discussed above, the characteristics of traditional Chinese medicine in both theory and practice make it very different from conventional Western Medicine [28]. A distinctive difference between the two is that Western medicine focuses solely on the body as an organism. On the other hand, Chinese medicine considers the soul or spirit as an integral element of the body. Therefore, one essential difference between them is that through the learning of Chinese medicine, students are trained to conceptualise the entire body in an holistic manner to solve a single ailment, rather than focusing on disparate body parts (which is more of a feature of Western medicine). Furthermore, Chinese medicine not only offers professional medical knowledge, but it also emphasises humanities, social, legal, and ethical education [22, 23]. Having said this, there might be other alternative explanations, including that Chinese medicine might attract more humanities-focused students.
We believe that role modeling may also partially explain this difference. Role modeling is thought to be an integral component of medical education and an important factor in shaping the values, attitudes, behavior, and ethics of medical trainees. In comparison with traditional Chinese medicine, Western medicine strongly features scientific technology, with frequent use of high-technology instruments as a defining feature: while not an exact science, behind many diagnoses lie a variety of measurements with developed formula for signs of specific pathology. Thus the focus is split between measurements and the patient, with emotional detachment from the patient being a defining feature of professionalism. Traditional Chinese medicine doctors operate differently. They typically communicate with their patients, focusing on patients’ feelings during diagnoses, taking the human body as balance and harmony. Therefore, although the symptoms might be the same, Chinese and Western medicine physicians have very different relationships with patients and offer different therapies based on their personal experiences [29]. Thus, traditional Chinese medicine physicians as clinical teachers and therefore role models, demonstrate how to focus on patients’ illness through caring for their feelings. Given that the presence of role models during clinical training is a determining factor in the acquisition of medical expertise, including enhancing learning, influencing career choices and facilitating the acquisition of humanistic attitudes [30, 31], we believe this powerful force is partly the reason why we find such a difference between student groups: TCMSs being more familiar with the concept of medicine as an holistic healing art. This state of affairs not only plays into students’ recognition, and therefore acceptance of narrative medicine, but it also impacts on students’ willingness to go the extra mile: our narrative medicine programme relied on the clerks committing their own time to participate. Thus the different learning cultures of MS and TCMS medical education affect both acceptance to, and benefit from, a narrative medicine course.
The predominance of female students in medical education is an important issue. A four-nation study published in 2002 conducted in Western cultures (Australia, Canada, England and the United States) showed that women make up half of all medical students and 30% of all practicing physicians [32]. In many Western cultures, like the United Kingdom, women even form the majority of the physician workforce [33]. However, female doctors are a relative minority in Taiwan. By 1980, Taiwan had only around 4.3% female doctors. The percentage has steadily increased: from 6% in 1990 to 12% in 2000. Female medical graduates have also increased from 1990 (10%) to 2000 (29.9%) [34]. There are 29.1% female medical students in our previous study in 2013, in which females had better behavior records and more attendance in community services than men [35]. Furthermore, research suggests that Tunisian female students attach more value than males to the intrinsic aspects of a physician’s job, such as the desire to help others and to work with people [36]. In a psychometric study of candidates admitted to Scottish medical schools, female applicants as a group were identified as being more empathic, with a greater communitarian orientation than men [37]. Patient-Practitioner Orientation Scale (PPOS) scores from Swedish female students were higher compared to their male counterparts, and females scored significantly higher in later in their studies compared with early on [38]. However, in our study, we have found no difference in terms of gender on the perceptions on narrative medicine, despite there being more females in TCMS. This suggests that the learning culture between MS and TCMS is the predominant factor rather than that of gender.
Strengths and weaknesses of the study
This study, recruiting clerks from different training programs (MSs and TCMSs), obtained a high response rate and analyzed data collected at the end of a 13-week long study employing prompted narrative medicine. The current study is unique, being the first to examine the perceptions of narrative medicine between two different groups of medical students: MSs and TCMSs.
There are some limitations to this study. First, the study was surveyed in an internal medicine rotation only, but not in pediatrics, or surgical systems such as surgery or gynecology. Although this work was carried out in two separate groups of clerks, caution should be taken in generalizing the findings to other medical trainees apart from the Department of Traditional Chinese Medical. Secondly, our MSs or TCMSs followed a prospective-based program on clerkship narrative medicine, however they could not be randomized. For the purposes of data analysis, we did not hypothesize that their choice of specialization would be a significant contributing factor. Nevertheless, this is unlikely to be an important factor as the students were from two different groups. Thirdly, as previously mentioned, there is the possibility that the two programs of medical education may attract different kinds of students: Chinese medicine might seem more suitable for holistic thinkers who could be more open to the humanities. As such this could be a possible contributor to the differential impact of the narrative medicine course. Finally, narrative medicine as a teaching practice has been criticized as being too naïve a use of ‘reflective practice’ in pedagogy [39, 40]. Indeed, the key issues that underpin how such practices can be valuable are far more complex than could be captured in this single study. Thus further studies are needed to better understand the differences between MS and TCMS groups of students in their engagement with, and reactions towards, narrative medicine.
Suggestions for practice
The act of narrative writing involves thinking explicitly about a thought, experience, or action and has profound implications for medical education [41, 42]. Thus, educators may consider incorporating narrative writing into their curriculum to promote humanism since it may be difficult for young pre-doctors to feel, understand, and think about humanistic situations. For medical students, narrative medicine may be a good complement to the philosophies of a bio-psychosocial approach and patient-centered practice and could be brought in at an earlier point in the curriculum for Western medicine students as an ‘antidote’.
The most important aspect of narrative writing is to review one’s assumptions or beliefs to enhance self-awareness. A medical student’s journey through the healthcare system is often difficult and accompanied with self-doubts and frustration. Although we have not found our narrative medicine course to be best at relieving their own grief or pressure, our hope is that by having the clerks begin writing about their experiences, they will gain a sense of themselves through reflection over time and, through the sharing of stories, see that others feel the same or similar to themselves.
Suggestions for future research
In this study, three factors were extracted: personal attitude, self-development/reflection, and emotional benefit. We also found that the perceptions of narrative medicine were significantly higher in the TCMS than the MS group. However, definitions and actualisations of narrative or narrative medicine are often broad. Indeed, what lies within the ‘black box’ of narrative medicine needs to be better explored [43,44,45]. Despite the different learning cultures of medical education in which these student groups engage can partially explain our results, we do not fully understand what it is about narrative medicine that works, for whom, and why across different learning culture contexts, As such, the impact of learning cultures deserves to be further studied in order to explore the complex interactions and to develop a transferable theoretical model of what works, for whom and why [46]. In this way, not only will we understand similarities and differences between Chinese and Western medical students learning with narrative medicine processes, we will also be able to tailor educational strategies to promote narrative medicine into early pre-doctoral medical education for specific groups and further enhance reflection and humanism.
