Number of Citations: 0

Submitted: 5 July 2024
Accepted: 25 November 2024
Published online: 1 April, TAPS 2025, 10(2), 13-16
https://doi.org/10.29060/TAPS.2025-10-2/GP3456

Eng Koon Ong^1-4,7 & Wen Shan Sim^4-6

¹Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore; ²Office of Medical Humanities, SingHealth Medicine Academic Clinical Programme, Singapore; ³Division of Cancer Education, National Cancer Centre Singapore, Singapore; ⁴Duke-NUS Graduate Medical School, Singapore; ⁵Maternal Fetal Medicine, KK Women’s and Children’s Hospital, Singapore; ⁶PGY1 Programme, SingHealth, Singapore; ⁷Assisi Hospice, Singapore

Abstract

Introduction: The medical humanities (MH) have the potential to support medical education (ME) by developing observational skills, promote reflective practice and transformative growth. However, contextual content and methods relevant to our local and regional learners and teachers are lacking.

Methods: We describe three MH-based ME programmes within SingHealth to illustrate our considerations in the choice of conceptual frameworks and content selection in programme development and evaluation.

Results: Highlighting pertinent challenges in developing the field due to poor awareness, lack of resources and research capability, we emphasise the importance of interdisciplinarity, engaging leadership, and generating research output. Broad strategies to achieve these goals are then presented.

Conclusion: Highlighting challenges due to the lack of awareness, administrative and funding support, and research capability, we propose strategies to overcome such barriers and hope that readers will be inspired to contribute to this developing landscape where science and art intersect.

Practice Highlights

• Established frameworks and methods should be employed in programme development and evaluation.
• Art, literature, and theatre may be employed in medical humanities-programmes.
• Interdisciplinarity, leadership engagement and development of research capability are essential.
• Alignment with organisational needs and vision will ensure relevance and sustained support.
• The impact of the humanities on fostering wellbeing should not be neglected.

I. INTRODUCTION

The medical humanities (MH) is an interdisciplinary field characterised by critical enquiry and engagement of humanities disciplines. In medical education (ME), content or pedagogy derived from the arts and humanities may be employed to develop observational skills, promote reflective practice and transformative growth, and support humanistic clinical practice and communications (Dennhardt et al., 2016). However, while the integration of the MH in ME in Western countries has been widely supported and reported, a similar movement within Asian countries appears to be lacking and challenging. Educators in Arab-Muslim environments have lamented the lack of culturally-relevant content and concepts that remain predominantly Western-centric (Daher-Nashif & Kane, 2022), while additional challenges cited in China, Hong Kong, and Taiwan include limited awareness exacerbated by conflicting priorities of academic institutions (Tan et al., 2021; Wu & Chen, 2018). These factors result in a lack of impetus for higher education reform and slow research advancement of the field. To address these gaps, we first describe three educational programmes to highlight how local content and methods of co-facilitation may be employed. Next, we list the respective conceptual frameworks, learning objectives and programme evaluation methods selected. Finally, we discuss strategies to increase awareness, maintain leadership and participant interest, secure sustained funding, and promote scholarly efforts. We hope that this article will support and inspire like-minded clinician educators with structurally relevant guidance that is currently lacking in the literature.

II. PROGRAMME DESCRIPTION

One of the first programmes we implemented was the HAPPE (Humanistic Aspirations as a Propellor for Palliative care Education) workshop, a 1.5-hour small group discussion session for junior doctors in a palliative care rotation at the Division of Supportive and Palliative Care, National Cancer Centre Singapore, facilitated by an accredited clinical psychologist and art therapist. Schon’s theory of Reflective Practice defined by reflection-in-action and reflection-on-action guided the discussions that focused on the participants’ experience with challenging clinical encounters that they expressed through readings of literary work and art-based craftwork. Parts of Gagne’s model of lesson planning such as the importance of gaining the learner’s attention, stimulating recall, presenting stimulus, and providing learning guidance were aptly supported by our choice of materials and facilitation. The themes of empathy and wellbeing were discussed and highlighted the importance of reflective practice on past challenging encounters. As a pilot educational intervention started since 2018, we chose to investigate the feasibility and acceptability of the MH-based workshop using self-reported quantitative scales such as the Consultation and Relational Empathy (CARE) Measure and Jefferson Physician Empathy Scale (JPES) pre- and post-workshop. Both scores improved after attendance of the workshop, supporting continual efforts for future runs of the workshop.

One year later, the half-day ADEPT (Arts and Drama to Enable Perspective Taking) workshop was implemented. In contrast to HAPPE, ADEPT was conducted for final year medical students from the Duke-NUS medical school within their core rotation to palliative care. Addressing the lack of adequate clinical exposure and role-modelling due to the brevity of the week-long rotation, a full recording of a local play A Good Death which portrayed theatrical presentations of severe pain, end-of-life conversations, and physician burnout was shown to the students. They then participated in small group discussions about perceptions of palliative care, professional identity formation, clinical communications, and physician wellbeing. These discussions were co-facilitated by a palliative care specialist, trained counsellor, and the director of the play and served to dispel myths about palliative care, promote self-awareness, and introduce coping strategies. The workshop was guided by Knowles’ theory of adult-learning and we ensured that a sense of agency and empowerment was promoted, with the students participating in self-directed reflection and learning. Building on the quantitative results of the HAPPE workshop, ADEPT was evaluated through a qualitative lens where students were invited to participate in individual semi-structured interviews by an independent interviewer to share their experiences of the workshop.

Finally, the full-day HEARTEN (Harnessing Educational approaches with the Arts to encourage End of life Conversations) workshop was started in 2022 and employed theatre-based techniques to address healthcare professionals’ discomfort in initiating advanced care planning (ACP) conversations with patients. The workshop marked our first formal collaboration with a local professional theatre group (ArtsWok) external to the SingHealth Duke-NUS Academic Medicine Centre and was attended by physicians, nurses, and various allied health professionals. This collaboration further cemented our approach of engaging local content and co-facilitators. Together, the team of physicians, social workers, art therapists, humanities researchers, and a theatre director employed Mezirow’s framework of transformational change to design experiential theatre- and acting-based exercises to trigger discussions about deep-seated perceptions and misgivings about initiating ACP discussions. We evaluated participants’ change in confidence levels in ACP discussions pre- and post-workshop through the Self-Competence in Death Work Scale (SC-DWS) survey quantitatively. An open-ended question was also embedded within the post-workshop survey to allow triangulation of the quantitative data collected. Preliminary data analysis showed an improvement in the SC-DWS surveys, with participants reflecting that their pre-existing concerns about triggering unhappiness and anxiety in patients might have been unfounded.

III. CHALLENGES

The HAPPE, ADEPT, and HEARTEN workshops illustrate a spectrum of MH-based ME programmes in terms of scale (5 to 20 participants per workshop; workshop durations of 1.5 to 8 hours), learning objectives, involvement of co-facilitators, choice of materials, and evaluation methods. In addition, all three workshops were supported by local institutional academic research funding, the amount of which increased over the years (SGD$5,000 – $42,000). By clearly enunciating our choice of educational conceptual frameworks and validated scales for programme evaluation, and consistently incorporating local content and engaging local stakeholders, we posit that some of the challenges such as the lack of contextually relevant content and frameworks and rigor in programme development and evaluation may be addressed.

However, several pertinent challenges exist. Firstly, awareness about the MH remains poor, with its integration into ME at a nascent stage compared to Western countries. Competing with other educational programmes that are better established, the small group size and similar pools of participants who enrolled in our programmes risk the case of “preaching to the choir.” This in turn may lead to challenges in garnering leadership support to encourage staff participation. In addition, securing sustained programme funding is challenging as education grants are limited to smaller, project-based programmes. Relative to clinical research, institutional management and administrative teams have less experience and expertise in supporting medical education research. Often, the project team members find themselves overwhelmed with administrative tasks including financial processes and manpower recruitment. These barriers towards research capacity building may deter interested but busy clinician educators from contributing to scholarly work that is crucial to support the growth of the field.

IV. PROPOSED STRATEGIES

We propose three areas of consideration that we have found helpful in navigating challenges in the landscape. While our experience stems from a single local healthcare centre, similar cultural, societal, and systemic factors in other parts of the Asia-Pacific region will allow applicability and relevance to other clinician educators.

A. Promoting Interdisciplinary Teaching and Learning

The MH is defined by an interdisciplinary approach and we adopt a collaborative approach in engaging various stakeholders such as local and regional humanities scholars, creative arts therapists, professional artistes, and community arts organisations. This allows us access to content from diverse subjects including anthropology, literature, history, philosophy, and other social sciences and to methods such as narrative inquiry, close reading, narrative therapy, and conversational analysis which were previously unfamiliar to us. Learners have described our programmes as refreshing and eye-opening.  However, we are also mindful that some may not take to the arts and humanities naturally. Thus, co-facilitators take extra care to emphasise that learners need not be experts in the arts to engage in reflective practice, and co-facilitators from the humanities are always paired with a clinician educator to ensure the discussions are balanced and relevant.

B. Alignment with Individual Needs and Organisational Goals

An awareness about existing needs and organisational vision is crucial to ensure relevance of the MH programmes. In the SingHealth Duke-NUS Academic Medicine Centre (AMC), our programmes support pillars of the medical education (ME) masterplan such as interprofessional education, educational excellence, and fostering wellbeing. By including other health professions besides doctors, approaching programme development and evaluation through established educational frameworks and methods, and promoting wellbeing by engaging in the arts, the ADEPT workshops have now been adopted by the SingHealth College of Allied Health and Singapore Institute of Technology for allied health professionals and trainees respectively. Notably, the impact of the arts in fostering wellbeing by providing an avenue for expression of difficult emotions, building a sense of community, and processing grief for healthcare professionals provides further impetus for leadership support of our programmes. While MH programmes are not psychotherapy-based per se, participants have shared that the experience was therapeutic and with an increased awareness about struggles, some have been prompted to seek support from professional mental health professionals after programme attendance. Seeing the value of the MH, various offices of the medical humanities have been set up within the AMC since 2019. In 2023, the SingHealth Duke-NUS Medical Humanities Institute was established to further provide centre-wide administrative and funding support for MH programmes within ME. Supported by social media platforms, these offices have organised webinars, colloquiums, and Medical Humanities conferences that increase the visibility of our endeavours and continue to engage leadership, increase interest, and sustain awareness of MH-based programmes.

C. Developing Research Capability

Despite its rich history and diverse cultural perspectives, research in the medical humanities (MH) in medical education (ME) within Asian countries remains at a nascent stage compared to our Western counterparts. To develop research capability, we adopt a two-pronged approach. Firstly, all of our programmes follow a best practice approach towards development and evaluation guided by established educational theoretical frameworks and methods respectively. Secondly, all of our programmes include a scholarly component, as illustrated above. We are currently analysing qualitative data collected from the ADEPT and HEARTEN workshops and preliminary findings suggest that more data is needed to guide the choice of content, teaching methods, learning objectives, and matching of these aspects to different learner populations. Future funding from the MH offices coupled with national and regional funding on a larger scale made possible by our cross-institutional and interdisciplinary collaborations will allow us to embark on further research to address these gaps.

V. CONCLUSION

The medical humanities (MH) have the potential to impact medical education (ME) learning and teaching outcomes but contextual content and methods relevant to our local and regional learners are lacking. We have described three MH-based ME programmes to illustrate considerations in programme development and evaluation. Highlighting considerations in awareness, administrative and funding support, and research capability, we propose strategies to overcome such challenges and hope that readers will be inspired to contribute to this developing landscape where science and art intersect.

As Carlo Rubbia, Nobel prize winner in physics says,

“Science for me is very close to art. Scientific discovery is an irrational act. It’s an intuition which turns out to be reality at the end of it – and I see no difference between a scientist developing a marvellous discovery and an artist making a painting.”

Notes on Contributors

Both OEK and SWS contributed to the conceptualisation of the paper through their experience and work in both undergraduate and postgraduate training. With repeated discussions, the approach towards explaining the value of the paper and learning points for readers were finalised. Both authors worked on the initial draft of the manuscript, before refining the contents though an iterative process of literature review and discussions with other educators and participants of the various programs. The final draft of the paper was reviewed by both authors who reached the consensus that the paper was ready for submission for publication. Both authors agree to be accountable for all aspects of the paper.

Acknowledgements

We would like to thank Ms Chiam Min and Ms April Thant Aung for proofreading the article.

Funding

No funding was received.

Declaration of Interest

Both OEK and SWS state no conflicts of interest.

References

Daher-Nashif, S., & Kane, T. (2022). A culturally competent approach to teach humanities in international medical school: Potential frameworks and lessons learned. MedEdPublish, 12(6). https://doi.org/10.12688/mep.18938.1

Dennhardt, S., Apramian, T., Lingard, L., Torabi, N., & Amtfield, S. (2016). Rethinking research in the medical humanities: A scoping review and narrative synthesis of quantitative outcome studies. Medical Education, 50(3), 285-299. https://doi.org/10.1111/medu.12812

Ong, E. K., & Anantham, D. (2019). The medical humanities: Reconnecting with the soul of medicine. Annals of the Academy of Medicine Singapore, 48(7), 233-237.

Tan, M. K. B., Tan, C. M., Tan, S. G., Yoong, J., & Gibbons, B. (2021). Connecting the dots: The state of arts and health in Singapore. Arts & Health, 15(2), 119-134. https://doi.org/10.1080/17533015.2021.2005643

Wu, H. Y. J., & Chen, J. Y. (2018). Conundrum between internationalisation and interdisciplinarity: Reflection on the development of medical humanities in Hong Kong, Taiwan and China. MedEdPublish, 7(184). https://doi.org/10.15694/mep.2018.0000184.1

*Ong Eng Koon
National Cancer Centre Singapore
30 Hospital Blvd, Singapore 168583
Email: ong.eng.koon@assisihospice.org.sg