Table 3.  Components of the HAPPE programme designed according to the theory of reflective practice.

Acceptability was measured by a Likert-scale questionnaire (see Annex 1). Feasibility of the curriculum was defined as a completion rate of at least 80%. The efficacy of the curriculum was measured by the self-reported Jefferson Physician Empathy Scale (JSPES) (Hojat et al., 2001) as well as the third-party reported modified-Consultation and Relational Empathy (CARE) Measure (Mercer, Maxwell, Heaney, & Watt, 2004).

B. Study Design

This was a quantitative study that assessed the acceptability, feasibility, and effectiveness of the HAPPE programme pre- and post-intervention. Participants: All junior doctors who rotated through the department between 1st July 2018 and 30th June 2019 were invited to participate in this study. About 30 junior doctors (residents and medical officers) rotate through the division of palliative medicine as part of their postgraduate training yearly. The junior doctors have varying levels of prior training and exposure to palliative medicine. These junior doctors worked in palliative care teams each consisting of a consultant, registrar/resident physician, and a nurse who assess and manage patients with palliative care needs. The duration of each rotation ranged from 1 to 6 months. An independent research coordinator provided the participants with information regarding the study and took written consent from each participant face-to-face.

C. Intervention

The HAPPE programme consisted of two 1.5-hour sessions during office hours of small group discussions held at the National Cancer Centre Singapore (NCCS) facilitated by two clinical psychologists 1-week apart. The two facilitators are senior psychologists who are trained in counselling and group facilitation and regularly encounter complex clinical scenarios in communications and grief. The programme was repeated throughout the year at regular intervals for all new junior doctors rotated into the department. The junior doctors were considered to have completed the curriculum in its entirety when they attend both sessions of the HAPPE programme during their posting.

In the first session, a brief introduction on the novel, The Death of Ivan Ilyich was presented by the facilitators (Charlton & Verghese, 2010; Florijn & Kaptein, 2013). There was no need for the learners to read the entirety of the novel before the session. The sections of the novel used are found in Annex 2. 

The learners were asked the following questions that addressed the tenets of empathy. (standing in patient’s shoes, compassionate care, and perspective-taking):

1. What was described about Ivan Ilyich’s life preceding his illness that you think was important to know if you were his doctor?
2. Why do you think Ivan Ilyich was so distressed before he died?
3. How different do you think you will feel if you were Ivan Ilyich?

In the second session, learners were asked to bring along any arts-based material (paintings, literature, music, drama) and share with the class their reflections on why the material was chosen and how appreciation and/or critique of the art piece helped them develop empathy and patient-centred care. The participants brought materials available from the internet like photographs, paintings, illustrations from magazines, and references to non-fiction books that they had previously read.

Prompting questions included:

• Why was the material chosen?
• How did the material trigger reflections on the concept of empathy?
• What were some of the emotions elicited when reflecting on the concepts of empathy using the materials?

The two clinical psychologists employed techniques that encouraged personal sharing in a safe environment. Participants were reassured that their sharing was confidential, and they were free to leave the session at any point in time if they felt uncomfortable. Sharing was encouraged by picking up themes of similarities and contrasts between participant’s sharing, asking questions with the intention to clarify, reflect and hypothesise, progressing from “participant to facilitators communication” to “between-participants communications” and progressing from talking about “Ivan Ilyich” to “themselves if they were Ivan Ilyich or Ivan’s doctor or Ivan’s family member/friend” to “themselves”. 

This study was submitted for review in the Institutional Review Board but was exempted in view of its nature as a medical education project.

D. Outcomes Assessment

To assess acceptability, the junior doctors were asked to complete a questionnaire post-intervention (see Annex 1). Feasibility was defined as at least 80% of junior doctors completing the curriculum in its entirety.

The assessment of efficacy is investigated using 2 scales pre- and post-intervention:

1. The Jefferson Physician Empathy Scale (JPES) is a self-reported 20-item empathy measure based on a seven-point Likert scale designed to assess empathy in physicians. It has been validated, has an alpha coefficient of 0.87 for internal consistency, and is the most widely used in literature. There are ten positively worded items and ten negatively worded items, and the negatively worded items will be reverse scored on a Likert scale of 7 (strongly disagree) to 1 (strongly agree). Scores can range from 20 to 140 with higher scores indicating participants to be more empathic.

1. As there were currently no validated tools for the assessment of empathy of palliative care doctors, the Consultation and Relational Empathy (CARE) Measure was chosen. It is a 10-item patient-rated questionnaire developed and validated to assess a physician’s level of empathy and patient-centred care when used by patients, with an alpha coefficient of 0.92 for internal consistency. However, as the enrolment of patients for this purpose for the study was not possible, this measure was modified with permission from its developer, to generate third party-rated outcomes from the junior doctors’ team members (consultant, registrar or resident physician and the nurse) (see Annex 3). As the participants work in small teams of not more than three, all their respective team members were invited to perform the assessment. They will observe interactions between the junior doctors and their patients during their daily work and rate the 10 items that are each described in the questionnaire. No prior training is needed.

III. RESULTS

A total of 17 junior doctors agreed to participate in the study and all of them completed the programme and assessments. Out of a full score of 50, the acceptability score ranged from 18 to 50. The median and mean were both 38. 

The JPES scores pre-test had a range of 77 to 123 out of 140. The mean was 103.6 (SD 11). Post-test, the JSPE scores ranged from 93 to 132. The mean value was 108.9 (SD 9.9). This gave a paired t-score difference of 2.49 with P value of 0.02.

The modified-CARE score pre-test had a range of 12 to 31 out of 50, a mean of 22.9 (SD 5.8). Post-test, the scores ranged from 17 to 37, with a mean of 28.5 (SD 5.9). This gave a paired t-score difference of 5.22 with a P value of <0.001.

 IV. DISCUSSION

This is a quantitative pilot study conducted to investigate the acceptability, efficacy, and feasibility of a novel educational intervention based on the humanities to teach empathy to junior doctors in a palliative medicine rotation. It is the first project under the Humanities Initiative Programme (HIP) at the Division of Supportive and Palliative Care (DSPC) at the National Cancer Centre of Singapore (NCCS). The results of this pilot study are encouraging and are consistent with other similar pilot studies that investigated the efficacy of a humanities-based programme in medical education and will propel the development of the HIP (Perry et al., 2011). The positive results regarding acceptability and feasibility are important as they suggest that the implementation of such an intervention on a larger scale that spans across disciplines is possible. The increase in empathy scores demonstrates the efficacy of the programme, although further analysis is needed to investigate whether such a change is due to other factors as the intervention is relatively short and effects may not be sustainable.

There are other limitations to this study. The study is limited by the small number of participants in a single institution and deficiencies of a self-assessed rating scale (Boud & Falchikov, 1989). The possible reasons that the enrolment rate is low include lack of awareness about the concept of the humanities and its role in medical education and difficulty with balancing time between clinical duties and educational activities. The programme was also novel and junior doctors may be hesitant to enrol due to uncertainties about the nature of the programme.

The limitations of self-assessment tools are mitigated by the employment of a third-party empathy measure that allowed triangulation of results, but caution should remain about the clinical significance of the results. Inherent biases by fellow team members and difficulty in having adequate time and making effort for observation and accurate grading of the participants in a busy clinical service may render third-party assessment unreliable. Ideally, an independent party observing the participants during their daily work may reduce biases. Stealthy observations may also avoid both conscious and unconscious alteration in behaviour from the participants’ awareness of being observed. Unfortunately, this was not logistically possible in this study.

The use of a modified-CARE measure which has not been validated for use by fellow colleagues of the doctor may also render the increase in scores post-intervention less reliable and valid.

Lastly, the indication for programme feasibility is set at 80% based on the investigator’s discretion. This is due to a lack of data about standards on feasibility from existing studies of humanities-based educational programmes. It could be possible that there are other measures of feasibility that are more valid.

Future research will need to address the choice of outcome measures including assessment of feasibility and empathy scores. Discrete studies for the design and validation of such measures will grant important rigor to future studies in this field.

Studies that utilise qualitative research methodology could also provide rich data that answers questions about the choice of materials and facilitators. Possible methods include thematic analysis (Braun & Clarke, 2006) and narrative inquiry – a developing methodology of investigating lived experiences in the context of place, sociality, and time (Clandinin & Connelly, 2000). This will help the investigator assess the suitability and transferability of the HAPPE programme to other disciplines with varying participant demographics and how further refinement in design and methods can improve efficacy and sustainability.

A. Moving Forward

As this was a pilot study, the investigator had chosen to focus on only quantitative parameters to achieve the aims of the study. It is recognised that qualitative analysis will provide richer data on the experiences of the participants and further guide implementation and refinement of programmes based on the humanities and there are ongoing projects that have started within the institution based on the need to address this gap of the pilot study.

Research done on humanities programmes in medicine has commonly been criticised in terms of methodology. A literature review of arts-based interventions in medical education found poor designs of methodology (Perry et al., 2011) while another study on needs assessment noted only a minority of studies describing outcome measures beyond learner satisfaction (Taylor, Lehmann, & Chisolm, 2017). Publications have also been criticised for the lack of a conceptual basis in the design of interventions. This pilot study aimed to address some of these challenges by clearly stately the conceptual theory of reflective practice that impacts the study results. In addition, the Gagne Instructional Plan guided lesson planning with the steps of gaining attention, informing the learner of objectives, stimulating recall, presenting stimulus, and providing learning guidance achieved (Gagne, Briggs, & Wager, 1988). However, the lack of validated and relevant assessment outcomes remains.  Future research should focus on developing suitable assessment tools that can achieve their aims without stifling the responses of participants. One possible approach may be the adoption of formative assessments that focus on feedback, in contrast to summative tools that typically impact outcomes of appraisals (Taras, 2008).

Finally, there is a paucity of studies that employ the humanities as educational resources in the Asia-Pacific region. This is despite the rich multi-cultural nature of the societies in this region, many with deep-rooted and unique practices in the arts. The investigator of this study hopes that this pilot programme will inspire like-minded medical educators in the region to embark on similar projects within their institutions and develop the arts as an educational tool for the benefit of both healthcare professionals and patients.

V. CONCLUSION

This pilot study has produced encouraging results regarding the use of humanities in medical education. The humanities have the potential for multiple functions in medicine and perhaps most importantly serve to bridge the gap between biomedical sciences and the “art of medicine” (Best, 2015; Chew, 2008; Ong & Anantham, 2019). Further research in this field will provide guidance on the development of a robust educational intervention that adheres to the best practices of medical education research.

Note on Contributor

OEK is a consultant at the Division of Supportive and Palliative Care in the National Cancer Centre of Singapore. OEK reviewed the literature, designed the study, engaged the facilitators for the programme, analysed results, and wrote the manuscript.

Ethical Approval

This study was submitted to the institution’s review board but received an exemption due to its nature as an educational intervention (CIRB Ref: 2018/2276).

Acknowledgements

The author would like to acknowledge Ms Tan Yee Pin and Ms Jacinta Phoon from the Division of Psycho-oncology at the National Cancer Centre of Singapore who facilitated the HAPPE sessions. The author would like to thank Professor Steward Mercer for his generosity in sharing the CARE measure as an evaluation tool in this study.

Funding

This study was supported by the Lien Centre of Palliative Care, Singapore, Education Incubator Grant (Reference code: LCPC-EX18-0001).

Declaration of Interest

The author declares no conflict of interest in this study.

References