{"id":1504,"date":"2020-12-15T09:09:53","date_gmt":"2020-12-15T01:09:53","guid":{"rendered":"https:\/\/medicine.nus.edu.sg\/taps\/?post_type=issues&#038;p=1504"},"modified":"2021-05-04T08:35:08","modified_gmt":"2021-05-04T00:35:08","slug":"happe-a-pilot-programme-using-humanities-to-teach-junior-doctors-empathy-in-a-palliative-medicine-posting","status":"publish","type":"issues","link":"https:\/\/medicine.nus.edu.sg\/taps\/issues\/happe-a-pilot-programme-using-humanities-to-teach-junior-doctors-empathy-in-a-palliative-medicine-posting\/","title":{"rendered":"HAPPE\u2014A pilot programme using humanities to teach junior doctors empathy in a palliative medicine posting"},"content":{"rendered":"<p>Submitted: 16 April 2020<br \/>\r\nAccepted: 24 June 2020<br \/>\r\nPublished online: 5 January, TAPS 2021, 6(1), 83-92<br \/>\r\n<a href=\"https:\/\/doi.org\/10.29060\/TAPS.2021-6-1\/OA2251\">https:\/\/doi.org\/10.29060\/TAPS.2021-6-1\/OA2251<\/a><\/p>\r\n<p><span lang=\"EN-GB\">Eng Koon Ong<\/span><span lang=\"EN-GB\"><\/span><span lang=\"EN-GB\">\u00a0<\/span><\/p>\r\n<p><i><span lang=\"EN-GB\">Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore; Assisi Hospice, Singapore<\/span><\/i><i><span lang=\"EN-GB\"><\/span><\/i><\/p>\r\n<p style=\"text-align: center\"><b><span lang=\"EN-GB\">Abstract<\/span><\/b><\/p>\r\n<p style=\"text-align: justify\"><b><span lang=\"EN-GB\">Introduction:<\/span><\/b><span lang=\"EN-GB\"> <\/span><span lang=\"EN-GB\">Physician empathy is declining due to an unproportionate focus on technical knowledge and skills. The medical humanities can counter this by allowing connection with our patients. This is a pilot study that aims to investigate the acceptability, efficacy, and feasibility of a humanities educational intervention to develop physician empathy.<\/span><\/p>\r\n<p style=\"text-align: justify\"><b><span lang=\"EN-GB\">Methods:<\/span><\/b><span lang=\"EN-GB\"> <\/span><span lang=\"EN-GB\">Junior doctors at the Division of Supportive and Palliative Care at the National Cancer Centre Singapore between July 2018 and June 2019 attended two small-group sessions facilitated by psychologists to learn about empathy using literature and other arts-based materials. Feasibility was defined as a completion rate of at least 80% while acceptability was assessed by a 5-question Likert-scale questionnaire. Empathy was measured pre- and post-intervention using Jefferson\u2019s Scale of Physician Empathy (JSPE) and the modified-CARE (Consultation and Relational Empathy) measure.<\/span><\/p>\r\n<p style=\"text-align: justify\"><b><span lang=\"EN-GB\">Results:<\/span><\/b><span lang=\"EN-GB\"> <\/span><span lang=\"EN-GB\">Seventeen participants consented, and all completed the programme. Acceptability scores ranged from 18 to 50 out of 50 (mean 38, median 38). There was an increase in JSPE scores (pre-test mean 103.6, SD=11.0 and post-test mean 108.9, SD=9.9; t (17) =2.49, P=.02). The modified-CARE score increased between pre-test mean of 22.9(SD=5.8) and a post-test mean of 28.5(SD=5.9); t (17) = 5.22, P&lt;0.001.<\/span><\/p>\r\n<p style=\"text-align: justify\"><b><span lang=\"EN-GB\">Conclusion:<\/span><\/b><span lang=\"EN-GB\"> <\/span><span lang=\"EN-GB\">Results indicate that the programme was acceptable, effective, and feasible. The results are limited by the lack of longitudinal follow-up. Future studies that investigate the programme\u2019s effect over time and qualitative analysis can better assess its efficacy and elicit the participants&#8217; experiences for future implementation and refinement.<\/span><\/p>\r\n<p style=\"text-align: justify\"><b><span lang=\"EN-GB\">Keywords<\/span><\/b><b><span lang=\"EN-GB\">:<\/span><\/b><span lang=\"EN-GB\">\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/span><i><span lang=\"EN-GB\">Empathy, Humanities, Literature, Palliative Medicine<\/span><\/i><span lang=\"EN-GB\"><\/span><\/p>\r\n<p align=\"center\"><strong><span lang=\"EN-GB\">Practice Highlights<\/span><\/strong><\/p>\r\n<ul style=\"list-style-type: square\">\r\n\t<li style=\"text-align: justify\"><span lang=\"EN-GB\"> <\/span><span lang=\"EN-GB\">The medical humanities can be used to teach empathy by facilitating reflective practice.<\/span><span lang=\"EN-GB\"><\/span><\/li>\r\n\t<li style=\"text-align: justify\"><span lang=\"EN-GB\"> <\/span><span lang=\"EN-GB\">This novel educational programme was acceptable, effective, and feasible.<\/span><span lang=\"EN-GB\"><\/span><\/li>\r\n\t<li style=\"text-align: justify\"><span lang=\"EN-GB\"> <\/span><span lang=\"EN-GB\">Limitations include the lack of longitudinal follow-up and the quantitative nature of assessment.<\/span><span lang=\"EN-GB\"><\/span><\/li>\r\n\t<li style=\"text-align: justify\"><span lang=\"EN-GB\"> <\/span><span lang=\"EN-GB\">Future studies should investigate the programme\u2019s effect over time and include qualitative analysis.<\/span><span lang=\"EN-GB\"><\/span><\/li>\r\n<\/ul>\r\n<div>\r\n<p align=\"center\"><strong><span lang=\"EN-GB\">I. <\/span><span lang=\"EN-GB\">INTRODUCTION<\/span><\/strong><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">Empathy can be defined as having feelings that are more congruent with another situation than one\u2019s own by recognising the perspectives of others (Hojat et al., 2002). Higher physician empathy leads to better patient care outcomes and satisfaction (Hall et al., 2002) and has also been associated with lower levels of physician burnout (Lee, Loh, Sng, Tung, &amp; Yeo, 2018). However, studies suggest a worrying trend that empathy levels decline as training progresses for medical students and residents as well as a correlation between decreasing empathy and increasing burnout (Lee et al., 2018). The various reasons for such a decline were elicited in a recent systematic review and can be summarised into 4 main domains (refer Table 1) (Neumann et al., 2011).<\/span><\/p>\r\n<div align=\"center\">\r\n<table border=\"1\" cellspacing=\"0\" cellpadding=\"0\">\r\n<tbody>\r\n<tr>\r\n<td width=\"300\" valign=\"top\">\r\n<p><b><span lang=\"EN-SG\">Domains of\u00a0 various reasons for empathy decline<\/span><\/b><\/p>\r\n<\/td>\r\n<td width=\"300\" valign=\"top\">\r\n<p><b><span lang=\"EN-SG\">Details<\/span><\/b><\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"300\" valign=\"top\">\r\n<p><span lang=\"EN-SG\">1.\u00a0 Individual variables<\/span><\/p>\r\n<\/td>\r\n<td width=\"300\" valign=\"top\">\r\n<p><span lang=\"EN-SG\">Personality traits, upbringing, and experiences during adulthood<\/span><\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"300\" valign=\"top\">\r\n<p><span lang=\"EN-SG\">2.\u00a0 Individual distress<\/span><\/p>\r\n<\/td>\r\n<td width=\"300\" valign=\"top\">\r\n<p><span lang=\"EN-SG\">Burnout, depression, and decreased quality of life are associated with decreased empathy levels.<\/span><\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"300\" valign=\"top\">\r\n<p><span lang=\"EN-SG\">3.\u00a0 Nature of medical practice<\/span><\/p>\r\n<\/td>\r\n<td width=\"300\" valign=\"top\">\r\n<p><span lang=\"EN-SG\">Uncertainties increase the vulnerability of the medical practitioner and lead to negative coping mechanisms like depersonalisation and detachment from patients.<\/span><\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"300\" valign=\"top\">\r\n<p><span lang=\"EN-SG\">4.\u00a0 Learning environment<\/span><\/p>\r\n<\/td>\r\n<td width=\"300\" valign=\"top\">\r\n<p><span lang=\"EN-SG\">Inadequate and inappropriate role models and the hidden curriculum cause moral distress and decrease empathy as a consequent of poor coping mechanisms.\u00a0 <\/span><\/p>\r\n<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n<p align=\"center\"><span lang=\"EN-GB\" style=\"font-size: 10pt\">Table 1.\u00a0 Reasons contributing to decline in empathy<\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">The medical humanities are an inter-disciplinary field where the 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 (Shapiro, Coulehan, Wear, &amp; Montello, 2009). It is hypothesised that experiences and perspectives illustrated by the medical humanities through stories depicted in novels, literature, drama, and poetry can promote the development of empathy by encouraging deep reflection, facilitating meaning-finding and comfort with uncertainty and providing new perspectives (Bleakley, 2015; Bleakley &amp; Marshall, 2014; Dennhardt, Apramian, Lingard, Torabi, &amp; Amtfield, 2016). The medical humanities have the potential to address the factors mentioned in Table 1.<\/span><\/p>\r\n<p style=\"text-align: justify\"><i><span lang=\"EN-GB\"><\/span><\/i><i><span lang=\"EN-GB\">A. Individual Distress:<\/span><\/i><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">The medical humanities allow an avenue for physicians to express difficult emotions encountered in clinical practice like anxiety, guilt, and regret. Such emotions may be due to uncertain disease trajectories, ethical dilemmas, and physical exhaustion. The medical humanities allow such emotions to be expressed and discussed, with the intention to support physicians and decrease distress from burnout.<\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">\u00a0<em>B.<\/em> <\/span><i><span lang=\"EN-GB\"><\/span><\/i><i><span lang=\"EN-GB\">Nature of Medical Practice:<\/span><\/i><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">The uncertainties of medical practice and the consequent vulnerability of the medical practitioner affect empathy levels. Doctors may develop negative coping mechanisms like depersonalisation that may seemingly help meet the unrealistic expectation that medicine can always cure. To counter this, physicians must be given the time to share their clinical experiences in a safe environment and subsequently support each other by establishing relationships and reducing isolation (Batt-Rawden, Chisolm, Anton, &amp; Flickinger, 2013; Feld &amp; Heyse-Moore, 2006; Wear &amp; Zarconi, 2016). Reflective writings and creative arts are some of the methods that have been used to facilitate such a process (West, Dyrbye, Erwin, &amp; Shanafelt, 2016).<\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">\u00a0<em>C.<\/em> <\/span><i><span lang=\"EN-GB\"><\/span><\/i><i><span lang=\"EN-GB\">Learning Environment:<\/span><\/i><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">Palliative medicine has been touted to be able to provide an ideal environment to impart empathetic values in view of its patient-centred philosophy of care (Block &amp; Billings, 1998; Othuis &amp; Dekkers, 2003). This is achieved through the routine use of the humanities to understand the personhood of our patients and develop empathetic connections. History, art, music, and narratives define our patients\u2019 life experiences and influence their responses to disease and treatment. Learning through mentorship and role-modelling of such an approach to patient care allows junior doctors to appreciate the importance of using the humanities to achieve better patient care outcomes.\u00a0 <\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">There is currently no conclusive evidence on the best method of teaching empathy or the best person to teach it. Where educators have tried to teach humanism and empathy in medicine, research done on its curriculum has been criticised in terms of clinical relevance and methodology (Birden et al., 2013; Ousager &amp; Johannessen, 2010; Perry, Maffulli, Wilson, &amp; Morrissey, 2011; Schwartz et al., 2009; Wear &amp; Zarconi, 2016). However, the impact of the humanities on the factors that cause declining physician empathy levels illustrated above demonstrates that the medical humanities may be an important tool in teaching empathy. This pilot study has the potential to fill this gap by taking the first step in establishing the acceptability and feasibility of a pilot humanities education programme based on established conceptual frameworks. There were two specific aims to this pilot study: 1) To determine the acceptability and feasibility of the proposed curriculum; 2) To assess the efficacy of the HAPPE programme. The data collected will inform future studies on whether the humanities can be one of the best tools to use in teaching empathy.<\/span><\/p>\r\n<\/div>\r\n<\/div>\r\n<p style=\"text-align: center\"><span lang=\"EN-GB\"><\/span><strong><span lang=\"EN-GB\">II. METHODS<\/span><\/strong><\/p>\r\n<p style=\"text-align: left\"><i><span lang=\"EN-GB\">A. Intervention Design<\/span><\/i><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">The Humanistic Aspirations as a Propeller of Palliative medicine Education (HAPPE) programme was conceived to introduce and develop a novel curriculum in empathy for junior doctors undergoing a palliative medicine rotation.\u00a0 The overall goal of the study was to design an effective education programme based on the humanities to teach doctors empathy. Our study draws upon Schon\u2019s work of Reflective Practice (see Table 2; Sch\u00f6n, 1987).<\/span><\/p>\r\n<div align=\"center\">\r\n<table border=\"1\" cellspacing=\"0\" cellpadding=\"0\">\r\n<tbody>\r\n<tr>\r\n<td width=\"211\" valign=\"top\">\r\n<p><b><span lang=\"EN-GB\">Concepts of Reflective Practice<\/span><\/b><\/p>\r\n<\/td>\r\n<td width=\"223\" valign=\"top\">\r\n<p><b><span lang=\"EN-GB\">Planned activities during HAPPE<\/span><\/b><\/p>\r\n<\/td>\r\n<td width=\"167\" valign=\"top\">\r\n<p><b><span lang=\"EN-GB\">Expected Outcomes<\/span><\/b><\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"211\" valign=\"top\">\r\n<p><span lang=\"EN-GB\">\u201cReflection-in-action\u201d \u2013 reflecting during an event and act on a decision \u201con the spot\u201d<\/span><\/p>\r\n<\/td>\r\n<td width=\"223\" valign=\"top\">\r\n<p><span lang=\"EN-GB\">Discussion and awareness of perspectives that trigger powerful emotions and empathetic reflections and responses.<\/span><\/p>\r\n<\/td>\r\n<td width=\"167\" valign=\"top\">\r\n<p><span lang=\"EN-GB\">Recalls triggers, leading to empathetic change in behaviour and decisions in actual practice.<\/span><\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"211\" valign=\"top\">\r\n<p><span lang=\"EN-GB\">\u201cReflection-on-action\u201d \u2013 reflecting after an event, process feelings and experiences, gain new perspectives.<\/span><\/p>\r\n<\/td>\r\n<td width=\"223\" valign=\"top\">\r\n<p><span lang=\"EN-GB\">Uses rich perspectives of patients, caregivers, and healthcare providers via humanities, leading to deep reflections.\u00a0\u00a0\u00a0 <\/span><\/p>\r\n<\/td>\r\n<td width=\"167\" valign=\"top\">\r\n<p><span lang=\"EN-GB\">Reinforces changes in practice \u201con the ground\u201d.<\/span><\/p>\r\n<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n<p align=\"center\"><span lang=\"EN-GB\" style=\"font-size: 10pt\">Table 2. Application of the Theory of Reflective Practice in the design of the HAPPE programme<\/span><\/p>\r\n<div>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">Based on the theory of reflective practice, the components of the HAPPE programme are elaborated in Table 3.\u00a0 The principles listed are supported by existing research literature (Gibbs, 1988; Shapiro et al., 2009).<\/span><\/p>\r\n<div align=\"center\">\r\n<table border=\"1\" cellspacing=\"0\" cellpadding=\"0\">\r\n<tbody>\r\n<tr>\r\n<td width=\"208\" valign=\"top\">\r\n<p><b><span lang=\"EN-SG\">Principles<\/span><\/b><\/p>\r\n<\/td>\r\n<td width=\"393\" valign=\"top\">\r\n<p><b><span lang=\"EN-SG\">Component of HAPPE<\/span><\/b><\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"208\" valign=\"top\">\r\n<p><span lang=\"EN-SG\">1.\u00a0 Facilitating factors of reflective practice include a safe environment, conducive settings, and trained facilitators.\u00a0 <\/span><\/p>\r\n<p><sup><span lang=\"EN-SG\">\u00a0\u00a0 <\/span><\/sup><u><span lang=\"EN-SG\"><\/span><\/u><\/p>\r\n<\/td>\r\n<td width=\"393\" valign=\"top\">\r\n<p><span lang=\"EN-SG\">1.\u00a0 The sessions are facilitated by two trained clinical psychologists who are experienced in conducting support group sessions for both patients and staff.<\/span><\/p>\r\n<p><span lang=\"EN-SG\">\u00a0<\/span><\/p>\r\n<p><span lang=\"EN-SG\">2.\u00a0 To ensure psychological safety for intimate sharing, all participants are provided explicit consent for the study.\u00a0 The project was submitted for the institution review board review but was exempted.\u00a0 <\/span><\/p>\r\n<p><span lang=\"EN-SG\">\u00a0\u00a0 <\/span><\/p>\r\n<p><span lang=\"EN-SG\">3.\u00a0 The sessions are conducted via small-group discussions and ground rules are set before the start of each session (see Appendix A).\u00a0 <\/span><\/p>\r\n<p><span lang=\"EN-SG\">\u00a0<\/span><\/p>\r\n<p><span lang=\"EN-SG\">4.\u00a0 Data collected is blinded to the investigator.\u00a0 <\/span><\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"208\" valign=\"top\">\r\n<p><span lang=\"EN-SG\">2.\u00a0 Reflective practice is propelled by materials and modalities that provide rich perspectives and trigger strong emotions and empathetic personal inquiry.\u00a0 <u><\/u><\/span><\/p>\r\n<\/td>\r\n<td width=\"393\" valign=\"top\">\r\n<p><span lang=\"EN-SG\">1.\u00a0 Arts-based materials are used to prompt deep reflection and facilitate by examining multiple perspectives and challenging expectations and vulnerabilities of junior doctors.<u><\/u><\/span><\/p>\r\n<p><u><span lang=\"EN-SG\">\u00a0<\/span><\/u><\/p>\r\n<p><span lang=\"EN-GB\">2.\u00a0 The novel <i>The Death of Ivan Ilyich<\/i> is chosen in view of its ability to elicit deep reflections about suffering and care.<\/span><span lang=\"EN-SG\"> The interpretation of the apparently ambiguous piece of fictitious literary piece based on the learner\u2019s personal beliefs can stimulate personal growth, develop non-judgmental attributes as well as improve coping with uncertainty in medical practice.<u><\/u><\/span><\/p>\r\n<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n<p align=\"center\"><span lang=\"EN-GB\" style=\"font-size: 10pt\">Table 3.\u00a0 Components of the HAPPE programme designed according to the theory of reflective practice.<\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">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, &amp; Watt, 2004).<\/span><\/p>\r\n<p style=\"text-align: justify\"><em><span lang=\"EN-GB\">B. <\/span><\/em><em><span lang=\"EN-GB\">Study Design<\/span><\/em><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">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.<\/span><\/p>\r\n<p style=\"text-align: justify\"><em><span lang=\"EN-GB\">C. <\/span><\/em><em><span lang=\"EN-GB\">Intervention<\/span><\/em><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">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.<\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">In the first session, a brief introduction on the novel, The Death of Ivan Ilyich was presented by the facilitators (Charlton &amp; Verghese, 2010; Florijn &amp; 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.\u00a0 <\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">The learners were asked the following questions that addressed the tenets of empathy. (standing in patient\u2019s shoes, compassionate care, and perspective-taking):<\/span><\/p>\r\n<ol>\r\n\t<li style=\"text-align: justify\"><span style=\"text-align: left\">What was described about Ivan Ilyich\u2019s life preceding <\/span>his illness that you think was important to know if you were his doctor?<\/li>\r\n\t<li style=\"text-align: left\">Why do you think Ivan Ilyich was so distressed before he died?<\/li>\r\n\t<li style=\"text-align: left\">How different do you think you will feel if you were Ivan Ilyich?<\/li>\r\n<\/ol>\r\n<p>&nbsp;<\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">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.<\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">Prompting questions included:<\/span><\/p>\r\n<ul style=\"text-align: justify\">\r\n\t<li><span lang=\"EN-GB\"> Why was the material chosen?<\/span><\/li>\r\n\t<li><span lang=\"EN-GB\"> How did the material trigger reflections on the concept of empathy?<\/span><\/li>\r\n\t<li><span lang=\"EN-GB\"> What were some of the emotions elicited when reflecting on the concepts of empathy using the materials?<\/span><\/li>\r\n<\/ul>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">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\u2019s sharing, asking questions with the intention to clarify, reflect and hypothesise, progressing from \u201cparticipant to facilitators communication\u201d to \u201cbetween-participants communications\u201d and progressing from talking about \u201cIvan Ilyich\u201d to \u201cthemselves if they were Ivan Ilyich or Ivan\u2019s doctor or Ivan\u2019s family member\/friend\u201d to \u201cthemselves\u201d.\u00a0 <\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">This study was submitted for review in the Institutional Review Board but was exempted in view of its nature as a medical education project.<\/span><\/p>\r\n<p style=\"text-align: justify\"><i><span lang=\"EN-GB\">D. Outcomes Assessment<\/span><\/i><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">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.<\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">The assessment of efficacy is investigated using 2 scales pre- and post-intervention:<\/span><\/p>\r\n<ol>\r\n\t<li style=\"text-align: justify\">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.<\/li>\r\n<\/ol>\r\n<p>&nbsp;<\/p>\r\n<ol>\r\n\t<li style=\"text-align: justify\">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\u2019s 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\u2019 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.<\/li>\r\n<\/ol>\r\n<p>&nbsp;<\/p>\r\n<p style=\"text-align: center\"><strong><span lang=\"EN-GB\">III. RESULTS<\/span><\/strong><\/p>\r\n<ul style=\"text-align: justify\"><\/ul>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">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.\u00a0 <\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">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.<\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">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 &lt;0.001.<\/span><\/p>\r\n<p style=\"text-align: center\"><span lang=\"EN-GB\">\u00a0<strong>IV. <\/strong><\/span><strong><span lang=\"EN-GB\"><\/span><span lang=\"EN-GB\">DISCUSSION<\/span><\/strong><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">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.<\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">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 &amp; 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.<\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">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\u2019 awareness of being observed. Unfortunately, this was not logistically possible in this study.<\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">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.<\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">Lastly, the indication for programme feasibility is set at 80% based on the investigator\u2019s 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.<\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">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.<\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">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 &amp; Clarke, 2006) and narrative inquiry \u2013 a developing methodology of investigating lived experiences in the context of place, sociality, and time (Clandinin &amp; 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.<\/span><\/p>\r\n<p style=\"text-align: justify\"><i><span lang=\"EN-GB\">A. Moving Forward<\/span><\/i><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">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.<\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">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, &amp; 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, &amp; Wager, 1988). However, the lack of validated and relevant assessment outcomes remains.\u00a0 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).<\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">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.<\/span><\/p>\r\n<p style=\"text-align: center\"><span lang=\"EN-GB\"><\/span><strong><span lang=\"EN-GB\">V. CONCLUSION<\/span><\/strong><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">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 \u201cart of medicine\u201d (Best, 2015; Chew, 2008; Ong &amp; 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.<\/span><\/p>\r\n<p align=\"center\" style=\"text-align: center\"><strong><span lang=\"EN-GB\">Note on Contributor<\/span><\/strong><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">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.<\/span><\/p>\r\n<p align=\"center\" style=\"text-align: center\"><strong><span lang=\"EN-GB\">Ethical Approval<\/span><\/strong><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">This study was submitted to the institution\u2019s review board but received an exemption due to its nature as an educational intervention (CIRB Ref: 2018\/2276).<\/span><\/p>\r\n<p align=\"center\" style=\"text-align: center\"><strong><span lang=\"EN-GB\">Acknowledgements<\/span><\/strong><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">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.<\/span><\/p>\r\n<p align=\"center\" style=\"text-align: center\"><strong><span lang=\"EN-GB\">Funding<\/span><\/strong><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">This study was supported by the Lien Centre of Palliative Care, Singapore, Education Incubator Grant (Reference code: LCPC-EX18-0001).<\/span><\/p>\r\n<p align=\"center\" style=\"text-align: center\"><strong><span lang=\"EN-GB\">Declaration of Interest<\/span><\/strong><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">The author declares no conflict of interest in this study.<\/span><\/p>\r\n<p align=\"center\" style=\"text-align: center\"><strong><span lang=\"EN-GB\">References<\/span><\/strong><\/p>\r\n<\/div>\r\n<\/div>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">Batt-Rawden, S. A., Chisolm, M. S., Anton, B., &amp; Flickinger, T. E. (2013). Teaching empathy to medical students: An updated, systematic review. <i>Academic Medicine<\/i>, <i>88<\/i>(8), 1171-1177. <\/span><a href=\"https:\/\/doi.org\/10.1097\/acm.0b013e318299f3e3\"><span lang=\"EN-GB\">https:\/\/doi.org\/10.1097\/acm.0b013e318299f3e3<\/span><\/a><span lang=\"EN-GB\"><\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">Best, J. (2015). 22<sup>nd<\/sup> Gordon Arthur Ransome oration: Is medicine still an art? <i>Annals of the Academy of Medicine Singapore<\/i>, <i>44<\/i>, 353-357.<\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">Birden, H., Glass, N., Wilson, I., Harrison, M., Usherwood, T., &amp; Nass, D. (2013). Teaching professionalism in medical education: A Best Evidence Medical Education (BEME) systematic review. BEME Guide No. 25. <i>Medical Teacher<\/i>, <i>35<\/i>(7), e1252-e1266. <\/span><a href=\"https:\/\/doi.org\/10.3109\/0142159x.2013.789132\"><span lang=\"EN-GB\">https:\/\/doi.org\/10.3109\/0142159x.2013.789132<\/span><\/a><span lang=\"EN-GB\"><\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">Bleakley, A. (2015). <i>Medical Humanities and Medical Education: How the Medical Humanities Can Shape Better Doctors<\/i>. New York: Routledge. <\/span><a href=\"https:\/\/doi.org\/10.4324\/9781315771724\"><span lang=\"EN-GB\">https:\/\/doi.org\/10.4324\/9781315771724<\/span><\/a><span lang=\"EN-GB\"><\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">Bleakley, A., &amp; Marshall, R. (2014). Can the science of communication inform the art of the medical humanities? <i>Medical Education<\/i>, <i>47<\/i>(2), 126-133. <\/span><a href=\"https:\/\/doi.org\/10.1111\/medu.12056\"><span lang=\"EN-GB\">https:\/\/doi.org\/10.1111\/medu.12056<\/span><\/a><span lang=\"EN-GB\"><\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">Block, S., &amp; Billings, A. (1998). Nurturing Humanism through teaching palliative care. <i>Academic Medicine<\/i>, <i>73<\/i>(7), 763-765. <\/span><a href=\"https:\/\/doi.org\/10.1097\/00001888-199807000-00012\"><span lang=\"EN-GB\">https:\/\/doi.org\/10.1097\/00001888-199807000-00012<\/span><\/a><span lang=\"EN-GB\"><\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">Boud, D., &amp; Falchikov, N. (1989). Quantitative studies of student self-assessment in higher education: A critical analysis of findings. <i>Higher Education<\/i>, <i>18<\/i>, 529-549. <\/span><a href=\"https:\/\/doi.org\/10.1007\/bf00138746\"><span lang=\"EN-GB\">https:\/\/doi.org\/10.1007\/bf00138746<\/span><\/a><span lang=\"EN-GB\"><\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">Braun, V., &amp; Clarke, V. (2006). Using thematic analysis in psychology. <i>Qualitative Research in Psychology<\/i>, <i>3<\/i>(2), 77-101. <\/span><a href=\"https:\/\/doi.org\/10.1191\/1478088706qp063oa\"><span lang=\"EN-GB\">https:\/\/doi.org\/10.1191\/1478088706qp063oa<\/span><\/a><span lang=\"EN-GB\"><\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">Charlton, B., &amp; Verghese, A. (2010). Caring for Ivan Ilyich. <i>Journal of General Internal Medicine<\/i>, <i>25<\/i>(1), 93-95. <\/span><a href=\"https:\/\/doi.org\/10.1007\/s11606-009-1177-4\"><span lang=\"EN-GB\">https:\/\/doi.org\/10.1007\/s11606-009-1177-4<\/span><\/a><span lang=\"EN-GB\"><\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">Chew, C. H. (2008). 5<sup>th<\/sup> College of Physicians lecture\u2014A physician\u2019s odyssey: Recollections and reflections. <i>Annals of the Academy of Medicine Singapore<\/i>, <i>37, <\/i>968-976.<\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">Clandinin, D. J., &amp; Connelly, F. M. (2000). <i>Narrative Inquiry: Experience and Story in Qualitative Research<\/i>. San Francisco, CA: Jossey-Bass. <\/span><a href=\"https:\/\/doi.org\/10.1016\/b978-008043349-3\/50013-x\"><span lang=\"EN-GB\">https:\/\/doi.org\/10.1016\/b978-008043349-3\/50013-x<\/span><\/a><span lang=\"EN-GB\"><\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">Dennhardt, S., Apramian, T., Lingard, L., Torabi, N., &amp; Amtfield, S. (2016). Rethinking research in the medical humanities: A scoping review and narrative synthesis of quantitative outcome studies. <i>Medical Education<\/i>, <i>50<\/i>, 285-299. <\/span><a href=\"https:\/\/doi.org\/10.1111\/medu.12812\"><span lang=\"EN-GB\">https:\/\/doi.org\/10.1111\/medu.12812<\/span><\/a><span lang=\"EN-GB\"><\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">Feld, J., &amp; Heyse-Moore, L. (2006). An evaluation of a support group for junior doctors working in palliative medicine. <i>American Journal of Hospice and Palliative Care<\/i>, <i>23<\/i>(4), 287-296. <\/span><a href=\"https:\/\/doi.org\/10.1177\/1049909106290717\"><span lang=\"EN-GB\">https:\/\/doi.org\/10.1177\/1049909106290717<\/span><\/a><span lang=\"EN-GB\"><\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">Florijn, B. W., &amp; Kaptein, A. A. (2013). How Tolstoy and Solzhenitsyn define life and death in cancer: Patient perceptions in oncology. <i>American Journal of Hospice and Palliative Care<\/i>, <i>30<\/i>(5), 507-511. <\/span><a href=\"https:\/\/doi.org\/10.1177\/1049909112452626\"><span lang=\"EN-GB\">https:\/\/doi.org\/10.1177\/1049909112452626<\/span><\/a><span lang=\"EN-GB\"><\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">Gagne, R. M., Briggs, L. J., &amp; Wager, W. W. (1988). <i>Principles of Instructional Design<\/i>. New York: Holt, Rinehart and Winston Inc.<\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">Gibbs, G. (1988). <i>Learning by Doing: A Guide to Teaching and Learning Methods<\/i>. Oxford: Further Education Unit, Oxford Polytechnic.<\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">Hall, M. A., Zheng, B., Dugan, E., Camacho, F., Kidd, K. E., Mishra, A., &amp; Balkrishnan, R. (2002). Measuring patients\u2019 trust in their primary care providers. <i>Medical Care Research and Review<\/i>, <i>59<\/i>, 293-318. <\/span><a href=\"https:\/\/doi.org\/10.1177\/1077558702059003004\"><span lang=\"EN-GB\">https:\/\/doi.org\/10.1177\/1077558702059003004<\/span><\/a><span lang=\"EN-GB\"><\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">Hojat, M., Gonnella, J. S., Nasca, T. J., Mangione, S., Vergare, M., &amp; Magee, M. (2002). Physician empathy: Definition, components, measurement, and relationship to gender and specialty. <i>American Journal of Psychiatry<\/i>, <i>159<\/i>(9), 1563-1569. <\/span><a href=\"https:\/\/doi.org\/10.1176\/appi.ajp.159.9.1563\"><span lang=\"EN-GB\">https:\/\/doi.org\/10.1176\/appi.ajp.159.9.1563<\/span><\/a><span lang=\"EN-GB\"><\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">Hojat, M., Mangione, S., Nasca, T. J., Cohen, M. J. M., Gonnella, J. S., Erdmann, J. B., \u2026 Magee, M. (2001). The Jefferson Scale of Physician Empathy: Development and Preliminary Psychometric Data.\u00a0 <i>Educational and Psychological Measurement<\/i>, <i>61<\/i>(2), 349-365. <\/span><a href=\"https:\/\/doi.org\/10.1177\/00131640121971158\"><span lang=\"EN-GB\">https:\/\/doi.org\/10.1177\/00131640121971158<\/span><\/a><span lang=\"EN-GB\"><\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">Lee, P. T., Loh, J., Sng, G., Tung, J., &amp; Yeo, K. K. (2018). Empathy and burnout: A study on residents from a Singapore institution. <i>Singapore Medical Journal<\/i>, <i>59<\/i>(1), 50-54. <\/span><a href=\"https:\/\/doi.org\/10.11622\/smedj.2017096\"><span lang=\"EN-GB\">https:\/\/doi.org\/10.11622\/smedj.2017096<\/span><\/a><span lang=\"EN-GB\"><\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">Mercer, S. W., Maxwell, M., Heaney, D., &amp; Watt, G. C. (2004). The consultation and relational empathy (CARE) measure: Development and preliminary validation and reliability of an empathy-based consultation process measure. <i>Family Practice<\/i>, <i>21<\/i>(6), 699-705. <\/span><a href=\"https:\/\/doi.org\/10.1093\/fampra\/cmh621\"><span lang=\"EN-GB\">https:\/\/doi.org\/10.1093\/fampra\/cmh621<\/span><\/a><span lang=\"EN-GB\"><\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">Neumann, M., Edelh\u00e4user, F., Tauschel, D., Fischer, M. R., Wirtz, M., Woopen, C., \u2026 Scheffer, C. (2011). Empathy decline and its reasons: A systematic review of studies with medical students and residents. <i>Academic Medicine<\/i>, <i>86<\/i>(8), 996-1009. <\/span><a href=\"https:\/\/doi.org\/10.1097\/acm.0b013e318221e615\"><span lang=\"EN-GB\">https:\/\/doi.org\/10.1097\/acm.0b013e318221e615<\/span><\/a><span lang=\"EN-GB\"><\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">Ong, E. K., &amp; Anantham, D. (2019). The medical humanities: Reconnecting with the soul of medicine. <i>Annals of the Academy of Medicine Singapore<\/i>, <i>48<\/i>(7), 233-237.<\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">Othuis, G., &amp; Dekkers, W. (2003). Professional competence and palliative care: An ethical perspective. <i>Journal of Palliative Care<\/i>, <i>19<\/i>(3), 192-197. <\/span><a href=\"https:\/\/doi.org\/10.1177\/082585970301900308\"><span lang=\"EN-GB\">https:\/\/doi.org\/10.1177\/082585970301900308<\/span><\/a><span lang=\"EN-GB\"><\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">Ousager, J., &amp; Johannessen, H. (2010). Humanities in undergraduate medical education: A literature review. <i>Academic Medicine<\/i>, <i>85<\/i>, 988-998. <\/span><a href=\"https:\/\/doi.org\/10.1097\/acm.0b013e3181dd226b\"><span lang=\"EN-GB\">https:\/\/doi.org\/10.1097\/acm.0b013e3181dd226b<\/span><\/a><span lang=\"EN-GB\"><\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">Perry, M., Maffulli, N., Wilson, S., &amp; Morrissey, D. (2011). The effectiveness of arts-based interventions in medical education: A literature review. <i>Medical Education<\/i>, <i>45<\/i>(2), 141-148. <\/span><a href=\"https:\/\/doi.org\/10.1111\/j.1365-2923.2010.03848.x\"><span lang=\"EN-GB\">https:\/\/doi.org\/10.1111\/j.1365-2923.2010.03848.x<\/span><\/a><span lang=\"EN-GB\"><\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">Sch\u00f6n, D. A. (1987). <i>Educating the Reflective Practitioner: Toward a New Design for Teaching and Learning in the Professions<\/i>. San Francisco, CA: Jossey\u2010Bass.<\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">Schwartz, A. W., Abramson, J. S., Wojnowich, I., Accordino, R., Ronan, E. J., &amp; Rifkin, M. R. (2009). Evaluating the impact of the humanities in medical education. <i>Mount Sinai Journal of Medicine<\/i>, <i>76<\/i>, 372-380.\u00a0 <\/span><a href=\"https:\/\/doi.org\/10.1002\/msj.20126\"><span lang=\"EN-GB\">https:\/\/doi.org\/10.1002\/msj.20126<\/span><\/a><span lang=\"EN-GB\"><\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">Shapiro, J., Coulehan, J., Wear, D., &amp; Montello, M. (2009). Medical humanities and their discontents: Definitions, critiques, and implications. <i>Academic Medicine<\/i>, <i>84, <\/i>192-198. <\/span><a href=\"https:\/\/doi.org\/10.1097\/acm.0b013e3181938bca\"><span lang=\"EN-GB\">https:\/\/doi.org\/10.1097\/acm.0b013e3181938bca<\/span><\/a><span lang=\"EN-GB\"><\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">Taras, M. (2008). Summative and formative assessment: Perceptions and realities. <i>Active Learning in Higher Education<\/i>, <i>9<\/i>(2), 172-192. <\/span><a href=\"https:\/\/doi.org\/10.1177\/1469787408091655\"><span lang=\"EN-GB\">https:\/\/doi.org\/10.1177\/1469787408091655<\/span><\/a><span lang=\"EN-GB\"><\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">Taylor, A., Lehmann, S., &amp; Chisolm, M. (2017). Integrating humanities curricula in medical education: A needs assessment. <i>MedEdPublish<\/i>. <\/span><a href=\"https:\/\/doi.org\/10.15694\/mep.2017.000090\"><span lang=\"EN-GB\">https:\/\/doi.org\/10.15694\/mep.2017.000090<\/span><\/a><span lang=\"EN-GB\"><\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">Wear, D., &amp; Zarconi, J. (2016). Humanism and other acts of faith.\u00a0 <i>Medical Education<\/i>, <i>50<\/i>, 271-281. <\/span><a href=\"https:\/\/doi.org\/10.1111\/medu.12974\"><span lang=\"EN-GB\">https:\/\/doi.org\/10.1111\/medu.12974<\/span><\/a><span lang=\"EN-GB\"><\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-GB\">West, C. P., Dyrbye, L. N., Erwin, P. J., &amp; Shanafelt, T. D. (2016). Interventions to prevent and reduce physician burnout: A systematic review and meta-analysis. <i>The<\/i> <i>Lancet<\/i>, <i>388<\/i>(10057), 2272-2281. <\/span><a href=\"https:\/\/doi.org\/10.1016\/S0140-6736(16)31279-X\"><span lang=\"EN-GB\">https:\/\/doi.org\/10.1016\/S0140-6736(16)31279-X<\/span><\/a><span lang=\"EN-GB\"><\/span><\/p>\r\n<p style=\"text-align: left\">*Ong Eng Koon<br \/>\r\nDivision of Supportive and Palliative Care, <br \/>\r\nNational Cancer Centre Singapore<br \/>\r\n11 Hospital Drive, Singapore 169610<br \/>\r\nTel: +6564368462<br \/>\r\nEmail address: ong.eng.koon@singhealth.com.sg<\/p>\r\n<\/div>","protected":false},"featured_media":0,"parent":0,"menu_order":8,"template":"","issues_category":[12],"archive_category":[],"issue_type":[25],"volume_category":[59],"class_list":["post-1504","issues","type-issues","status-publish","hentry","issues_category-original-articles","issue_type-past-issue","volume_category-volume-6-number-1-january-2021"],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v26.4 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>HAPPE\u2014A pilot programme using humanities to teach junior doctors empathy in a palliative medicine posting - The Asia Pacific Scholar<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/medicine.nus.edu.sg\/taps\/issues\/happe-a-pilot-programme-using-humanities-to-teach-junior-doctors-empathy-in-a-palliative-medicine-posting\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"HAPPE\u2014A pilot programme using humanities to teach junior doctors empathy in a palliative medicine posting - The Asia Pacific Scholar\" \/>\n<meta property=\"og:description\" content=\"Submitted: 16 April 2020 Accepted: 24 June 2020 Published online: 5 January, TAPS 2021, 6(1), 83-92 https:\/\/doi.org\/10.29060\/TAPS.2021-6-1\/OA2251 Eng Koon Ong\u00a0 Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore; Assisi Hospice, Singapore Abstract Introduction: Physician empathy is declining due to an unproportionate focus on technical knowledge and skills. The medical humanities can counter [&hellip;]\" \/>\n<meta property=\"og:url\" content=\"https:\/\/medicine.nus.edu.sg\/taps\/issues\/happe-a-pilot-programme-using-humanities-to-teach-junior-doctors-empathy-in-a-palliative-medicine-posting\/\" \/>\n<meta property=\"og:site_name\" content=\"The Asia Pacific Scholar\" \/>\n<meta property=\"article:modified_time\" content=\"2021-05-04T00:35:08+00:00\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<meta name=\"twitter:label1\" content=\"Est. reading time\" \/>\n\t<meta name=\"twitter:data1\" content=\"23 minutes\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\/\/schema.org\",\"@graph\":[{\"@type\":\"WebPage\",\"@id\":\"https:\/\/medicine.nus.edu.sg\/taps\/issues\/happe-a-pilot-programme-using-humanities-to-teach-junior-doctors-empathy-in-a-palliative-medicine-posting\/\",\"url\":\"https:\/\/medicine.nus.edu.sg\/taps\/issues\/happe-a-pilot-programme-using-humanities-to-teach-junior-doctors-empathy-in-a-palliative-medicine-posting\/\",\"name\":\"HAPPE\u2014A pilot programme using humanities to teach junior doctors empathy in a palliative medicine posting - The Asia Pacific Scholar\",\"isPartOf\":{\"@id\":\"https:\/\/medicine.nus.edu.sg\/taps\/#website\"},\"datePublished\":\"2020-12-15T01:09:53+00:00\",\"dateModified\":\"2021-05-04T00:35:08+00:00\",\"breadcrumb\":{\"@id\":\"https:\/\/medicine.nus.edu.sg\/taps\/issues\/happe-a-pilot-programme-using-humanities-to-teach-junior-doctors-empathy-in-a-palliative-medicine-posting\/#breadcrumb\"},\"inLanguage\":\"en-US\",\"potentialAction\":[{\"@type\":\"ReadAction\",\"target\":[\"https:\/\/medicine.nus.edu.sg\/taps\/issues\/happe-a-pilot-programme-using-humanities-to-teach-junior-doctors-empathy-in-a-palliative-medicine-posting\/\"]}]},{\"@type\":\"BreadcrumbList\",\"@id\":\"https:\/\/medicine.nus.edu.sg\/taps\/issues\/happe-a-pilot-programme-using-humanities-to-teach-junior-doctors-empathy-in-a-palliative-medicine-posting\/#breadcrumb\",\"itemListElement\":[{\"@type\":\"ListItem\",\"position\":1,\"name\":\"Home\",\"item\":\"https:\/\/medicine.nus.edu.sg\/taps\/\"},{\"@type\":\"ListItem\",\"position\":2,\"name\":\"HAPPE\u2014A pilot programme using humanities to teach junior doctors empathy in a palliative medicine posting\"}]},{\"@type\":\"WebSite\",\"@id\":\"https:\/\/medicine.nus.edu.sg\/taps\/#website\",\"url\":\"https:\/\/medicine.nus.edu.sg\/taps\/\",\"name\":\"The Asia Pacific Scholar\",\"description\":\"\",\"potentialAction\":[{\"@type\":\"SearchAction\",\"target\":{\"@type\":\"EntryPoint\",\"urlTemplate\":\"https:\/\/medicine.nus.edu.sg\/taps\/?s={search_term_string}\"},\"query-input\":{\"@type\":\"PropertyValueSpecification\",\"valueRequired\":true,\"valueName\":\"search_term_string\"}}],\"inLanguage\":\"en-US\"}]}<\/script>\n<!-- \/ Yoast SEO plugin. -->","yoast_head_json":{"title":"HAPPE\u2014A pilot programme using humanities to teach junior doctors empathy in a palliative medicine posting - The Asia Pacific Scholar","robots":{"index":"index","follow":"follow","max-snippet":"max-snippet:-1","max-image-preview":"max-image-preview:large","max-video-preview":"max-video-preview:-1"},"canonical":"https:\/\/medicine.nus.edu.sg\/taps\/issues\/happe-a-pilot-programme-using-humanities-to-teach-junior-doctors-empathy-in-a-palliative-medicine-posting\/","og_locale":"en_US","og_type":"article","og_title":"HAPPE\u2014A pilot programme using humanities to teach junior doctors empathy in a palliative medicine posting - The Asia Pacific Scholar","og_description":"Submitted: 16 April 2020 Accepted: 24 June 2020 Published online: 5 January, TAPS 2021, 6(1), 83-92 https:\/\/doi.org\/10.29060\/TAPS.2021-6-1\/OA2251 Eng Koon Ong\u00a0 Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore; Assisi Hospice, Singapore Abstract Introduction: Physician empathy is declining due to an unproportionate focus on technical knowledge and skills. The medical humanities can counter [&hellip;]","og_url":"https:\/\/medicine.nus.edu.sg\/taps\/issues\/happe-a-pilot-programme-using-humanities-to-teach-junior-doctors-empathy-in-a-palliative-medicine-posting\/","og_site_name":"The Asia Pacific Scholar","article_modified_time":"2021-05-04T00:35:08+00:00","twitter_card":"summary_large_image","twitter_misc":{"Est. reading time":"23 minutes"},"schema":{"@context":"https:\/\/schema.org","@graph":[{"@type":"WebPage","@id":"https:\/\/medicine.nus.edu.sg\/taps\/issues\/happe-a-pilot-programme-using-humanities-to-teach-junior-doctors-empathy-in-a-palliative-medicine-posting\/","url":"https:\/\/medicine.nus.edu.sg\/taps\/issues\/happe-a-pilot-programme-using-humanities-to-teach-junior-doctors-empathy-in-a-palliative-medicine-posting\/","name":"HAPPE\u2014A pilot programme using humanities to teach junior doctors empathy in a palliative medicine posting - The Asia Pacific Scholar","isPartOf":{"@id":"https:\/\/medicine.nus.edu.sg\/taps\/#website"},"datePublished":"2020-12-15T01:09:53+00:00","dateModified":"2021-05-04T00:35:08+00:00","breadcrumb":{"@id":"https:\/\/medicine.nus.edu.sg\/taps\/issues\/happe-a-pilot-programme-using-humanities-to-teach-junior-doctors-empathy-in-a-palliative-medicine-posting\/#breadcrumb"},"inLanguage":"en-US","potentialAction":[{"@type":"ReadAction","target":["https:\/\/medicine.nus.edu.sg\/taps\/issues\/happe-a-pilot-programme-using-humanities-to-teach-junior-doctors-empathy-in-a-palliative-medicine-posting\/"]}]},{"@type":"BreadcrumbList","@id":"https:\/\/medicine.nus.edu.sg\/taps\/issues\/happe-a-pilot-programme-using-humanities-to-teach-junior-doctors-empathy-in-a-palliative-medicine-posting\/#breadcrumb","itemListElement":[{"@type":"ListItem","position":1,"name":"Home","item":"https:\/\/medicine.nus.edu.sg\/taps\/"},{"@type":"ListItem","position":2,"name":"HAPPE\u2014A pilot programme using humanities to teach junior doctors empathy in a palliative medicine posting"}]},{"@type":"WebSite","@id":"https:\/\/medicine.nus.edu.sg\/taps\/#website","url":"https:\/\/medicine.nus.edu.sg\/taps\/","name":"The Asia Pacific Scholar","description":"","potentialAction":[{"@type":"SearchAction","target":{"@type":"EntryPoint","urlTemplate":"https:\/\/medicine.nus.edu.sg\/taps\/?s={search_term_string}"},"query-input":{"@type":"PropertyValueSpecification","valueRequired":true,"valueName":"search_term_string"}}],"inLanguage":"en-US"}]}},"_links":{"self":[{"href":"https:\/\/medicine.nus.edu.sg\/taps\/wp-json\/wp\/v2\/issues\/1504","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/medicine.nus.edu.sg\/taps\/wp-json\/wp\/v2\/issues"}],"about":[{"href":"https:\/\/medicine.nus.edu.sg\/taps\/wp-json\/wp\/v2\/types\/issues"}],"wp:attachment":[{"href":"https:\/\/medicine.nus.edu.sg\/taps\/wp-json\/wp\/v2\/media?parent=1504"}],"wp:term":[{"taxonomy":"issues_category","embeddable":true,"href":"https:\/\/medicine.nus.edu.sg\/taps\/wp-json\/wp\/v2\/issues_category?post=1504"},{"taxonomy":"archive_category","embeddable":true,"href":"https:\/\/medicine.nus.edu.sg\/taps\/wp-json\/wp\/v2\/archive_category?post=1504"},{"taxonomy":"issue_type","embeddable":true,"href":"https:\/\/medicine.nus.edu.sg\/taps\/wp-json\/wp\/v2\/issue_type?post=1504"},{"taxonomy":"volume_category","embeddable":true,"href":"https:\/\/medicine.nus.edu.sg\/taps\/wp-json\/wp\/v2\/volume_category?post=1504"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}