{"id":71190,"date":"2021-12-13T08:11:17","date_gmt":"2021-12-13T00:11:17","guid":{"rendered":"https:\/\/medicine.nus.edu.sg\/taps\/?post_type=issues&#038;p=71190"},"modified":"2022-04-05T10:59:35","modified_gmt":"2022-04-05T02:59:35","slug":"humanism-in-asian-medical-education-a-scoping-review","status":"publish","type":"issues","link":"https:\/\/medicine.nus.edu.sg\/taps\/issues\/humanism-in-asian-medical-education-a-scoping-review\/","title":{"rendered":"Humanism in Asian medical education &#8211; A scoping review"},"content":{"rendered":"<p>Submitted: 1<span lang=\"EN-GB\"> March 2021<\/span><br \/>\r\nAccepted: 13 September 2021<br \/>\r\nPublished online: <span lang=\"EN-GB\">4 January, TAPS 2022, <\/span><span lang=\"EN-GB\">7(1), 9-20<\/span><br \/>\r\n<a href=\"https:\/\/doi.org\/10.29060\/TAPS.2022-7-1\/RA2460\">https:\/\/doi.org\/10.29060\/TAPS.2022-7-1\/RA2460<\/a><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-US\">Cindy Shiqi Zhu<sup>1<\/sup>, Ryan Kye Feng Yap<sup>2,3<\/sup>, Samuel Yong Siang Lim<sup>2,3<\/sup>, Ying Pin Toh<sup>2,4<\/sup> &amp; Victor Weng Keong Loh<sup>1,2<\/sup><\/span><\/p>\r\n<p style=\"text-align: justify\"><i><sup><span lang=\"EN-US\">1<\/span><\/sup><\/i><i><span lang=\"EN-US\">Department of Family Medicine, National University Health System, Singapore; <sup>2<\/sup>Division of Family Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; <sup>3<\/sup>Ministry of Health Holdings, Singapore; <sup>4<\/sup>HCA Hospice, Singapore<\/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-US\"> Humanistic values lie at the heart of medicine. In the wake of professional breaches among health care professionals, the place of humanistic values in medical training has been the subject of much debate and development in the literature. This scoping review aims to map the current understanding of how humanism in the Asian socio-cultural context may be understood and applied, and how the strengthening of humanistic values may be further integrated into medical schools in Asia.<\/span><\/p>\r\n<p style=\"text-align: justify\"><b><span lang=\"EN-GB\">Methods:<\/span><\/b><span lang=\"EN-US\"> Arksey and O&#8217;Malley&#8217;s approach to scoping reviews was used to guide the study protocol. Databases PubMed, ERIC, EMBASE, Scopus, CINAHL, and Web of Science were searched for articles on humanism and medical education in Asia. Data charting and thematic analysis were performed on the final articles selected.<\/span><span lang=\"EN-GB\"><\/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-US\">Three hundred and six abstracts were retrieved, 93 full-text articles were analysed, and 48 articles were selected. Thematic analysis revealed four themes on the <i>need to strengthen<\/i> humanistic values, the <i>challenge of finding a common framework<\/i> and definition, <i>opportunities in medical school<\/i> for curriculum design and training, and the need for validated tools in <i>program evaluation<\/i> in Asia.<\/span><span lang=\"EN-GB\"><\/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-US\">Themes highlighted in this review show an increasing recognition amongst Asian medical educators of the importance of inculcating humanistic values into medical training. Further research and ongoing discussion are needed to develop culturally relevant, effective, and integrative curricula in order to promote humanistic attitudes and behaviours among medical students and physicians in Asia.<\/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 <\/span><i><span lang=\"EN-GB\">Humanism, Asia, Medical Education, Medical Students, Admission, Curriculum, Mentorship, Assessment, Medical Humanities, Humanistic Values<\/span><\/i><\/p>\r\n<p align=\"center\" style=\"text-align: center\"><strong><span lang=\"EN-GB\">Practice Highlights<\/span><\/strong><\/p>\r\n<ul>\r\n\t<li style=\"text-align: justify\"><span lang=\"EN-US\"> <\/span><span lang=\"EN-US\">This review maps how medical schools in Asia impart humanistic values.<\/span><\/li>\r\n\t<li style=\"text-align: justify\"><span lang=\"EN-US\"> <\/span><span lang=\"EN-US\">There is a pressing need to strengthen humanistic values among medical students in Asia.<\/span><\/li>\r\n\t<li style=\"text-align: justify\"><span lang=\"EN-US\"> <\/span><span lang=\"EN-US\">The outcomes of current strategies are varied; mentorship and reflection on experience are crucial. <\/span><\/li>\r\n\t<li style=\"text-align: justify\"><span lang=\"EN-US\"> <\/span><span lang=\"EN-US\">There is much scope for further research in culturally relevant pedagogy that may impart humanism.<\/span><\/li>\r\n\t<li style=\"text-align: justify\"><span lang=\"EN-GB\"> <\/span><span lang=\"EN-US\">Validated tools need to be developed for evaluating interventions to impart humanism in healthcare.<\/span><span lang=\"EN-GB\"><\/span><\/li>\r\n<\/ul>\r\n<p style=\"text-align: center\"><span lang=\"EN-GB\"><\/span><strong><span lang=\"EN-GB\">I. INTRODUCTION<\/span><\/strong><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-US\">Humanistic values lie at the heart of medicine. Humanism in health care has been defined as <i>\u201can intrinsic set of deep-seated convictions about one&#8217;s obligations toward others\u201d, <\/i>and <i>\u201cdevotion to human welfare\u201d,<\/i> characterised by a respectful and compassionate relationship between physicians, their patients, and other members of the healthcare team <\/span><span lang=\"EN-US\">(Cohen, 2007; Gold, 2018)<\/span><span lang=\"EN-US\">.<\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-US\">Recent increased <\/span><span lang=\"EN-US\">interest in the development of humanism in medical education <\/span><span lang=\"EN-US\">(Maheux et al., 2000; Moyer et al., 2010; Wald et al., 2015)<\/span><span lang=\"EN-US\"> may be in response to concerns regarding the erosion of humanistic qualities among medical professionals <\/span><span lang=\"EN-US\">(Haque &amp; Waytz, 2012; Thibault, 2019)<\/span><span lang=\"EN-US\">. The push for medical humanism gained momentum through various advocacy movements, such as the Arnold P. Gold foundation in the United States, where the \u2018IECARES\u2019 framework was created to facilitate systematic discourse and study of humanism <\/span><span lang=\"EN-US\">(Gold, 2018)<\/span><span lang=\"EN-US\">.<\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-US\">Medical educators in Asia have long recognised that humanistic traits are key to the art of medicine. They recognise that humanistic values have a positive effect on the patient-physician relationship, correlate positively with patient satisfaction, positively influence treatment outcome and adherence, and help maintain harmony in the working environment <\/span><span lang=\"EN-US\">(Asai et al., 2007; Chiu et al., 2009; Saw, 2018; Song et al., 2017; Tokuda et al., 2008)<\/span><span lang=\"EN-US\">. Training in humanistic attitudes may therefore provide ballast to the thorny relationships sometimes seen in medical practice.\u00a0 In China, for example, more than 70% of doctors have experienced medical violence in hospitals, and strengthening humanistic values during medical training has been proposed as an urgent and important strategy to counteract this phenomenon <\/span><span lang=\"EN-US\">(Hu, 2016)<\/span><span lang=\"EN-US\">.<\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-US\">Published studies from Asian medical training contexts that examine the perception, pedagogy, and assessment of humanistic values, and how humanism education frameworks derived from Western sociocultural contexts resonate with the cultural values, social history, and healthcare infrastructure in Asia are however relatively scarce.<\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-US\">As a social construct <\/span><span lang=\"EN-US\">(Cohen, 2007; Kelly &amp; Dornan, 2016; Rios, 2016)<\/span><span lang=\"EN-US\">, the discourse on humanism in Asian medical education and medical practice must consider cultural and contextual distinction from the main body of current literature that stems mainly from the West <\/span><span lang=\"EN-US\">(Claramita et al., 2013; Schouten &amp; Meeuwesen, 2006; Tsai, 2001)<\/span><span lang=\"EN-US\">. This study aims to explore how humanism has been understood and applied in medical education in the Asian sociocultural context by scoping current knowledge and evidence.<\/span><\/p>\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: justify\"><span lang=\"EN-US\">A preliminary literature review revealed that existing literature on humanism in medical education in Asia was heterogeneous and limited. As such, a scoping review methodology was selected <\/span><span lang=\"EN-US\">(Thomas et al., 2017)<\/span><span lang=\"EN-US\">. Arksey and O\u2019Malley&#8217;s approach to scoping reviews was used to guide the study protocol <\/span><span lang=\"EN-US\">(Arksey &amp; O&#8217;Malley, 2005)<\/span><span lang=\"EN-US\">. Ethics approval was not required for this study, as it does not involve human subjects or data.<\/span><\/p>\r\n<p style=\"text-align: left\"><i><span lang=\"EN-US\"><\/span><\/i><i><span lang=\"EN-US\">A. Identifying the Research Question and Relevant Studies<\/span><\/i><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-US\">This study aims to provide an overview of the current knowledge on humanism in Asian medical education, identify successes and deficiencies in current practice, and guide further research.<\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-US\">The PICOS format was used to structure the research question for the literature search (Table 1). <\/span><span lang=\"EN-GB\">While alternate frameworks of humanism such as the Interactive Heart and Head model <\/span><span lang=\"EN-GB\">(Montgomery et al., 2017)<\/span><span lang=\"EN-GB\"> and the outcome-oriented approach <\/span><span lang=\"EN-GB\">(Ferry-Danini, 2018)<\/span><span lang=\"EN-GB\"> were considered, the authors decided that the Gold Foundation\u2019s IECARES framework which knit together different strands of the humanism construct into a meaningful cohesive unit was most suited as a scaffold for our search terms.<\/span><span lang=\"EN-US\"> We thus included studies of any design on humanism and its core characteristics (Integrity, Excellence, Compassion &amp; Collaboration, Altruism, Respect &amp; Resilience, Empathy, and Service) as defined by the Gold Foundation\u2019s IECARES framework), among medical students and educators in Asia. We excluded articles in foreign languages, on non-Asian populations, and allied health professionals (e.g. dentistry, pharmacy, nursing students). The search strategy was formulated through discussions between the authors and a medical librarian (A.C). Comprehensive search terms were constructed to expansively identify studies containing any synonyms or variation of three key concepts: humanism, medical education, and Asian countries and regions as defined by the United Nations Statistical Division<\/span><span lang=\"EN-US\"> <\/span>(United Nations Statistics Division, n.d.)<span lang=\"EN-US\">. Six databases \u2013 PubMed, ERIC, EMBASE<\/span>, Scopus, CINAHL, and Web of Science were searched.<\/p>\r\n<div align=\"center\">\r\n<table style=\"width: 100%;height: 880px\">\r\n<tbody>\r\n<tr style=\"height: 96px\">\r\n<td valign=\"top\" style=\"height: 96px\">\r\n<p><b><span lang=\"EN-US\">PICOS Table<\/span><\/b><\/p>\r\n<\/td>\r\n<td valign=\"top\" style=\"height: 96px\">\r\n<p><b><span lang=\"EN-US\">Inclusion Criteria<\/span><\/b><\/p>\r\n<\/td>\r\n<td valign=\"top\" style=\"height: 96px\">\r\n<p><b><span lang=\"EN-US\">Exclusion Criteria <\/span><\/b><\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr style=\"height: 208px\">\r\n<td valign=\"top\" style=\"height: 208px\">\r\n<p><span lang=\"EN-US\">Population<\/span><\/p>\r\n<\/td>\r\n<td valign=\"top\" style=\"height: 208px\">\r\n<p><span lang=\"EN-US\">Medical students and practising physicians including residents in Asia<\/span><\/p>\r\n<\/td>\r\n<td valign=\"top\" style=\"height: 208px\">\r\n<p><span lang=\"EN-US\">Allied health specialities such as nursing, pharmacy and physiotherapy. <\/span><\/p>\r\n<p><span lang=\"EN-US\">Non-medical specialities such as dentistry.<\/span><\/p>\r\n<p><span lang=\"EN-US\">Studies from non-Asian countries and regions<\/span><\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr style=\"height: 80px\">\r\n<td valign=\"top\" style=\"height: 80px\">\r\n<p><span lang=\"EN-US\">Intervention<\/span><\/p>\r\n<\/td>\r\n<td valign=\"top\" style=\"height: 80px\">\r\n<p><span lang=\"EN-US\">Studies on humanism and its core characteristics (<\/span><span lang=\"EN-US\">integrity, excellence, compassion, altruism, respect, empathy, and service) as defined by the GOLD foundation <\/span><\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr style=\"height: 56px\">\r\n<td valign=\"top\" style=\"height: 56px\">\r\n<p><span lang=\"EN-US\">Comparison<\/span><\/p>\r\n<\/td>\r\n<td valign=\"top\" style=\"height: 56px\">\r\n<p><i><span lang=\"EN-US\">N\/A<\/span><\/i><\/p>\r\n<\/td>\r\n<td valign=\"top\" style=\"height: 56px\">\r\n<p><i><span lang=\"EN-US\">N\/A<\/span><\/i><\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr style=\"height: 320px\">\r\n<td valign=\"top\" style=\"height: 320px\">\r\n<p><span lang=\"EN-US\">Outcome<\/span><\/p>\r\n<\/td>\r\n<td valign=\"top\" style=\"height: 320px\">\r\n<p><span lang=\"EN-US\">Definition of humanism<\/span><\/p>\r\n<p><span lang=\"EN-US\">Similarities and differences between Asian and Western concepts of humanism<\/span><\/p>\r\n<p><span lang=\"EN-US\">Perceptions on the integration of humanism as a subject\/concept in medical education<\/span><\/p>\r\n<p><span lang=\"EN-US\">Methods of teaching humanism<\/span><\/p>\r\n<p><span lang=\"EN-US\">Assessment of humanistic characteristics and behaviour <\/span><\/p>\r\n<p><span lang=\"EN-US\">Suggested time point in training for teaching humanism<\/span><\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr style=\"height: 120px\">\r\n<td valign=\"top\" style=\"height: 120px\">\r\n<p><span lang=\"EN-US\">Study Design<\/span><\/p>\r\n<\/td>\r\n<td valign=\"top\" style=\"height: 120px\">\r\n<p><span lang=\"EN-US\">All study designs and article types were included (observation studies, cross-sectional studies, nominal group studies, Delphi study, literature review, and scoping review) <\/span><\/p>\r\n<\/td>\r\n<td valign=\"top\" style=\"height: 120px\">\r\n<p><span lang=\"EN-US\">Studies published in a non-English language <\/span><\/p>\r\n<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n<p align=\"center\"><span lang=\"EN-US\">Table 1: PICOS Table of Inclusion and Exclusion Criteria<\/span><\/p>\r\n<p align=\"center\" style=\"text-align: left\"><i><span lang=\"EN-US\">B. Study Selection <\/span><\/i><\/p>\r\n<p style=\"text-align: justify\">The selection process for articles is summarised in the PRISMA format (Moher et al., 2015) in Figure 1. Three hundred and six abstracts were identified through the initial search and reviewed after the removal of duplicates. <span lang=\"EN-US\">Ninety-three full-text articles were examined to determine suitability for inclusion according to the selection criteria. Forty-eight full-text articles were included in the final review for thematic analysis.<\/span><\/p>\r\n<p style=\"text-align: left\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/medicine.nus.edu.sg\/taps\/wp-content\/uploads\/sites\/10\/2021\/11\/RA2460-Figure-1-282x300.png\" alt=\"\" class=\" wp-image-71191 aligncenter\" width=\"471\" height=\"501\" srcset=\"https:\/\/medicine.nus.edu.sg\/taps\/wp-content\/uploads\/sites\/10\/2021\/11\/RA2460-Figure-1-282x300.png 282w, https:\/\/medicine.nus.edu.sg\/taps\/wp-content\/uploads\/sites\/10\/2021\/11\/RA2460-Figure-1-768x817.png 768w, https:\/\/medicine.nus.edu.sg\/taps\/wp-content\/uploads\/sites\/10\/2021\/11\/RA2460-Figure-1.png 838w\" sizes=\"auto, (max-width: 471px) 100vw, 471px\" \/><\/p>\r\n<p align=\"center\"><span lang=\"EN-US\">Figure 1. PRISMA Flowchart<\/span><\/p>\r\n<p align=\"center\" style=\"text-align: left\"><i><span lang=\"EN-US\">C. Data Charting<\/span><\/i><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-US\">Braun and Clarke\u2019s inductive approach to reflective thematic analysis was utilised <\/span><span lang=\"EN-US\">(Braun &amp; Clarke, 2013, pp. 248-273)<\/span><span lang=\"EN-US\">. Two researchers (CZ and RY) independently reviewed the studies. Articles were read and analysed in detail, and key ideas were recorded into a data abstraction coding sheet <\/span><span lang=\"EN-US\">(Zhu et al., 2021a)<\/span><span lang=\"EN-US\">. Frequently discussed ideas were identified and generated into a list of initial themes, which were added to a data extraction form <\/span><span lang=\"EN-US\">(Zhu et al., 2021b)<\/span><span lang=\"EN-US\">. <\/span><span lang=\"EN-GB\">The researchers iteratively reviewed the independently extracted themes for agreement. This entailed a familiarisation with the depth and breadth of current knowledge through literature review and immersion in the derived data. The researchers subsequently ensured consistency in data extraction by applying the same coding sheet and data extraction forms on the entire data set, forming a template that included all the key ideas that were coded. Sessions for peer debriefing were set up to discuss more complex ideas by discussing each researchers\u2019 interpretation all the while ensuring relevance to the research question.<\/span><\/p>\r\n<p style=\"text-align: justify\"><i><span lang=\"EN-US\">D. Collating, Summarising, and Reporting Results <\/span><\/i><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-US\">Codes and initial themes from the data abstraction sheet were reviewed and summarised into four final themes based on semantic and conceptual similarity. The themes were refined during the abstraction phase, and multiple discussions were conducted amongst all authors to achieve consensus on their definition and content. The results are reported in figures and narrative form below.<\/span><\/p>\r\n<p style=\"text-align: center\"><strong><span lang=\"EN-GB\">III. RESULTS<\/span><\/strong><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-US\">The final articles included in this review consisted mainly of cross-sectional studies of survey-based quantitative or mixed-method design and commentaries\/essays by medical educators. There were a smaller number of nominal group studies, literature reviews, one Delphi study, and one scoping review on medical professionalism (Figure 2). East Asian studies (China, Taiwan, Japan, and Korea) comprised 58.33% of the articles included, South Asian (India, Pakistan, and Bangladesh) studies accounted for 16.7%, while studies from West Asia (Israel, Lebanon, Saudi Arabia) and Southeast Asia (Malaysia, Singapore, and Thailand) each accounted for 12.5% (Figure 3). The articles ranged in publication date from 1995 to 2018. Notably, there was a steady increase in the number of articles over this period (Figure 4). Thematic analysis revealed the following themes on humanism in Asian medical education <\/span><span lang=\"EN-US\">(Zhu et al., 2021a, 2021b)<\/span><span lang=\"EN-US\">.<\/span><\/p>\r\n<\/div>\r\n<p><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/medicine.nus.edu.sg\/taps\/wp-content\/uploads\/sites\/10\/2021\/11\/RA2460-Figure-2-300x174.png\" alt=\"\" class=\" wp-image-71193 aligncenter\" width=\"430\" height=\"249\" srcset=\"https:\/\/medicine.nus.edu.sg\/taps\/wp-content\/uploads\/sites\/10\/2021\/11\/RA2460-Figure-2-300x174.png 300w, https:\/\/medicine.nus.edu.sg\/taps\/wp-content\/uploads\/sites\/10\/2021\/11\/RA2460-Figure-2-768x445.png 768w, https:\/\/medicine.nus.edu.sg\/taps\/wp-content\/uploads\/sites\/10\/2021\/11\/RA2460-Figure-2.png 902w\" sizes=\"auto, (max-width: 430px) 100vw, 430px\" \/><\/p>\r\n<p align=\"center\" style=\"text-align: center\"><span lang=\"EN-US\">Figure 2. Graphical representation of article types included in the current review<\/span><span lang=\"EN-US\"><\/span><\/p>\r\n<p><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/medicine.nus.edu.sg\/taps\/wp-content\/uploads\/sites\/10\/2021\/11\/RA2460-Figure-3-300x265.png\" alt=\"\" class=\" wp-image-71194 aligncenter\" width=\"398\" height=\"352\" srcset=\"https:\/\/medicine.nus.edu.sg\/taps\/wp-content\/uploads\/sites\/10\/2021\/11\/RA2460-Figure-3-300x265.png 300w, https:\/\/medicine.nus.edu.sg\/taps\/wp-content\/uploads\/sites\/10\/2021\/11\/RA2460-Figure-3-768x678.png 768w, https:\/\/medicine.nus.edu.sg\/taps\/wp-content\/uploads\/sites\/10\/2021\/11\/RA2460-Figure-3.png 793w\" sizes=\"auto, (max-width: 398px) 100vw, 398px\" \/><\/p>\r\n<p align=\"center\"><span lang=\"EN-GB\">Figure 3. Region of origin of articles included in the current review<\/span><\/p>\r\n<p align=\"center\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/medicine.nus.edu.sg\/taps\/wp-content\/uploads\/sites\/10\/2021\/11\/RA2460-Figure-4-300x188.png\" alt=\"\" class=\"alignnone  wp-image-71195 aligncenter\" width=\"426\" height=\"267\" srcset=\"https:\/\/medicine.nus.edu.sg\/taps\/wp-content\/uploads\/sites\/10\/2021\/11\/RA2460-Figure-4-300x188.png 300w, https:\/\/medicine.nus.edu.sg\/taps\/wp-content\/uploads\/sites\/10\/2021\/11\/RA2460-Figure-4-768x482.png 768w, https:\/\/medicine.nus.edu.sg\/taps\/wp-content\/uploads\/sites\/10\/2021\/11\/RA2460-Figure-4.png 854w\" sizes=\"auto, (max-width: 426px) 100vw, 426px\" \/><\/p>\r\n<p><i><span lang=\"EN-US\"><\/span><\/i><i><span lang=\"EN-US\">A. Training in Humanistic Values: A Pressing Need in Asian Medical Schools<\/span><\/i><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-US\">The common refrain of concern for the current state of medical students&#8217; and physicians\u2019 humanistic qualities was highlighted in many articles from several Asian countries and regions. Issues<\/span><span lang=\"EN-US\"> related to breaches of professional and ethical behaviour among medical students and young physicians were widespread and of serious concern to medical educators and the general public in Japan <\/span><span lang=\"EN-US\">(Tokuda et al., 2008)<\/span><span lang=\"EN-US\">.<\/span><span lang=\"EN-US\"> Taiwanese educators lamented a lack of dedication and personal commitment among young Taiwanese physicians compared to their predecessors <\/span><span lang=\"EN-US\">(Chiu et al., 2010)<\/span><span lang=\"EN-US\">. In Pakistan, concerns regarding the deterioration of humanism and professional values in medicine were raised, with students overestimating the self-rated quality of their bedside manner compared to objective assessments <\/span><span lang=\"EN-US\">(Farooq et al., 2013)<\/span><span lang=\"EN-US\">. Bhatia et al from India indicated that humanistic traits such as empathy, caring, altruism, and compassion were often underdeveloped in medical students and doctors (Bhatia et al., 2013). In China, medical students were described to be lacking in humanistic concerns, humanistic knowledge (cultural, geographical, historical), and awareness of the importance of humanism education <\/span><span lang=\"EN-US\">(Liu &amp; Li, 2012)<\/span><span lang=\"EN-US\">.<\/span> A<span lang=\"EN-US\"> cross-sectional study of emergency physicians in Singapore found that they were perceived to be weak in humanistic traits including patient communication, holistic management, and professional relationship with colleagues <\/span><span lang=\"EN-US\">(Fones et al., 1998)<\/span><span lang=\"EN-US\">.\u00a0 There was a clear and pressing need to foster humanistic values in medical training in Asian medical schools <\/span><span lang=\"EN-US\">(Asai et al., 2007; Chiu et al., 2009; Hu, 2016; Saw, 2018; Song et al., 2017; Tokuda et al., 2008)<\/span><span lang=\"EN-US\">.<\/span><\/p>\r\n<p><i><span lang=\"EN-US\"><\/span><\/i><i><span lang=\"EN-US\">B. \u201cSeeking the Welfare of the Other\u201d: Unity Amidst Diversity of Meanings of Humanistic Values<\/span><\/i><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-US\">Studies on Asian medical humanism adopted definitions and frameworks from the West, such as the Gold Foundation\u2019s IECARES framework, and ABIM\u2019s charter of physician professionalism <\/span><span lang=\"EN-US\">(Chiu et al., 2009; Tsai et al., 2007)<\/span><span lang=\"EN-US\">. <\/span><span lang=\"EN-US\">However, the direct application of these definitions and frameworks in Asia has been questioned (Chiu et al., 2009; Wang et al., 2016)<\/span><span lang=\"EN-US\">{Chiu, 2009 #53}<\/span><span lang=\"EN-US\">. It has been recognised that the interpretations of medical humanism may vary due to the influence of local cultural, religious and philosophical systems, as well as difficulties<\/span><span lang=\"EN-US\"> in translating abstract concepts such as \u201cethics\u201d that have been derived from a Western context\u00a0 <\/span><span lang=\"EN-US\">(Ho et al., 2014; Pan et al., 2013; Qian et al., 2018; Zhang &amp; Cheng, 2000)<\/span><span lang=\"EN-US\">.<\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-US\">While Western notions of humanism dichotomised physicians\u2019 professional and personal lives, studies found that the collectivism imbued in East Asian physicians underpinned by Confucian cultural traditions blurred the lines between one\u2019s personal and societal roles <\/span><span lang=\"EN-US\">(Ho et al., 2014)<\/span><span lang=\"EN-US\">. Pan et al. (2013) commented that healthcare professionals in China considered the Western-derived term of \u201cethics\u201d as being external to the individual, and thus ranked it low on the list of desired professional values in deference to \u201cmoral character\u201d which was perceived to be more innate. The Confucian collectivistic slant could further be gleaned in concepts such as <i>guanxi<\/i> \u2013 the fostering of social relationships through the mutual exchange of favours, <i>renai <\/i>\u2013 \u201chumane love\u201d and <i>gongxin <\/i>or \u201cpublic-spiritedness\u201d. Traditional Chinese medical ethics, while influenced by two other major traditions \u2013 Taoism which leaned toward the pursuit of longevity, and Buddhism whose goal was the transcendence of the endless cycles of rebirth through non-attachment and garnering of merit, nonetheless had Confucianism as its core position <\/span><span lang=\"EN-US\">(Zhang &amp; Cheng, 2000)<\/span><span lang=\"EN-US\">. <\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-US\">While Jiang and Liu from mainland China proposed a narrative definition of humanistic medicine as <i>\u201can interdisciplinary science that synthesizes knowledge concerning medical philosophy, medical ethics, medical law, medical history, medical sociology, medical logic, and doctor-patient communication&#8221; <\/i><\/span><span lang=\"EN-US\">(Jiang &amp; Liu, 2014)<\/span><span lang=\"EN-US\">, Wong from Taiwan has proposed the same to be<\/span><span lang=\"EN-US\"> <i>\u201c[a service environment where] patient welfare, patient autonomy, and social justice take primacy, and [practitioners] offer charitable and dignified treatment\u201d <\/i><\/span><i><span lang=\"EN-US\">(<\/span><\/i><span lang=\"EN-US\">Wong et al., 2012<i>)<\/i><\/span><span lang=\"EN-US\">.<\/span><span lang=\"EN-US\"> <\/span><span lang=\"EN-US\">Among Asians of the Muslim tradition, Al-Eraky et al. (2014) described a four-gates model that pointed to four relationships the Muslim-Arab medical professional did well to align him\/herself with; these include right relationships with the <i>self<\/i> \u2013 self-awareness, with the <i>task-at-hand<\/i> \u2013 excellence and reflective practice, with <i>others<\/i> \u2013 respect of patients and team members, and with <i>God<\/i> \u2013 self-awareness and right relationship with the Divine<\/span><span lang=\"EN-US\"> <\/span><span lang=\"EN-US\">(Al-Eraky et al., 2014)<\/span><span lang=\"EN-US\">. Meanwhile, <\/span><span lang=\"EN-US\">the perspective of patients in Singapore and Israel while highlighting the importance of moral-humanistic traits such as empathy highly, nonetheless ranked professional expertise above all other traits <\/span><span lang=\"EN-US\">(Fones et al., 1998; Schattner et al., 2004)<\/span><span lang=\"EN-US\">.<\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-US\">Amid the broad differences in individual differences in how humanistic values were articulated regionally \u2013 for instance, the reference to collectivism in the East Asian context, and the reference to the divine in the Arab-Muslim context \u2013 these expressed how each sociocultural context sought that common humanistic goal of <i>\u201cseeking the welfare of the other.\u201d <\/i>We propose that the universal attributes of the IECARES framework <\/span><span lang=\"EN-US\">(Gold, 2018)<\/span><span lang=\"EN-US\"> arguably encompasses these values. <\/span><\/p>\r\n<p><i><span lang=\"EN-US\"><\/span><\/i><i><span lang=\"EN-US\">C. Humanistic Values in Medical Training<\/span><\/i><span lang=\"EN-US\"><\/span><\/p>\r\n<p><i><span lang=\"EN-US\"><\/span><\/i><i><span lang=\"EN-US\">1) Select for humanistic values:<\/span><\/i><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-US\">For medical admissions to successfully select candidates that would become humanistic <i>and <\/i>competent medical professionals at the end of training, any process for entry into medical school based narrowly on academic criteria was inadequate. Authors argued that <\/span><span lang=\"EN-US\">in addition to academic performance, medical admissions processes should include involvement in community work, extra-curricular activities, and the consideration of recommendation letters to better reflect the humanistic attributes of candidates that academic performance alone would not capture <\/span><span lang=\"EN-US\">(Chiu et al., 2009; Lee &amp; Ahn, 2004; Tokuda et al., 2008)<\/span><span lang=\"EN-US\"><\/span><\/p>\r\n<p><i><span lang=\"EN-US\"><\/span><\/i><i><span lang=\"EN-US\">2) An afterthought in planning:<\/span><\/i><i><span lang=\"EN-US\"><\/span><\/i><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-US\">As a non-traditional curricular item, the introduction of humanism learning activities into already heavily packed curricula would often be met with resistance and\/or inertia, be ranked lower in priority <\/span><span lang=\"EN-US\">(Rao &amp; Rao, 2007; Tokuda et al., 2008)<\/span><span lang=\"EN-US\"> and thereby poorly integrated into Asian medical school curricula <\/span><span lang=\"EN-US\">(Liu &amp; Li, 2012; Rao &amp; Rao, 2007)<\/span><span lang=\"EN-US\">. <\/span><span lang=\"EN-US\">When these existed in the curriculum, humanism courses were usually of short duration, offered as an elective <\/span><span lang=\"EN-US\">(Liu &amp; Li, 2012; Qian et al., 2018; Wang et al., 2016)<\/span><span lang=\"EN-US\">, and scheduled at unfavourable time slots <\/span><span lang=\"EN-US\">(Kosik et al., 2014; Notzer et al., 2005)<\/span><span lang=\"EN-US\">. Students were often hard-to-manage and poorly motivated <\/span><span lang=\"EN-US\">(Tsai et al., 2007; Woratanarat, 2014)<\/span><span lang=\"EN-US\">, and faculty would often have variable credentials <\/span><span lang=\"EN-US\">(Liu &amp; Li, 2012)<\/span><span lang=\"EN-US\">. Compounding this was the common experience of observing humanistic values being sidelined by busy healthcare providers on entering the workforce <\/span><span lang=\"EN-US\">(Tsai et al., 2007)<\/span><span lang=\"EN-US\">. <\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-US\">Caught where holistic care is valued. Humanistic values would be best caught in specialities that prioritised the holistic care of individuals and families such as Family Medicine. Authors lamented<\/span><span lang=\"EN-US\"> how<\/span><span lang=\"EN-US\"> paternalistic medical cultures <\/span><span lang=\"EN-US\">(Farooq et al., 2013)<\/span><span lang=\"EN-US\"> prioritised the draw of cutting-edge technologies and hospital specialities in the curriculum <\/span><span lang=\"EN-US\">(Akhund et al., 2014)<\/span><span lang=\"EN-US\"> over disciplines where humanistic biopsychosocial <\/span><span lang=\"EN-US\">(Engel, 1977)<\/span><span lang=\"EN-US\"> care was explicitly valued <\/span><span lang=\"EN-US\">(Biderman, 2003; Iqbal, 2010; Rao &amp; Rao, 2007)<\/span><span lang=\"EN-US\">.<\/span><\/p>\r\n<p><i><span lang=\"EN-US\"><\/span><\/i><i><span lang=\"EN-US\">3) Begin early, continue longitudinally:<\/span><\/i><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-US\">Asian medical educators generally agreed that learning humanistic values should start early, and continue into post-graduate education, with contextualisation of how these could be applied at different workplace settings\u00a0 <\/span><span lang=\"EN-US\">(Biderman, 2003; Karunakaran et al., 2017; Kosik et al., 2014; Qian et al., 2018; Singh &amp; Talwar, 2013; Wang et al., 2016)<\/span><span lang=\"EN-US\">. The Medical Council of India recommended that humanistic values be introduced in the early pre-clinical years to students who often harboured ideals and a sense of duty to their home communities before these sentiments waned with further training <\/span><span lang=\"EN-US\">(Karunakaran et al., 2017)<\/span><span lang=\"EN-US\">. These learning opportunities should then extend longitudinally into post-graduate years when values may be challenged in the face of real-world challenges in clinical practice <\/span><span lang=\"EN-US\">(Biderman, 2003; Singh &amp; Talwar, 2013; Wang et al., 2016)<\/span><span lang=\"EN-US\">.<\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-US\">\u00a04) <\/span><i><\/i><i><span lang=\"EN-US\">Learning methods: Experiences and reflection:<\/span><\/i><i><\/i><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-US\">A range of teaching methods has been tried in the attempt to impart humanistic values in Asia. In addition to lecture-<\/span><span lang=\"EN-US\">based learning, it was recommended that interactive experiential learning activities <\/span><span lang=\"EN-US\">where humanistic attributes were practised should be designed into the curriculum <\/span><span lang=\"EN-US\">(Wang et al., 2016)<\/span><span lang=\"EN-US\">. The Silent Mentor Program where students met and interacted with the families of human cadaver donors, listened to their narratives, and respectfully participated in culturally and religiously appropriate ceremonies, was an example of a successful program where students learnt to integrate humanistic values as they learnt about human anatomy <\/span><span lang=\"EN-US\">(Karunakaran et al., 2017; Rao &amp; Rao, 2007; Saw, 2018)<\/span><span lang=\"EN-US\">. Other teaching activities include the use of art in Hong Kong to prompt self-awareness and empathy <\/span><span lang=\"EN-US\">(Potash &amp; Chen, 2014)<\/span><span lang=\"EN-US\">,<\/span><span lang=\"EN-US\"> <\/span><span lang=\"EN-US\">the use of <\/span>film and <span lang=\"EN-US\">photography <\/span><span lang=\"EN-US\">(Kosik et al., 2014; Lee &amp; Ahn, 2004; Nakayama, 2009; Woratanarat, 2014)<\/span><span lang=\"EN-US\">, and training in communications skills that integrated interpersonal- and clinical- skills training\u00a0 <\/span><span lang=\"EN-US\">(Biderman, 2003; Kaga &amp; Asakage, 2007; Yazigi et al., 2006)<\/span><span lang=\"EN-US\">, narrative medicine <\/span><span lang=\"EN-US\">(Chiu et al., 2009)<\/span><span lang=\"EN-US\"> and community humanitarian work <\/span><span lang=\"EN-US\">(Chen &amp; Chou, 2015; Wang et al., 2016)<\/span><span lang=\"EN-US\">. Courses in the humanities and social sciences, such as history, literature, ethics, law, and medical social studies have also become part of some medical curricula; they provide insight into the human condition and have been successfully used to foster humanistic qualities in medical students <\/span><span lang=\"EN-US\">(Fones et al., 1998; Lee &amp; Ahn, 2004; Liu &amp; Li, 2012; Song &amp; Tang, 2017)<\/span><span lang=\"EN-US\">.<\/span> The<span lang=\"EN-US\"> co-design and co-facilitation of medical humanities course of home-faculty based basic scientists or clinicians <i>with<\/i> social scientist colleagues as opposed to having social scientists running a programme solo was a promising curriculum strategy that legitimised and contextualised the importance of learning the medical humanities <\/span><span lang=\"EN-US\">(Rider et al., 2014; Singh &amp; Talwar, 2013).<\/span><\/p>\r\n<p><i><span lang=\"EN-US\"><\/span><\/i><i><span lang=\"EN-US\">5) Mentorship and role-modelling crucial:<\/span><\/i><span lang=\"EN-US\"><\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-US\">Fostering strong and dedicated mentor-mentee relationships is crucial for the development of humanistic traits through positive role-modeling <\/span><span lang=\"EN-US\">(Bhatia et al., 2013; Islam et al., 2014)<\/span><span lang=\"EN-US\">. Positive attributes in mentors motivated learners to model their humanistic behaviour <\/span><span lang=\"EN-US\">(Bhatia et al., 2013; Chiu et al., 2009; Farooq et al., 2013; Islam et al., 2014; Singh &amp; Talwar, 2013)<\/span><span lang=\"EN-US\">, whereas negative behaviours in the informal and hidden curriculum constituted a formidable counter-influence <\/span><span lang=\"EN-US\">(Akhund et al., 2014; Salam et al., 2012; Wong et al., 2012)<\/span><span lang=\"EN-US\">. Authors highlighted the importance of faculty development where faculty learnt to internalise their responsibility as role models; strengthened awareness of their learner&#8217;s needs, expectations, and feelings; and recognised how as mentors they unwittingly enabled or hindered the positive development of humanistic attitudes among learners <\/span><span lang=\"EN-US\">(Biderman, 2003; Liu &amp; Cheng, 2017; Notzer et al., 2005; Rao &amp; Rao, 2007)<\/span><span lang=\"EN-US\">.<\/span><\/p>\r\n<p><i><span lang=\"EN-US\"><\/span><\/i><i><span lang=\"EN-US\">D. Program Evaluation: Need for Validated Tools<\/span><\/i><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-US\">A small number of articles in this review examined how humanism was evaluated in Asian medical schools. Most used self-assessment tools developed in Western contexts. For example, the Jefferson Scale of Physician Empathy (JSPE) has been validated in several Asian cultures and languages and has a version for medical students <\/span><span lang=\"EN-US\">(Mostafa et al., 2014)<\/span><span lang=\"EN-US\">. Taiwanese educators have translated and applied a 32-item self-administered questionnaire reflecting students\u2019 perception of seven characteristics of professionalism defined by the American Board of Internal Medicine, many of which overlap with humanistic traits <\/span><span lang=\"EN-US\">(Tsai et al., 2007)<\/span><span lang=\"EN-US\">. A novel instrument to measure students\u2019 perception of personal attributes including honesty, respectfulness, and compassion was developed and validated by Malaysian educators, which included both a Likert scale and open-ended questions <\/span><span lang=\"EN-US\">(Salam et al., 2012).<\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-US\">Few observer-rated and arguably more objective methods of humanistic behaviours were identified in this review. In a limited number of studies, the 360-degree peer evaluation was well received for evaluation of humanistic skills among physician trainees and residents <\/span><span lang=\"EN-US\">(Tham, 2007; Wang et al., 2016)<\/span><span lang=\"EN-US\">, whereas the Defining Issues Test (DIT) may be a better tool for medical students with little working experience <\/span><span lang=\"EN-US\">(Wang et al., 2016)<\/span><span lang=\"EN-US\">.<\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-US\">The need to develop validated methods to assess humanistic attributes was recognised, both to evaluate the effectiveness of teaching at the programmatic level <\/span><span lang=\"EN-US\">(Tsai et al., 2007)<\/span><span lang=\"EN-US\">, as well as to identify students who required remediation and guidance in their professional development\u00a0 <\/span><span lang=\"EN-US\">(Liu &amp; Cheng, 2017)<\/span><span lang=\"EN-US\">.<\/span><\/p>\r\n<p style=\"text-align: center\"><span lang=\"EN-GB\"><\/span><strong><span lang=\"EN-GB\">IV. DISCUSSION<\/span><\/strong><span lang=\"EN-GB\"><\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-US\">The current article presents a scoping review of peer-reviewed publications on humanism in Asian medical education. The four themes identified include the <i>need to strengthen<\/i> humanistic values among Asian medical students and physicians; the <i>challenge of finding a common conceptual framework<\/i> for operationalising humanistic values in Asia; <i>opportunities in medical school <\/i>to foster humanistic values at admissions, in curriculum planning, implementation within disciplines which teach holistic care, the use of different pedagogies, the role of mentorship, and fourthly the need for validated tools in <i>program evaluation.<\/i><\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-US\">This review encompassed a diversity of types of articles and broad geographical representation.<\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-US\">Several findings of this review resonate with international literature. Both Western and Asian literature highlighted the importance of imparting humanistic values in medical training <\/span><span lang=\"EN-US\">(Bombeke et al., 2010; Rios, 2016; Wald et al., 2015)<\/span><span lang=\"EN-US\">.<\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-US\">There was a lack of a common definition of humanistic medicine in this review, and that it was often conflated with other education concepts such as professionalism <\/span><span lang=\"EN-US\">(Cohen, 2007; Hauck et al., 1990; Thibault, 2019; Tsai et al., 2007)<\/span><span lang=\"EN-US\">. We found nonetheless that the Gold foundation\u2019s IECARES framework provided a broad enough scaffold to encompass the key notions of humanistic values in the Asian context. One of the key discrepancies between Asian and Western notions of humanism that surfaced in this review was that while humanistic medicine in the Western context often referred to a set of physician attributes, most commonly compassion, respect, and empathy toward patients, the therapeutic relationship in Asia may have distinct priorities. This would include the <\/span><span lang=\"EN-GB\">role of the patient in relation to his\/her family, community, and society given the more collectivistic stance of the Asian patient<\/span><span lang=\"EN-US\">. In addition, the notion of physician expertise may need to be more explicitly articulated <\/span><span lang=\"EN-US\">(Fones et al., 1998; Ho et al., 2014; Schattner et al., 2004)<\/span><span lang=\"EN-US\">. In addition, the notion of relationship with self and the divine was highlighted in the West Asian four doors framework that is not explicitly mentioned in IECARES.<\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-US\">Much like educators in the West, Asian educators in this review describe the challenges associated with teaching humanism alongside the existing rigorous medical curricula for acquiring scientific and clinical skills, which often overshadows the humanistic aspect of medical education <\/span><span lang=\"EN-US\">(Doran, 1983; Mostafa et al., 2014; Singh &amp; Talwar, 2013)<\/span><span lang=\"EN-US\">. Nevertheless, <\/span><span lang=\"EN-GB\">some of the current methods used to impart humanism in Asian medical schools show promise in improving students\u2019 humanistic attitudes. For example, medical-themed films were rated highly by students in their ability to enable understanding of humanistic and social aspects of medicine <\/span><span lang=\"EN-GB\">(Lee &amp; Ahn, 2004)<\/span><span lang=\"EN-GB\">, art-mediate learning increased students\u2019 empathy on the State Empathy Scale <\/span><span lang=\"EN-GB\">(Potash &amp; Chen, 2014)<\/span><span lang=\"EN-GB\">, and the Silent Mentor Program nurtured the sense of responsibility and compassion within students as shown in their personal reflections <\/span><span lang=\"EN-GB\">(Lin et al., 2009)<\/span><span lang=\"EN-GB\">. I<\/span><span lang=\"EN-US\">t remains a challenge for both Asian and Western medical educators to develop tools to objectively evaluate humanistic attitudes and behaviours <\/span><span lang=\"EN-US\">(Buck et al., 2015; Shrank et al., 2004; Wang et al., 2016)<\/span><span lang=\"EN-US\">, which would be valuable in both assessing the effectiveness of teaching methods as well as motivate trainees to foster an active learning attitude <\/span><span lang=\"EN-US\">(Pacifico et al., 2020)<\/span><span lang=\"EN-US\">.<\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-US\">Furthermore, methods to impart humanism must evolve along with students\u2019 level of medical training. A qualitative study conducted in Singaporean found that medical trainees at different stages of their training valued different types of teachers, preferring a didactic approach in their earlier years, in contrast to more role-modelling and feedback once they step into clinical practice <\/span><span lang=\"EN-US\">(Ooi et al., 2021)<\/span><span lang=\"EN-US\">.<\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-US\">This study has several limitations. Firstly, the term \u201chumanism\u201d and its conjugations were used in our search strategy to identify articles on humanistic attitudes and behaviours as a collective concept rather than its parts. However, there may be articles focused on one or more aspects of humanism education, such as empathy or compassion alone, which may not have been identified in the search. Furthermore, the inclusion criteria were constructed using Gold Foundation\u2019s \u2018IECARES\u2019 framework, while it was later revealed through inductive thematic analysis that culturally relevant definitions should be developed to explore humanism in Asian medical education. Secondly, only English language databases were searched, and foreign language articles were excluded for practical purposes. Thirdly, there were notable intra-continental differences between various Asian countries represented, and there were a larger proportion of articles from East Asia in this review with Confucianism-based cultural origins. As such, conclusions drawn from these regions may be internally similar but require further adaptation for regions with differing religious or cultural origins.<\/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-US\">Though Asia has been the cradle of many humanistic traditions since the dawn of civilisation, the explicit introduction of humanism education into the discourse of Asian medical schools is a recent phenomenon. This scoping review unveiled themes on key contentions around why, when, and how humanism should be integrated into the curriculum, and how this may impact the professional development of students, physicians and their relationship with their patients. Many of these topics are exciting areas of research that deserves greater attention.<\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-US\">Culturally validated frameworks and definitions of Asian medical humanism are lacking, and the agreed-upon frameworks may need to consider the sociocultural contexts of the different regions. What is clearly agreed upon is that the humanistic qualities of Asian medical students and physicians are in pressing need of improvement. Progress has been stifled by a slow start, the inertia from existing traditions that constrain changes, and differing opinions regarding the need for change. Various approaches to teaching humanism have been devised, such as elective humanities courses, participatory learning, mentorship, and the hidden curriculum. Authors called for improved quantity and quality of humanities courses, learning experiences outside of the classroom, and positive role-modeling in a longitudinal manner with constant integration back to the learner\u2019s evolving clinical setting.<\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-US\">The current review presents an exciting growing body of literature advocating for the development of medical humanism in Asia. Further research, especially longitudinal studies, is needed to evaluate medical school admission processes, teaching and evaluation strategies in the instillation of humanistic medicine in Asia. <\/span><\/p>\r\n<p align=\"center\" style=\"text-align: center\"><strong><span lang=\"EN-GB\">Notes on Contributors<\/span><\/strong><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-US\">TYP and VL designed and conceived the study. CZ and SL constructed search terms. CZ and RY conducted the literature review. CZ wrote the draft of the manuscript. CZ and VL co-edited the final draft. All authors have reviewed and approved 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-US\">Ethics approval is not application for this review, as it does not involve human subjects or data.<\/span><\/p>\r\n<p align=\"center\" style=\"text-align: center\"><strong><span lang=\"EN-GB\">Data Availability<\/span><\/strong><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-AU\">The manuscript\u2019s data is available at Figshare and may be accessed via the following public digital object identifier: <\/span><\/p>\r\n<ul style=\"text-align: justify\">\r\n\t<li><span lang=\"EN-US\"><\/span><span lang=\"EN-AU\">Coding Sheet<\/span><span lang=\"EN-AU\"> <\/span><span lang=\"EN-US\"><a href=\"https:\/\/doi.org\/10.6084\/m9.figshare.14245850.v1\">https:\/\/doi.org\/10.6084\/m9.figshare.14245850.v1<\/a><\/span><span lang=\"EN-US\"> <\/span><\/li>\r\n\t<li><span lang=\"EN-US\">Data Abstraction Sheet <\/span><span lang=\"EN-US\"><a href=\"https:\/\/doi.org\/10.6084\/m9.figshare.14245991.v1\">https:\/\/doi.org\/10.6084\/m9.figshare.14245991.v1<\/a><\/span><\/li>\r\n<\/ul>\r\n<p align=\"center\" style=\"text-align: center\"><strong><span lang=\"EN-GB\">Acknowledgement<\/span><\/strong><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-US\">The authors wish to thank Ms. Annelissa Chin Mien Chew for her assistance with search terms and database search. <\/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-US\">This research received no specific grant or funding from any agency in the public, commercial, or not-for-profit sectors.<\/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\">All authors certify that they have no affiliations with any organisation or entity with any financial or non-financial interest in the subject matter or materials discussed in this manuscript.<\/p>\r\n<p align=\"center\" style=\"text-align: center\"><strong><span lang=\"EN-GB\">References<\/span><\/strong><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-US\">Akhund, S., Shaikh, Z. 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Clinical teachers as role models: Perceptions of interns and residents in a Lebanese medical school. <i>Medical Education<\/i>,<i> 40<\/i>(7), 654-661. <\/span><span lang=\"EN-US\"><a href=\"https:\/\/doi.org\/10.1111\/j.1365-2929.2006.02502.x\">https:\/\/doi.org\/10.1111\/j.1365-2929.2006.02502.x<\/a><\/span><span lang=\"EN-US\"><\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-US\">Zhang, D., &amp; Cheng, Z. (2000). Medicine is a humane art. The basic principles of professional ethics in Chinese medicine. <i>The<\/i> <i>Hastings Center Report<\/i>,<i> 30<\/i>(4), S8-S12.<\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-US\">Zhu, C., Yap, R., Lim, S., Toh, Y., &amp; Loh, V. (2021a). <i>Coding sheet (Humanism in Medical Education \u2013 A Scoping Review) <\/i>[Data set]. Figshare.\u00a0 <\/span><span lang=\"EN-US\"><a href=\"https:\/\/doi.org\/10.6084\/m9.figshare.14245850.v1\">https:\/\/doi.org\/10.6084\/m9.figshare.14245850.v1<\/a><\/span><span lang=\"EN-US\"><\/span><\/p>\r\n<p style=\"text-align: justify\"><span lang=\"EN-US\">Zhu, C., Yap, R., Lim, S., Toh, Y., &amp; Loh, V. (2021b). <i>Data Abstraction Sheet for Thematic Analysis (Humanism in Medical Education &#8211; A Scoping Review) <\/i>[Data set]. Figshare. <\/span><span lang=\"EN-US\"><a href=\"https:\/\/doi.org\/10.6084\/m9.figshare.14245991.v1\">https:\/\/doi.org\/10.6084\/m9.figshare.14245991.v1<\/a><\/span><\/p>\r\n<p><span lang=\"EN-NZ\"><span lang=\"EN-AU\">*<span lang=\"EN-US\">Cindy Shiqi Zhu<\/span><br \/>\r\n<span lang=\"EN-US\">National University Health System,<\/span><br \/>\r\n<\/span><span lang=\"EN-AU\"><span lang=\"EN-US\">1E Kent Ridge Road<\/span>,<br \/>\r\n<span lang=\"EN-US\">Singapore 119228<\/span><br \/>\r\n<span lang=\"EN-US\">Email: Shi_Qi_ZHU@nuhs.edu.sg<\/span><br \/>\r\n<br \/>\r\n<\/span><\/span><\/p>","protected":false},"featured_media":0,"parent":0,"menu_order":3,"template":"","issues_category":[16],"archive_category":[],"issue_type":[25],"volume_category":[61870],"class_list":["post-71190","issues","type-issues","status-publish","hentry","issues_category-review-article","issue_type-past-issue","volume_category-volume-7-number-1-january-2022"],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v26.4 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>Humanism in Asian medical education - A scoping review - 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\/humanism-in-asian-medical-education-a-scoping-review\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Humanism in Asian medical education - A scoping review - The Asia Pacific Scholar\" \/>\n<meta property=\"og:description\" content=\"Submitted: 1 March 2021 Accepted: 13 September 2021 Published online: 4 January, TAPS 2022, 7(1), 9-20 https:\/\/doi.org\/10.29060\/TAPS.2022-7-1\/RA2460 Cindy Shiqi Zhu1, Ryan Kye Feng Yap2,3, Samuel Yong Siang Lim2,3, Ying Pin Toh2,4 &amp; 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