In the current study, we demonstrated that students' performance in medical humanities and the number of medical humanity courses taken by students was positively associated with clinical course performance, clerkship performance, and weighted average mark. To the best of our knowledge, this study is the first to predict medical students' academic and clinical performance by quantifying medical humanities courses in Asia. In contrast to the influences of philosophical concepts described by Aristotle, Plato, and Socrates on educational institutions in Western countries, the education system in the East Asian cultural sphere, including Taiwan, is strongly influenced by Confucianism, which particularly emphasizes the importance of the family and social harmony. Our study proves that medical humanities are as effective in East Asian cultures. We found that compared with the number of medical humanities courses, the quality of medical humanities courses showed a greater association with medical students’ clinical and academic performance. Consequently, an appropriate number of humanities medicine courses may be included in the curriculum at medical schools to reinforce medical students' performance in the future.
The definition and precise role of the humanities in medical education, whether at the premedical, medical school, or postgraduate level, remain controversial[9]. There is even a claim that the value of the humanities cannot and should not be measured[10]. However, the role of medical humanities in cultivating compassionate practice among physicians is gaining appreciation, particularly in the context of current concerns about the wellbeing of health care professionals, medical students, and other practitioners[11]. Several studies have been conducted on the positive influence of medical humanities on certain characteristics, such as personality traits, using questionnaires or online surveys[12, 13]. Nevertheless, the potential bias in questionnaire research is a limitation[14], and these studies on the impact of medical humanities courses inevitably lack robust and comprehensive support. As a result, a comprehensive assessment of the medical humanities is needed. In this study, we analyzed objective humanities course grades and found that medical humanities education positively correlated with clinical performance and academic performance. A study conducted at Harvard University also reached a similar conclusion[6]. Nevertheless, the study predicted clinical performance during the internship phase based on the learning performance of a single medical humanities course, whereas in the present paper our findings are more generalizable and representative as more comprehensive and complete MHC grades were evaluated. A 2019 study evaluated the effects of holistic preclinical education on clerkship performance and found similar results[15]. In addition, we further quantified the impact of the number of medical humanities courses taken by a student on the student's future performance. However, as shown in supplement 1, we found that students who take more than five MHC performed worse than those who take less MHC. Instead, the appropriate number of humanities courses and better quality of MHC were related to better clinical and academic performance of students. This result may be due to tight study schedules, which leave little time to develop personal hobbies or to take part in extracurricular activities to deal with stress. This is a cause of concern as high prevalence of stress among medical students may impair the behavior of students, diminish learning, and ultimately affect patient care after their graduation.
It is noteworthy that no association between the adjusted number of humanities courses and clinical course performance, assessed by written examination, was observed. Combined with the fact that performance of clerkship was better in the group with a higher adjusted number of humanities courses, this finding indicates that medical humanities courses had greater influence on clinical performance. This result also shows that the medical humanities are essential for practicing the six-core medical education proposed by ACGME, including patient care, medical knowledge, interpersonal communications, professionalism, practice-based learning and improvement, and systems-based practice. A qualified physician needs to have knowledge about treating diseases, and should also possess humanistic qualities. Some studies support our results. Gordon et al. showed that medical humanities can overcome the separation of clinical care from the "human sciences" and foster interdisciplinary teaching to optimize patient care through a more holistic approach[16]. Moreover, diverse medical humanities curriculum such as arts and sports activities could help to prepare students for challenging cases and lectures[17, 18]. Another report revealed that taking medical humanities courses may provide much-needed opportunities for self-reflection about the intensive process of becoming a physician and may ease feelings of isolation or burnout[19]. This is essential as it has been shown that burnout is a significant challenge during the early training years of residency and is influenced by time demands, lack of control work planning, work environment and setting, inherently difficult job situations, and interpersonal relationships[20].
In the present study, we also evaluated the impact of different confounding factors, such as gender, residential area, age at enrollment, type of administration, and length of schooling, on our outcomes. A diversified analysis allows the possibility of customizing medical humanities education to maximize the benefits. Our results showed that male gender was a negative predictor for weighted average mark, clinical course performance, and clerkship performance. This may be explained by higher self-efficacy in males than in females, which has been reported previously in medical students[21, 22]. The impact on medical school performance of gender-related differences in self-efficacy, and possibly also in emotional responses, may be an interesting area for further research, especially as previous research has shown relationships between self-efficacy, achievement emotions, and academic performance[23]. Furthermore, several studies concluded that females performed better than their male counterparts in interpersonal skills and were more patient-centered[24, 25]. The length of the medical school curriculum in Taiwan has been shortened from seven to six years since 2013, and this special experience of medical curriculum reform provides a useful window to observe its impact on medical education. In addition to strengthening clinical training and improving educational outcomes based on the theory of ‘learning-by-doing theory’[26], the curricular reform is also relevant to the gray area of implementing medical interventions during internships. It is interesting to note that students who received seven-year medical education had a better performance in clerkship performance when compared with six-year medical students. The better performance in clerkship may be due to more experience of patient care and clinical practice, and may also be related to the better performance in humanities courses in seven-year students, as shown in Table 1. However, it is worth noting that the shorter medical school curriculum may not seem to interfere with students’ clinical competence development. Recently, a study conducted in Taiwan demonstrated that medical students studying a shorter curriculum had lower objective structured clinical examinations(OSCE) scores at the beginning of their internship, but there were no differences between 6- and 7-year curricula outcomes after the internship training[7]. The main reason for these results may be the ceiling effect, since OSCE is a standardized examination, which is much more predictable than actual clinical situations and hence the measurable variance was smaller. Moreover, our results did not show a significant difference when residential area was included as a confounding factor on a student’s performance, which is surprising as rural schools may struggle with a host of challenges, including a lack of necessary resources and difficulty in attracting and retaining teacher talent[27]. This result may be explained by the fact that Taiwan is a highly urbanized country, and the gap between urban and rural areas is not especially obvious[28]. Nevertheless, after controlling for several confounding factors, we indeed proved that the quality and quantity of medical humanities courses were independently associated with medical students’ performance.
Our study had several limitations. First, the sample comprised only one cohort of medical students from a single medical school in Taiwan, which may limit the generalizability of our results. Second, some scholars argue that humanities performance cannot be quantified numerically[10]. Consequently, we should interpret our results carefully since medical humanities education focuses on the process of establishing self-values, and it takes time to develop and internalize these concepts. Therefore, our assessment time points may not be optimal. Third, this article does not address the impact of medical humanities courses on postgraduate medical students, such as PGY or residency performance. Fourth, since many MHCs are elective courses, there was inevitably some potential selection bias in this study. Nevertheless, it is worth noting that some MHCs were already included as required courses in the recent curriculum reform. However, it is impossible to create a randomized controlled trial for comparing differences between medical humanities courses due to ethical issues. A more in-depth exploration to identify possible relevant humanities courses is warranted in future research.