Constructing a medical humanistic competency framework for medical undergraduate students in China: a grounded theory approach

Grounded theory methodology

Our research is based on the Charmaz’s constructive philosophical perspective [16], which asserts that new knowledge is actively constructed and the value of the embedded researcher acknowledged. We also acknowledge that knowledge is intimately linked to its context [17], 18]. Therefore, readers are encouraged to draw locally relevant inferences in light of the cultural and context-dependent complexities within the field of MHC.

A grounded theory methodology (GTM) was employed within a qualitative design framework to conduct coding and analysis, aiming to provide a qualitative perspective on the dimensions of medical humanistic competence. The primary data collection involved semi-structured interviews and document analysis, followed by inductive analysis using different GTM coding techniques, such as simultaneous data collection, constant comparison, memo writing [19], and coding, until theoretical saturation was achieved [20], 21]. This meticulous and iterative process not only yielded valuable insights but also facilitated a comprehensive understanding of MHC.

Data collection and sampling

From December 2022 to March 2023, we utilized purposive and theoretical sampling methods to recruit clinical educators and medical undergraduates from 10 medical universities in China [22]. For the clinical medical educators, the selection criteria included: (1) engagement in clinical medicinal practice and teaching, and (2) a minimum of two years of experience working in a hospital. Clinical educators without Chinese clinical doctor qualifications or teaching certification were excluded. As for the medical undergraduates, the inclusion criteria were: (1) being senior clinical medical undergraduates in their fifth year in China with a deeper understanding of medical humanities, and (2) having practiced in a clinical setting for more than three months. Data collection involved conducting semi-structured interviews with participants in various formats, including face-to-face and online video interviews, based on the preferences of each interviewee. The interviews were conducted in a comfortable and safe setting.

The interviewer was a female medical researcher who held a Doctor of Education (Ed.D) degree. Prior to this study, she received comprehensive training in qualitative research and had accumulated extensive experience in conducting interviews. The first and co-first author transcribed the audio recordings within 24 h after each interview to facilitate further analysis.

In-depth interview implementation

The effectiveness of these interviews largely depends on the interviewers’ ability to ask appropriate questions. To ensure the quality of the research, specific interview guidelines focusing on the research question have been designed. The interview outline includes the following questions: (1) What behaviors exhibited by a physician make you think that they are competent in medical humanistic skills? (2) Which medical humanities abilities are currently being cultivated through medical humanities education? In what areas do improvements need to be made? (3) What essential humanistic competencies should medical undergraduate possess? (4) What are the most important humanistic competencies that should be taught in medical schools? (5) Please provide a detailed description of a key event during your clinical practice where you utilized your humanistic competencies. By utilizing these interview guidelines, we aimed to gather valuable insights and data on the topic at hand.

Semi-structured interviews were conducted with the interviewee’s consent. Theoretical sampling pinpointed 32 participants from 10 universities across seven Chinese provinces, encapsulating 22 clinical medical educators, and 10 senior medical undergraduates. Verbal informed consent preceded each interview, which lasted between 1.5 and 2.0 h. Supplementary data were gleaned from direct or virtual participatory teaching observations and associated teaching blueprints, serving as triangulation evidence. These 32 co-researchers were involved in multiple interview rounds, adhering strictly to qualitative research standards. Participant details are enumerated in Table 1.

Data analysis

Thematic analysis of the primary data was conducted using the tri-level coding methodology of grounded theory. The process involved initially organizing, distilling, and synthesizing textual information that was relevant to the structure of medical undergraduates’ humanities competency. Figure 1 illustrates the data collection and analysis process.

Figure 1:

Data collection and analysis process.

In the “open coding” stage, the raw data was carefully deconstructed, examined, compared, and categorized. Categories emerged and concepts were refined through line-by-line and sentence-by-sentence coding, utilizing the original terms employed by the interviewees. Continuous comparison during the iterative process resulted in the abstraction of themes such as respect, empathy, narrative discourse, and therapeutic acknowledgment. From the interviews conducted with 32 participants, a total of 28 concepts were identified. During the “axial coding” stage, the objective was to discern and formalize relationships between established concepts and categories, showcasing their interplay. The 28 identified concept were grouped into five sub-categories: MHC, effective expression, therapeutic recognition, ethical compliance, and narrative competence. Moving to the “selective coding” stage, the aim was to identify core category and develop preliminary theories by linking the core category with ancillary ones. The comprehensive transcripts revealed four dimensions: comprehension of humanities, communication capacity, cooperation skill, and concern for “LEE” (law abidance, ethical reasoning, and emotional care).

Verification of theoretical saturation

Our iterative approach to data collection and interviewing ensured that the main categories remained consistent, with no novel categories emerging. This consistency demonstrated that our research had achieved theoretical saturation [23].

Ensuring study integrity

We implemented three strategies to bolster the study’s credibility.

1. Peer reviewing: Initial coding was executed by a primary researcher and scrutinized by another. Discrepancies were addressed by emphasizing the interviewee’s original language to enhance reliability.

2. Feedback mechanism: Preliminary findings were shared with peers and colleagues. Feedback from six academic experts on our initial coding results informed necessary refinements.

3. Triangulation: Data from interviews, observations and archival were juxtaposed and cross-verified. This multiple sourcing ensured a comprehensive understanding of the research data, strengthened the evidence base for our conclusions, and enhanced the credibility of our findings.

Furthermore, we drew upon reflexive grounded theory model to buttress both the study’s reliability and validity [24].

Category 1 – comprehension of humanities: medical humanities concept, medical humanities cognition, and medical humanities expression

The comprehension of humanities dimension is defined as espousing a balanced appreciation of both the scientific and humanistic facets of medicine, encapsulated within the holistic health humanities; understanding the basic connotation, value, and significance of medical humanities, and transforming one’s own cognition of medical humanities and the medical humanistic concept into medical humanistic practice. The results of the coding showed that the understanding of humanities dimension includes three sub-categories.

Category 2 – communication capacity: interpersonal communication, multi-dimensional narration, and cross-cultural communication

Communication capacity is essential for medical students, constituting an amalgamation of knowledge, abilities, and attitudes ensuring effective communication. This skillset is multi-faceted, encapsulating language proficiency, narrative aptitude, reading proficiency, writing capabilities, cognitive insights, and socio-emotional adeptness. The coding results showed three sub-categories of communication skills.

Category 3 – cooperation skill: team-building skills, interdisciplinary collaboration, and shared problem-solving

Cooperation skill in medical education refers to the ability of medical students and professionals to effectively collaborate and work together in a healthcare setting to provide optimal patient care. It encompasses three key aspects.

Category 4 – concern for “LEE”: law abidance, ethical reasoning, and emotional consideration

The acronym “LEE” represents the integration of three crucial elements in the provision of medical services: law abidance, ethical reasoning, and emotional care. The concept of concern for “LEE” emphasizes the deep and inseparable integration of medical humanities with medical science. It showcases a distinct humanistic approach to medical thought and practice, highlighting the significance of integrating legal, ethical, and emotional aspects in patient care [26], [27], [28]. This integration can be further classified into three distinct subcategories.

Quality analysis of developing a model of MHC

The study aimed to develop a middle-range theory of MHC model for medical undergraduates, utilizing a systematic application of grounded theory methodologies for synchronous data acquisition, analysis, and abstraction of theoretical concepts. Sample selection aligned with theoretical needs, adopting the grounded theory’s theoretical sampling technique. This iterative process continued until reaching theoretical saturation, where no fresh insights emerged. The research findings are deeply rooted in the raw and triangulation verification data. The entire analysis process was data-driven in a “bottom-up” way, which allowed the codes and themes to emerge inductively from the data [31]. Although face-to-face interviews were the primary data source, the research embraced a multi-faceted approach, incorporating diverse data such as observations, documents, articles, charts, and more. This diversified data pool enriched the conceptual generation related to Chinese medical students’ MHC, ensuring the resultant theory’s relevance and robust explanatory strength. Employing feedback methods, among others, ensured the research’s credibility and validity. As a result, the framework presented exhibits a commendable level of reliability and applicability.

The unique trait of the MHC model within Chinese culture context

Within the Chinese cultural context, the MHC model exhibits several distinctive traits. One notable trait is its integration with the competency model of medical undergraduates. This interconnection highlights the significance of MHC as a professional competence, emphasizing its essential role in the comprehensive development of medical students. Additionally, the MHC model is shaped by distinct Chinese cultural attributes. These attributes recognize the importance of cultural sensitivity and empathy in patient care. Chinese culture places great emphasis on harmony, respect, and interpersonal relationships. As such, the MHC model incorporates these values into its framework, emphasizing the need for medical undergraduates to cultivate effective communication skills, empathy, and cultural understanding. Furthermore, the MHC model acknowledges the importance of humanistic education in medical training. It emphasizes the need for a specialized and scientific approach to medical humanities education. This approach aims to deepen medical students’ understanding of the social, cultural, and ethical dimensions of healthcare, enabling them to provide more comprehensive and patient-centered care. By integrating these unique traits, the MHC model within the Chinese cultural context contributes to the cultivation of well-rounded and culturally competent medical professionals. The “4C” framework (comprehension of humanities, communication capacity, cooperation skills, and concern for “LEE”) represents a distinctive Chinese approach to medical humanities education that both complements and contrasts with Western models like CanMEDS (representing for communicator, collaborator, leader, health advocate, scholar, and professional) and ACGME (representing for patient care, medical knowledge, interpersonal and communication skills, professionalism, practice-based learning and improvement, and systems-based practice) in three significant aspects. Structurally, it moves beyond the role-based compartmentalization of Western frameworks by organically integrating narrative medicine, legal-ethical-emotional reasoning, and interdisciplinary collaboration into a unified system – reflecting China’s holistic medical philosophy. Culturally, it embeds Confucian values like ren (benevolence) and physician-patient harmony into its core competencies, offering a collectivist counterpoint to Western individualism. Practically, its innovative legal-ethical-emotional dimension addresses the unique demands of family-centered decision-making prevalent in Chinese clinical contexts. These culturally-grounded innovations provide valuable alternative perspectives while maintaining constructive dialogue with global medical education standards.

The “4C” framework offers several contributions in the field of medical humanities

The “4C” framework makes significant contributions to the field of medical humanities. Firstly, the model provides a comprehensive competency structure, presenting an inclusive framework that meticulously categorizes competencies within medical humanities into well-defined and explicit dimensions. This systematic categorization facilitates the methodical instruction, acquisition, and evaluation of these competencies. The framework expands the understanding and scope of medical students’ communication skills by incorporating narrative medicine as a multi-dimensional narrative competence and incorporating multi-dimensional storytelling into the communication skills dimension. Additionally, it innovatively integrates legal, ethical, and emotional reasoning into the core dimension of “LEE,” viewing it as a form of medical humanistic thinking and action. Secondly, the “4C” framework emphasizes the importance of integrating medical humanities into clinical education and practice. It recognizes medical humanities as a fundamental component of healthcare professional education and highlights its role in enhancing patient-centered care and communication. Thirdly, the framework promotes interdisciplinary collaboration in the field of healthcare. It emphasizes the significance of effective communication and collaboration among healthcare professionals, patients, families, and other members of the healthcare team. This collaborative approach improves patient care outcomes and contributes to a more holistic and compassionate healthcare environment. Fourthly, the “4C” framework recognizes the diverse cultural and social aspects of healthcare. It highlights the need for medical professionals to understand and appreciate cultural diversity, as well as the ability to navigate ethical dilemmas and provide culturally sensitive care. Overall, the “4C” framework adopts a holistic systems approach to construct a structural model of medical humanities literacy for medical students. It offers valuable insights and guidelines for developing medical humanities competence, promoting patient-centered care, facilitating interdisciplinary collaboration, and addressing cultural and ethical complexities in healthcare. This theory contributes to a more comprehensive understanding of medical humanities education and can have an impact on fields such as medical education. By incorporating these principles into medical education, this framework has the potential to elevate the medical profession to new heights, ensuring that healthcare professionals are well-rounded and capable of providing holistic care to their patients [31].

The “4R” approach for cultivating competencies

A method to enhance MHC among medical students was suggested based on the established theoretical MHC model. This approach encompasses four fundamental principles: rules, relevance, responsiveness, and reflective practice.

“Rules” underscores the adoption of the MHC theoretical model as the foundational framework guiding the implementation of medical humanities education. “Relevance” addresses the need to anchor the educational content of medical humanities, both in classroom and practical settings, to the MHC model. This principle stresses that medical humanities educational initiatives should align with societal expectations and patient needs. “Responsiveness” calls for the continual evaluation and refinement of medical students’ MHC by medical institutions, advocating for ongoing assessments and corresponding adjustments to educational activities based on these evaluations. Lastly, “reflective practice” advocates for the incorporation of reflective exercises – such as journaling, peer discussions, and ethical dilemma analysis – to promote self-awareness and ethical reasoning, thereby enabling medical undergraduates to better their MHC and deliver more compassionate care. The “4R” approach ensures that medical humanities education is in concert with the MHC theoretical framework, with an emphasis on relevance, continuous responsiveness to evolving societal needs, and dynamic adjustments within the medical field [32], 33].

This study verified the effectiveness of the “4C”–“4R” co-cultivation mechanism through typical clinical cases. Taking “tumor condition notification” as an example in humanistic teaching for medical students, the approach integrates medical narrative theory (understanding), SPIKES communication guidelines (communication), and multi-role simulation exercises (cooperation), and ethical reflection reports (“LEE” care). It also involves dynamic adjustments to training content (responsiveness) based on monthly patient satisfaction surveys. This comprehensive training chain significantly improved the excellent rate in humanistic literacy evaluations among medical students and reduced the incidence of medical disputes. This empirical study confirmed the “4R” strategies systematically support the cultivation of “4C” capabilities, which is highly consistent with existing theoretical models.