Huang et al.

BMC Medical Education (2017) 17:85

DOI 10.1186/s12909-017-0925-0

RESEARCH ARTICLE Open Access

Different perceptions of narrative medicine

between Western and Chinese medicine
students
Chien-Da Huang1,2,3*, Kuo-Chen Liao1,2,4, Fu-Tsai Chung3, Hsu-Min Tseng1,8, Ji-Tseng Fang5, Shu-Chung Lii9,
Han-Pin Kuo3, San-Jou Yeh2,6 and Shih-Tseng Lee7

Abstract
Background: Western medicine is an evidence-based science, whereas Chinese medicine is more of a healing
art. To date, there has been no research that has examined whether students of Western and Chinese medicine
differentially engage in, or benefit from, educational activities for narrative medicine. This study fills a gap in current
literature with the aim of evaluating and comparing Western and Chinese Medicine students’ perceptions of
narrative medicine as an approach to learning empathy and professionalism.
Methods: An initial 10-item questionnaire with a 5-point Likert scale was developed to assess fifth-year Western
medical (MS) and traditional Chinese medical (TCMS) students’ perceptions of a 4-activity narrative medicine
program during a 13-week internal medicine clerkship. Exploratory factor analysis was undertaken.
Results: The response rate was 88.6% (412/465), including 270 (65.5%) MSs and 142 (34.5%) TCMSs, with a large
reliability (Cronbach alpha = 0.934). Three factors were extracted from 9 items: personal attitude, self-development/
reflection, and emotional benefit, more favorable in terms of enhancement of self-development/reflection. The
perceptions of narrative medicine by scores between the two groups were significantly higher in TCMSs than MSs
in all 9-item questionnaire and 3 extracted factors.
Conclusions: Given the different learning cultures of medical education in which these student groups engage,
this suggests that undertaking a course in Chinese medicine might enhance one’s acceptance to, and benefit from,
a medical humanities course. Alternatively, Chinese medicine programmes might attract more humanities-focused
students.
Keywords: Narrative medicine, Perception, Medical students, Chinese medicine, Learning culture

Background notion, [4, 5] many argue that medicine requires physi-

Following advances in medical informatics and technol- cians to establish narrative connections and dive deep into
ogy, nowadays medicine as science for practicing is much the crying soul of the patient [1, 6].
easier than medicine as an art for healing [1, 2]. However,
medicine is not merely the taking of a comprehensive his-
tory, physical examination, diagnostic workup and the Narrative medicine
final discussion about a plan for action [1, 3]. Although Rita Charon first used the phrase “narrative medicine”
some academics have contested the universality of the in 2000 to refer to clinical practice fortified by narrative
competence [7]. Narrative medicine is medicine per-
formed with narrative skill and offered as a model for
* Correspondence: cdhuang@adm.cgmh.org.tw
1
Chang Gung Medical Education Research Center, Chang Gung Memorial humanism and effective medical practice, illuminating
Hospital, Chang Gung University, College of Medicine, 199 Tun Hua N. Rd, medicine’s crucial narrative relations: physician and pa-
Taipei, Taiwan tient, physician and self, physician and colleagues, and
2
Department of Medical Education, Chang Gung Memorial Hospital, Chang
Gung University, College of Medicine, Taipei, Taiwan physicians and society [6, 8]. Such narrative skill can be
Full list of author information is available at the end of the article developed through engaging in one’s own narrative
© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Huang et al. BMC Medical Education (2017) 17:85 Page 2 of 8

reading and writing episodes, particularly through ex- synthetic approach. Chinese medicine, however, lacks
pressive writing: “Building a narrative, then, may be proper diagnostic tools, whereas Western medicines’
critical in reaching understanding or knowledge” [9]. strength is its powerful diagnostic ability [22]. Thus,
The development of narrative skill can also include lis- Western medicine is based on standards and evidence,
tening to stories of patients, self- reflection, and reflec- with Chinese medicine relying on experience over time
tion on the profession as a whole, or even on society as through numerous trials and clinical observations [22, 23].
a whole [8, 10]. In short, while Western medicine is a standardized and
For physicians, narrative medicine is therefore thought evidence-based science, Chinese medicine is experience-
to be a good way to understand the personal connections based and more of a healing art [22].
between themselves and their patients [6]. It is believed to
help physicians recognize, interpret, and be moved to ac-
Traditional features of Chinese medicine
tion by the problems of others and develop confidence
The ancient medical scientists within traditional Chinese
and competence while identifying the conflicts they face
medicine explain the phenomenology of human physi-
[6]. Narrative medicine practitioners assert that physicians
ology, pathology-based Yin and Yang and summarize the
are able to link to their patients with narrative compe-
medical experience. Chinese medicine has taken the hu-
tence; further understanding their own personal journeys
man body as a whole, from the key concepts of “qi,
through medicine; recognise empathy with, and responsi-
blood, yin-yang, viscera (Zang-Fu), and meridian and
bilities toward, other health care professionals; and en-
channel”, rather than a single cell or a particular organ
gaging in meaningful discussions with the public about
[23]. In Chinese medicine, disease is not viewed as some-
health care [11]. By connecting physicians to patients, col-
thing that a patient has, but something that the patient is.
leagues and society, narrative medicine is thought to pro-
Disease is considered as an imbalance in the patient’s be-
vide new opportunities for respectful, empathic, and
ing. There is only a whole person whose body functions
nourishing medical care [12–14].
may be balanced or imbalanced, harmonious or disharmo-
nious. Thus, understanding the nature of the imbalance is
Medical students’ reactions to narrative medicine
the goal of diagnosis, while restoring balance is the focus
Research suggests that there is a benefit for physicians-
of treatment [22]. This suggests that people studying
in-training and surgical residents to engage patients, to
Chinese medicine might therefore have a different world-
elicit their story in the context of illness and to under-
view than those studying medicine within a Western
take reflection through narrative writing [15, 16]. Fur-
framework, and this world-view might impact on how
thermore, medical students believe narrative medicine to
they engage with different aspects of their curricular, in-
be an important, effective, and counter-cultural means
cluding narrative medicine activities.
of enhancing their communication, collaboration, and
This study aims to fill the gap in current literature by
professional development by supporting complex inter-
comparing Western and Chinese Medicine students’ per-
ior, interpersonal, perceptual and expressive capacities
ceptions of narrative medicine as an approach to learning
[17, 18]. Indeed, an experiential narrative medicine cur-
empathy and professionalism. We specifically asked the
riculum for medical students involving patient storytell-
following research question: Are there any differences in
ing and group reflection was found to be feasible and
the perception of a narrative medicine programme be-
acceptable to both patients and students, with some pa-
tween Western and Chinese Medicine students during a
tients and students being profoundly moved by the experi-
pre-doctor clerkship?
ence [19]. However, studies examining the impact of
narrative medicine training have predominantly been con-
ducted within a Western medicine perspective, even when Methods
the research context itself comprises a non-Western set- Context
ting [20]. Furthermore, even research that includes a mix- The context of this study is a large teaching hospital in
ture of students studying Western and Chinese medicine Taiwan. Western medical students (MS) have a 7-year
has failed to examine differences between these two undergraduate programme [24]. During the first 2 years,
groups [21]. As such we do not know whether the concept they not only have fundamental courses that provide an
of narrative medicine will be equally well received across introduction to medicine, but they also have courses re-
these different medical cultural contexts. lated to general education, such as information technol-
ogy, art and literature. In the following 2 years, they
Differences between Western and traditional Chinese have the opportunity to learn further medical skills and
medicine knowledge. From Year 5, students have an opportunity
Western medicine uses a reductive and analytical ap- to apply the knowledge they have gained in practice:
proach, while Chinese medicine uses an inductive and each student completes a 2-year clerkship and a 1-year
Huang et al. BMC Medical Education (2017) 17:85 Page 3 of 8

internship in hospitals so they can master all the re- physician-patient communication into practice thus
quired techniques and know-how of patient care. facilitating a better understanding of patients.
Traditional Chinese medical students (TCMS) have Activity 4: This comprises a small group discussion
an 8-year undergraduate programme. The characteristic between 6 and 8 medical students and one clinical
of the Department of Traditional Chinese Medicine is teacher facilitator. In this one-hour activity, each student
the teaching of both Chinese and Western medicine. reads his or her narrative writing assignment, reflects on
The courses offered include Basic Education, General the experiences of their patient encounter and receives
Education, Basic Education of Chinese and Western feedback from peers and the facilitator. The performance
Medicine, Clinical Education of Chinese and Western of each student is assessed by the modified REFLECT
Medicine, Practice of Western Medicine (7th year), and (Reflection Evaluation For Learners’ Enhanced Competen-
Practice of Chinese Medicine (8th year). In order to de- cies Tool) Rubric [27].
velop the students’ life-long learning ability, problem Four hundred and sixty five medical students compul-
oriented teaching is added to the courses in coordin- sorily participated in this 4-activity narrative medicine
ation with the General Education. This course focuses program during a 13-week clerkship of internal medicine
on the nurture of personalities with the aim of develop- during the 2012–2014 academic years.
ing excellent doctors with ability and moral integrity in
a combination of both Chinese and Western medicine. Study methods and participants
Thus, when they are in a practice environment, they A three-cohort cross-sectional questionnaire study design
are more aware of the health attitudes of their patients was used. The questionnaire comprised a 10-item survey
from different ethnic backgrounds, leading to a better instrument administered using a 5-point Likert scale
patient-doctor relationship and better adherence with (strongly disagree to strongly agree). Ethical approval was
treatment [25]. obtained from the Chang Gung Memorial Hospital and
The narrative medicine model was introduced into the Chang Gung University Institutional Review Boards (IRB
clerkship program of 5th-year clerks, for both MSs and No. 102-4138B, No.103-1755B, 105-2716C, 106-1287C)
TCMSs. Using a narrative approach, clerks write about and participation in the study was voluntary.
daily clinical events and encounters, their struggles and
their accomplishments without the critical eye of the Questionnaire development
preceptor, the attending or their seniors. The survey instrument investigated two domains of stu-
dent perceptions: perceptions about the narrative medi-
The narrative medicine program activities cine activity and personal attitudes about the narrative
Activity 1: The protocol for narrative writing begins with medicine progress model. Perceptions about the narra-
a typical lecture explaining the theory and introducing tive medicine activity included items such as “Narrative
the process. This activity is integrated as a one-hour ses- medicine (NM) is helpful for reflection, enhancement
sion into the curriculum of Basic Clinical Skills for Med- of empathy, relationship between patients and doctors,
ical Clerkship. and relieving my grief during medical care”, “NM is es-
Activity 2: A narrative medicine workshop for clinical sential for medical care” and “NM relieves my pressure
teachers. during medical care”. While, personal attitudes about
This workshop is held twice each year – BEGAN (The the narrative medicine progress model included “I have
Brown Educational Guide to the Analysis of Narrative) a good overall impression on NM”, “I am interested in
[26] – A framework for enhancing educational impact of NM”, “I will tell my junior schoolmates about the concept
faculty feedback to students’ reflective writing is used. of NM” and “I will continue with my narrative writing”.
Activity 3: In the session, medical students are allowed Four experts in clinical education and faculty development
to represent clinical stories in their narrative writing reviewed the items for content and content validity. A
assignments in different ways, such as story-telling or pilot check with faculty members was performed examin-
poetry-reading. This activity is designed to enhance ing internal consistency and reliability.
humanism sensitivity of medical students through the
processes of enabling medical students to recognize, Procedure
to interpret and to be moved to action by the prob- Students were invited to participate in the study an-
lems of others. Through the act of narrative writing, onymously at the end of each semester. The question-
medical students can review their journeys through naire was voluntary and open for a 14-day period. A
their clerkship: rethinking and reflecting on the stories total of 412 fifth year medical students completed the
they gather from patients. One of the objectives of this questionnaires (412/465 = 88.6%), including 270 (65.5%)
course is the opportunity for medical students to MSs and 142 (34.5%) TCMSs: 255 (61.9%) were male
transfer their cognitive knowledge and attitudes of and 157 (38.1%) were female students. There were 123
Huang et al. BMC Medical Education (2017) 17:85 Page 4 of 8

(29.9%), 159 (38.6%), and 130 (31.6%) in 2012, 2013, Table 1 Exploratory factor analysis: rotated component matrix
and 2014 academic years respectively. There was no co- Items Factors
hort difference. Personal Self-Development/ Emotional
attitude Reflection benefit
1 I will continue with my .846 .238 .269
Exploratory factor analysis narrative writing
An exploratory factor analysis (EFA) was conducted using 2 I will tell my junior .818 .285 .292
principal component analysis to test the assumption of schoolmates about the
concept of NM
whether the questionnaire contained two underlying
factors as originally designed. The Kaiser–Meyer–Olkin 3 I have a good overall .727 .440 .270
impression on NM
measure of sampling adequacy was 0.939, and Bartlett’s
4 I am interested in NM .688 .385 .405
test of sphericity was significant (p < 0.0001), indicating
that the sample was suitable for factor analysis. Factors 5 NM is essential for medical .550 .427 .532
care
were extracted and rotated to orthogonal simple structure
6 NM is helpful for reflection .314 .811 .162
using the varimax method.
In the following section, data are expressed as mean 7 NM is helpful for in .295 .766 .282
enhancing empathy
values and standard deviation (SD) or as numeric values
8 NM is helpful for patients- .295 .737 .396
(%). Unpaired t-tests were used to compare 5-Likert doctor relationships
scales that were considered to be parametric data. The
9 NM relieves my pressure .324 .228 .842
level of statistical significance was set at p < 0.05. All during medical care
analyses were conducted using SPSS software (version 10 NM relieves my grief during .314 .335 .777
13.0, SPSS, Chicago, IL). medical care
NM narrative medicine

Results
Three factors identified: Personal attitude, self- For the three-factor model, the mean and standard
development/reflection, emotional benefit deviation scores of subscales personal attitude, self-
Several criteria were taken into account simultaneously development/reflection, and emotional benefit were
to determine how many factors to settle on. First, we 3.35 ± 0.995, 3.82 ± 0.871, and 3.19 ± 1.056 respectively.
used the Kaiser’s criterion and the scree plot which
showed that three of those factors explain most of the Western versus Chinese medical student differences
variability because the line starts to straighten after fac- The unique aspect of this project is that we compared
tor 3. The remaining factors explained a very small pro- and analyzed responses from two different groups:
portion of the variability (accounting for 19.7%) and Western (MSs) and Chinese (TCMSs) medicine. Narra-
thus likely unimportant. Secondly and most importantly, tive medicine scores were significantly higher in TCMSs
we wanted to get a reasonable proportion of variance ex- than MSs for all 9 items. They were also significantly higher
plained and substantive sense of the data achieved. The in TCMSs than MSs for all three factors: personal attitude
results suggested that the first three factors, accounting (p < 0.001), self-development/reflection (p < 0.001) and
for 80.3% of the total variance, should be retained emotional benefit (p < 0.01). TCMSs had better global per-
(Table 1). Several questions (Item 3, Item 4, and Item ception for total factors than MSs (p < 0.001) (Table 2).
5) had their highest loading from the first factor but
had a cross-loading over 0.4 on the competence factor. Table 2 Comparison of perception towards narrative medicine
between students of Medicine department and Chinese Medicine
In order to deal with the cross loadings issue, we exam-
department
ined the factor loadings using oblimin to see if these
Factors Department N Mean SD
cross-loadings still appeared. The results suggested that
Item 5 continued to load on multiple factors after using Personal attitude (4 items, Item 1–4) MS 270 3.26 1.028
the oblimin rotation. Therefore, this item was discarded. TCMS 142 3.52 0.906
On the basis of the characteristics of the items that con- Self-development/Reflection MS 270 3.74 0.908
stituted each factor, the first factor was interpreted as (3 items, Item 6–8)
TCMS 142 3.98 0.774
“personal attitude” (4 items), the second as “self-develop- Emotional benefit (2 items, Item 9–10) MS 270 3.10 1.061
ment/reflection” (3 items) and the third as “emotional
TCMS 142 3.34 1.033
benefit” (2 items). Students’ responses to this 9-item ques-
tionnaire yielded a Cronbach alpha measure of reliability Total (9 items) MS 270 3.39 1.030
equal to 0.934. Cronbach’s alpha coefficients for each TCMS 142 3.63 0.930
subscale were 0.92, 0.85, and 0.72 respectively. MS medical student, TCMS traditional Chinese medical student
Huang et al. BMC Medical Education (2017) 17:85 Page 5 of 8

There was no difference in terms of gender on the percep- features scientific technology, with frequent use of high-
tions on narrative medicine for all 9 items, although there technology instruments as a defining feature: while not an
were more females in the TCMS group. exact science, behind many diagnoses lie a variety of mea-
surements with developed formula for signs of specific
Discussion pathology. Thus the focus is split between measurements
This study aimed to assess the impact of narrative and the patient, with emotional detachment from the pa-
medicine for 5th year Western and Chinese medical tient being a defining feature of professionalism. Trad-
students using a purposively developed questionnaire. itional Chinese medicine doctors operate differently. They
Three factors were extracted from the 9 questionnaire typically communicate with their patients, focusing on pa-
items: personal attitude, self-development/reflection tients’ feelings during diagnoses, taking the human body
and emotional benefit. Overall, students were signifi- as balance and harmony. Therefore, although the symp-
cantly more likely to agree that the course facilitated toms might be the same, Chinese and Western medicine
their self-development and reflection than it facilitating physicians have very different relationships with patients
personal attitudes about narrative medicine and emo- and offer different therapies based on their personal expe-
tional benefits. This finding that students’ empathy, re- riences [29]. Thus, traditional Chinese medicine physi-
flection and interpersonal relationships all benefit from cians as clinical teachers and therefore role models,
their engagement with the narrative medicine course demonstrate how to focus on patients’ illness through car-
resonates with previous research analysing writing con- ing for their feelings. Given that the presence of role
tent during courses. Through these narratives students models during clinical training is a determining factor in
described how their engagement in narrative writing, the acquisition of medical expertise, including enhancing
they received a greater understanding of themselves, learning, influencing career choices and facilitating the
patients’ and families’ feelings, reflection, humanistic acquisition of humanistic attitudes [30, 31], we believe this
situations, and motivation to improve [12–14, 16]. powerful force is partly the reason why we find such a
The current study is unique in that we examined two difference between student groups: TCMSs being more fa-
different groups of medical students: Western (MSs) and miliar with the concept of medicine as an holistic healing
Chinese (TCMSs) medicine students. We found percep- art. This state of affairs not only plays into students’ recog-
tions of narrative medicine to be significantly higher in nition, and therefore acceptance of narrative medicine,
TCMSs than MSs for each of the 9 items in the ques- but it also impacts on students’ willingness to go the extra
tionnaire and therefore for the 3 extracted factors. Such mile: our narrative medicine programme relied on the
a finding leads us to wonder why this might be so. As clerks committing their own time to participate. Thus the
discussed above, the characteristics of traditional Chin- different learning cultures of MS and TCMS medical edu-
ese medicine in both theory and practice make it very cation affect both acceptance to, and benefit from, a narra-
different from conventional Western Medicine [28]. A tive medicine course.
distinctive difference between the two is that Western The predominance of female students in medical
medicine focuses solely on the body as an organism. On education is an important issue. A four-nation study
the other hand, Chinese medicine considers the soul or published in 2002 conducted in Western cultures
spirit as an integral element of the body. Therefore, one (Australia, Canada, England and the United States)
essential difference between them is that through the showed that women make up half of all medical stu-
learning of Chinese medicine, students are trained to dents and 30% of all practicing physicians [32]. In many
conceptualise the entire body in an holistic manner to Western cultures, like the United Kingdom, women
solve a single ailment, rather than focusing on disparate even form the majority of the physician workforce [33].
body parts (which is more of a feature of Western medi- However, female doctors are a relative minority in
cine). Furthermore, Chinese medicine not only offers Taiwan. By 1980, Taiwan had only around 4.3% female
professional medical knowledge, but it also emphasises doctors. The percentage has steadily increased: from
humanities, social, legal, and ethical education [22, 23]. 6% in 1990 to 12% in 2000. Female medical graduates
Having said this, there might be other alternative expla- have also increased from 1990 (10%) to 2000 (29.9%)
nations, including that Chinese medicine might attract [34]. There are 29.1% female medical students in our
more humanities-focused students. previous study in 2013, in which females had better be-
We believe that role modeling may also partially havior records and more attendance in community ser-
explain this difference. Role modeling is thought to be vices than men [35]. Furthermore, research suggests
an integral component of medical education and an im- that Tunisian female students attach more value than
portant factor in shaping the values, attitudes, behavior, males to the intrinsic aspects of a physician’s job, such
and ethics of medical trainees. In comparison with trad- as the desire to help others and to work with people
itional Chinese medicine, Western medicine strongly [36]. In a psychometric study of candidates admitted to
Huang et al. BMC Medical Education (2017) 17:85 Page 6 of 8

Scottish medical schools, female applicants as a group implications for medical education [41, 42]. Thus, edu-
were identified as being more empathic, with a greater cators may consider incorporating narrative writing into
communitarian orientation than men [37]. Patient- their curriculum to promote humanism since it may be
Practitioner Orientation Scale (PPOS) scores from difficult for young pre-doctors to feel, understand, and
Swedish female students were higher compared to their think about humanistic situations. For medical students,
male counterparts, and females scored significantly narrative medicine may be a good complement to the
higher in later in their studies compared with early on philosophies of a bio-psychosocial approach and patient-
[38]. However, in our study, we have found no differ- centered practice and could be brought in at an earlier
ence in terms of gender on the perceptions on narrative point in the curriculum for Western medicine students
medicine, despite there being more females in TCMS. as an ‘antidote’.
This suggests that the learning culture between MS and The most important aspect of narrative writing is to
TCMS is the predominant factor rather than that of review one’s assumptions or beliefs to enhance self-
gender. awareness. A medical student’s journey through the
healthcare system is often difficult and accompanied
Strengths and weaknesses of the study with self-doubts and frustration. Although we have not
This study, recruiting clerks from different training pro- found our narrative medicine course to be best at re-
grams (MSs and TCMSs), obtained a high response rate lieving their own grief or pressure, our hope is that by
and analyzed data collected at the end of a 13-week long having the clerks begin writing about their experiences,
study employing prompted narrative medicine. The they will gain a sense of themselves through reflection
current study is unique, being the first to examine the over time and, through the sharing of stories, see that
perceptions of narrative medicine between two different others feel the same or similar to themselves.
groups of medical students: MSs and TCMSs.
There are some limitations to this study. First, the study Suggestions for future research
was surveyed in an internal medicine rotation only, but In this study, three factors were extracted: personal atti-
not in pediatrics, or surgical systems such as surgery or tude, self-development/reflection, and emotional benefit.
gynecology. Although this work was carried out in two We also found that the perceptions of narrative medi-
separate groups of clerks, caution should be taken in gen- cine were significantly higher in the TCMS than the MS
eralizing the findings to other medical trainees apart from group. However, definitions and actualisations of narra-
the Department of Traditional Chinese Medical. Secondly, tive or narrative medicine are often broad. Indeed, what
our MSs or TCMSs followed a prospective-based program lies within the ‘black box’ of narrative medicine needs to
on clerkship narrative medicine, however they could not be better explored [43–45]. Despite the different learn-
be randomized. For the purposes of data analysis, we did ing cultures of medical education in which these student
not hypothesize that their choice of specialization would groups engage can partially explain our results, we do
be a significant contributing factor. Nevertheless, this is not fully understand what it is about narrative medicine
unlikely to be an important factor as the students were that works, for whom, and why across different learning
from two different groups. Thirdly, as previously men- culture contexts, As such, the impact of learning cul-
tioned, there is the possibility that the two programs of tures deserves to be further studied in order to explore
medical education may attract different kinds of students: the complex interactions and to develop a transferable
Chinese medicine might seem more suitable for holistic theoretical model of what works, for whom and why
thinkers who could be more open to the humanities. As [46]. In this way, not only will we understand similarities
such this could be a possible contributor to the differential and differences between Chinese and Western medical
impact of the narrative medicine course. Finally, narrative students learning with narrative medicine processes, we
medicine as a teaching practice has been criticized as will also be able to tailor educational strategies to pro-
being too naïve a use of ‘reflective practice’ in pedagogy mote narrative medicine into early pre-doctoral medical
[39, 40]. Indeed, the key issues that underpin how such education for specific groups and further enhance reflec-
practices can be valuable are far more complex than could tion and humanism.
be captured in this single study. Thus further studies are
needed to better understand the differences between MS Conclusions
and TCMS groups of students in their engagement with, In our study, students from both TCMS and MS groups
and reactions towards, narrative medicine. perceived their narrative medicine learning experiences
to be potentially beneficial to their self-development and
Suggestions for practice capacity for reflection. The perceptions of the narrative
The act of narrative writing involves thinking explicitly medicine course, however, were more favorable in the
about a thought, experience, or action and has profound TCMS group than in the MS group. The characteristics
Huang et al. BMC Medical Education (2017) 17:85 Page 7 of 8

of TCM in both theory and practice make it different from Taiwan. 5Nephrology, Chang Gung Memorial Hospital, Chang Gung
conventional Western Medicine. Given the different learn- University, College of Medicine, Taipei, Taiwan. 6Cardiology, Chang Gung
Memorial Hospital, Chang Gung University, College of Medicine, Taipei,
ing cultures of medical education in which these groups Taiwan. 7Neurosurgery, Chang Gung Memorial Hospital, Chang Gung
engage, it could be that undertaking a course in Chinese University, College of Medicine, Taipei, Taiwan. 8Department of Health Care
medicine might actually enhance one’s acceptance to, and Management, Chang Gung University, College of Medicine, Taipei, Taiwan.
9
Department of Medical Humanities and Social Sciences, Chang Gung
benefit from, a medical humanities course. Alternatively, University, College of Medicine, Taipei, Taiwan.
Chinese medicine might attract more humanities-focused
students. Received: 2 August 2016 Accepted: 4 May 2017

Abbreviation
BEGAN: The Brown Educational Guide to the Analysis of Narrative; References
EFA: exploratory factor analysis; MS: medical student; NM: narrative medicine; 1. Johna S, Dehal A. The power of reflective writing: narrative medicine and
REFLECT: Reflection Evaluation For Learners’ Enhanced Competencies Tool; medical education. Perm J. 2013;17(4):84–5.
SD: standard deviation; TCMS: traditional Chinese medical student 2. Novack DH, Epstein RM, Paulsen RH. Toward creating physician-healers:
fostering medical students’ self-awareness, personal growth, and well-being.
Acknowledgements Acad Med. 1999;74(5):516–20.
We thank the Work Team for Narrative Medicine of Department of Internal 3. Kleinman A. The illness narratives: suffering, healing, and the human
Medicine in Chang Gung Memorial Hospital. We also sincerely thank condition. New York: Basic Books; 1988.
Professor Lynn Monrouxe for her critical review for this manuscript. 4. Bolaki S. Capturing the worlds of multiple sclerosis: Hannah Laycock's
photography. Med Humanit. 2016;0:1–8. doi:10.1136/medhum-2016-011073.
Funding 5. Woods A. The limits of narrative: provocations for the medical humanities.
This study was supported by Chang Gung Memorial Hospital, Taiwan Med Humanit. 2011;37(2):73–8.
[CDRPG 3D0011–3] and the Ministry of Science and Technology, ROC 6. Charon R. The patient-physician relationship. Narrative medicine: a model
[MOST 104–2511-S-182-009]. for empathy, reflection, profession, and trust. JAMA. 2001;286(15):1897–902.
7. Charon R. Reading, writing, and doctoring: literature and medicine. Am J
Availability of data and materials Med Sci. 2000;319(5):285–91.
The data are kept at the Chang Gung Medical Education Research Center, 8. Charon R. Narrative and medicine. New Eng J Med. 2004;350(9):862–4.
Chang Gung Memorial Hospital, Chang Gung University College of Medicine, 9. Pennebaker JW, Chung CK. Expressive writing and its links to mental and
Taipei, Taiwan. Any questions or requests regarding the data can be physical health. In: Oxford handbook of health psychology. Edn. Edited by
addressed to Chien-Da Huang (cdhuang@adm.cgmh.org.tw). Friedman HS. New York: Oxford University Press; 2011.
10. Hunter KM. Doctors stories: the narrative structure of medical knowledge.
Authors’ contributions Princeton: Princeton University Press; 1991.
CDH contributed to development of study, analysis and interpretation of 11. Charon R. What to do with stories: the sciences of narrative medicine. Can
data, writing, reviewing and finalizing the manuscript. KCL participated in Fam Physi. 2007;53(8):1265–7.
study conceptualization, analyzed data, and wrote the manuscript. FTC 12. Brady DW, Corbie-Smith G, Branch WT. “What's important to you?” the use
participated in study conceptualization, analyzed data, and wrote the of narratives to promote self-reflection and to understand the experiences
manuscript. HMT had full access to the data in the study for exploratory of medical residents. Ann Intern Med. 2002;137(3):220–3.
factor analysis and contributed to the conception of the study. JTF 13. Gaver A, Borkan JM, Weingarten MA. Illness in context and families
contributed to the conception of the research theme and conception and as teachers: a year-long project for medical students. Acad Med.
design of the study. SCL contributed to the conception and design of the 2005;80(5):448–51.
study and humanism education. HPK contributed to the conception and 14. DasGupta S, Charon R. Personal illness narratives: using reflective writing to
design of the study. SJY contributed to the conception and design of the teach empathy. Acad Med. 2004;79(4):351–6.
study. STL contributed to the conception and design of the study. All 15. Pearson AS, McTigue MP, Tarpley JL. Narrative medicine in surgical
authors have read and approved the finial version of the manuscript. education. J Surg Educ. 2008;65(2):99–100.
16. Levine RB, Kern DE, Wright SM. The impact of prompted narrative writing
Competing interests during internship on reflective practice: a qualitative study. Adv Health Sci
The authors declare that they have no competing interests. Edu. 2008;13(5):723–33.
17. Arntfield SL, Slesar K, Dickson J, Charon R. Narrative medicine as a means of
Consent for publication training medical students toward residency competencies. Patient Educ
No individual’s data is included in this study. Counsel. 2013;91(3):280–6.
18. Miller E, Balmer D, Hermann N, Graham G, Charon R. Sounding narrative
Ethics approval and consent to participate medicine: studying students’ professional identity development at
Ethical approval for this study was obtained from the Chang Gung Memorial Columbia University College of physicians and surgeons. Acad Med.
Hospital and Chang Gung University Institutional Review Board (IRB No.102-4138B, 2014;89(2):335–42.
103-1755B, 105-2716C, and 106-1287C). 19. Chretien KC, Swenson R, Yoon B, Julian R, Keenan J, Croffoot J, Kheirbek R.
Tell me your story: a pilot narrative medicine curriculum during the
medicine clerkship. J Gen Intern Med. 2015;30(7):1025–8.
Publisher’s Note 20. Tsai SL, Ho MJ. Can narrative medicine training improve OSCE performance?
Springer Nature remains neutral with regard to jurisdictional claims in Med Educ. 2012;46(11):1112–3.
published maps and institutional affiliations. 21. Yang KT, Yang JH. A study of the effect of a visual arts-based program
on the scores of Jefferson scale for physician empathy. BMC Med Educ.
Author details 2013;13:142.
1
Chang Gung Medical Education Research Center, Chang Gung Memorial 22. Compare and Contrast Traditional Chinese Medicine and Conventional
Hospital, Chang Gung University, College of Medicine, 199 Tun Hua N. Rd, Western Medicine [http://www.academia.edu/7161668/]. Accessed 15 June
Taipei, Taiwan. 2Department of Medical Education, Chang Gung Memorial 2016.
Hospital, Chang Gung University, College of Medicine, Taipei, Taiwan. 23. Sun DZ, Li SD, Liu Y, Zhang Y, Mei R, Yang MH. Differences in the origin of
3
Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University, philosophy between Chinese medicine and Western medicine: exploration
College of Medicine, Taipei, Taiwan. 4General Medicine, Chang Gung of the holistic advantages of Chinese medicine. Chin J Integr Med. 2013;
Memorial Hospital, Chang Gung University, College of Medicine, Taipei, 19(9):706–11.
Huang et al. BMC Medical Education (2017) 17:85 Page 8 of 8

24. Chou JY, Chiu CH, Lai E, Tsai D, Tzeng CR. Medical education in Taiwan.
Med Teacher. 2012;34(3):187–91.
25. Lam TP. Strengths and weaknesses of traditional Chinese medicine and
Western medicine in the eyes of some Hong Kong Chinese. J Epidemiol
Community Health. 2001;55(10):762–5.
26. Reis SP, Wald HS, Monroe AD, Borkan JM. Begin the BEGAN (the Brown
educational Guide to the analysis of narrative) - a framework for enhancing
educational impact of faculty feedback to students’ reflective writing.
Patient Educ Counsel. 2010;80(2):253–9.
27. Wald HS, Borkan JM, Taylor JS, Anthony D, Reis SP. Fostering and evaluating
reflective capacity in medical education: developing the REFLECT rubric for
assessing reflective writing. Acad Med. 2012;87(1):41–50.
28. Xutian S, Cao D, Wozniak J, Junion J, Boisvert J. Comprehension of the
unique characteristics of traditional Chinese medicine. Am J Chin Med.
2012;40(2):231–44.
29. Song T. A study of experiment technology and scientific technology,
exemplified by Chinese and Western medicine. Front Philos China.
2011;6(2):298–315.
30. Yazigi A, Nasr M, Sleilaty G, Nemr E. Clinical teachers as role models:
perceptions of interns and residents in a Lebanese medical school.
Med Educ. 2006;40(7):654–61.
31. Wright SM, Kern DE, Kolodner K, Howard DM, Brancati FL. Attributes of
excellent attending-physician role models. New Eng J Med. 1998;339(27):
1986–93.
32. McMurray JE, Cohen M, Angus G, Harding J, Gavel P, Horvath J, Paice E,
Schmittdiel J, Grumbach K. Women in medicine: a four-nation comparison.
J Am Med Womens Assoc. 2002;57(4):185–90.
33. Dacre J, Shepherd S. Women and medicine. Clin Med. 2010;10(6):544–7.
34. Cheng L-F. Gender and medical profession in Taiwan. In: Frontiers of
Gender Studies (F-GENS), Institute for Gender Studies. Tokyo: Ochanomizu
University; 2008. p. 152–7.
35. Huang CD, Chang YJ, Kuo HP, Huang JL, Fang JT. Gender differences in
performances of medical students at one medical School in Taiwan. J Med
Educ. 2013;17(2):55–63.
36. Nabli Ajmi T, Bougmiza MI, Mtiraoui A. Attitudes of Tunisian medical
students to medical practice: gender differences. East Mediterr Health J.
2008;14(3):686–96.
37. Lumsden MA, Bore M, Millar K, Jack R, Powis D. Assessment of personal
qualities in relation to admission to medical school. Med Educ.
2005;39(3):258–65.
38. Wahlqvist M, Gunnarsson RK, Dahlgren G, Nordgren S. Patient-centred
attitudes among medical students: gender and work experience in health
care make a difference. Med Teacher. 2010;32(4):e191–8.
39. Kinsella EA, Whiteford GE. Knowledge generation and utilisation in
occupational therapy: towards epistemic reflexivity. Aust Occup Ther J.
2009;56(4):249–58.
40. Mackintosh C. Reflection: a flawed strategy for the nursing profession. Nurse
Educ Today. 1998;18(7):553–7.
41. Bolton G. Literature and medicine. Lancet. 2001;357(9266):1441–2.
42. Bolton G. Reflective practice: writing and professional development.
London: Paul Chapman Publishing Ltd; 2001.
43. Garden R, Yoo Murphree HJ. Class and ethnicity in the global market for
organs: the case of Korean cinema. J Med Humanit. 2007;28(4):213–29.
44. Garden R. Expanding clinical empathy: an activist perspective. J Gen Intern
Med. 2009;24(1):122–5.
45. Woods A. Post-narrative - an appeal. Narrat Inq. 2011;21(2):399–406.
46. Wong G, Greenhalgh T, Westhorp G, Pawson R. Realist methods in medical
education research: what are they and what can they contribute? Med Submit your next manuscript to BioMed Central
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