Effects of a narrative medicine program on empathic ability of dental students: a comparative study

Abstract

Background

Narrative medicine (NM), a model for medical humanism, has become an effective educational tool to cultivate medical students’ empathy. However, the role of NM in dental education still lacks experimental evidence. This study aims to analyze the effects of NM on dental students’ empathic ability and explore the correlation between empathic ability and academic performance.

Methods

A comparative study was conducted at Jinan University, China, during 2023 to 2024 year. The NM education program was integrated into the fixed prosthodontics course. The participants of this study were senior undergraduate dental students in pre-clinical stage. Control group students received traditional teaching and experimental group students received NM-integrated teaching. Self-report questionnaires of empathic ability and perceptions about NM as well as academic performance were analyzed in two groups.

Results

A total of 134 participants were recruited. Empathy scores in the experimental group (n = 62) were higher than those in the control group (n = 72). In the experimental group, students writing parallel charts as coursework received higher empathy scores than students writing reflection reports on medical novels or films. Empathic scores were positively correlated to theoretical exam scores but almost uncorrelated to skill exam scores. Most dental students held positive perceptions towards NM, especially regarding self-development.

Conclusion

In dental education, NM as an educational tool for empathy is feasible. It might provide insights for dental educators in planning and managing dental courses that integrate humanities.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-025-05580-8.

Background

Patient-centered care has been defined as care that is respectful and responsive to individual patient preferences, needs and values, and ensuring that patient values guide all clinical decisions [1]. Patient-centered approaches are beneficial for clinicians to understand patients’ lived experiences related to health, communicate regarding treatment decisions, and improve physician job satisfaction [2, 3]. Empathy is an essential characteristic of patient-centered approaches. Clinical empathy can be defined as a predominantly cognitive attribute that involves understanding the patients’ pain and suffering, combined with a capacity to communicate this understanding and an intention to help [4]. Showing empathy can improve the quality of clinical interactions, especially by improving patients’ adherence to recommended therapies [5]. Empathic ability has been identified as an innate characteristics, which nevertheless can be fostered by educational interventions and exercises [6].

Dentistry has attached great importance to technical skills for many years. Consequently, developing students’ manual skills and dexterity is a priority in all dental education institutions. However, cognitive, affective, and psychomotor capacities are also requirements for dentists to achieve highly competent clinical practice outcomes [7, 8]. Patient-centered dental treatment was recently proposed [9], which involved providing holistic and person-focused care, making the patient feel good about the treatment they are receiving/going to receive, ensuring effective communication from the dental professional and having a flexible approach to decision-making [10]. Psychosocial factors play a crucial role in oral health. For example, dental anxiety may be linked to the avoidance of dental treatment and reluctance to seek care. Patient-centered dental treatment considers the biopsychosocial factors of the patient during the treatment process, which have advantages in decreasing dental anxiety and perceived operative pain, as well as improving oral hygiene and periodontal compliance [11]. For dental students, limited presence of humanities might lead to a possibility of losing empathic ability in clinical practice [12]. Many dental education experts have been calling upon the humanistic curriculum to teach students to be interested in the patient as a whole rather than the symptom alone [13, 14, 15].

Narrative medicine (NM) is a typical representative of medical humanism, coined in 2000 by Dr. Rita Charon, a professor in medicine and literature at Columbia University. NM refers to clinical practice fortified by narrative competence, the capacity to recognize, absorb, metabolize, interpret, and be moved by stories of illness [16]. NM has been developed as an effective educational intervention that help students hone their listening and observation skills, stimulate their empathic ability, and increase their capacity for self-reflection and perspective-taking [17]. Specific education programs have been introduced in many medical faculties around the world. Several studies demonstrated that the NM program could help cultivate empathic ability for medical students, clinical internships and residents who majored in public health, nursing, neurology, gynecology and obstetrics [18, 19, 20, 21, 22, 23, 24, 25]. Narrative dentistry was first suggested in 2015 to promote patient-centered dental treatment [26]. NM was recommended as a humanistic teaching tool in dental education to develop narrative competency, including empathy, reflection, professionalism, and trust [26, 27, 28, 29]. A study at The Arctic University of Norway used storytelling as an emotional competence course for undergraduate dental students and found it beneficial for students’ reflection on their role as dental health professionals [30]. Three cross-sectional surveys by questionnaires in Chung Shan Medical University showed that most dental students at Taiwan agreed that NM could be helpful in non-operational capabilities including patient-dentist discourse, clinical judgment and treatment plan [31, 32, 33]. Although experimental evidence about narrative dentistry is still rare, it can be seen that NM has the potential to become a novel and valuable humanities program in dental education.

There is an urgent lack of attention on humanities in current dental education. Integrating humanistic education within dental specialty curriculums does not create additional academic burden to students and demonstrates a clear need. Fixed prosthodontics is the clinical core content of dentistry, focusing on permanently affixed dental prostheses. Communication and clinical judgment in fixed prosthodontic treatment is generally considered challenging and require high empathy from dentists, due to the features that include multiple visits, various prosthesis type and high aesthetic expectation of patients. Thus, the fixed prosthodontics course is appropriate and necessary for integrating humanistic education. This study designed a NM education program for undergraduate dental students in pre-clinical stage, including NM theory learning, practice learning and narrative writing, and integrated the NM program into the fixed prosthodontics course. Comparison of empathy scores was conducted between two group students, assessing differences depending on whether they participated in the NM program.

This study fills a gap in the current literature to evaluate the effects of NM on dental students’ empathic ability. The following research questions were specifically addressed: (1) Does the NM program increase dental students’ empathic ability? (2) Do different types of narrative writing impact empathy scores? (3) Is there a correlation between empathic ability and academic performance? (4) What are the perceptions of dental students on NM?

Methods

Participants

A comparative study was conducted at the School of Stomatology, Jinan University in Guangzhou, Guangdong, China, during 2023–2024 year. Fourth-year dental medicine (called stomatology in China) undergraduate students were selected as the research subjects. The cohort was in the pre-clinical stage, with little clinical shadowing experience. A total of 172 students in the fixed prosthodontics course were divided into the control group (receiving traditional teaching, n = 91) and the experimental group (receiving NM-integrated teaching, n = 81). The study was approved by the ethics committee of Jinan University (JNUKY-2023-0041).

Teaching method

Fixed prosthodontics is a compulsory course for fourth-year dental students. Two groups of students were taught by the same teachers. All teachers have specialized in fixed prosthodontics and received adequate NM training. The control group received traditional teaching in the fixed-prosthodontics course. The experimental group received NM-integrated teaching. The NM program comprised lectures, clinical shadowing and discussion (Table 1). In multi-media lectures, teachers introduced knowledge of NM combining fixed prosthodontics clinical situations, not pure humanistic teaching. Clinical shadowing was conducted in the Department of Prosthodontics, The First Affiliated Hospital of Jinan University. Students did not participate in patient care but observed the teacher/dentist treated patients. Teachers focused on demonstrating patient-dentist discourse to encourage students to listen to the patients’ stories and show empathy. Problem-based learning required students to discuss arguments about NM and summarize narrative elements of some fixed prosthodontic clinical cases. After theory learning and practice learning, students needed to complete coursework on narrative writing by self-learning. They could freely choose to write a parallel chart of clinical experience, or a reflection report on a medical literature/film work. Teachers checked the coursework but the evaluation of coursework did not affect students’ academic performance.

Table 1.

Teaching arrangement of NM program

Content	Class hours	Teaching Approach
Introduction: from medical humanities to NM	0.5	Multi-media lecturing
NM and empathy	0.5	Multi-media lecturing
NM in patient-dentist discourse and clinical judgment	0.5	Multi-media lecturing
NM literatures reading	0.5	Multi-media lecturing
Introduction of parallel chart	0.5	Multi-media lecturing
Transition from a dental student to a dentist	0.5	Multi-media lecturing
Dental clinical shadowing	2	Demonstration
Discussion on NM arguments and clinical cases	2	Problem-based learning
Writing a parallel chart of clinical experience, or a reflection report about a medical novel/film	/	Coursework

NM: narrative medicine

Academic performance evaluation

The course’s final exam included two assessments with separate scores, both only covering fixed prosthodontics knowledge, but not assessing the NM content. The evaluation adopted a single-blind method. The same teacher awarded all scores, and the teacher was unaware of the groups’ identities. The assessment for theoretical lessons evaluated students’ memory, comprehension, and application of fixed prosthodontics knowledge, comprising of single choices, multiple choices, noun interpretation, and essay questions. The assessment item of the skill sessions was metal crown tooth preparation of the mandibular first molar on the head-simulator. The preparation quality of the two groups’ students was graded according to the same uniform standard (including operating posture, reduction amount, morphology of tooth, and damage to adjacent teeth and gums).

Questionnaire

At the end of the course, the two groups’ students were requested to participate in an online questionnaire utilizing Wenjuanxing, a prevalent online survey platform in China. Participants were informed that their individual information was only available to the research team and that the questionnaire results were completely unrelated to their academic performance. Informed consent was obtained from all participants.

The level of empathy was evaluated using the Jefferson Empathy Scale (JSE), developed by Mohammadreza Hojat and colleagues at Jefferson Medical College [4, 34]. The scale was a broadly used instrument measuring empathy in the context of medical education and patient care. The Chinese version used in this study has proven reliable and valid by previous evidence-based research [35]. JSE comprises 20 items and could be divided into three dimensions: perspective selection, compassionate care, and transposition thinking. JSE scores are calculated by a 7-point Likert scale (strongly agree = 7 point, strongly disagree = 1 point). The higher the score, the greater the level of empathy was.

Perceptions towards NM were evaluated using a questionnaire fully adapted from prior studies by medical education experts in Taiwan [20, 36]. The questionnaire comprised 9 items using a 5-point Likert scale (strongly agree, agree, neutral, disagree, strongly disagree) and could be divided into three dimensions: self-development, emotional benefit and personal attitude.

For the control group, the questionnaire comprised two categories, demographic characteristics (name and sex) and JSE questions (Appendix 1). For the experimental group, the questionnaire comprised three categories (Appendix 2). Apart from demographic characteristics and JSE questions, the third category is the questions of perceptions toward NM. All outcomes were self-reported through the questionnaire.

Statistical analysis

All data were expressed as mean values and standard deviation (SD) or numeric values and percentages (%). SPSS 27.0 software (IBM Corp. New York, NY, USA) was used for statistical analysis of the relevant data. Comparations of empathy scores and final exam scores between the control group and experimental group were measured by the independent t-test. The Pearson correlation described the correlation between empathy scores, perceptions towards NM, and final exam scores. P-value < 0.05 was considered statistically significant.

Results

Comparison of empathy scores

The response rate of this questionnaire survey was 87.2% (150/172). Among the questionnaire results, 16 abnormal responses were considered unreliable and excluded, where participants either provided the same answer for all 29 or 20 questioning items or completed the survey in an unusually short time (less than 30 s for filling in both demographic characteristics and all items). Finally, a total of 134 participants were recruited, including 62 experimental group students and 72 control group students. The gender difference between the two groups was not significant (Table 2, Chi-square test P > 0.05).

Table 2.

Demographic characteristics of the participants

Gender	All (n, %)	Experimental group (n, %)	Control group (n, %)	P
Male	48 (35.8%)	18 (29.0%)	30 (41.7%)	0.128
Female	86 (64.2%)	44 (71.0%)	42 (58.3%)

Comparisons of empathy scores between the two groups were shown in Table 3. JSE scores of the experimental group were significantly higher than those of the control group (115.0 ± 11.7 vs. 110.5 ± 11.5, P = 0.026). As for the three dimensions of empathy, compassionate care was significantly higher (45.4 ± 5.9 vs. 42.9 ± 6.1, P = 0.018), while perspective selection (60.2 ± 5.8 vs. 58.7 ± 6.8) and transposition thinking (9.4 ± 2.5 vs. 8.9 ± 2.2) were slightly higher without significant differences (P > 0.05).

Table 3.

Comparison of empathy scores between two groups (Mean ± SD)

	Experimental group (n = 62)	Control group (n = 72)	P-value
JSE scores	115.0 ± 11.7	110.45 ± 11.5	0.026*
Perspective selection	60.2 ± 5.8	58.±6.8	0.188
Compassionate care	45.4 ± 5.9	42.9 ± 6.1	0.018*
Transposition thinking	9.4 ± 2.5	8.9 ± 2.2	0.173

NM: narrative medicine. JSE: Jefferson scale of empathy. SD: standard deviation. *P < 0.05

In the experimental group, 30 students chose writing a parallel chart as their coursework, and 32 chose writing a reflection report on a medical novel or film (Table 4). Their JSE scores were significantly different (118.0 ± 11.4 vs. 112.2 ± 11.0, P = 0.048). Compared with students writing reflections, compassionate care was significantly higher in students writing parallel charts (47.0 ± 5.6 vs. 43.8 ± 5.7, P = 0.029). There were no significant differences (P > 0.05) in perspective selection (61.2 ± 5.9 vs. 59.3 ± 5.4,) and transposition thinking (9.8 ± 2.7 vs. 9.1 ± 2.1).

Table 4.

Empathy scores in experimental group: coursework difference (Mean ± SD)

	Parallel chart (n = 30)	Reflection report (n = 32)	P-value
JSE scores	118.0 ± 11.4	112.2 ± 11.0	0.048*
Perspective taking	61.2 ± 5.9	59.3 ± 5.4	0.186
Compassionate care	47.0 ± 5.6	43.8 ± 5.7	0.029*
Transposition thinking	9.8 ± 2.7	9.1 ± 2.1	0.309

NM: narrative medicine. JSE: Jefferson scale of empathy. SD: standard deviation. *P < 0.05

Comparison of academic performance

Academic performance in the fixed prosthodontics course used percentage grading system (Table 5). Theoretical exam scores of experimental group and control group were 80.6 ± 11.2 and 76.9 ± 11.7, and skill exam scores were 85.6 ± 4.6 and 84.4 ± 2.7, respectively. The two groups have no significant difference in theoretical and skill exam scores (P > 0.05).

Table 5.

Comparison of academic performance between two groups (Mean ± SD)

	Experimental group (n = 62)	Control group (n = 72)	P-valve
Theoretical exam scores	80.6 ± 11.2	76.9 ± 11.7	0.062
Skill exam scores	85.6 ± 4.6	84.4 ± 2.7	0.065

Correlation analysis was undertaken between academic performance and empathy scores (Fig. 1). In total, JSE scores were weakly positively correlated with theoretical exam scores (r = 0.3253, P < 0.001), while almost not correlated with skill exam scores (r < 0.2, P > 0.05). Besides, the correlation between JSE scores and theoretical exam scores was stronger in the experimental group (r = 0.3523, P = 0.005), than in the control group (r = 0.2633, P = 0.025).

Fig. 1.

Correlation analysis of academic performance and empathy scores

(A) JSE scores and theoretical exam scores in two groups. (B) JSE scores and skill exam scores in two groups. (C) JSE scores and theoretical exam scores in the experimental group. (D) JSE scores and theoretical exam scores in the control group. JSE: Jefferson scale of empathy

.

Perceptions towards the NM

The results of 62 experimental group students’ perceptions towards NM were shown in Table 6. Students’ perceptions were positive (strongly agree and agree) in terms of self-development: reflection (91.9%), empathy (95.2%), and patient-doctor relationships (93.5%). Concerning emotional benefit, 74.2% and 64.5% of students were positive in relieving grief and pressure during medical care. As for personal attitude, students generally had a good overall impression on NM (91.9%); 74.2% of students was interested in NM; 72.6% of students were willing to talk about the concept of NM to their co-workers; and only 58.1% of students planned to continue with narrative writing.

Table 6.

Perceptions towards NM in experimental group (n = 62)

Items	Strongly agree and agree (n, %)	Neutral (n, %)	Strongly disagree and disagree (n, %)
NM is helpful for reflection	57 (91.9%)	5 (8.1%)	0 (0.0%)
NM is helpful for enhancement of empathy	59 (95.2%)	3 (4.8%)	0 (0.0%)
NM is helpful for the relationship between patients and doctors	58 (93.5%)	4 (6.5%)	0 (0.0%)
NM is helpful for relieving my grief during medical care	46 (74.2%)	13 (21.0%)	3 (4.8%)
NM relieves my pressure during medical care	40 (64.5%)	21 (33.9%)	1 (1.6%)
I have a good overall impression on NM	57 (91.9%)	4 (6.5%)	1 (1.6%)
I am interested in NM	46 (74.2%)	15 (24.2%)	1 (1.6%)
I will tell my co-workers about the concept of NM	45 (72.6%)	16 (25.8%)	1 (1.6%)
I will continue with my narrative writing	36 (58.1%)	22 (35.5%)	4 (6.4%)

NM: narrative medicine

Discussion

Many dental educators have been calling upon the humanities curriculum for dental students, which can expand students’ perceptions of dentistry and increase clinical competence. Empathy is the most frequently mentioned personal quality of the humanistic physician, involving attempting to understand the patients’ perspective and feelings and communicate that understanding back to them [37]. The current study designed a NM integrated dental specialized course and found that the NM program could enhance the empathic ability of dental students, and the empathic level was positively correlated to academic performance in theoretical exam.

In Jinan University and most dental education institutions in China, undergraduate education of dental students is a five-year program, composed of the first four years of class learning (theoretical courses, experimental courses and simulation practice) and the fifth year of clinical training. Humanistic education should take longitudinal learning, from the preclinical years, continuing into their clinical years, and being evaluated in real clinical situations [11, 38]. Humanistic knowledge learned through theoretical and experiential learning strategies in the preclinical stage can be the foundations upon clinical learning experiences [39]. Therefore, we selected senior undergraduate dental students as research subjects to give some enlightenment about NM in preclinical stage. In this study, JSE scores of dental students were comparable to those measured worldwide for medical students, for whom the means of the JSE values were predominantly distributed in the range 100–110 [40]. These scores are also comparable to those obtained with dental students in USA [41] and Chile [42], but are much higher than those from dental students in Malaysia [43] and India [44, 45] (range 80–90). Additionally, although a majority of studies (over 70%) in medical students [46] and several studies in dental students [41, 42, 44] reported higher JSE scores for females than males, no significant gender difference in JSE scores were detected in this study (t-test P > 0.05, data not presented). Different dental education institutions provide different curricula, and students from different geographic areas are affected by different sociocultural backgrounds, which impacts the cross-cultural differences of empathy levels in dental students.

A NM educational program, including theory learning, practice learning and self-learning, was designed in the current study. The comparative results showed that this NM program could increase JSE scores of dental students, which provided experimental evidence for the effectiveness of NM stimulating empathy in dental education. This outcome is consistent with the findings from other NM educational studies in undergraduate nursing students in China [19, 25], internal interns in Iran [21], and neurology residents in China [22]. Most NM related studies adopted sole humanistic courses or programs separate from clinical specialized courses, while the difference in the current research was the integrated teaching methods. NM was integrated into the fixed prosthodontics course, a major compulsory course for dental students. The teachers delivering NM program were dental specialized educators who received adequate humanities training. They introduced knowledge of NM combining clinical situations of fixed prosthodontics, not purely humanistic teaching. During clinical shadowing in the Department of Prosthodontics, teachers, also as dentists, demonstrated how to listen to patients’ stories and show empathy in real clinical environment. The NM program involved the integration of humanities within clinical components of dental education, rather than parallel and separate to dental knowledge learning. Compared with pure humanistic teaching, there were advantages regarding the absence of additional academic burden, instant application and better interest attraction for students. Such a nascent integrated program has flaws, such as occupying some time for specialized knowledge learning and dual teacher requirements.

Parallel charts, a type of narrative writing, are private humanistic records integrating the patients’ stories in clinical practice [47]. Unlike standard clinical records, parallel charts use plain language from a non-technical perspective, and serve as a prominent method of practicing NM. A clinical study in Italy showed that the adoption of parallel charts could help clinicians improve treatment compliance and clinical care of chronic obstructive pulmonary disease [48]. A pilot qualitative study in France asked pediatric dental students to write a parallel chart for each patient treated, and found that most parallel charts were compiled from a disease-centered perspective, and that writing parallel charts helped dental students to express both positive and negative feelings [49]. The current study provided two options of narrative writing as students’ coursework, writing a parallel chart based on clinical shadowing experience, or read/watch a medical novel/film and write a reflection report. The second finding of this study was that students writing parallel charts got higher JSE scores, especially in compassionate care. Writing parallel charts allows students to see, talk and assess themselves as carers for the first time. If dental students know they will be required to write a parallel chart at the end of a treatment session, they may listen more closely and attend more to emotional aspects of the case. Therefore, parallel charts could be a better narrative writing for dental students to cultivate empathic ability and help them develop their narrative competence as an additional clinical skill in patient-centered dental treatment.

A third key finding was the positive correlation between JSE scores and theoretical exam scores of the fixed prosthodontics course, which indicated improving the empathy level of dental students might be helpful for theoretical knowledge learning. The result is inconsistent with several cross-sectional surveys which demonstrated a non-significant relationship between empathy and academic performance in medical students[34, 51, 52], possibly due to the intervention of NM. Actually, the skill exam scores showed almost no correlation to JSE scores. Maybe this outcome was because NM training deepened students’ understanding of the essence of dentistry, enabling dental students to master theoretical knowledge, but had little or no facilitation for manual skills and dexterity. Previous studies found that NM training improved professional knowledge achievements of undergraduate nursing students (internship score and graduation thesis achievement) [19] and neurology residents (theoretical knowledge, skill operation, clinical management, case teaching/discussion) [22]. Another study showed that NM training for interns did not affect the total score of the objective and structured clinical examinations (including 12 stations), but significantly improved the performance in the communication stations [50]. The current study also found that dental students who receive NM-integrated education showed slightly better academic performance in both theoretical exam and skill exam. Academic performance, typically focusing on cognitive skills and manual dexterity, might not be directly related to affective empathy. Dental students who can achieve good grades in exams often exhibit characteristics such as strong learning capability, positive learning attitudes, and quick understanding ability. As a result, achieving teaching effectiveness of NM training might be easier in these students. These results indicated that students with different learning levels varied in their sensitivities to NM, and that targeted reinforcement measures might be necessary.

Fourth, the current study revealed that most dental students held a positive impression towards NM after completing the integrated course. Overall, students were significantly more likely to agree that the NM program facilitated their self-development regarding reflection and empathy, than outcomes such as facilitating personal attitudes about NM and emotional benefits. Notably, only half of the dental students planned to continue with narrative writing. Such a relatively low rate indicated that the coursework in this NM program might increase the burden and cause difficulties for dental students who are overloaded with study, and that perhaps several students did not understand the significance of narrative writing for empathy and patient-centered dental treatment.

Limitations still exist within the design of the current study. Firstly, the JSE questionnaire was not conducted at the beginning of the course to enable data comparison between of baseline and follow-up information. Secondly, the empathy and perceptions data primarily relied on self-reported online questionnaires, which were vulnerable to self-reported biases. Finally, the richness of teaching content and the type of coursework should be further improved for a greater students’ acceptance.

Future research on NM in dental education could focus on the following aspects: (1) In addition to empathy, can NM educational programs cultivate other skills/competency, such as trust, reflective ability, and communicative efficiency? (2) Would NM education yield better outcomes if implemented as a longitudinally continuous way, throughout the entire process of dental training, from the preclinical stage to the clinical stage and the professional life? (3) How can NM be integrated with other aspects of medical humanism to further enhance both humanistic literacy and clinical competence?

Conclusions

The present study highlights the benefits of the NM educational program for cultivating dental students’ empathic ability and reflects the feasibility of NM-integrated teaching in contemporary dental education. Adopting NM as an educational intervention for dental students could have impacts on professionalism outcomes. The number of humanities-integrated courses and the richness of teaching content should be increased in undergraduate dental education.

Electronic supplementary material

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Abbreviations

NM

Narrative medicine

JSE

Jefferson scale of empathy

SD

Standard deviation

Author contributions

C.L. implemented the program, collected data and drafted the manuscript; T.Z. managed/analyzed data and revised the manuscript; M.X. and Y.Z. analyzed data; X.L. designed the work and implemented the program.

Funding

This work was supported by Guangdong Province Undergraduate Teaching Quality and Teaching Reform Project, the Science and Technology Projects in Guangzhou (No.2024A03J0229 & No.2023A03J1030) and the Clinical Frontier Technology Program of the First Affiliated Hospital of Jinan University, China (No.a01210).

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author (liuxiangning2003@126.com) on reasonable request.

Declarations

Ethics approval and consent to participate

The experimental protocol was established according to the ethical guidelines of the Helsinki Declaration. All procedures were approved by the ethics committee of Jinan University (approval number: JNUKY-2023-0041). Informed consent was obtained from all participants.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.