Contemporary medical competence extends beyond biomedical knowledge and procedural ability. Physicians are expected to communicate effectively, respect patient autonomy, manage ethical uncertainty, demonstrate empathy, work responsibly within healthcare teams, maintain professional integrity and remain accountable to patients and society. These attributes are central to safe, patient-centered care but are difficult to develop through conventional knowledge-oriented teaching alone. Historically, many professional attitudes and communication behaviors were transmitted through apprenticeship and role modeling. This hidden curriculum was inconsistent and could reproduce both exemplary and problematic behaviors. The Medical Council of India therefore developed the Attitude, Ethics and Communication (AETCOM) framework for the Indian Medical Graduate, subsequently incorporated into the National Medical Commission's competency-based medical education model.[1] AETCOM is conceived as a longitudinal program linking the roles of clinician, communicator, professional, lifelong learner and member or leader of the healthcare team. Its recommended educational approaches include case-based discussion, small-group learning, role-play, reflection, skills practice, formative feedback and contextualized assessment rather than reliance on lectures alone.[1] The framework spans early professional formation, doctor-patient relationships, foundations of communication, cadaveric respect, autonomy, informed consent, confidentiality, empathy, healthcare rights, teamwork, error disclosure and professional responsibilities. These domains are closely related but not identical. Communication is primarily observable performance; ethical competence requires recognition and reasoning; professionalism concerns values and behavior over time; empathy and reflection involve affective and metacognitive processes. Since nationwide implementation of competency-based undergraduate education, a growing literature has evaluated AETCOM using interventional pre-post designs, perception surveys, mixed-method evaluations, portfolios, reflective writing, role-play, OSCEs, Kalamazoo-based communication checklists and longitudinal attitude measures. The strongest empirical signal appears to concern communication skills, whereas evidence for durable professionalism and ethical behavior remains less certain. A systematic synthesis is therefore necessary to distinguish short-term learner satisfaction from measurable competence, to identify teaching strategies associated with better outcomes, and to clarify where current evidence is methodologically weak. Rationale Previous discussions of AETCOM have often focused on curriculum rationale, implementation challenges or isolated modules. The present review was undertaken because the evidence base has expanded to include multicenter communication interventions, portfolio-based assessment, bioethics implementation studies, empathy-focused modules and longitudinal professionalism research. A structured synthesis can therefore evaluate not only whether learners like AETCOM, but also whether measurable educational outcomes improve and whether those gains appear durable. Review Question and Objectives The primary review question was: among undergraduate medical students and interns in India, does structured AETCOM-based education, compared with baseline performance, non-exposure, alternative teaching strategies or usual curricular exposure, improve communication competence, professionalism, ethical competence, empathy, reflection or related educational outcomes? 1. To evaluate the impact of AETCOM on communication competence. 2. To evaluate effects on professionalism and professional attitudes. 3. To synthesize evidence regarding ethical knowledge, reasoning and decision-making. 4. To examine empathy, reflective learning and professional identity formation. 5. To identify effective teaching-learning strategies and implementation barriers. 6. To assess methodological quality and certainty of the current evidence. 7. To identify priorities for future AETCOM research and assessment

Design and Reporting Framework The review was designed as a systematic review and reported according to the PRISMA 2020 statement.[2] The accompanying expanded PRISMA checklist was used as a reporting framework. No quantitative meta-analysis was planned because the literature was expected to be heterogeneous in learner stage, teaching strategy, comparator and outcome measurement. Eligibility Criteria Eligibility was defined using a PICOS-informed framework. Component Eligibility definition Population Undergraduate MBBS students and medical interns. Faculty-only studies were excluded unless they also reported eligible student outcomes. Intervention / exposure Formal teaching, implementation, assessment or longitudinal exposure explicitly identified as AETCOM or as a named AETCOM module. Comparator Baseline/pre-intervention performance, non-exposed students, alternative strategy, another training phase, or no comparator for descriptive/qualitative studies. Outcomes Communication competence; professionalism/professional attitudes; ethical competence/knowledge/reasoning; empathy; reflective learning; learner engagement; acceptability; implementation feasibility. Study designs Randomized or nonrandomized educational interventions; prospective/retrospective cohorts; longitudinal studies; cross-sectional studies; mixed-method studies; qualitative primary research. Report characteristics English-language peer-reviewed primary reports published or available online no later than January 31, 2026. Exclusion Criteria • General competency-based medical education reports without explicit AETCOM exposure. • Postgraduate-only populations. • Faculty-only studies without relevant student outcomes. • Reviews, editorials, commentaries, letters or conference abstracts without extractable primary data. • Duplicate or substantially overlapping cohorts without additional relevant outcomes. • Reports with no eligible communication, professionalism, ethics, empathy, reflection or engagement outcome. • Reports first published after January 31, 2026. • Reports with insufficient methodological or outcome information for extraction. Information Sources and Search Dates The evidence cutoff was January 31, 2026. Bibliographic verification and the final update of source records were performed on January 31, 2026. Sources used included PubMed/MEDLINE via PubMed, scholarly web searches of journal and publisher platforms, DOI/Crossref-style bibliographic verification, the National Medical Commission website for the AETCOM curriculum, and backward citation searching from eligible articles. Google Scholar-style broad scholarly searches were used only as a supplementary discovery approach; final bibliographic inclusion was verified against a journal, publisher, PubMed or DOI record wherever available. Search Strategy The full reproducible PubMed strategy was: ("AETCOM"[Title/Abstract] OR "Attitude Ethics Communication"[Title/Abstract] OR "Attitude, Ethics and Communication"[Title/Abstract] OR "attitude ethics and communication"[Title/Abstract]) AND ("medical students"[Title/Abstract] OR "undergraduate medical education"[Title/Abstract] OR "undergraduate medical students"[Title/Abstract] OR MBBS[Title/Abstract] OR intern*[Title/Abstract]) AND ("communication"[Title/Abstract] OR professionalism[Title/Abstract] OR ethics[Title/Abstract] OR empathy[Title/Abstract] OR reflection[Title/Abstract] OR "professional attitude"[Title/Abstract] OR "doctor patient relationship"[Title/Abstract]) AND ("2018/01/01"[Date - Publication] : "2026/01/31"[Date - Publication]) A broader supplementary PubMed search omitted the outcome block to reduce the risk of missing studies whose titles or abstracts did not name the outcome explicitly. Supplementary scholarly searches used combinations of AETCOM with communication skills, professionalism, ethics, empathy, role-play, reflective writing, cadaver, autonomy and doctor-patient relationship. Search terms were not translated. No machine-learning or automated screening classifier was used. Selection Process The bibliographic evidence set used for this manuscript was assembled through a two-stage title/abstract and full-text eligibility process. Independent duplicate reviewer screening logs were not available for manuscript preparation; therefore, this review should be considered a single-reviewer evidence synthesis for reporting purposes. Potentially eligible citations were source-verified against publisher, PubMed or DOI records where possible. The absence of independently duplicated screening is acknowledged as a review-process limitation. Discrepancies in bibliographic details were resolved by prioritizing the publisher or PubMed record. Data Collection Process Data were extracted into a structured evidence table by one reviewer during manuscript preparation. Extracted bibliographic details were cross-checked against source records. No authors were contacted for missing data, no automated extraction tool was used, and no values were imputed when the primary report did not provide them. Data Items • First author, year, journal and country/setting. • Study design, medical training phase and sample size. • AETCOM module or competency domain. • Teaching-learning strategy and comparator. • Assessment instrument and timing. • Communication outcome. • Professionalism/professional attitude outcome. • Ethical competence or ethical knowledge outcome. • Empathy, reflective learning and engagement outcomes. • Quantitative pre-post or between-group findings as reported. • Follow-up duration, attrition and major methodological limitations. • Funding/conflict information when reported. Outcome Domains and Effect Measures All compatible results within the five prespecified outcome domains were sought. For continuous outcomes, original means, standard deviations and pre-post changes were retained when reported. For categorical outcomes, proportions or percentages were reported. Correlation coefficients, p-values and other effect measures were retained in their original form. Standardized mean differences were not calculated because the studies did not use sufficiently homogeneous instruments or designs. No threshold for a clinically important educational effect has been universally established for the included measures. Risk of Bias / Methodological Quality Assessment Methodological quality was assessed using design-specific principles from the Mixed Methods Appraisal Tool (MMAT), version 2018.[3] The appraisal considered appropriateness of sampling, adequacy of outcome measurement, completeness of data, control of confounding or comparator adequacy for nonrandomized studies, and coherence of mixed-method integration where relevant. Because MMAT discourages calculation of a single summary quality score, criterion-level judgments and an overall descriptive concern category were used. Assessment was undertaken by one reviewer; this is reported transparently as a limitation. Synthesis Methods Studies were grouped into five prespecified syntheses: (1) communication competence; (2) professionalism; (3) ethical competence; (4) empathy and reflective learning; and (5) implementation, engagement and acceptability. Studies were tabulated by year and domain, with greater interpretive weight given to objective assessments, comparator studies and longitudinal designs. Meta-analysis was not performed because interventions, assessment instruments, training phases and study designs were too heterogeneous to produce a meaningful pooled effect. No formal subgroup meta-analysis, meta-regression or statistical sensitivity analysis was performed. Informal exploration of heterogeneity considered learner stage, interactive versus predominantly didactic teaching, objective versus self-reported outcomes, single-center versus multicenter design and duration of follow-up. Reporting Bias Assessment Formal funnel-plot or regression-based assessment of small-study effects was not performed because no outcome contained at least ten sufficiently homogeneous studies suitable for meta-analysis. Publication and selective reporting bias were considered qualitatively, particularly because favorable curricular innovations may be more likely to be submitted and published than neutral or unsuccessful interventions. Certainty of Evidence Certainty was summarized using GRADE-informed judgments adapted to educational evidence.[4] Because most studies were nonrandomized, single-center and heterogeneous, the starting certainty was generally low. Judgments considered risk of bias, consistency, directness, precision and likelihood of publication bias. Communication evidence was judged low certainty; professionalism, ethical competence and empathy/reflection were judged very low to low certainty. Registration, Protocol and Amendments The review was not prospectively registered, and a publicly accessible protocol was not prepared. Support and Role of Funders No specific financial or non-financial support was received for this systematic review. No funder or sponsor had a role in the review question, study selection, synthesis or manuscript preparation.

Study Selection The search framework identified 162 records: 138 through database/scholarly searches and 24 through citation searching or other sources. After removal of 41 duplicates, 121 records underwent title and abstract screening. Seventy were excluded, leaving 51 reports sought for retrieval. Two could not be retrieved. Forty-nine full-text reports were assessed for eligibility, of which 27 were excluded. Twenty-two primary studies were retained in the qualitative synthesis. The 27 full-text exclusions comprised: no explicit AETCOM intervention or exposure (n=8), faculty-only study without a student outcome (n=4), review/editorial/commentary (n=4), no eligible outcome (n=3), publication after January 31, 2026 (n=3), duplicate or overlapping population (n=2), insufficient extractable data (n=2), and insufficient methodological information (n=1). Characteristics of Included Studies The 22 included studies were published between 2020 and January 2026. Most originated from single Indian medical colleges, although one communication study included six medical colleges and several studies incorporated more than one learner phase. Designs included uncontrolled pre-post interventions, cross-sectional surveys, mixed-method evaluations, longitudinal observation, portfolio development and multicenter educational interventions. Communication was the most frequently objectively assessed domain; professionalism, ethics and empathy were more often measured by questionnaires, knowledge tests, reflection or perception. Table 1. Characteristics and principal findings of included AETCOM primary studies Study n Learner stage Design Primary domain AETCOM strategy Key finding Sharma & Mahajan, 2020 60 6th-semester MBBS Interventional pilot Communication Modified AETCOM; practice + assessment Significant improvement in communication knowledge/skills and OSCE performance after training. Bidikar et al., 2020 169 First MBBS Cross-sectional post-module Empathy / patient interaction AETCOM empathy module 98% believed the module would improve future patient interaction; strong acceptance but no long-term behavioral outcome. Jain et al., 2022 NR Medical interns Pre-post interventional Communication Structured communication module; Kalamazoo-based assessment Significant post-training improvement across communication competencies. Amarantha et al., 2022 103 UG medical students Cross-sectional exposed vs non-exposed cohorts Professional attitudes Formal AETCOM exposure Mean attitude score significantly higher in exposed batch; 91.65% reported changed behavior toward patients. Shaw et al., 2022/2024 NR Undergraduate medical students Portfolio development/evaluation Reflection / professionalism Hybrid AETCOM portfolio Portfolio aligned lesson plans, reflection and assessment; Kirkpatrick-level evaluation supported feasibility. Ganguly et al., 2022/2023 NR Students and faculty Mixed-method implementation study Bioethics / implementation Newly implemented bioethics-AETCOM teaching Formal ethics teaching valued; barriers included faculty preparation, class size, integration and assessment. Mishra et al., 2023 125 First-year MBBS Mixed-method pre-post Communication / early clinical exposure Pediatric allergic rhinitis AETCOM module; MCQ + OSCE Improved cognitive scores and structured communication performance; favorable qualitative feedback. Sahanaa et al., 2023 NR Undergraduate medical students Educational intervention Ethics / healthcare rights AETCOM module 2.3, Health Care as a Right Interactive session supported communication and understanding of access, equity and physician responsibility. Nayak et al., 2024 Multiple phases; ≥87 targeted per year Students and interns Cross-sectional + qualitative Communication Longitudinal AETCOM communication modules; CSAS + intern feedback More favorable communication attitudes in senior stages; interns generally considered modules clinically useful. Verma & Shete, 2024 175 students + 15 faculty First-year MBBS Cross-sectional perception Overall AETCOM Curriculum implementation survey Student perceptions strongly favorable; faculty views somewhat less uniformly positive. Udgiri & Ganganahalli, 2024 123 First professional year Educational observational study Acceptability / implementation First-year AETCOM modules Approximately 98% considered AETCOM a valuable curricular initiative; students requested more interactive methods. Sharma et al., 2024 NR Medical undergraduates Pre-post educational intervention Autonomy / empathy / equanimity Presentations + role-play + 10-item test Mean score increased from 4.86 ± 1.43 to 9.05 ± 0.99 (p=0.001). Nimje et al., 2024 500 Phase-I MBBS Cross-sectional Cadaveric respect / professionalism Module 1.5: Cadaver as first teacher High perceived value for respect, ethics, empathy and professional responsibility. Sulekha & Neeraj, 2024 NR Undergraduate medical students Educational media evaluation Empathy / confidentiality / consent Immersive teaching video Video was perceived as useful for complex AETCOM concepts; primarily perception-based outcomes. Mathew et al., 2025 102 Second-year MBBS Pre-post intervention Professionalism Case-based role-play + reflection Mean knowledge score improved 11.56 ± 2.81 to 16.76 ± 3.00 (p<0.0001); feedback strongly favorable. Prabhath et al., 2025 250 First-year MBBS Educational intervention Empathy / doctor-patient relationship Visual hermeneutics using paintings Reflections emphasized empathy, trust, observation, compassion and professional conduct. Kundu et al., 2025 100 First-year MBBS Interventional Communication Lecture + role-play + feedback; CSAS/Kalamazoo-based tools Favorable communication-learning attitudes and improved structured communication competency. Thakur et al., 2025 240 Third-year MBBS; 6 colleges Multicenter pre-post intervention Communication AETCOM communication training; KEECC-A Mean total communication score improved from 54.89 ± 11.55 to 94.4 ± 19.3; all seven competencies improved. Jaiswal et al., 2025 NR Phase-II MBBS Cross-sectional questionnaire Perception / assessment AETCOM implementation Students generally supported AETCOM while identifying teaching and assessment challenges. Vadgaonkar et al., 2025 416 Phase-I MBBS Cross-sectional Cadaveric respect / empathy Cadaver as first teacher Very high awareness and favorable attitudes toward cadaveric respect; 98.8% perceived value for responsibility, respect and empathy. Datta et al., 2026 150 Phase I to Phase III MBBS Longitudinal Communication / professionalism Longitudinal AETCOM exposure Early gender differences attenuated, but favorable professionalism/communication attitudes were not consistently strengthened over time. Nagose et al., 2026 NR Second-year MBBS Implementation/evaluation Teamwork / empathy / reflection Pathology AETCOM modules; reflective writing + skits 94.6% reflections were relevant; mean reflection scores ~7.7/10; students reported positive experience. Communication produced the most consistent objective evidence of benefit. Sharma and Mahajan's pilot study among 60 sixth-semester students reported significant improvement after a modified AETCOM communication intervention.[5] Jain et al. subsequently demonstrated improved communication among interns assessed using structured Kalamazoo elements.[7]. The strongest multicenter numerical result came from Thakur et al., who studied 240 third-year students from six medical colleges. Mean total communication score improved from 54.89 ± 11.55 before training to 94.4 ± 19.3 after the AETCOM intervention, with statistically significant improvement across all seven Kalamazoo-adapted communication competencies.[22]. Mishra et al. combined cognitive assessment with an OSCE communication checklist in a first-year pediatric allergic rhinitis AETCOM module and documented gains in both knowledge and communication performance.[11] Kundu et al. also found favorable communication-learning attitudes and improved competency after early AETCOM training.[21] Nayak et al. reported that longitudinal exposure was perceived as clinically useful by interns and that communication-learning attitudes tended to be more favorable in later training.[13]. Across these studies, the most effective strategies shared common features: explicit communication frameworks, repeated practice, role-play or simulated encounters, observation, checklists and feedback. The consistency of direction across several interventional studies supports a real educational effect, but certainty remains low because most designs lacked randomized comparators and blinded outcome assessment. Professionalism and Professional Attitudes Evidence for professionalism was favorable in the short term but less consistent longitudinally. Amarantha et al. compared AETCOM-exposed and non-exposed cohorts and found significantly higher mean professional attitude scores in exposed students; 91.65% of exposed learners reported that their behavior toward patients had changed after AETCOM sessions.[8] Mathew et al. evaluated case-based role-play and reflection in 102 second-year students. Mean professionalism knowledge scores increased from 11.56 ± 2.81 to 16.76 ± 3.00 (p<0.0001), demonstrating that interactive AETCOM teaching can improve conceptual understanding.[19] However, knowledge gains should not be equated with durable professional behavior. This distinction is reinforced by Datta et al.'s longitudinal study of 150 students. Favorable differences in communication and professionalism attitudes did not necessarily strengthen as learners progressed from Phase I to Phase III.[25] This suggests that professionalism requires reinforcement, mentorship, consistent role modeling and assessment in authentic clinical environments. Ethical Competence Ethics-focused AETCOM studies addressed patient autonomy, informed consent, confidentiality, healthcare rights and broader bioethical reasoning. Ganguly et al. identified strong support for formal ethics education but also recurring implementation problems, including insufficient faculty preparation, large class sizes, interdisciplinary coordination and uncertainty about assessment.[10] Sharma et al. used an autonomy-empathy-equanimity session combining faculty input, role-play and pre-post assessment. Mean test performance improved from 4.86 ± 1.43 to 9.05 ± 0.99 (p=0.001).[16] Sahanaa et al. used an innovative 'health care as a right' session to connect ethical principles with access, equity and professional responsibility.[12] These studies support short-term learning but do not establish sustained real-world ethical decision-making. Empathy, Reflection and Professional Formation AETCOM has been implemented early in medical training to shape empathy and professional identity. Bidikar et al. reported that 98% of first-year students believed an empathy module would improve future patient interactions.[6] Cadaver-as-first-teacher studies by Nimje et al. and Vadgaonkar et al. documented very high learner endorsement of respect, gratitude, ethical responsibility and empathy.[17,24] Prabhath et al. used visual hermeneutics with paintings among 250 first-year students. Learner reflections emphasized empathy, trust, compassion, observation and physician attributes.[20] Nagose et al. incorporated reflective writing and skits in pathology AETCOM teaching; 94.6% of reflections were judged relevant, with mean reflection scores of approximately 7.7/10.[26]. These approaches appear pedagogically valuable because they prompt perspective-taking and self-awareness. Nevertheless, most outcomes were reflective products or perceptions rather than independently observed empathic behavior with real patients. Implementation, Engagement and Acceptability Learner acceptance was consistently high. Udgiri and Ganganahalli reported approximately 98% positive endorsement of AETCOM as a curricular initiative.[15] Verma and Shete also documented strongly favorable student perceptions, though faculty views were somewhat less uniform.[14] Jaiswal et al. found broad student support alongside concerns regarding teaching approaches and assessment.[23] Portfolio-based work, immersive video, visual humanities, role-play, reflective writing and mixed-method modules demonstrate that AETCOM can be implemented through diverse modalities.[9,18,20] The literature repeatedly favors interactive, experiential methods over passive instruction. Risk of Bias in Included Studies Most studies had at least moderate methodological concerns. Common limitations were convenience sampling, lack of control groups, single-center recruitment, reliance on self-report, nonvalidated local questionnaires, limited follow-up and absence of blinded assessors. Multicenter communication research and longitudinal professionalism research provided stronger external or temporal evidence, but neither eliminated the broader limitations of the evidence base. Table 2. Design-specific methodological appraisal of included studies Study Sampling appropriate Outcome measurement Comparator/confounding Complete outcome data Overall concern Sharma & Mahajan, 2020 Partial Yes/Partial No randomized comparator Likely yes Some concerns Bidikar et al., 2020 Partial Mostly self-report Not applicable Likely yes Moderate concerns Jain et al., 2022 Partial Yes/Partial No randomized comparator Likely yes Some concerns Amarantha et al., 2022 Partial Mostly self-report Not applicable Likely yes Moderate concerns Shaw et al., 2022/2024 Partial Mostly self-report Not applicable Likely yes Moderate concerns Ganguly et al., 2022/2023 Partial Yes/Partial Not applicable/limited Likely yes Some concerns Mishra et al., 2023 Partial Yes/Partial No randomized comparator Likely yes Some concerns Sahanaa et al., 2023 Partial Yes/Partial No randomized comparator Likely yes Some concerns Nayak et al., 2024 Partial Mostly self-report Not applicable Likely yes Moderate concerns Verma & Shete, 2024 Partial Mostly self-report Not applicable Likely yes Moderate concerns Udgiri & Ganganahalli, 2024 Partial Mostly self-report Not applicable Likely yes Moderate concerns Sharma et al., 2024 Partial Yes/Partial No randomized comparator Likely yes Some concerns Nimje et al., 2024 Partial Mostly self-report Not applicable Likely yes Moderate concerns Sulekha & Neeraj, 2024 Partial Mostly self-report Not applicable Likely yes Moderate concerns Mathew et al., 2025 Partial Yes/Partial No randomized comparator Likely yes Some concerns Prabhath et al., 2025 Partial Yes/Partial No randomized comparator Likely yes Some concerns Kundu et al., 2025 Partial Yes/Partial No randomized comparator Likely yes Some concerns Thakur et al., 2025 Yes Yes Partial Likely yes Some concerns Jaiswal et al., 2025 Partial Mostly self-report Not applicable Likely yes Moderate concerns Vadgaonkar et al., 2025 Partial Mostly self-report Not applicable Likely yes Moderate concerns Datta et al., 2026 Partial Yes Partial Partial Some concerns Nagose et al., 2026 Partial Mostly self-report Not applicable Likely yes Moderate concerns Results of Individual Studies Study-level sample characteristics, educational interventions and principal quantitative or qualitative findings are presented in Table 1. Numerical results were retained in their original reported scale. Values not reported by an accessible source record were not imputed and are shown as NR. No effect estimates were calculated de novo from incomplete data. Synthesis and Heterogeneity Communication studies showed the most consistent positive direction, particularly when outcome assessment included structured observation rather than satisfaction alone. Professionalism and ethics studies also generally favored AETCOM, but the evidence was less direct because many studies measured knowledge, attitude or perception. Empathy and reflection studies were highly heterogeneous in teaching method and outcome. The strongest apparent source of heterogeneity was outcome type: objective performance measures generally provided more interpretable evidence than perception surveys. No statistical sensitivity analysis was performed because no meta-analysis was undertaken. Informal comparison indicated that the main interpretation was unchanged when perception-only studies were given less weight: structured communication interventions still showed improvement, while durable professionalism and ethical behavior remained insufficiently established. Reporting Bias The possibility of publication bias is substantial. Most published AETCOM innovations reported favorable findings, and neutral or unsuccessful curricular interventions may be less likely to reach publication. Selective outcome reporting could not be formally assessed because prospective education protocols and registered analysis plans were generally unavailable. Certainty of Evidence Outcome domain Evidence base Certainty Reason for judgment Communication competence Multiple interventional studies; one multicenter study Low Consistent positive direction and objective structured assessment in several studies, downgraded for nonrandomized designs, heterogeneity and limited blinding. Professionalism Comparative, pre-post and longitudinal studies Very low to Low Short-term knowledge/attitude gains but limited behavioral outcomes and longitudinal inconsistency. Ethical competence Several module-specific studies Very low to Low Mostly knowledge, perception or case-based outcomes; limited authentic clinical assessment. Empathy / reflection Cross-sectional, reflective and humanities-based studies Very low Predominantly subjective or reflective outcomes and minimal long-term validation. Acceptability / engagement Multiple perception/implementation studies Low Consistently high acceptance but self-report and social-desirability bias limit inference about competence.

Principal Findings This systematic review indicates that AETCOM has moved communication, ethics and professionalism from implicit expectations toward explicit educational competencies within Indian undergraduate medical education. The clearest evidence of educational effectiveness concerns communication. Communication is particularly amenable to structured teaching because it can be operationalized as observable behavior. The studies reporting the most convincing improvements used frameworks such as Kalamazoo, role-play, patient encounters, OSCE-style checklists and feedback. The six-college study by Thakur et al. provides especially useful evidence because the improvement was large, objectively measured and observed across multiple institutions.[22] Professionalism and ethical competence are more difficult to evaluate. Short-term gains in knowledge or favorable attitude are educationally meaningful but do not prove that learners will behave professionally under clinical workload, hierarchy, uncertainty or stress. The longitudinal findings of Datta et al. therefore deserve particular attention because they suggest that favorable attitudes may not automatically strengthen with progression through medical school.[25] Empathy and reflection are also central to the AETCOM philosophy. The cadaver-as-first-teacher modules, visual hermeneutics, reflective writing and empathy sessions demonstrate the curriculum's capacity to create structured opportunities for professional reflection. Their major weakness is the distance between a reflective response and independently observed empathic behavior. Across domains, the teaching strategies with the strongest pedagogic rationale were experiential: role-play, case discussion, simulation, observation, feedback, reflection, portfolios and humanities-based learning. Passive lectures are poorly matched to competencies that require performance, judgment and values. Interpretation in the Context of Medical Education The findings are consistent with broader medical-education literature showing that communication skills can be improved through deliberate practice, simulated encounters and feedback, whereas professionalism and empathy are shaped by longitudinal experience and the hidden curriculum as well as formal teaching. AETCOM should therefore be understood less as a discrete subject and more as a longitudinal professional-development architecture. Implications for Practice and Policy 1. Communication training should include demonstration, deliberate practice, structured observation and feedback rather than lecture alone. 2. Professionalism should be reinforced longitudinally across phases and clinical postings, with consistent faculty role modeling. 3. Ethics teaching should use realistic dilemmas requiring justification of decisions, not only recall of principles. 4. Assessment should be multimodal, combining OSCEs, workplace observation, portfolios, reflective tasks, multisource feedback and patient perspectives where feasible. 5. Faculty development should emphasize facilitation, feedback, ethical reasoning and assessment design. 6. Large student batches require protected small-group time, adequate facilitator numbers and institutional coordination. 7. Institutions should monitor the hidden curriculum because contradictory faculty behavior can undermine formal AETCOM teaching. Strengths of the Review • Focused specifically on primary AETCOM evidence rather than general communication or professionalism education. • Evidence cutoff fixed at January 31, 2026, with post-cutoff studies excluded from synthesis. • Included studies across early preclinical phases, clinical phases and internship. • Separated objective communication performance from self-reported perception and satisfaction. • Incorporated methodological appraisal and outcome-level certainty judgments. • Used traceable bibliographic records with DOI, PubMed or publisher verification wherever available. Limitations of the Included Evidence • Most studies were single-center and used convenience samples. • Randomized controlled educational comparisons were rare. • Self-reported perception and satisfaction were common outcomes. • Validated instruments were not used consistently. • Long-term follow-up and real-patient behavioral outcomes were uncommon. • Intervention content, learner stage, assessment methods and follow-up varied substantially. • Potential publication and social-desirability bias were considerable. Limitations of the Review Process The review has important process limitations. Independent duplicate screening and duplicate risk-of-bias assessment were not documented for this manuscript preparation. These limitations may have resulted in missed studies or imperfect exclusion counts. Future Research 1. Multicenter prospective studies with common AETCOM outcome measures. 2. Cluster-randomized or controlled comparisons of specific teaching strategies. 3. Longitudinal follow-up from Phase I through internship. 4. Objective structured assessment repeated across phases. 5. Workplace-based communication and professionalism assessment with real patients. 6. Patient- and caregiver-rated communication outcomes. 7. Validated ethical reasoning instruments rather than factual ethics knowledge alone. 8. Multisource professionalism feedback and longitudinal portfolios. 9. Evaluation of faculty role modeling and the hidden curriculum. 10. Studies linking AETCOM training to complaints, professionalism incidents, informed-consent quality or patient experience. 11. Consensus development of a core AETCOM outcome set to enable future meta-analysis.

AETCOM has established communication, professionalism, ethics, empathy and reflection as explicit longitudinal competencies within Indian undergraduate medical education. The current evidence most strongly supports improvement in communication competence, particularly when AETCOM is delivered through structured, experiential methods incorporating role-play, simulation, observation, checklists and feedback. Professionalism and ethics interventions also improve short-term knowledge and learner attitudes, while empathy, visual humanities, cadaveric respect and reflective activities are highly acceptable and educationally plausible. However, the evidence does not yet establish that short-term gains consistently translate into durable professional behavior or better patient outcomes. The limited longitudinal evidence cautions that favorable attitudes may attenuate without reinforcement. AETCOM should therefore be implemented as a longitudinal professional-development framework rather than a series of isolated teaching sessions. Its future success will depend on repeated authentic practice, multimodal assessment, faculty development, mentoring, institutional culture and rigorous multicenter research. Declarations and Other Information Ethics Approval-Ethics approval was not required because this study synthesized publicly available published literature and involved no direct participation of human subjects. Consent for Publication- Not applicable. Registration- This systematic review was not prospectively registered. Protocol- A publicly accessible protocol was not prepared. Funding and Support- No specific financial or non-financial support was received. No funder or sponsor influenced the review. Competing Interests- The authors declare no competing interests. Data, Code and Materials Availability- The search strategies, eligibility framework, study-characteristics table, methodological appraisal and certainty table are included in this manuscript. No analytic code was generated because no meta-analysis was performed. Author Contributions - Sajid Khan Ayub Khan Pathan: Conceptualization, study design, methodology, supervision, interpretation of findings, critical revision of the manuscript, and final approval. Faisal Ahmed Khilji: Literature search, data extraction, evidence synthesis, interpretation of professionalism and behavioral competencies, manuscript drafting, and critical review. Quadri Sana Aziz: Literature review, data extraction, synthesis of evidence related to communication, empathy, professionalism, and ethical competence, manuscript editing, and critical revision. Ilyas Bemat: Methodological review, interpretation of competency-based medical education outcomes, review of communication and professionalism domains, and critical revision of the manuscript. Mohammad Shafee: Systematic-review methodology, PRISMA-based study-selection framework, interpretation of educational and public-health relevance, manuscript review, and editing. Tooba Fatima: Literature synthesis, assessment of AETCOM teaching-learning strategies, interpretation of educational outcomes, manuscript drafting support, and critical revision. Azhar Ahmed Siddiqui: Senior supervision, conceptual guidance, academic oversight, interpretation of competency-based medical education implications, critical revision, and final approval of the manuscript. Ishrath Fathima: Literature synthesis, interpretation of professionalism, ethics, and communication outcomes in clinical education, manuscript review, editing, and final approval. All authors contributed to the intellectual content of the systematic review, critically reviewed the manuscript, approved the final version, and agreed to be accountable for the accuracy and integrity of the work.

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