Medical competence encompasses considerably more than the acquisition of scientific knowledge and technical skills. Physicians are expected to communicate clearly and compassionately, respect patient autonomy, maintain confidentiality, obtain valid informed consent, work effectively within multidisciplinary teams, disclose medical errors appropriately and demonstrate integrity and accountability throughout professional practice.[1] Traditionally, many of these attributes were acquired indirectly through apprenticeship, observation of senior clinicians and the institutional “hidden curriculum.” Such an approach is inherently variable because students may encounter both exemplary and undesirable professional behaviors. Recognizing this limitation, medical education has progressively moved toward explicitly defining, teaching and assessing competencies related to communication, professionalism and ethics. The Medical Council of India, subsequently replaced by the National Medical Commission (NMC), introduced the Attitude, Ethics and Communication (AETCOM) framework as an essential component of competency-based undergraduate medical education.[1] AETCOM was conceptualized as a longitudinal program extending across the professional years of the MBBS curriculum. It aims to prepare the Indian Medical Graduate to fulfil multiple roles, including clinician, communicator, professional, lifelong learner and member or leader of the healthcare team. AETCOM differs from conventional knowledge-oriented teaching because much of its content lies within affective and behavioral domains. Teaching strategies therefore include case discussions, role-play, simulated patients, reflective writing, portfolios, small-group learning, audiovisual material and structured encounters rather than relying exclusively on didactic lectures. Since implementation of AETCOM, studies from different regions of India have examined communication training, professionalism, ethical reasoning, patient autonomy, empathy, doctor-patient relationships, respect for cadavers, confidentiality, reflective practice and professional identity formation.[5-30] However, considerable heterogeneity exists in study design and outcome measurement. Early studies generally demonstrated favorable learner perceptions, whereas more recent research has incorporated structured communication checklists, objective structured clinical examinations, multicentre interventions, portfolios and longitudinal assessment. Consequently, a synthesis of the rapidly evolving evidence is necessary to distinguish improvement in learner satisfaction from demonstrable development of competence. Review Question Among undergraduate medical students and interns, what impact does structured AETCOM-based education have on communication competence, professionalism, ethical competence, empathy, reflective capacity and related professional attributes? Objectives The objectives of this systematic review were: 1. To evaluate the impact of AETCOM-based education on communication competence. 2. To assess its influence on professionalism and professional attitudes. 3. To synthesize evidence regarding ethical knowledge, reasoning and decision-making. 4. To evaluate effects on empathy, reflection and professional identity formation. 5. To identify teaching-learning strategies associated with favorable outcomes. 6. To identify barriers affecting implementation and assessment. 7. To examine methodological limitations in existing AETCOM research. 8. To identify priorities for future medical-education research.

Study Design This systematic review was structured according to the principles of the PRISMA 2020 statement.[2] Because of substantial methodological and clinical heterogeneity across educational studies, a narrative evidence-synthesis approach was selected. Eligibility Criteria Inclusion Criteria Studies were included when they: • involved undergraduate MBBS students or medical interns; • explicitly evaluated an AETCOM module, AETCOM-based teaching strategy or AETCOM-related competency; • assessed communication, professionalism, ethics, empathy, reflection, professional attitudes or closely related outcomes; • employed observational, interventional, mixed-method, longitudinal or qualitative designs; • provided primary empirical data; and • were available in English. Exclusion Criteria Studies were excluded when they: • involved only postgraduate medical trainees or practicing physicians; • discussed AETCOM conceptually without primary learner data; • evaluated general communication or bioethics teaching without an identifiable relationship with AETCOM; • consisted solely of editorials, letters, narrative reviews or commentaries; or • provided insufficient information regarding educational intervention or outcomes. Information Sources and Search Strategy Literature was identified using PubMed/MEDLINE and PubMed Central, supplemented with targeted searches of journal and publisher platforms and backward reference screening. Search terms were combined using appropriate Boolean operators and included: “AETCOM” OR “Attitude Ethics Communication” OR “Attitude Ethics and Communication” combined with: “medical students,” “medical education,” “communication skills,” “professionalism,” “ethics,” “bioethics,” “empathy,” “reflection,” “doctor patient relationship,” “competency based medical education,” “role play,” “simulation,” and “portfolio.” The evidence search was updated through 30 June 2026. Study Selection Titles and abstracts were assessed for relevance, followed by evaluation of potentially eligible full-text reports. The final qualitative evidence base consisted of 26 primary studies explicitly addressing AETCOM implementation or educational outcomes. Data Extraction Information extracted from eligible studies included: • author and year; • geographical setting; • study design; • sample size; • stage of undergraduate training; • AETCOM competency addressed; • teaching-learning method; • assessment instrument; • major quantitative or qualitative findings; and • methodological limitations. Outcome Classification Outcomes were categorized into five domains: 1. Communication competence 2. Professionalism and professional attitudes 3. Ethical competence 4. Empathy, reflection and professional identity 5. Implementation, engagement and acceptability Quality Assessment Methodological quality was considered using design-appropriate principles derived from the Mixed Methods Appraisal Tool. Particular attention was given to participant selection, outcome measurement, comparators, completeness of outcome data, confounding and appropriateness of qualitative analysis.[3] Formal pooling of results was not attempted because study populations, AETCOM modules, teaching approaches, assessment instruments and follow-up periods differed substantially.

Characteristics of Included Evidence Studies published from 2020 through June 2026 demonstrated a progressive evolution in AETCOM research. Earlier studies predominantly measured learner perception and immediate responses, whereas later research increasingly incorporated structured checklists, OSCE-type assessment, portfolios, multicentre interventions and process evaluation. Sample sizes ranged from small reflective-learning cohorts to multicentre studies involving several hundred medical students. Table 1. Key Studies Evaluating AETCOM-Based Medical Education Study Participants Educational approach Principal outcome Sharma & Mahajan, 2020 Third-year MBBS students Video, simulated interaction, OSCE Significant improvement in structured communication performance Bidikar et al., 2020 169 first-year students Empathy-focused AETCOM sessions 98% believed training would improve future patient interaction Jain et al., 2022 Medical interns Communication module + Kalamazoo checklist Significant post-intervention improvement Amarantha et al., 2022 103 students Formal AETCOM exposure Improved professional attitudes Shaw et al., 2022/2024 UG students Hybrid portfolio and reflection Improved self-assessment and quality of reflection Ganguly et al., 2023 Students and faculty Bioethics/AETCOM implementation Value recognized; faculty training and assessment remained barriers Mishra et al., 2023 125 first-year students Clinical case/OSCE-based AETCOM Improvement in knowledge and communication performance Nayak et al., 2024 Multiple MBBS phases/interns Longitudinal communication modules Favorable communication-learning attitudes and clinical utility Udgiri & Ganganahalli, 2024 123 students First-year AETCOM modules 98% supported AETCOM; interactive sessions preferred Sharma et al., 2024 Medical undergraduates Autonomy-empathy-equanimity module Mean assessment score increased from 4.86 to 9.05 Mathew et al., 2025 102 second-year students Case-based role-play Professionalism knowledge increased from 11.56 to 16.76 Prabhath et al., 2025 250 first-year students Visual hermeneutics Strong themes of empathy, trust and compassionate practice Thakur et al., 2025 240 students, six colleges Structured communication training Score increased from 54.89 to 94.4 Datta et al., 2026 150 students Longitudinal assessment Positive attitudes were not uniformly sustained over training Pallavi et al., 2026 250 first-year students Video-recorded peer role-play + checklist 98% met/exceeded competency expectations Verma et al., 2026 16 enrolled; 13 respondents Case-driven reflective writing Strong perceived benefit for AETCOM learning Dhaneria et al., 2026 126 students Small groups, role-play and ethics discussions Satisfaction approximately 88–90%; high engagement Pawde et al., 2026 180 interns, three colleges 12-hour structured AETCOM program Significant improvement in knowledge, attitude and communication Communication Competence Communication was the domain supported by the most consistent objective evidence. Sharma and Mahajan reported significant improvements in structured communication assessment following a modified AETCOM intervention incorporating video-based learning and OSCE-type assessment.[5] Jain et al. subsequently demonstrated significant improvement among medical interns following structured AETCOM communication teaching evaluated using the Kalamazoo Essential Elements Communication framework.[8] Mishra et al. integrated an AETCOM-based pediatric allergic-rhinitis module into early undergraduate teaching. Improvements were demonstrated not only in cognitive assessment but also in structured communication performance.[12] Particularly important multicentre evidence was provided by Thakur et al., who evaluated 240 third-year MBBS students from six medical colleges. Mean communication scores increased from 54.89 ± 11.55 before training to 94.4 ± 19.3 after intervention, with significant improvement across all seven assessed communication competencies.[24] More recent evidence supports combining active practice with structured feedback. Pallavi et al. introduced video-recorded peer doctor-patient encounters using a culturally contextualized Observation-Based Communication Skills Checklist among 250 first-year students. Of 241 valid submissions, 70% met expectations and 28% exceeded expectations. Furthermore, 87% considered peer role-play effective and 91% considered checklist guidance valuable.[27] Among interns, Pawde et al. reported significant improvements following a 12-hour structured program: mean knowledge increased from 18.6 ± 4.2 to 27.9 ± 3.1, professional-attitude scores from 62.4 ± 8.7 to 79.6 ± 6.4, and communication-practice scores from 58.3 ± 10.2 to 91.4 ± 12.1, with p<0.001 for each comparison.[30] Collectively, the evidence suggests that communication is most effectively developed when learners are required to perform observable behaviors rather than simply acquire theoretical knowledge. Professionalism and Professional Attitudes Professionalism outcomes were generally favorable but were more difficult to quantify. Amarantha et al. reported higher professional-attitude scores among learners exposed to structured AETCOM education, with a large proportion of students reporting perceived behavioral changes in their interaction with patients.[9] Case-based role-play appears particularly useful. Mathew et al. evaluated professionalism teaching among 102 second-year MBBS students and reported an increase in mean knowledge scores from 11.56 ± 2.81 to 16.76 ± 3.00 (p<0.0001) following role-play and reflection.[21] Professional development was also addressed through portfolio-based education. Shaw et al. demonstrated that a structured hybrid portfolio enabled longitudinal documentation of reflective learning while offering faculty an assessment mechanism.[10] However, longitudinal evidence warrants caution. Datta et al. followed communication and professionalism attitudes among students across different phases of medical training and found that favorable attitudes were not necessarily strengthened progressively with increasing seniority.[27] This observation highlights a critical distinction between learning about professionalism and consistently behaving professionally. Professional behavior is influenced not only by classroom teaching but also by institutional culture, clinical workload, hierarchy, role modelling and the hidden curriculum. Ethical Competence Ethical competence addressed through AETCOM included patient autonomy, confidentiality, informed consent, fiduciary responsibility, medical-error disclosure, equity and healthcare rights. Ganguly et al. found broad support for structured bioethics education but identified several practical barriers, including inadequate faculty preparation, large class sizes, difficulty achieving horizontal and vertical integration and uncertainty regarding assessment.[11] An AETCOM module addressing autonomy, empathy and equanimity demonstrated substantial immediate improvement, with mean assessment scores increasing from 4.86 ± 1.43 to 9.05 ± 0.99 (p=0.001).[17] Sahanaa et al. demonstrated that healthcare rights and equity could be integrated into AETCOM through interactive learning rather than conventional lectures.[13] Dhaneria et al. recently evaluated AETCOM sessions addressing patient autonomy, medical-error disclosure, confidentiality and fiduciary duty in 126 students. Satisfaction ratings ranged from 87.97% to 89.86%. Eye contact during sessions ranged from 91–96%, while on-task behavior ranged from 84–94.4%. A strong association was observed between facilitator professional attitude and student engagement (r=0.70, p<0.01).[29] The findings suggest that ethical concepts can be effectively introduced using case discussions and experiential learning. Nevertheless, objective evidence demonstrating that students subsequently resolve ethical dilemmas more effectively during independent clinical practice remains limited. Empathy, Reflection and Professional Identity AETCOM has provided an important platform for introducing empathy early in undergraduate medical training. Bidikar et al. found that 98% of participating first-year students believed empathy-oriented AETCOM teaching would improve their future interaction with patients.[6] The “Cadaver as our First Teacher” module has similarly been used to promote respect, gratitude, dignity and professional responsibility during the earliest stage of medical training.[18,26] Visual humanities represent another innovative approach. Prabhath et al. used paintings and visual hermeneutics with 250 first-year students to explore the doctor-patient relationship. Student reflections frequently emphasized empathy, compassion, trust, observation and characteristics of a good physician.[22] Reflective writing has also emerged as an important pedagogical strategy. Nagose et al. incorporated reflective writing and student activities into pathology AETCOM teaching, demonstrating good learner engagement and relevant reflections.[28] In 2026, Verma et al. evaluated case-vignette-driven reflective writing during an early psychiatry enrichment program. All respondents regarded the activity as useful for AETCOM learning, while qualitative findings highlighted peer discussion, facilitator guidance, self-directed learning and a psychologically supportive educational environment.[28] These findings support reflection as a mechanism through which students integrate cognitive learning with affective and professional development. Teaching-Learning Strategies Associated With Better Outcomes Across studies, beneficial AETCOM programs consistently incorporated one or more of the following: • role-play; • simulated or standardized patients; • direct patient encounters; • case-based discussion; • reflective writing; • structured portfolios; • observation checklists; • OSCE or communication stations; • video-recorded encounters; • visual humanities; • small-group discussion; • peer learning; and • individualized faculty feedback. Passive didactic teaching was less consistently valued. The evidence therefore suggests that AETCOM is most effective when learners progress through a cycle of: experience → observation → feedback → reflection → repeated practice. Implementation Challenges Despite favorable learner responses, several recurring implementation barriers were identified. Faculty preparedness AETCOM requires facilitation rather than conventional information delivery. Faculty members must therefore be trained in small-group facilitation, reflection, communication assessment and management of ethically sensitive discussions. Large student numbers Role-play, simulation and individualized feedback become challenging when class sizes are large. Assessment Knowledge examinations alone cannot adequately evaluate attitudes, ethics and communication. A multimodal assessment system incorporating OSCE stations, portfolios, direct observation, multisource feedback and reflective exercises is preferable. Subjectivity Professionalism and empathy are complex constructs, and locally developed questionnaires may lack adequate validity or reliability. Hidden curriculum Students may receive contradictory messages when behaviors encouraged in formal AETCOM sessions differ from those observed in clinical settings. Limited longitudinal reinforcement One-time teaching sessions are unlikely to produce enduring behavioral change without repeated exposure during clinical training. Methodological Quality of the Evidence The overall direction of evidence favored AETCOM; however, methodological limitations were common. The principal concerns were: • single-centre recruitment; • convenience sampling; • absence of randomized controls; • uncontrolled pre-test/post-test designs; • self-reported outcomes; • institution-specific nonvalidated questionnaires; • short follow-up periods; • Hawthorne effects; • absence of blinded assessors; and • limited assessment during authentic clinical care. Communication studies using structured observational instruments provide stronger evidence than studies relying exclusively on satisfaction surveys. The multicentre intervention by Thakur et al. improves generalizability, while newer video-based structured assessments offer scalable approaches to objective competency evaluation. Nevertheless, randomized or well-controlled longitudinal investigations remain uncommon.

The present review indicates that AETCOM represents an important transition within Indian medical education from implicitly expected professional attributes toward explicitly taught competencies. The strongest evidence concerns communication competence. Multiple independent interventions demonstrate improvement when students receive structured teaching combined with practice, observation and feedback. The magnitude of improvement reported in multicentre and intern studies supports the educational value of explicit communication training. Evidence concerning professionalism is encouraging but less definitive. Short-term knowledge or attitude improvement does not necessarily demonstrate professional behavior under the pressures of actual clinical practice. Professionalism is socially situated and influenced by institutional culture and role models. Similarly, ethical competence requires more than remembering ethical principles. Students must recognize competing values, manage uncertainty, understand contextual factors and justify decisions appropriately. Existing AETCOM studies demonstrate improved engagement and understanding, but relatively few evaluate authentic ethical decision-making longitudinally. Empathy and reflection appear particularly responsive to humanities-based and reflective interventions. Cadaver-related professionalism, paintings, narratives, role-play and reflective writing allow students to explore the patient's perspective and their evolving professional identity. Why Communication Demonstrates Stronger Evidence Communication skills consist of observable actions: introducing oneself, establishing rapport, listening actively, eliciting patient concerns, responding empathetically, explaining information and achieving shared decisions. Consequently, performance can be assessed through structured instruments such as Kalamazoo-derived checklists and OSCE stations. Professionalism and ethical conduct, in contrast, often depend on situational judgment and longitudinal behavior. Their assessment requires repeated observation across clinical settings. Educational Implications AETCOM should not function as an isolated course detached from clinical medicine. Instead, its principles should be vertically and horizontally integrated throughout undergraduate education. Communication can be reinforced during history taking, informed consent, breaking bad news and discharge counselling. Ethical reasoning can be incorporated into clinical case discussions. Professionalism can be evaluated during ward-based activity, teamwork and longitudinal patient contact. Assessment also requires alignment. When students perceive AETCOM as peripheral to high-stakes examinations, engagement may become superficial. Competencies should therefore contribute meaningfully to formative and summative assessment. Role of Faculty Recent process-assessment evidence demonstrates a strong relationship between facilitator professionalism and student engagement. Faculty members consequently function not only as instructors but also as professional role models. Faculty development should therefore address: • facilitation of reflective discussions; • constructive feedback; • handling difficult ethical conversations; • assessment of communication behavior; • use of standardized rubrics; and • recognition and mitigation of unconscious bias. Technology-Enabled AETCOM The 2026 evidence on video-recorded peer encounters demonstrates the feasibility of integrating digital learning platforms with structured communication assessment. Such approaches may address scalability problems in institutions with large class sizes by allowing students to record encounters, perform peer observation and receive asynchronous faculty feedback. Digital portfolios can similarly document competency development longitudinally. Strengths of the Review This review: • specifically focuses on AETCOM rather than general communication or ethics education; • incorporates evidence across preclinical, clinical and internship stages; • separates objective performance outcomes from learner perception; • examines communication, professionalism, ethics and empathy as related but distinct outcomes; and • identifies both educational effectiveness and implementation limitations. Limitations The review has several limitations. First, the published AETCOM literature remains dominated by Indian single-centre educational studies. Second, heterogeneity of interventions and assessment instruments prevented meaningful meta-analysis. Third, many studies relied upon self-reported perception or immediate post-intervention evaluation. Fourth, publication bias is possible because unsuccessful curricular interventions may be less likely to be reported. Fifth, few studies measured sustained behavior in authentic patient-care environments. Future Research Priorities Future research should prioritize: 1. multicentre prospective cohorts; 2. randomized or controlled educational designs where feasible; 3. longitudinal follow-up throughout MBBS and internship; 4. validated communication, professionalism and ethics instruments; 5. workplace-based assessment; 6. objective structured clinical examinations; 7. standardized-patient assessment; 8. multisource feedback from faculty, peers and patients; 9. behavioral rather than exclusively perception-based outcomes; 10. patient-centred outcomes; 11. evaluation of professional identity formation; 12. comparison of simulation, role-play and real-patient learning; 13. faculty-development interventions; and 14. assessment of technology-enabled AETCOM teaching.

AETCOM-based education has contributed substantially to formalizing the teaching of communication, professionalism, ethics, empathy and reflective practice within Indian undergraduate medical education. Available evidence demonstrates the clearest and most consistent benefit for communication skills, particularly when students participate in structured practice, role-play, simulation, direct observation and feedback. Professionalism and ethical competence also show favorable short-term outcomes, but evidence demonstrating sustained behavioral change is less robust. Empathy-oriented teaching, reflective writing, portfolios, visual humanities and respectful engagement with cadavers offer important opportunities for professional identity formation. The next phase of AETCOM research should move beyond demonstrating that students enjoy or value the curriculum. It should determine whether AETCOM produces physicians who communicate more effectively, make ethically defensible decisions, demonstrate professionalism consistently and provide more compassionate patient-centred care.

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