The competence of a physician cannot be defined solely by diagnostic accuracy, factual knowledge or procedural proficiency. Contemporary medical practice requires clinicians to communicate effectively with patients and families, respect autonomy, preserve confidentiality, obtain meaningful informed consent, disclose uncertainty and error appropriately, collaborate with healthcare teams and demonstrate professional accountability. The transition toward competency-based medical education reflects recognition that these abilities must be deliberately developed and assessed. In India, competency-based undergraduate medical education was implemented for the MBBS cohort beginning in 2019. The AETCOM framework forms a central component of this transformation. The National Medical Commission describes AETCOM as a longitudinal approach designed to balance the five major roles expected of the Indian Medical Graduate: clinician, communicator, professional, lifelong learner, and leader/member of the healthcare team.[1] The AETCOM framework differs fundamentally from conventional discipline-centred teaching. Attitudes, ethical behavior and communication cannot be adequately developed through memorization alone. Consequently, the curriculum incorporates case scenarios, small-group activities, reflection, role-play, self-directed learning and structured assessment. The national framework specifically links competencies to defined teaching-learning methods and assessments across professional years.[1] Early evaluations of AETCOM largely concentrated on student satisfaction and perception. The evidence base has subsequently diversified. Investigators have used pre/post communication assessments, the Kalamazoo framework, Communication Skills Attitude Scale, OSCE-type encounters, simulated patients, reflective portfolios, audiovisual interventions, qualitative thematic analysis and longitudinal assessment. For example, AETCOM communication training among interns has demonstrated statistically significant improvement in structured communication performance, while a longitudinal Manipal study found more favorable communication-learning attitudes among senior students and interns than first-year students.[6,12] More recent studies extend AETCOM beyond conventional classroom teaching. A 2026 PLOS ONE study incorporated video-recorded peer role-play and a standardized Observation-Based Communication Skills Checklist into a learning-management system, while an AI-augmented standardized-patient pilot used a virtual patient and automated scoring system to assess informed-consent competence.[26,29] The increasing diversity of interventions makes a contemporary synthesis necessary. It is important to distinguish favorable learner perceptions from objective competency improvement and to determine which educational approaches have the strongest evidence. Review Question Among undergraduate medical students and interns exposed to AETCOM within competency-based medical education, what effects do structured AETCOM interventions have on communication competence, ethics, professionalism, empathy and reflective learning? Objectives The review aimed to: 1. evaluate the effects of AETCOM interventions on communication competence; 2. examine changes in professional attitudes and professionalism-related outcomes; 3. assess the contribution of AETCOM to ethical knowledge and reasoning; 4. evaluate empathy, reflective learning and professional identity-related outcomes; 5. compare educational approaches including role-play, simulation, audiovisual learning, reflection and portfolios; 6. identify implementation and assessment challenges; 7. evaluate methodological quality of the available evidence; and 8. identify priorities for future research

Review Design and Reporting Standard This systematic review was prepared according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 statement.[2] PRISMA 2020 provides a 27-item reporting framework and updated flow diagrams for transparent reporting of systematic-review identification, screening, eligibility and synthesis processes. Protocol and Registration A separate prospective protocol was not registered in PROSPERO or another review registry. Any future update of this review should preferably be prospectively registered before formal screening begins. Eligibility Framework Population Undergraduate MBBS students and compulsory rotating medical interns. Intervention/Exposure Formal education, training, assessment or structured exposure explicitly described as: • AETCOM; • Attitude, Ethics and Communication training; • an identified AETCOM module; or • a teaching activity explicitly implemented under the AETCOM component of CBME. Comparator Eligible comparators included: • pre-intervention performance; • post-intervention performance; • alternative teaching strategy; • simulated patient versus role-play; • AETCOM-exposed versus non-exposed cohorts; or • no comparator in qualitative or descriptive implementation studies. Outcomes The primary outcome domains were: • communication competence; • ethical knowledge or ethical decision-making; • professionalism; • empathy; • reflective ability; and • professional attitude. Secondary outcomes included: • learner satisfaction; • engagement; • acceptability; • perceived usefulness; • faculty-student interaction; • feasibility of assessment; and • implementation challenges. Study Designs Eligible designs included: • randomized or quasi-experimental studies; • pre-test/post-test educational interventions; • observational studies; • cross-sectional learner-outcome studies; • prospective educational studies; • mixed-method studies; • longitudinal investigations; and • qualitative studies. Exclusion Criteria The following were excluded: • reviews; • systematic reviews; • narrative reviews; • editorials; • letters without primary learner data; • faculty-only perception studies; • postgraduate-only studies; • general CBME studies in which AETCOM outcomes could not be separated; • studies evaluating an artificial intelligence system without medical-student or intern participation; • conceptual descriptions without learner outcomes; and • duplicate reports from the same cohort where the same outcome was reported. Information Sources The search covered literature available through July 31, 2026. Information was identified from: • PubMed/MEDLINE; • PubMed Central; • journal and publisher platforms; • reference lists of included publications; • citation tracking; and • supplementary scholarly web searching for AETCOM-specific publications not readily indexed in MEDLINE. Search Strategy The core PubMed strategy was structured around the following concepts: ("AETCOM" OR "Attitude Ethics Communication" OR "Attitude Ethics and Communication")AND ("medical student" OR "undergraduate medical education" OR "MBBS" OR "medical intern") AND ("communication" OR "professionalism" OR "ethics" OR "empathy" OR "reflection" OR "role play" OR "simulation" OR "professional attitude")** Supplementary searches used combinations including: • “AETCOM communication medical students” • “AETCOM ethics medical students” • “AETCOM professionalism” • “AETCOM reflective writing” • “AETCOM simulated patients” • “AETCOM empathy” • “AETCOM role play” • “AETCOM Kalamazoo” • “AETCOM cadaver first teacher” • “AETCOM informed consent” No restriction based on medical discipline was imposed. Study Selection Titles and abstracts were initially assessed against the eligibility criteria. Potentially relevant articles subsequently underwent full-text assessment. The review focused more narrowly on learner outcomes following AETCOM exposure than earlier broad reviews of AETCOM implementation. General discussions of CBME or faculty preparedness were therefore excluded unless eligible student outcomes were separately available. PRISMA 2020 Study Selection The working PRISMA screening pathway was: Identification • Records identified through PubMed/MEDLINE and indexed biomedical searching: n = 44 • Records identified from publisher/journal databases and supplementary scholarly searches: n = 32 • Records identified through citation/reference searching: n = 20. Total records identified = 96 Duplicate Removal • Duplicate records removed: n = 27 Records remaining = 69 Screening • Records screened by title and abstract: n = 69 • Records excluded at title/abstract stage: n = 26. Reports sought for retrieval = 43 Retrieval • Reports not retrieved: n = 2. Full-text reports assessed = 41 Full-Text Exclusions Twelve full-text reports were excluded: • no specific AETCOM intervention or learner outcome: n = 4 • general CBME study without separately extractable AETCOM outcome: n = 3 • faculty-only population: n = 2 • review/editorial/non-primary study: n = 2 • overlapping or duplicate cohort: n = 1 Total full-text exclusions = 12 Included Studies Studies included in qualitative synthesis = 29 No quantitative meta-analysis was undertaken. Data Extraction For every eligible study, the following information was extracted: • author; • publication year; • institution/geographical setting; • learner phase; • sample size where reported; • study design; • AETCOM competency; • educational intervention; • assessment method; • major results; • follow-up interval; • learner feedback; and • methodological limitations. Methodological Quality Assessment Because the evidence incorporated qualitative, quantitative and mixed-method educational research, methodological appraisal was based on principles of the Mixed Methods Appraisal Tool (MMAT).[3] The MMAT was developed specifically to facilitate critical appraisal of heterogeneous evidence included in mixed-studies reviews. Studies were examined for: • appropriateness of sampling; • representativeness; • appropriateness and validity of outcome measurement; • completeness of follow-up; • suitability of the comparator; • risk of confounding; • coherence of qualitative analysis; and • integration of qualitative and quantitative components. Rather than calculating a potentially misleading overall numerical quality score, methodological concerns were classified narratively as low, some concerns, or substantial concerns. Synthesis Strategy A meta-analysis was considered inappropriate because of extensive heterogeneity in: • learner stage; • AETCOM competency; • teaching strategy; • duration; • comparator; • measurement instruments; and • reported outcomes. Findings were therefore synthesized narratively according to five themes: 1. communication competence; 2. ethics and ethical reasoning; 3. professionalism and professional attitude; 4. empathy and reflective learning; and 5. implementation, assessment and educational innovation.

Study Selection Twenty-nine primary studies met the eligibility criteria. The evidence extended from early pilot interventions and reflective-writing studies to multicentre communication assessments, longitudinal implementation studies and technology-supported assessment. AETCOM interventions were conducted across first professional MBBS, second professional MBBS, clinical phases and internship. Table 1. Representative Characteristics of the Included Evidence Study Learners Main intervention/exposure Primary domain Principal finding Sharma & Mahajan, 2020 Third-year students Modified AETCOM, videos, OSCE, SPIKES Communication Significant post-training improvement Tikare & Dhundasi, 2021 First professional students Reflection/narrative writing Reflection/professional values Narratives effectively revealed attitudes and perceived physician roles Jain et al., 2022 Medical interns Structured AETCOM + Kalamazoo Communication Significant post-training improvement Amarantha et al., 2022 103 students AETCOM-exposed vs non-exposed cohorts Professional attitude Higher mean professional-attitude score among exposed students Shaw et al., 2022/2024 Undergraduate students Hybrid longitudinal portfolio Reflection/professionalism Improved self-assessment and quality of reflection Ganguly et al., 2022/2023 Students + teachers Bioethics/AETCOM implementation Ethics Identified learner and implementation barriers Mishra et al., 2023 125 first-year students Pediatric AR module, OSCE encounter Communication Improved knowledge and observable communication Sahanaa et al., 2023 114 respondents Documentary, role-play, group discussion, reflection Ethics/equity Improved understanding of healthcare rights and professional conduct Nayak et al., 2024 441 students + intern feedback Longitudinal communication modules Communication More favorable communication-learning attitudes in senior learners Udgiri & Ganganahalli, 2024 123 students First-year AETCOM exposure Acceptability Approximately 98% supported AETCOM Sharma et al., 2024 115 students Autonomy-empathy-equanimity session Ethics/empathy Test score 4.86→9.05 Nimje et al., 2024 Up to 500 Phase-I students Cadaver as first teacher Professionalism Marked improvement in cadaver-related ethical awareness Nautiyal & Neeraj, 2024 151 students Lecture versus lecture + video Ethics/communication Correct responses 82% versus 94% Sirsikar & Mahendrakar, 2024 230 students Video + role-play AETCOM 1.4 Communication Significant improvement across communication domains Mathew et al., 2025 Second-year students Case-based professionalism role-play Professionalism Knowledge 11.56→16.76 Prabhath et al., 2025 250 students Paintings/visual hermeneutics Empathy Reflection emphasized empathy, trust and compassion Kundu et al., 2025 100 first-year students Communication training + simulated patient Communication KEECC score approximately 36→89 Thakur et al., 2025 240 students, six colleges Structured AETCOM communication training Communication Mean score approximately 55→94 Jaiswal et al., 2025 172 students AETCOM implementation evaluation Ethics/acceptability 98.25% considered AETCOM essential Vadgaonkar et al., 2025 416 students Cadaver as first teacher Professionalism/empathy 98.8% linked oath with respect and empathy Poongavi et al., 2025 143 students Role-play versus simulated patient Communication Simulated patients received higher perception scores Datta et al., 2026 150 students Longitudinal AETCOM exposure Professionalism/communication Positive attitudes were not uniformly sustained Nagose et al., 2026 Second-year students Skits + reflective writing Empathy/teamwork 94.6% of reflections were relevant Pallavi et al., 2026 250 first-year students Video-recorded role-play + checklist Communication 98% met or exceeded expectations Verma et al., 2026 16 enrolled/13 respondents Case-driven reflective writing Reflection All respondents considered activity valuable Dhaneria et al., 2026 126 students Small-group ethics sessions Ethics/engagement High engagement and approximately 88–90% satisfaction Pawde et al., 2026 180 interns 12-hour structured AETCOM training Communication/professional attitude Significant improvements in all three domains Dawane et al., 2026 113 students Caregiver encounters + reflection Empathy Strong awareness of caregiver burden and empathic care Iqbal et al., 2026 33 interns AI virtual standardized patient Informed consent/communication AI assessment showed high reproducibility and agreement with expert consensus Key individual study findings were independently verifiable across PubMed, publisher sites and journal records. Communication Competence Communication was the most extensively investigated AETCOM domain and the domain supported by the strongest objective evidence. Sharma and Mahajan used a modified AETCOM intervention involving videos, structured communication instruction, OSCE assessment and SPIKES training. Significant improvement occurred in structured written assessment and observed communication performance.[4] Jain et al. evaluated interns posted at peripheral health centres using the Kalamazoo Essential Element Communication checklist. Post-intervention performance was significantly higher than baseline across multiple communication elements.[6] Mishra et al. introduced a pediatric allergic-rhinitis teaching module to 125 first-year students. The intervention combined cognitive teaching with an OSCE-style student-patient communication checklist, thereby extending assessment beyond factual knowledge.[9] A larger quasi-experimental investigation by Sirsikar and Mahendrakar included 230 first-year MBBS students completing AETCOM Module 1.4. The intervention combined video learning, self-directed learning, role-play and closure sessions. Significant improvements occurred across major communication domains, and 99.5% recognized the importance of communication in clinical practice.[16] Kundu et al. used standardized communication instruments among 100 first-year students. Mean Kalamazoo-based communication performance increased from approximately 36.17 before training to 89.40 after training, representing a substantial improvement in observable communication behavior.[19] The strongest multicentre evidence was provided by Thakur et al., involving 240 third-year medical students across six colleges. Structured AETCOM communication training improved mean communication scores from approximately 54.89 ± 11.55 to 94.4 ± 19.3, with improvement across the assessed communication competencies.[20] The 2026 study by Pallavi et al. moved assessment into a digital environment. Among 241 valid video submissions from a 250-student cohort, 70% met expectations and 28% exceeded expectations. Eighty-seven percent considered peer role-play effective, while 91% considered checklist guidance valuable. Pawde et al. subsequently evaluated 180 interns across three Maharashtra colleges following a structured 12-hour AETCOM intervention. 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, all statistically significant. Together, these findings indicate that communication competence is particularly responsive to repeated practice, structured observation and feedback. Role-Play Versus Simulated Patients Experiential approaches were more consistently effective than passive instruction. Poongavi et al. directly compared students' perceptions of role-play and simulated-patient teaching among 143 second-year students. Positive attitudes toward communication learning were high overall, but simulated-patient learning received a significantly higher perception score (48.8 ± 5.3) than role-play (46.5 ± 5.2, p<0.05). This does not imply that role-play is ineffective. Rather, standardized or simulated patients may create greater realism and emotional authenticity. Role-play remains attractive because it is inexpensive, scalable and allows learners to alternate between physician, patient and observer roles. Ethics and Ethical Reasoning AETCOM ethics teaching covered: • autonomy; • confidentiality; • informed consent; • healthcare equity; • fiduciary responsibility; • medical-error disclosure; and • ethical physician behavior. Sharma et al. evaluated an intervention addressing autonomy, empathy and equanimity among 115 second-phase students. Overall positive responses increased from 38.20 ± 6.60 to 91.30 ± 9.27, while mean knowledge-assessment scores increased from 4.86 ± 1.43 to 9.05 ± 0.99 (p<0.001). Sahanaa et al. used documentary material, role-play, group discussion and reflective writing to teach “Health Care as a Right.” All 114 students attending the intervention submitted reflective responses. Themes included equitable access, respectful care, professional misconduct, communication barriers, empathy and responsibilities of healthcare personnel. Nautiyal and Neeraj compared interactive teaching with an additional purpose-developed video in 151 MBBS students. Correct responses were approximately 82% in the conventional interactive group and 94% in the video-supported group, with statistically significant improvement. Topics included empathy, confidentiality and informed consent. The Dhaneria et al. study extended ethics teaching to patient autonomy, disclosure of medical errors, confidentiality and fiduciary duty. It demonstrated high learner engagement and satisfaction with small-group and role-play-based teaching. These studies indicate that applied ethics is best taught through clinical situations rather than isolated memorization of ethical principles. Professionalism and Professional Attitudes Professionalism is more difficult to measure than communication because professional behavior depends on context, longitudinal consistency and institutional culture. Amarantha et al. compared students exposed to AETCOM with students from an earlier non-exposed cohort. The exposed group demonstrated a significantly higher mean professional-attitude score, and 91.65% reported perceived changes in their behavior toward patients after AETCOM exposure.[7] Mathew et al. used case-based role-play to teach professionalism in pharmacology. Mean knowledge increased from 11.56 ± 2.81 before teaching to 16.76 ± 3.00 afterward (p<0.0001), accompanied by strongly favorable learner feedback. Cadaver-based AETCOM interventions also appear to promote early professional socialization. Nimje et al. evaluated Module 1.5 among Phase-I students in Maharashtra. Following the module, 97.7% reported understanding the importance of the cadaver as a teacher, while knowledge concerning body donation, embalming, anatomy legislation and dissection-hall etiquette increased substantially. Vadgaonkar et al. similarly reported that 98.8% of participating Phase-I students believed the cadaveric oath could promote responsibility, respect and empathy. However, the longitudinal findings of Datta et al. introduce an important caution: favorable communication and professionalism attitudes did not necessarily strengthen consistently as students progressed through medical school. This suggests that formal AETCOM teaching may be counteracted by clinical workload, hierarchy, stress and the hidden curriculum. Empathy and Reflective Learning Empathy emerged across doctor-patient communication, cadaver learning, caregiver engagement, visual humanities and reflective writing. Prabhath et al. introduced first-year students to the doctor-patient relationship using paintings and visual hermeneutics. Reflective responses highlighted empathy, compassion, trust, observational sensitivity and professional conduct. Reflective writing represents another recurring educational strategy. The hybrid portfolio developed by Shaw et al. incorporated structured reflection with faculty assessment. Student self-assessment improved significantly, and by the end of the training period all assessed learners reached at least grade B on the reflection rubric. Nagose et al. used skits, discussion and reflective writing for pathology-based AETCOM teaching. Approximately 94.6% of reflective writings were relevant, with mean scores of 7.71/10 for empathy and 7.75/10 for healthcare teamwork. Verma et al. evaluated case-driven reflective writing in an early psychiatry enrichment program. Thirteen of sixteen participating students returned evaluation data, and all respondents regarded reflective writing as valuable for AETCOM learning and recognition of knowledge gaps. A newer 2026 study by Dawane et al. broadened empathy beyond the patient. Among 113 second-year students who had AETCOM exposure and caregiver interaction, learners demonstrated awareness of caregiver burden, communication gaps and the importance of incorporating family experiences into holistic care. Longitudinal Communication Learning Nayak et al. studied communication-learning attitudes across all undergraduate stages. A total of 441 responses were analyzed across the four professional years and internship. Positive communication-attitude scores differed significantly between stages and were higher among fourth-year learners and interns than first-year students. Among 132 interns who provided feedback, approximately 82% considered the communication modules an effective learning tool, although only about half directly reported improvement in communication skills. Faculty additionally warned that AETCOM modules alone may not be sufficient and that assessment needs strengthening. The implication is important: curriculum exposure must be accompanied by repeated clinical application. Emerging Technology in AETCOM Video-Based Learning Video-supported instruction offers standardized demonstration of difficult interpersonal encounters. Nautiyal and Neeraj showed superior cognitive outcomes when an interactive AETCOM class was supplemented by an in-house video. Pallavi et al. moved from passive video viewing to video production: learners performed and recorded peer doctor-patient interactions, reviewed performance against a checklist and received faculty feedback. Artificial Intelligence-Augmented Standardized Patients Iqbal et al. introduced an AI virtual standardized patient for informed-consent assessment involving 33 interns. Five subject experts independently scored anonymized transcripts. AI scoring demonstrated high internal reproducibility and close agreement with expert consensus, with an AI ICC of 0.904 for individual scoring and 0.979 for averaged repeated assessment. This represents an important emerging direction for AETCOM because automated standardized patients could permit repeated low-stakes practice without the cost and scheduling difficulties associated with human standardized patients. However, the study evaluated assessment reliability rather than evidence that AI training improves clinical communication; larger controlled studies remain necessary. Implementation and Learner Acceptability Acceptance of AETCOM was consistently favorable. Udgiri and Ganganahalli reported that approximately 98% of 123 students considered AETCOM a valuable curricular initiative. Jaiswal et al. found that among 172 respondents: • 98.25% considered learning AETCOM essential; • 98.83% considered ethics important to future medical practice; • 34% reported examination-related burden; and • 53.5% believed both formative and summative assessment were required. Students preferred case scenarios and role-play as teaching methods. Thus, acceptance does not eliminate concerns about workload, curricular crowding or assessment. Risk of Bias and Methodological Quality The evidence base was heterogeneous and generally of moderate methodological strength. Common Strengths Several recent studies incorporated: • validated communication scales; • standardized checklists; • pre/post assessment; • objective observed encounters; • multiple institutions; • quantitative and qualitative triangulation; and • explicit ethics approval. Common Limitations The most frequent concerns were: 1. single-centre design; 2. convenience sampling; 3. absence of random allocation; 4. lack of contemporaneous control groups; 5. self-reported attitude or satisfaction; 6. institution-developed questionnaires; 7. immediate post-test assessment; 8. lack of blinded evaluation; 9. limited follow-up; 10. social-desirability bias; and 11. absence of patient-level outcomes. Overall Appraisal Approximately one-third of studies provided relatively stronger evidence because they used structured performance measures, comparators, validated tools or multicentre recruitment. The remainder provided useful implementation evidence but had moderate or substantial concerns relating primarily to self-report and lack of longitudinal follow-up.

Principal Findings This systematic review found a broadly positive association between AETCOM exposure and development of communication, ethical understanding, professionalism, empathy and reflective learning. The strength of this association differed substantially according to outcome domain. Communication competence had the strongest evidence. Communication behaviors can be directly observed and operationalized. Learners can be evaluated on whether they: • introduce themselves; • establish rapport; • listen actively; • explore concerns; • demonstrate empathy; • share understandable information; • negotiate decisions; and • close an encounter appropriately. Consequently, communication studies were able to use Kalamazoo-based instruments, simulated encounters, standardized checklists and OSCE-type assessments. The magnitude of improvement in the Kundu and multicentre Thakur studies is particularly notable, while the 2026 intern intervention further demonstrates that improvement remains possible at the transition from medical school to clinical practice. Professionalism Requires Longitudinal Assessment Professionalism cannot be reduced to a single post-test score. A student may identify the correct professional response in a classroom scenario yet behave differently when exposed to hierarchy, fatigue, clinical pressure, conflicting role models or institutional culture. This explains why the positive results of professionalism interventions must be interpreted alongside longitudinal evidence showing that favorable attitudes are not automatically sustained. Professionalism assessment should therefore include: • portfolios; • multisource feedback; • workplace observation; • longitudinal mentoring; • professionalism incident reporting; and • reflective review. Ethics Should Be Taught as Clinical Reasoning Ethical competence requires more than defining autonomy, justice, beneficence and non-maleficence. Learners need to determine how these principles interact when: • patients refuse recommended treatment; • relatives demand concealment of information; • mistakes occur; • resources are limited; • confidentiality conflicts with safety; • consent is uncertain; or • personal and professional values conflict. The most promising ethics interventions therefore used clinical scenarios, role-play and reflection rather than conventional lectures alone. Experiential Learning Is a Consistent Theme Across the included literature, stronger educational outcomes repeatedly occurred when learners had to do something rather than merely listen. Successful strategies included: • role-play; • simulated patients; • video-recorded encounters; • group discussion; • reflective writing; • visual humanities; • direct observation; • peer feedback; • structured checklists; and • portfolios. This suggests a practical AETCOM learning cycle: clinical scenario → learner performance → observation → feedback → reflection → repeated performance. Reflection as a Bridge Between Knowledge and Behavior Reflective learning plays a particularly important role in affective competencies. Students may know the definition of empathy without considering how their own words or behavior affect a frightened patient. Reflection encourages learners to examine: • what occurred; • why it mattered; • how they reacted; • how others may have experienced the event; and • how future behavior should change. Portfolio and reflective-writing studies support this role, although assessment rubrics and trained faculty are necessary to prevent reflection from becoming a superficial documentation exercise. Importance of Faculty Role Modelling AETCOM is unusually vulnerable to the hidden curriculum. Students may attend a formal session emphasizing respect, shared decision-making and empathy and subsequently observe dismissive communication during clinical posting. Faculty development must therefore accompany student AETCOM teaching. Educators need competence in: • communication; • professional feedback; • reflective facilitation; • ethical discussion; • standardized assessment; and • constructive role modelling. Assessment Should Match the Competency Written examinations are useful for ethical knowledge but insufficient for behavioral competencies. A multimodal assessment framework is preferable: Communication OSCE, standardized patient, video assessment, mini-CEX. Ethics Case-based structured discussion, script concordance, OSCE, viva using ethical scenarios. Professionalism Portfolio, multisource feedback, direct observation, longitudinal mentoring. Empathy Observed patient interaction, reflective portfolio, standardized patient assessment. Teamwork Peer assessment and workplace-based observation. Implications for Medical Colleges The findings support several practical recommendations. AETCOM should not be treated as an isolated subject placed periodically in the timetable. Instead: 1. first-year training should establish communication, empathy and professional identity; 2. second-year teaching should link ethics and professionalism with pathology and pharmacology; 3. clinical phases should integrate communication with real patient encounters; 4. final-year teaching should address complex consent, serious illness, error disclosure and shared decisions; 5. internship should include workplace-based observation and feedback; 6. reflection should continue longitudinally through a portfolio; and 7. summative assessment should incorporate observable AETCOM competencies. Strengths of the Review This review has several strengths. First, it applies a narrower learner-outcome framework rather than combining conceptual AETCOM papers with intervention evidence. Second, it incorporates newly available evidence on: • simulated patients; • standardized checklists; • video-recorded role-play; • caregiver empathy; • longitudinal professionalism; • process assessment; • intern interventions; and • AI virtual standardized patients. Third, it distinguishes objective performance outcomes from learner satisfaction. Fourth, it evaluates implementation alongside educational effectiveness. Finally, it includes different study designs and consequently reflects the real methodological diversity of medical-education research. Limitations Several limitations should be recognized. Most AETCOM evidence originates from India, which is appropriate given the national origin of the curriculum but limits direct international generalizability. Many studies were single-centre educational interventions. Outcome instruments varied considerably, preventing statistically meaningful pooling. Some studies measured immediate knowledge or perceptions rather than competence. Follow-up beyond several weeks or months was uncommon. Few studies assessed actual patient interactions. Patient-reported experience and clinical outcomes were rarely reported. Why Meta-Analysis Was Not Performed A quantitative meta-analysis was considered inappropriate because studies differed substantially in: • intervention duration; • learner phase; • competency studied; • comparator; • scoring scales; • assessment design; and • outcome definitions. Pooling a Kalamazoo communication score with a professionalism knowledge score, empathy perception percentage or reflective-writing rubric would not generate a clinically or educationally interpretable summary estimate. Narrative synthesis was therefore selected a priori as the more appropriate strategy. Future Research Future AETCOM research should move from perception-based evaluation toward demonstration of sustained competence. Priority areas include: 1. multicentre controlled educational trials; 2. cluster-randomized interventions where feasible; 3. longitudinal follow-up from first year through internship; 4. standardized national AETCOM assessment tools; 5. repeated workplace-based assessment; 6. standardized-patient testing; 7. blinded assessor evaluation; 8. multisource professionalism feedback; 9. patient-reported communication experience; 10. behavioral outcomes during internship; 11. comparison between role-play and standardized patients; 12. evaluation of digital portfolios; 13. AI-assisted simulation; 14. assessment of faculty-development interventions; 15. evaluation of hidden-curriculum effects; and 16. cost-effectiveness analyses of simulation-based education. Research should increasingly ask not only whether students liked AETCOM, but whether they behave differently because of it.

AETCOM has transformed communication, ethics and professionalism from largely implicit expectations of medical training into identifiable competencies that can be deliberately taught, practiced and assessed. The available evidence supports a positive educational effect of AETCOM across multiple domains. Communication demonstrates the strongest objective evidence, particularly when teaching incorporates role-play, simulated patients, structured communication frameworks, direct observation and feedback. Ethics teaching appears most effective when principles are contextualized through authentic clinical dilemmas. Professionalism and empathy benefit from case-based learning, reflection, portfolios, humanities and experiential activities, although sustained behavioral effects remain less certain. Recent innovations involving video-recorded peer encounters, standardized checklists and artificial-intelligence-supported standardized patients indicate that AETCOM is entering a new phase in which behavioral competencies can be practiced and assessed at scale. The major future challenge is no longer establishing whether learners value AETCOM. It is determining whether longitudinal AETCOM education produces measurable, durable improvements in how future physicians communicate, reason ethically and behave professionally during real patient care

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