How Do Medical Students develop the self-awareness as social entities during

Running head: Students’ self-awareness as social entities

Authors: Takuya Saiki1, Keiko Abe2, Chihiro Kawakami1, Kazuhiko Fujisaki1, Yasuyuki Suzuki1

Affiliations: 1 Medical Educational Development Center, Gifu University; 2 Division of Nursing, Nagoya University Hospital

Corresponding author: Takuya Saiki

email:[email protected]

Tel & Fax: +81-58-230-6465, +81-58-230-6468

Address: 1-1 Yanagido, Gifu, Japan

Medical Educational Development Center, Gifu University

Objective: Diverse interactions with local citizens are known to broaden the health perspectives of medical students, stimulating their motivation to learn, and improving their communication skills. In recent years, the rapid decrease in birth rates and the transition toward a nuclear family structure have posed a challenge for medical students in Japan, given their lack of experience in communicating with citizens who are older than they are or whose social backgrounds differ from their own. We aim at exploring how a longitudinal interaction with citizens can develop medical students’ communication skills and understanding of themselves as social entities.

Method: Thematic analysis was used to analyze descriptive comments submitted to an e-portfolio by 100 first-year medical students who participated in longitudinal community-based experiential learning for six weeks with one of three different kinds of citizens such as the elderly, pregnant mothers, or nursery school children in 2011. Five independent researchers extracted themes from comments collected from 45 individual students on each six weekly encounters. The remaining data were used to confirm data saturation.

Results: Two different themes emerged from the analysis: 1) understanding of citizen’s centeredness in communication, and 2) understanding of human relationship and expansion of world as a social existence. The first theme contained three different stages: i) survival, ii) trial and error, and iii) shifting gaze. The second theme contained four different stages: i) narrow, self-centered worlds, ii) awareness of the citizen’s existence, iii) understanding the worlds of the citizens and expanding their views of life, and iv) self-realization as a social entity within an expanded worldview. These two themes became progressively deeper through the longitudinal and mutual interaction.

Conclusion: The longitudinal, mutual communication experiences with citizens has an impact on the students’ development of self-awareness as social entities accompanied with improving their communication skills.

Keywords: behavioral science, community-based medical education, early exposure, communication skills


Developing a social identity is an important goal in behavioral science education [1]. Social identity refers to the combination of views of us such as age, ethnicity, race, religion, gender, nationality and socioeconomic status. Understanding a social identity is crucial to all health professionals since misunderstandings and miscommunication are more likely to occur when interacting with people from different identity groups [2]. In fact, many reports on the outcomes of medical doctors declare the acquisition of such understanding is essential [3][4]. Nevertheless, educational programs in behavioral science in medical schools continues to be regarded, as “nice to know,” and rarely regarded as “need to know” [5]. As a result, educational programs for behavioral science are being subjected to pressure, as well as basic science, because of the perception that there is “no space” for the introduction of new aspects of knowledge [5]. Given the increasing volume of knowledge in the expanding field of clinical medicine, undergraduate medical curricula tend to emphasize the early introduction of clinical education. Introducing effective behavioral science education poses a long-standing yet pressing problem.

Multiple studies have addressed the effectiveness of experiential learning in early stages of medical training. They have been shown to increase motivation to learn among medical students. [6]. Similarly, early experiential learning has proven effective in several areas, including improving communication skills through interaction with patients, engendering confidence, and reducing stress. [7]. In the field of public health, it has been reported that longitudinal contacts with elderly people promotes an understanding of community health problems, in addition to deepening the attitude of understanding towards the elderly [8]. Furthermore, early experiential learning that involves interaction between medical students and pregnant women have been reported to improve the students’ understanding of pregnancy, in addition to promoting and understanding of the importance of providing family-centered medical treatment [9]. Students possess both positive and negative emotion in the hospital and nursing home after a 4 week clinical nursing attachment [10].

However, the majority of such longitudinal initiatives have been implemented in clinical contexts, based on conventional physician–patient relationships. Whilst there is a wealth of literature on the learning programs based on behavioral science aimed at encouraging communication with local citizens, few explored how students become aware of a person in society [7]. Furthermore few such educational interventions had been conducted with pregnant women or infants in nursery school.

Since 2008, we conducted a longitudinal community-based experiential learning with citizens for first-year medical students at Gifu University for a two months period. The program was designed not only to promote communication skills in non-clinical context between medical students and citizens such as elderly people, pregnant mothers, and nursery school children whom students would not normally encounter, but also to facilitate students’ understanding a social identity. By using an e-portfolio, students’ learning and reflection were deepened by experiential learning with supportive feedback from their instructors.

The objectives of this study are to explore (1) Japanese students’ learning ways that lead to the acquisition of communication skills and (2) the processes how they develop the understanding of the self within society, during longitudinal community-based learning experience with citizens in non-clinical settings. This study may add an important finding on the process of developing a social identity in East Asia, where new generations of students are entering medical school with extremely limited levels of social experience. This may also be true in other countries where six-year medical programs are implemented, in which students enroll immediately upon completing secondary school.

Operational term definitions

The elderly, pregnant mothers and nursery school children who were participants in this educational program are defined as “the participant-citizens” rather than patients. Since this educational placement was taken in the local area and students were expected to interact as citizens, allowing them to communicate easily in a context different from the medical context. The word “the participants” in this paper refers to the medical students who participated in this program since they are the central focus and the participants of this study.

Educational Interventions

Experiential learning was conducted every Thursday morning over a period of eight weeks, with individual shifts lasting three hours each. The setting and the participant-citizens were  1) at a senior housing facility with elderly but healthy people, 2) at a maternity clinic with pregnant mothers, and 3) at two separate nursery schools with children. Students were assigned to these placement they desired in advance. One to three students were matched with the same citizen for six weeks to communicate with. Learning strategies during middle 6 weeks consisted of six steps; 1) discussing the day’s plans for approximately 30 min (beginning with the second session, accompanied by reflection based on an e-portfolio feedback from the previous session), 2) the participant-citizens encounters for approximately 90 min, 3) group-based reflection and discussion for approximately 30 min, 4) personal reflection through e-portfolio entries at school or at home, and 5) feedback from instructors. As for sequence of the program, briefing and debriefing sessions (three hours each) were provided before and after the middle six weeks of the encounter with the participant-citizens. At least one instructor supervises students encounter in each setting (about 30 students). In general, one to four students make pairs to interact with the participant-citizens in every experiential learning session.

Participants and Data Collection

Data were drawn from the descriptive comments entered into an e-portfolio system by a hundred first-year medical students from across three kinds of facilities who participated in this longitudinal community-based experiential learning in 2011. Six hundred reports (100 students x 6 times) were retrieved in total from the e-portfolio system. The average age of the year-1 students of Gifu University School of medicine was 22.4 years old, with a gender ratio of one woman to four men.

Methodology and Data Analysis

A qualitative approach was deemed appropriate for performing a detailed analysis of the participants’ expressions of their feelings, thoughts, and subtle emotional conflict and exploring the cognitive-emotional processes associated with such learning experiences. Thematic analysis [11] was conducted to analyze the medical students’ text in an e-portfolio by hand. The reflective comments were collected on six occasions from groups of 15 medical students dispatched to each facility (45 students in total). The comments were subsequently analyzed, coded, and subjected to thematic extraction by five independent researchers, who agreed a final outcome. The remaining students’ comments were used to establish data saturation. The most impressive comments (quotation) in each category were provided in the results. To help readers recognize the characteristics of the raw data, the participants were identified by a unique ID that includes a gender (M=male, F=female), the student’s number in this paper, and the characteristics of the participant-citizens (Eld=the elderly, Preg= Pregnant mothers, Chi=Children). For example, “Male 1 with Preg” means a male student who were coded as 1 and interacted with the pregnant mother during the session.

Ethical Considerations

The study was conducted with the approval of the Investigational Review Board and Ethical Committee of Gifu University Graduate School of Medicine. Informed consent was obtained from the students after explaining the purpose of the research. There was no penalty for any student who declined to participate in this study.


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