Results of Studies of medical students in the minds of people – part 2

Thematic analysis was conducted 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. As far as we retrieved, this is the first study that demonstrates how medical students develop their social identity during longitudinal community-based learning experience with citizens in non-clinical setting. In the previous article we discussed the beginning of medical students ‘ education.

Two themes were extracted through the qualitative analysis of medical students’ e-portfolio comments (figure1). The first concept “understanding of citizen’s centrality in communication” contained three different themes: i) survival, ii) trial and error, and iii) shifting gaze. These stages reflect the shift in centrality from the students to the participant-citizens. And second concept “understanding of connectedness and expansion of world as a social existence.” contained four different themes: i) narrow, privately centered worlds, ii) awareness of the citizen’s existence, iii) understanding the worlds of the citizens and the expansion of worldview, and iv) self-realization as a social entity within an expanded worldview. These two concepts were constructed with influencing to each other.

Please Insert Fig 1 about here

1) Understanding of citizen’s centrality in communication

  • Survival

From the analysis at the start of the program, students were conscious of their awkwardness during conversation and communication. In addition, they admitted that they suffered from severe anxiety and nervousness because of insufficient skills and a dearth of ideas.

“I am bad at conversing, so I am more than a little tense, since I have to avoid negative facial expressions while taking care not to hurt the feelings of those I am dealing with” (Male 1 with Preg).

“I have never played with children before, so before the training, I was worried that it would be difficult” (Male 1 with Chi).

“At first, I was bewildered and could not think of any common topics to talk about” (Male 1 with Eld).

At the beginning of the practice, the students’ central concern was to make full use of their skills and the plans that had been discussed between the peer students. However, in the end, the students confronted various difficulties while interacting when things did not go as expected.

“Right after I introduced myself, I dived into a serious conversation about pregnancy, so I suspect the pregnant mothers saw me as being somewhat stiff” (Male 2 with Preg) .

“Since we were still facing mutual tension, our conversation didn’t really go anywhere, and it felt very stilted. There were a few extended silences when I exhausted the questions that I’d prepared beforehand, and couldn’t think of the next question” (Male 3 with Preg).

“Today was the first day of our practice, and I was completely unable to have any conversation with this kid in the nursery. Not only that, she shied away when I tried to hold her hand or give her a hug, she wouldn’t look me in the eye, and she burst out crying when the nursery teacher who was there as a go-between left the two of us alone in the room. I had the sense that, for a first day, today really did not go very well” (Male 2 with Chi).

“Frankly speaking, I did nothing during my first practice other than listen to the elderly’s story. I was really anxious about the fact that I had been hardly able to find anything to say. Nevertheless, it seems that the most important aspect here is not so much to communicate well as it is not to communicate poorly” (Male 2 with Eld).

  • Trial and Error

Having come through the survival period, the students began to display varying degrees of confidence in their interactions with the participant-citizens and undertake various strategies to achieve positive communication. They experienced minor successes and occasional failures in their attempts to assert control over communication on their own.

“I thought I would ask the pregnant mother to speak seriously about the illness, but … I couldn’t elicit anything. If it doesn’t seem like there is anything forthcoming, it’s not good to ask too much, so this time I tried to keep things in balance” (Male 4 with Preg).

“I didn’t prepare enough topics for conversation. I don’t think the silences were so bad, but there were a lot of meaningless silences this time, for whatever reason” (Male 5 with Preg).

“Holding hands went surprising smoothly this time, even though I wasn’t able to do it at all last time. I felt so happy being able to go for a stroll together like that” (Male 2 with Chi).

“Compared to the beginning, with regard to holding hands and talking together, I feel like the kid has really opened up to me. Nevertheless, maybe because there is some still embarrassment, I don’t get much response when I start chatting with her, and she won’t meet my gaze when she talks to me. It didn’t take us long to get used to this point, but I suspect it’s going to be difficult to move forward from here” (Male 2 with Chi).

“The kid consistently refuses to visit the washroom or have a snack, but he was eating candy when I was away for a little while. This time, I was struck by a feeling of frustration and sadness” (Male 3 with Chi).

“I’d planned for us to talk about our philosophies of life and death, but then we started talking about something else. It was great that the conversation really took off although the topic was not something I’d like to talk about” (Male 3 with Eld).

“For a while at first, when I looked at the elderly, he didn’t really look in my direction. I wonder why that was. Was my facial expression too severe? I remember during the training before this practice, when we were dealing with simulated patients, they told the colleague that he has a nice smile on his face, so I decided to face them with the corners of my mouth turned up. Perhaps because I had actively tried to elicit conversation, he gradually began to look in my direction” (Male 4 with Eld).

  • Shifting Gaze

As communication deepened, students gradually progressed from an egocentric worldview, in which they had attempted to control interactions by asserting their own skills, toward developing a deeper understanding of the ways in which the participant-citizens viewed the world.

“Because I didn’t really talk to the kid very much, I felt that he might have thought that I was not so interested in him. But, even though he was often sharing glances with other kids, I sensed that, once I affected a stance of ignorance and asked a question, they would turn to me and begin talking to me earnestly” (Male 4 with Chi).

“Recalling the first episode of my practice, I was shocked, not understanding why I was being ignored, even when I tried to start a conversation. The truth, however, was that they were just shy” (Male 5 with Chi).

“The elderly had no children due to infertility, but when I saw her smiling at and cradling babies in the elevator, her demeanor made me think that she might wish she would have had children” (Male 1 with Eld).

“When he talks about his life now, or about his or his wife’s illness, his voice grows somewhat quieter. This sort of thing helps you understand what someone likes and dislikes talking about. It will be a helpful insight in the future” (Male 1 with Eld).

“The elderly said that when she dies, she’d like to go suddenly. I could totally understood where she was coming from, since I have painful memories of seeing my own grandfather lying bedridden for seven years before dying of dementia” (Male 3 with Eld).

2)         Understanding of connectedness and expansion of world as a social existence

  • Narrow, Self-centered Worlds

Until the first day of the program, the medical students had held an egocentric and narrow worldview in which they were the principal characters. Other characters who were concerned with these worlds might have at the most included their family members and friends. This worldview in no way incorporated the presence of their participant-citizens. The students occasionally became preoccupied with abstract descriptions, as with reports of anecdotes that they had solicited about incidents affecting other people.

Despite instructions to describe particular details of the incidents they had experienced, the students entered no comments that reflected any transfer of emotion consistent with the context.

“To be able to make yourself understood, it is desirable to be conversant in a wide variety of topics of conversation, with an abundant store of the requisite knowledge. The same applies when your participant-citizens are able to understand your words. By building up experience, you become able to see things from a variety of perspectives and grow into an educated person. Communication might be the best tool for helping you to grow up to be wise, independent, and well-educated. I want to keep this in mind as I continue my work” (Male 7 with Preg).

Conversely, some of the descriptions entered by students consisted of narrow enumerations of the facts that they had heard, without any interpretation of the context.

“The elderly says he was born in Manchuria and withdrew to Japan after the war. I did not hear how many siblings he had, but it seems it was common at the time for families to have six or seven children. He says that his father founded a logistics company, and that his wife inherited it. I think it is evident that he has had an economically prosperous life, and that he is currently trying to lead an active life, filling his time by running some kind of errand every day. He appears to be physically healthy and enjoying a fulfilled, post-retirement old age” (Male 5 with Eld).

With regard to family-related questions that they raised as their own learning tasks, some students reacted in a self-centered fashion, expressing that the questions were irrelevant to their participant-citizens.

“The elderly with whom I was paired didn’t have any children, so it was a shame that I couldn’t ask them any sort of questions about their children or grandchildren” (Male 1 with Eld).

While the students did acknowledge the perspectives of their participant-citizens, they did not share their worldviews or transcend the boundaries of their own worldviews. As a result, they observed and analyzed their participant-citizens from an excessively objective standpoint.

“Death seems to be a topic of particular interest for elderly people. I felt like they talked about it quite seriously” (Male 3 with Eld).

“Even though it was time to listen to the teacher, they wouldn’t, and I couldn’t make these spoiled kids listen to their teacher. In other words, you could say that I failed to ‘manage’ or ‘control’ the children. The kids would also occasionally mutter something indistinct to me, and the fact that I couldn’t decipher it was a barrier to proper communication” (Male 6 with Chi).

  • Awareness of citizen’s existence

During the practice, the students had the unfamiliar experience of encountering pregnant mothers, children, and the elderly people. These groups consisted of people who were likely to be alien to the egocentric worldviews that the students had held before the practice. Dialog with these participant-citizens gave students their first opportunity to develop a palpable perception of the existence of these others, in addition to becoming palpably aware of the reality of their own lives and ways of living. In other words, the students were able to gain a clearer perception of the existence of others in their own lives (e.g., children, pregnant mothers, the elderly people, the recently deceased, the unborn, and others related by marriage).

“It appears that the unborn baby has recently been moving around inside, and she feels it pushing against her internal organs. For example, she feels the urge to urinate even when she has just gone to the toilet. There’s nothing in life comparable to this sensation for us men, so it was a valuable experience to hear about it directly” (Male 8 with preg).

“It’s her first pregnancy, and I was really struck by how much she took comfort in things like being sent vegetables and meals from time to time by her mother-in-law, who lives close by, and receiving advice from her own mother over the telephone” (Female 9 with Preg).

“Even though it’s been only six visits, at some point I started feeling like a mother does. In such a short time, I’ve been able to feel great fondness for this child, as though I’ve come to think of her as my own child. I wondered if I could have found her any cuter, any more lovable, or any more important if she had been my own” (Female 7 with Chi).

  • Understanding the worlds of the citizens and the expansion of worldview

The students turned their thoughts toward the feelings of people they had become newly aware of through their exchanges, as well as the feelings of those who had originally existed within their own worldviews. Their thoughts began to demonstrate an emotive transition as they gained an understanding of their respective relationships (e.g., those between families).       

“It’s quite a difficult matter to think about life with reference to the elderly who have no children. I thought that the only thing you could say was that some aspects of their lifestyles are completely different from those of families with children. I think that’s why relationships are so strong between couples who are forever alone with each other. This elderly also mentioned certain things in passing during our conversation, like his views of life and death and the difficulty of dying and leaving his wife behind. This made me realizes that he had a lot on his mind” (Male 1 with Eld).

As their worldviews expanded, the students began to self-project.

“We’re still just finding our feet in the world, at the border between childhood and adulthood. We are transitioning from a cared-for generation of kids like these kindergarteners we’ve been getting to know to a generation that cares for them. While there are some substantive differences, we probably act childishly ourselves sometimes, without noticing the trouble that we are causing to those around us” (Male 8 with Chi).

  • Self-realization as a social entity within an expanded worldview

As the medical students relived past episodes through ongoing, simultaneous interactions with the participant-citizens, they began to “share the lives” of the participant-citizens. From living within an egocentric view of society, they began to perceive themselves as social entities, living among various others, supporting and being supported in turn by each other.

Furthermore, the medical students began to accept others as constituent elements of their own worldviews and engage in further examination of their own existence from the perspective of others’ worldviews. Within these expanded worldviews, they were able to rethink their own images of the life cycle.

“I heard that some of the pregnant women saw in us (medical students) a future vision of their own children. Although they are still children now, I pictured them, decades from now, as medical students like me, and wondered if I’d be working as a doctor in the halls of medicine by then. I feel like this gave me an inkling of the overall view of the life cycle” (Female 10 with preg).

“For the first time, I felt a type of closeness with birth as a major life event. I felt kind of moved—it was a really strange feeling. When I think that this is something we all go through, being born one by one from our mothers’ bodies … it’s so obvious, but then I realized how amazing it is. When you think about life, you get the image of a single line traced out for each person. But it’s not like that, I think. Rather, you go along, you get married, you have kids—it’s something much more haphazard and messy” (Female 11 with Preg).

“If you think about the life cycle literally, picturing life as a giant circle, there is a point on that circle where we were born, and once we’ve gone around and come back to the same spot, we die. When I think about what this signifies from a religious point of view, I think of reincarnation. But thinking about it more generally, I feel that it means that our own lives are supported by the lives of those who have gone before us. I felt this most keenly when I started looking at the children in light of our being here now, after countless turns of this cycle” (Male 9 with Chi).

The medical students understood that their own selves were also positioned as social entities within this life cycle. As their thoughts were turned to the joys, transience, and effective limitations of this reality, the students were led to consider the inner workings of society itself.

“I understand that raising children is different from the experiences that we’ve had together during the program. Even so, my practice has made me feel more strongly that I’d like to become a mother in future. I am sure that it would be extremely tough to practice medicine and raise a family at the same time. Some people do manage to pull it off, however, and I dream of having a wonderful household, so I want to make it a reality” (Female 7 with Chi).

“Having to go on living, facing the sadness and pain of life after the death of a spouse or child, has a profound impact. We typically consider living a long, healthy life as a good thing, but under those conditions, there are cases where we can’t necessarily describe such a life as happy. In this sense, I guess it’s like the saying that good fortune is intertwined with bad, and that there’s no such thing as a life entirely without woe” (Male 5 with Eld).

“It’s a marvel to think that, about 20 years ago, I was also like this—the size of a pea and unable to string a sentence together. On the other hand, when I think that when I become a father, these little ones will be the age I am now, I get a sense of the mystery of human development and the passage of time (aside from the question of whether 20 years a long is or a short time). Some of my friends are already parents, but they seem to know what they’re doing, unlike the likes of me, who are still flunkies depending on our parents. All living things share the process of having children and becoming parents, growing old, and dying. But having children also has social implications. In addition, I feel that the opportunity to be involved with these infants, on the cusp of our comparatively long life cycle, is a life experience that has helped me to find a new sense of values” (Male 10 with Chi).


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