The final conclusion of the study of medical students in the field of social consciousness – part 3
We identified the themes of other-centric understanding and a deepened awareness of the self as a social entity. To our knowledge, this study of Japanese medical students participating in an early practice-based experience program is one of the few studies that focus on the development of self-awareness and transformative perceptions of the individual’s place in society, along with the associated acquisition of communication skills.
Several structural features of the practical training program are noteworthy. In conventional, one-off, early, practice-based experience programs, it is relatively easy to produce a passing reaction (e.g., “Okay, got it”) for students who are able to withstand the exercise. In contrast, the ongoing involvement with the participant-citizens over six occasions in this program created an environment in which the students had to think deliberately about how to begin their exchanges, how to continue and develop them, and how to confront their conclusions. Learning strategies ensuring that the students had indeed deepened their awareness were characterized with ongoing exchanges with their citizens, peer discussions for each session, self-reflection while preparing their e-portfolio entries, and discussions with instructors. The previous study investigated self-awareness over a two-day training course in nursing, it was possible to drive development over the continuous course of six sessions . In training programs that are limited to a single session, as suggested by student comments during the survival period, students have a tendency to think that as long as they do not cause any trouble, it is sufficient simply to obtain a passable impression from their participant-citizens. However, in too many cases, this merely instills an egocentric style of communication, as observed during the introductory period. Through ongoing interaction occurring over six sessions, the students developed a desire to maintain and cultivate a favorable impression that would carry over to the next session, thus becoming more actively involved in their exchanges. In single-session exchanges, the anecdotes and experiences that students heard through their interactions with the participant-citizens could be understood only as general or superficial, factual anecdotes (e.g., “That’s what happened”). However, after passing through a trial-and-error phase of communication through exchanges spread over six sessions in the context of their participant-citizens’ worlds, the students were able to experience such incidents vicariously by attaching a deeper reality to them. This learning outcome cannot be realized within conventional, one-off, practice-based experience programs. It was achieved precisely because of the ongoing exchanges employed here. These results strongly suggest the significance of ongoing, practice-based training.
Furthermore, the practice-based training conducted on this occasion was aimed at two learning objectives: communications training and behavioral scientific research. That the two themes of this study (i.e., the centrality of the client to communication and understanding the expansiveness and connectedness of social existence) grew progressively more profound through mutual influence was an important discovery in itself. For example, in communication training, instructors are advised to use simulated patients for role-playing in hospital settings. In such settings, which are likely to have been decontextualized from society, medical students participate in learning as legitimate members of the medical system, thereby training the participant-citizens (who play the role of patients in the same context) in communication as medical students within the framework of a medical interview. In this case, the practice-based training was implemented in the social context of a community comprising fellow citizens. However, in this context, absolute strangers (identified only as “medical students”) were partnered with the participant-citizens from different contexts, thereby becoming fellow inhabitants. This procedure created a learning environment in which the medical students could become familiar with the lives and lifestyles of these others. It was precisely this environment that allowed a deeper understanding of the theme of social existence. Nevertheless, this result does not mean that an understanding of the second theme (i.e., understanding the expansiveness and connectedness of social existence”) can be strengthened merely through face-to-face contact with fellow community residents. It would be difficult to foster such understanding without cultivating communication skills through the continuous accumulation of trial-and-error communication with the same participant-citizens. Moreover, the cultivation of such communication skills and the consideration of life history, lifestyle, and family connections in the participant-citizens’ backgrounds allowed the students to draw further connections between communication and this participant-citizens-centered experience.
Before conducting this study, we were also unaware of the nature of the locus of control  that promotes the deepening of self-awareness among medical students. In general, it is considerably important to understand the concept of locus control as an attitude for effective patient support. Medical students have an immature capacity for objective self-awareness. In other words, their worldviews are subjective and egocentric. Although “dominance” may be suggested as a quality that is characteristic of medical students , the fact that the participants in this study were initially unable to communicate effectively suggests that the awareness of medical students retains the potential to undergo change as they progress toward understanding the importance of “the centrality of the participant-citizens.” By viewing the lives of others, the students developed parts of themselves of which they had previously been unaware. Particularly in Japan, where the nuclear family is becoming the norm, it could be useful for medical students to undergo a “second-person” style of simulated experience reflecting the diversity of the members who make up society. By deepening their interactions and reflections even further and learning to see their counterparts within the contexts of family and society, students can become aware that they themselves are also supported within these contexts. In addition, the development of the concept of self could help students to deal with self-criticism. The ability to regard and accept one’s self objectively is even more important for assertive individuals because constructive assertions and acceptance of criticism are basic qualities that also contribute to interdisciplinary collaboration and daily medical treatment .
Whereas medical education tends to accentuate the relative importance of the “biological” element of the Bio Psycho-social model , our practice-based training program emphasized the understanding of the person, the family, and the community. In this way, we explored how the systematic acquisition of communication skills had a spiraling influence on that understanding. The ability to think about things from others’ perspectives could consequently enable a shift in perspective with regard to the understanding and treatment of families under medical care. Context-based adult learning is an brand new learning approach . For training involving interaction with the elderly, this might entail such activities as strolling together along a walking course or spending time at home, thus being in the participant-citizens’ life-world. In other words, experiencing life at the same pace at which it is lived by another can foster an understanding of how the other sees the world. For pregnant mothers, witnessing the fetal ultrasound image during a check-up (i.e., a world shared by student and patient) could be an experience that traces the participant-citizens’ world. With young children, important tasks might involve minding and caring for children in the nursery. Such activities might also emphasize consciousness of being in control. To increase the effectiveness of these experiences, it is important for students to experience events as they occur in the context of the participant-citizens’ world (e.g., visiting with parents, the experience of being admitted into care). The most important point in this regard is not early clinical exposure (i.e., exposure to a world in which the student is likely to be in a position of dominance), but rather a temporary decontextualization  from medicine. Such decontextualization could be considered indispensable as practical training for secondary students in East Asian countries and elsewhere, who are likely to lack social experience after having jumped through the hoops of an unforgiving examination system.
Learning through interaction with children is another new finding that had never been addressed in related literature. In contrast to visible attempts to overcome indications of egocentrism in communications with pregnant mothers and the elderly people, an opposite phenomenon was apparent toward nursery children. In these contexts, students displayed an overly strong awareness that they were trying to adapt to the children, thus becoming overly other-centered (e.g., taking too much notice) and demonstrating a tendency toward unnecessary involvement that often impaired relationships. Pampering had an adverse effect on the children’s development of self-concept. For example, undesirable actions (e.g., taking turns in playing with the children and being overly solicitous to selfish behavior) were perceived as such in retrospect. In the same way, the students recalled having tried to address such situations by controlling (i.e., disciplining) the children. However, in many cases, such strategies led to mistakes, causing the students to experience sadness and frustration, and thus teaching them to appreciate the skills of early childhood educators. On the other hand, the students experienced true joy when they perceived that they were forming relationships. For example, small victories (e.g., having a child hold their hand or hug them) were perceived as joyful experiences of vicarious parenthood. It is interesting to note that at the end of the program, several students were more keenly conscious of “separation” than they were of questions regarding how to summarize their findings. The students’ loneliness and sadness of being forgotten by the participant-citizens was probably more characteristic of the children, who were openly expressive of their feelings. Whereas adult participant-citizens were able to share their sadness at the end of the exchange, some students suggested that the parting should not be drawn out in cases involving children who could not understand the parting.
The generalizability of this study is subject to several limitations. As a qualitative study performed within a single university in Japan, how far the results are likely to be reflected as a global trend is open to speculation. Nevertheless, because the study explored fundamental aspects relating to processes of understanding the individual in society, many of the findings may be considered as having hidden potential applicability. In addition, it is not necessary that such learning of awareness can always be achieved in six weeks, given differences between medical students in terms of learning stage and readiness. Furthermore, although a writing ability might have affected the quality of the e-portfolio, e-portfolio as an assessment should be regarded as a drive for students’ learning. Nevertheless, comparison of a portion of the data from the participants in our study to the comments of other participating students demonstrated a certain level of data saturation. This suggests that the concepts based on the results are generic to some extent.
In conclusion, through the experience of ongoing exchanges with various community citizens and various interactions with the participant-citizens, medical students developed communication skills and deepened their perceptions of themselves as social beings. The processes identified in our findings portray the struggle of contemporary medical students to learn how to communicate. As such, they can contribute to improving the quality of future early, practice-based experience programs and behavioral science education.
We thank all the citizens and medical students who participated in this program. We also gratefully acknowledge Professor Phillip Evans at the University of Glasgow for his review and useful comments on the draft.
- Litva A, Peters S. “Exploring barriers to teaching behavioural and social sciences in medical education.” Medical education 2008;42(3): 309-314.
- Hannum K. Understanding Social Identity. In: Knowing Yourself, Knowing Others (Vol. 126). Center for Creative Leadership. North Carolina, the United States,pp8-15,2007.
- Simpson JG, et al. The Scottish doctor–learning outcomes for the medical undergraduate in Scotland: a foundation for competent and reflective practitioners. Medical Teacher 2002;24(2):136-143.
- General Medical Council. Tomorrow’s Doctors. Recommendations on Undergraduate Medical Education. GMC, London, England, 1993.
- Russell A, et al. Social and behavioural science education in UK medical schools: current practice and future directions. Medical education 2004;38.4:409-417.
- Littlewood S, et al. Early practical experience and the social responsiveness of clinical education: systematic review. British Medical Journal 2005;331(7513):387-391.
- Dornan T, et al. How can experience in clinical and community settings contribute to early medical education? A BEME systematic review. Medical Teacher 2006;28(1): 3-18.