Developing a broad perspective of future work and career in medical students through field trips to a disaster area: a qualitative study

Abstract

Objective

Field trips to disaster-affected areas (FTDAs) without a specific purpose, such as medical cooperation, are widely used in medical education. However, what medical students gain from FTDAs remains unclear. The present study aimed to clarify what medical students gain from FTDAs. Five medical students who had visited the Fukushima nuclear power plant in Japan participated in a semi-structured group interview to ask what they gained from such a visit. The narratives were analysed using open coding.

Results

The following four themes emerged: “Spirit of scientific inquiry”, “Foundation for lifelong education and personal growth”, “Broadened understanding of the medical profession”, and “Importance of practicing medicine in the community setting”. The ambiguity of medical students’ specific roles in the field trip compared to the fieldwork may have encouraged them to make sense of the experience from their perspective. As a result, students may have gained a broader perspective of their future work and career through the FTDA. If medical educators can gain consensus from the residents of a disaster site, different disaster-affected areas can be potential sites for medical education using FTDAs.

Introduction

Past studies suggested that visiting disaster-affected areas to interact with residents and see the effects of a disaster contributes to the growth of medical students such as enhanced psychological resilience and improved understanding of professional responsibility [1–2]. The learning method in which students visit the site without being assigned specific roles, such as providing medical care, could be referred to as a ‘field trip’ (FT), whereas the term ‘fieldwork’ could be an educational method where students may be assigned tasks such as medical collaboration or support.

Previous studies have suggested the medical educational benefits of FT in general, such as a better understanding of the concept of social determinants of health [3], and those of fieldwork, such as improved professionalism and social responsibility [1, 4]. In line with these educational benefits of FT and fieldwork, participation in field trips to disaster-affected areas (FTDAs) may provide valuable insights to help medical students improve their learning motivation and career options. However, little is known about what the medical student gains from FTDAs.

The Fukushima Daiichi Nuclear Power Plant (FDNPP), the site of an accident caused by the 2011 Great East Japan Earthquake (GEJE) and subsequent tsunami, and its circumstances are considered to be representative of disaster-affected areas in the post-disaster recovery period due to the severity of the damage caused to society. Therefore, the FT to the FDNPP is classified as an FTDA and assumed to be a suitable place to investigate what the medical student gains from FTDAs.

The present study aimed to investigate what the medical student gained from participating in FT to FDNPP using a group interview. Even though this is an exploratory study in a single area, essential implications can be drawn.

Methods

Recruitment

Using purposive sampling, the participants were five medical students from Fukushima Medical University (FMU) attending a six-week intensive course in social medicine, including the one-day FT to FDNPP. All participants were male, in their fourth year at the time of the FTDA, which is the last year before starting bedside learning at the hospital, and over 20 years of age, which is the legal age of majority in Japan. Participants included those from Fukushima Prefecture. However, none had suffered direct damage from the GEJE, such as injury to themselves or their family members or property loss due to the disaster.

In fiscal 2016, when the FTDA was conducted, there were 758 medical students at FMU. Of these, 147 were fourth-year students, five of whom participated in the FTDA.

Research design and setting

The students participated in an FT to the FDNPP on 7 February 2017 and then in a retrospective group interview on 17 December 2018. The participants were, therefore, in their fourth year at the time of the FT and in their sixth year at the time of the interview.

The restoration and tours of the FDNPP were managed by the Tokyo Electric Power Company (TEPCO), which operates the FDNPP and has been accepting small groups of visitors since 2011, the year of the accident (2017 telephone interview with a TEPCO spokesperson by the first author after the FT to the FDNPP; unreferenced). TEPCO initially did not allow young people to visit the plant for health and safety reasons but relaxed the policy when radiation levels at the FDNPP site fell to non-hazardous levels in 2016. Safety was also assured in 2017 when the current study joined the FT.

The FT began with a briefing by a TEPCO spokesperson on the history of the accident and the recovery status. The visitors, including five students and four teachers, took a bus tour of the FDNPP premises. The route included areas with clear traces of the accident, such as the Unit 1 and Unit 2 buildings where the hydrogen explosions occurred and the coastline directly affected by the tsunami. After the bus tour, the visitors’ exposure dose was checked for safety reasons. Then, a question and answer session with TEPCO spokespersons was held. The whole FT lasted about four hours.

The subjects may have been mentally affected by the destruction of the FDNPP and the surrounding area during the FT. Therefore, a medical doctor monitored the students’ mental health during the FT in 2017 and confirmed the same in 2018 when the interviews were conducted. No problems were reported.

The retrospective group interview was not part of a regular curriculum; it was conducted in a context unrelated to formal educational assessment in the authors’ institution. Thus, the student’s grades or standing at the university would remain unaffected by their shared experiences.

Interview procedure

A group interview was used to facilitate the subjects’ recall of past experiences. The interview was conducted in a conference room at FMU on 17 December 2018, with the first author as the moderator. The first author’s credentials and related information are listed in Table 1. The conversations were recorded with an IC recorder, with the participants’ permission, and a verbatim transcript was made. The group interview began with the question: “What have you gained from the FTDA experience? The interview lasted about 60 minutes.

Table 1 Credentials and related information of the authors

Analytic procedure

The transcript was inductively coded according to open coding, whereby labels were assigned to fragments of the transcript that had similar underlying meanings, and axial coding, whereby the meanings and interrelationships of labels/categories were examined [5]. The student’s reports and conversations were summarised in three steps. Starting with 67 narrative segments, the number of labels in each step was 15, 8 and 4. The concepts in step four were treated as the ‘main theme’, which reflected what the subjects had gained from the FT, and eight corresponding ‘sub-themes’ in step three, which provided more concrete explanations of the subjects’ evaluations of their experiences of the FT than the main themes.

The coding procedure was as follows. First, the first author conducted open and axial coding, producing an analytical draft with a code tree; the code tree organised the hierarchical relationships between labels and categories. Second, the third and fifth authors confirmed this draft for appropriateness of procedure, content and wording by asking the first author about the reasons and criteria for coding; the authors carefully checked whether the labels sufficiently reflected the medical students’ insights and examined the coding for arbitrariness. Thirdly, the third author, an experienced qualitative researcher, checked the adequacy of the analysis, and the fifth author contributed to the elaboration of the content and interpretation of the main and sub-themes through his profession as a medical doctor who knew the history and trends of medical education.

Results

The main and sub-themes and excerpts of narratives are shown in Table 2.

Table 2 Themes and their detailed explanations about what medical students gained from the FT

Spirit of scientific inquiry

The main theme, “Spirit of scientific inquiry,” represents the knowledge and mindset required to critically read and examine the prevailing notions and government’s pronouncements about the destruction and reconstruction after the disaster, the FDNPP accident.

Foundation for lifelong education and personal growth

The main theme, “Foundation for lifelong education and personal growth,” emphasises that the FTDA experience has been associated with a recognition of the importance of lifelong learning, an increased interest in public health and preventive medicine to reduce the risk of radiation exposure among FDNPP clean-up workers, and the enjoyment of problem-solving.

Broadened understanding of the medical profession

The main theme, “Broadened understanding of the medical profession”, indicates that students have gained a broader insight into the essential elements of becoming a doctor and different perspectives on their future career choices than before joining the FT.

Importance of practicing medicine in the community setting

In the main theme, “Importance of practising medicine in the community setting”, the students expressed their recognition of their future vision as medical practitioners. They mentioned the possibility of working in a region surrounding or close to the FDNPP and the feeling of having to contribute to the region.

Discussion

Findings

Our findings suggest that FT had a clarifying effect on students’ future perspectives, such as broadening their career options. The ambiguity of medical students’ specific roles in FT compared to fieldwork may have encouraged them to make sense of the experience from their perspective; in other words, the medical educational effects of fieldwork in disaster areas indicated by past studies, such as psychological growth [2, 6], professionalism and increased social responsibility [1, 4], may be determined by the presence of specific roles. Our findings on what the medical student gains from FTDA were novel and different from those of FT in general shown by previous studies, such as promoting understanding of the social determinants of health and refining professional knowledge [3, 7, 8].

Methodological implication

Regarding the methodology of the present study, we should mention that the retrospective group interviews conducted two years after the FT, 2019 may have helped the medical students to recall their past experiences and make sense of their studies; in other words, there may have been a ‘booster effect’ or promotion of effectiveness in their medical education. Although the data collection method may have inevitably acted as an intervention, we believe that this method contributed to clarifying the students’ past experiences rather than compromising the quality of the study design. It is suggested that an FTDA has an enhanced educational effect when students reflect on it over time.

Generalisability/transferability

We acknowledge that the generalisability of our findings is limited because the subjects of this study were selected from a single medical university. However, it should be noted that the concept of transferability is more appropriate for qualitative research than generalisability in quantitative research; transferability is defined as the extent to which findings from one setting can be found in another setting [9]. The main and sub-themes in the present study were generated from the narratives through a step-by-step coding analysis procedure; these themes were relatively abstract and may be common to FTDA cases in other settings. Therefore, we believe that our findings are transferable.

Applicability

Areas affected by disasters such as floods, volcanic eruptions and landslides can become sites for FTDAs if local residents are willing. Importantly, FTDAs should not become disaster tourism, which is a selfish and opportunistic visit to a disaster-affected area that lacks consideration and respect for the local situation and residents [10, 11] and can be described as “medical shame“ [12]. FTDAs should be conducted after building trust with local residents to avoid disaster tourism. Universities should explain the meaning and purpose of FTDAs to residents of disaster areas in order to build a trusting relationship with the local community for sustainable medical education in a region.

Limitations

The limitations of the present study are that there is room to explore how educational indicators such as career choices and learning outcomes are related to what students gain from the FTDA; such exploration may be a more practical contribution to medical education than the present study. Furthermore, in qualitative research using interview, it is generally desirable to explore the psychological state or transition of the participant in more depth by providing multiple interview opportunities; however, in the present study, data were obtained through a single group interview. A longitudinal study should be conducted to reveal the transition process of medical students’ growth. In terms of credibility, one of the criteria of a qualitative study is trustworthiness; the present study may need improvement in this regard. Future research should use the analytical option of triangulation to increase methodological rigour and trustworthiness. As an example of methodological triangulation, a psychological scale could be used to verify the consistency of interpreting the qualitative study results from a future perspective. However, this was not feasible in this study as a suitable scale could not be identified. Achieving data saturation and implementing participant check to analytical results will also be required in future studies.