Learning from Primary Health Care Centers in Nepal: reflective writings on experiential learning of third year Nepalese medical students

Background Medical education can play important role in cultivating the willingness among the medical students to work in underprivileged areas after their graduation. Experiential learning through early exposure to primary health care centers could help students better understand the opportunities and challenges of such settings. However, the information on the real experiences and reflections of medical students on the rural primary health care settings from low-income countries like Nepal are still limited. The aim of this study is to demonstrate the learning process of the medical students through their reflective writings based on Kolb’s theory of experiential learning. Methods The students wrote their experiences, observations and reflections on the experiential learning from the primary health care centers on individual logbook as part of their community posting assignments. We analyzed the data of 50 logbooks through content analysis using Kolb’s experiential learning cycle as a theoretical framework. Results The students’ reflections are structured around the four main learning stages of Kolb’s experiential learning theory. Each learning stage consisted of different categories. The first stage consisted of concrete experiences on rural health and learning by doing. The second stage included their reflective observations on primary versus tertiary care, application of theoretical knowledge and role of supervisors. In the third stage, the students developed and refined their concepts on self-development, understanding reality, compassion and sense of responsibility. The final stage, active experimentation, included their immediate future plans, suggestions to improve curriculum, plans after becoming a doctor and suggestions to improve policies. Conclusion This study provided important insights on different stages of experiential learning of medical students on primary health care in low resource rural settings. Reflective writing of experiential learning could be an important step to address the gaps in medical education for resource constraint settings like that of Nepal and other low-income countries.


Background
Globally, medical education focuses more on teaching and training in tertiary care settings where the latest technology, diagnostic tools and expert back up are easily available [1]. On the other hand, lack of sufficient human resources providing quality health care to the poorest and remotest places remain a major global health challenge [2]. Moreover, both the developed and developing parts of the world have been facing the challenges to recruit and retain medical doctors in rural areas [3][4][5][6].
The situation is far worse in middle and low-income countries, with 47 % of WHO member states reporting less than one doctor per 1000 population [7]. Nepal is one such low-income country in South Asia facing workforce crisis in healthcare, particularly in the rural areas [8]. In 2012, the number of doctors in Nepal was as low as 0.17 per 1000 population [9]. Over the last decade, Nepal has witnessed a dramatic increase in the production of medical graduates, with more than 1000 medical doctors registering at the Nepal Medical Council every year [10]. Despite the increase in the number of medical graduates, most remain concentrated in the urban areas [5].
In order to familiarize the medical students with the health system in general and rural community health in particular, it is mandatory for all the medical institutions in Nepal to incorporate community medicine or community health sciences in their undergraduate curriculum [11]. Also other south Asian countries like India, Bangladesh, and Pakistan have incorporated community medicine in their undergraduate curriculum [12][13][14]. However, the way the course is delivered may vary among different institutions and countries. The exposure to the health system and to rural health in particular may not be adequate or uniform among all institutions. Moreover, the information about the students' real experiences from being exposed to rural health care issues in their medical education, remain scant.
Reflective writing can be an important way to understand the medical students' learning process in their experiential learning [11,15]. Written reflections can help the students to think critically, increase their active involvement in learning, and increase their personal ownership of each learning stage [16]. It has been suggested that reflection can help health professionals to understand complex situations and enable them to learn from such experiences [15]. Although gaining popularity in medical education in many parts of the world [17,18], such practice is still uncommon in most low-income countries. However, it is argued that reflective writing of experiential learning becomes effective only if it is applied appropriately based on a theoretical framework [19].

Experiential learning theory
In 1984, David Kolb described a four-stage experiential learning cycle, suggesting that a combination of experience and subsequent reflection is important for 'real' learning [20]. Reflection is a concept used by many constructivists over the past decades [21][22][23]. Constructivism is a theory about how people construct their own knowledge and understanding of the world by experiencing and then reflecting upon those experiences [24]. Kolb's experiential cycle remains the most thoroughly explained and popular theory [25]. It includes four stages: concrete experience, reflective observation, abstract conceptualization, and active experimentation [20,25].
In Kolb's first stage, the learners have a concrete experience [20]. This can be an event or just a simple experience, which has the potential to add or change the learner's knowledge or skills. In the second stage, the learner deliberately tries to review the real experiences in order to understand their value [20]. In the third stage, the learners go through a deeper reflective process, and transform the past experiences into new conceptions or knowledge [20]. In the fourth stage, active experimentation, the students plan to translate the new knowledge into action. This could be either in the form of concrete actions or proposals, which could then lead to a new cycle of learning [20,25].
Even though experiential learning has been widely discussed and implemented over the years in medical education, little research has been done to demonstrate each process, particularly in resource constraint settings [25]. Thus, the aim of this study is to demonstrate the stages of experiential learning process of the medical students through their reflective writings based on Kolb's theory of experiential learning [20] (Fig. 1).

Study setting
Patan Academy of Health Sciences (PAHS), School of Medicine was established in 2010 as an autonomous notfor-profit institution in Nepal, with the purpose of preparing a new generation of medical graduates to work in rural areas. Problem based learning (PBL) and community based learning and education (CBLE), are the principal pedagogic strategies of its medical education program. A significant portion of the CBLE is delivered through mandatory experiential learning in diverse community settings that have different tiers of health facilities within the national health system.
In October 2013, a total of 55 third-year medical students, the first cohort at PAHS, were posted in seven rural Primary Health Care Centers (PHCCs) in two districts for a total duration of 4 weeks. The PHCCs in Nepal is the first level health facility with the provision of at least one medical doctor. The health services provided by the PHCCs where the students were placed included essential primary care like maternal and child health, family planning and outreach services.
In addition to clinical exposure at the PHCCs, the students were required to maintain a written log of their daily work, experiences, and reflections. The students were encouraged to think critically and write their reflections about community health experiences since their first year of medical school. In order to encourage students to write freely, logbooks were not evaluated on the basis of the contents of their writing. All the writings were in English, being the official language for medical education in Nepal.

Ethical considerations
We obtained ethical approval to use the students' logbooks for this study from Institutional Review Committee of PAHS. Fifty students provided written informed consent to analyze the written contents from the logbooks.

Data analysis
Data analysis was done through a qualitative content analysis using Kolb's categories [26]. To reduce bias and secure anonymity the personal identification of the students such as name, gender, and roll number written on the cover page of each logbook was first covered. Each logbook was then given a code number. The total logbooks were then divided among four researchers (RD, NP, KS and MM). The four researchers then identified any activity, observation, or reflection that the student had mentioned in the logbook. From the logbooks, the hand written information based on these categories was then entered into Microsoft Word. The information entered based on these categories were then verified by two researchers (MS and SU). The principle investigator then further performed content analysis, discussing with all the group members. The broad categories were divided into subcategories that were then fit into themes according to Kolb's different stages. Anonymous original quotes that reflected the experiences and expectations from the students were chosen to give more insight into the students' perceptions.

Results
The students' reflections are structured around Kolb's four main learning stages, each stage including different subcategories (Table 1).

Stage 1: concrete experiences Experiencing rural health
In this study, almost all the students explained about their observations of the patients in the PHCCs. They

Role of supervisors
Almost all the students reflected the importance of faculty to inspire and motivate them to learn in their experiential stay. "I got to learn so much from the doctor at PHCC. He taught us many things that will be useful for me in the coming examination. " (Code No. 13)

Stage 3: abstract conceptualization
Almost all the students reflected on how the experiences and reflective observations affected them at a personal level. The students were able to develop or refine their concepts on various aspects by connecting their prior experiences.

Self development
Many mentioned that the experiences at PHCC helped them to develop many skills and qualities on their own.

Stage 4: active experimentation
Almost all the students were able to translate past experiences and concepts into real action. Some actions were in the form of real activities to be undertaken immediately as a student, during their stay in the PHCCs. While others were in the form of future plans when they become doctors. They also expressed their future expectations from the institution and the policymakers.

Immediate future plans
Based on the prior knowledge and concepts, many students planned for immediate actions to be taken during their stay at PHCCs.
"Now I've made up my mind, I will call her up for a follow up visit. I will do everything and anything to make her feel better and make her pain go away. " (Code No. 25) "I should have taken a detailed history of the patient I examined. Now, I will improve on that aspect. " (Code No. 52) "I now feel that I am able to write and I feel more responsible to be careful and not mess it around next time again. " (Code 53)

Suggestions to improve curriculum
Many mentioned that the common problems that they would encounter in rural settings should be incorporated in the curriculum.
"I found out that most of the patients were coming with chief complaint of fall injury. Topography of the villages is a major reason for the fall injuries. So we should be able to manage different cases related to orthopedics before going to rural districts after completing our course. It is also worthy to give training to MBBS doctor to manage different obstetrics and gynecology complications before sending them to serve the rural underserved community. " (Code No. 13) "I saw antibiotics were indiscriminately prescribed. I thought this give rise to drug resistance organisms. I found it necessary to inculcate current status and possible situation of drug resistance in our curriculum. " (Code No. 11)

Plans after becoming a doctor
Many were able to internalize the experiences and transform them into active planning. They were able to reflect on what would they like to do when they become a doctor.
"In the near future, we will find ourselves in the similar scenario working in the resource poor settings. I will try my best to upgrade the quality of the lab tests. This will help the people to get the quality care in the community level. " (Code No. 18) "Making balance between patient's discomfort for follow up, compliance with standard treatment protocols and patient's demands and economic status is a very difficult technique. I will have to master if I am going to work in this setting. " (Code No. 24) "I so wish I can do something in future as a doctor to educate all my Nepalese brothers and sisters about healthy living issues, education, health, risk of teenage pregnancy and more. "(Code 51)

Suggestions for improving policies
Many highlighted the importance of improving the proper functioning of health facilities and expected future changes in the policies. "The doctor was not able give full effort as per his knowledge. This is because of non-functioning of some equipment (X-ray). So in conclusion, there should be balance between human resource and equipment. " (Code No. 28) "There is sanctioned post of medical officer but in our PHCC, there is no doctor. Not only in our PHCC, there are many PHCCs without doctor. Government should think about it and should try to find out the reason behind this. " (Code No. 26) "We saw few times, patients have to wait quite a long time for the health workers to be in emergency room. It would be better, if one of the staffs were available continuously in the emergency. For this, co-ordination between the staffs, management committee and the community is required. " (Code No. 25) Many students noticed that the cleanliness and sterility was not maintained in their posted health facilities. They realized that more efforts to raise awareness among the health workers were necessary.
"I think government should provide adequate materials and knowledge required to maintain sterile wound care. On one hand the patient is getting health service and on the other hand is being exposed to risk of infection. " (Code No. 14) Some students mentioned that the data recording system was extremely poor and suggested that data management should be improved.

Discussion
According to Kolb's theory, there are two dimensions of experiential learning that take place in the brain: perceiving and processing [20]. In this study, perceiving occurred in the first stage of their experiential learning when the students had the concrete experiences both in the forms of observing the ground realities and working under resource constraint settings. These concrete experiences were then processed and transformed into knowledge in the form of reflections and subsequent planning of future actions.
In the first stage of Kolb's experiential learning, the learners go through a concrete experience [20]. In this study, the students experienced the challenges through activities and observations. They had opportunities to observe from the patients' perspectives and also to learn to perform various tasks in PHCC as a service provider. Previous qualitative studies on medical students' experiential learning about rural health in other countries like Canada, Australia and South Africa have suggested that exposure to ground realities beyond tertiary care settings is an important element in learning [27][28][29]. Such experience can provide them an environment to understand not only the initial presence of disease and treatment, but also the importance of health promotion and social aspects of health [29,30].
In the second stage, the students were able to review the real experiences to understand their value as suggested in Kolb's theory [20]. The students were able to differentiate the clinical approach in primary health care and tertiary health care. They were able to reflect back on the difference between theoretical knowledge and their practical application in PHCCs. Even though these differences are known facts [28], early internalization of such differences could be important to prepare them to work in different settings in the future.
In the third stage, the learners go through a deeper reflective process, and transform the past experiences into new conceptions or knowledge [25]. In this study, the students were mainly able to understand and internalize the concept of compassion [31], by reflecting a deep awareness of other's suffering and a strong wish to release that suffering. It has been suggested that, in order to deliver quality health care to the underserved population in rural areas, it is important to understand the values beyond the conventional clinical medicine [32]. Furthermore, the students in this study showed more realistic conceptions of the complexities of existing problems in rural areas. Such early realization can influence and better prepare those medical students with an entirely urban background to choose to work in rural areas [33,34].
In the fourth stage, the medical students were able to use their experiences from the prior stages for planning their immediate future actions [20,25]. They also were able to reflect upon their attitudes and the activities they would embody when becoming doctors. They also expressed future expectations and suggestions for the institutions and policymakers. These plans could lead to the next cycle of experiential learning through the lessons they learnt during this experiential cycle, to enhance their growth in subsequent years of their medical education [20].
This study has certain limitations. Firstly, the reflective writing was part of the curriculum, so the students were aware of the fact that their writing would be read by the teachers. In the South Asian context and most traditional schools, where the hierarchy in academia remains very prominent, the rigidity often deprives the students of their own growth. Although, the students in this context were encouraged to think critically and write freely, the social desirability bias cannot be completely ruled out.
Secondly, we cannot conclude that these experiences would actually lead to a new cycle of learning based on the plans they made. Further studies of the same cohort would help to provide a longitudinal perspective on whether these reflections would actually lead to a new cycle of learning based on the plans they made.
Lastly, the reflections are not entirely representative of all the medical students in Nepal or other cohorts in the same institution. More studies on experiential learning from various institutions within Nepal and other low-income countries facing human resources for health crisis are necessary to provide a better comparative perspective.
Despite these limitations, this study is the first of its kind in Nepal to explore the medical students' reflections upon their experiential learning from PHCCs. Reflective writing of experiential learning can be an important step to address the gaps in medical education in countries like Nepal, where the perspectives of what it actually is like to learn from community settings have not yet been given adequate attention.

Conclusion
In this study we used medical students' written reflections to demonstrate the four stages of experiential learning in a low resource rural setting. Reflective writing in experiential learning should be encouraged as part of a medical education for future doctors that plan to practice in resource constrained settings and in low-income countries.