Abstract
Introduction
—Wilderness medical education for medical students is generally intended for senior medical students during their clinical years. Several universities have established elective rotations for clinical students or longitudinal 4-y tracks, but these opportunities are frequently restricted to a limited number of students. This novel program sought to fill a deficit of wilderness medicine curricula for preclinical medical students by creating a longitudinal course over one academic year.
Methods
—This curriculum includes a certification series of didactic lectures on core wilderness medical topics interspersed with hands-on skills sessions and simulated patient scenarios led by emergency medicine-trained faculty. Established medical education strategies were employed to improve learning, including spacing, interleaving, gamification, review quizzes, and frequent low-stakes assessments.
Results
—During the first 3 y of this innovative teaching method, 48 preclinical students completed all components of the course, with another 20 students in progress for this academic year. Postintervention surveys have yielded positive feedback, with students reporting improved confidence on patient assessment, increased wilderness medical knowledge, and the acquisition of procedural skills.
Conclusions
—Implementing a 1-y longitudinal wilderness medicine curriculum for preclinical medical students allows learners to gain valuable skills while building their confidence to assess and treat patients in a wilderness environment. The curriculum can be designed to incorporate best practices in medical education and adapted to a variety of practice situations and learners.
Introduction
Traditional medical school education consists of 2 y of preclinical didactic-based learning followed by 2 y of clinical rotations. In the preclinical years, didactic experiences are supplemented with standardized patient encounters, simulation-based learning, and physician shadowing experiences to teach the basics of patient encounters and examination skills. For many students, these experiences are their first immersion into learning to provide direct patient care. Although these are valuable opportunities, some students find that learning in these environments leads them to feel stressed and underprepared to translate these skills into clinical practice. 1 Additionally, many students feel that the first 2 y of preclinical didactic curriculum and the comparably small proportion of these standardized encounters are inadequate to prepare them for a real-life medical emergency, during which they may be the sole medical provider. 2
I aimed to create a longitudinal program that uses wilderness medical education to better prepare preclinical students for real-world emergencies. Additional benefits include contributing to their knowledge for licensing examinations and enhancing of their curriculum vitae by obtaining a certification. With class sizes of 160 students at the associated medical school, it was hypothesized that 5 to 10 preclinical students would be interested in the course if it were held in affiliation with a student interest group.
Given the rigorous time demands and costs of medical school, different certification programs were explored, with special consideration given to cost to students and flexibility with the curriculum. Additionally, I hoped to use and modify at least some existing resources because designing such a curriculum from the ground up would delay implementation. Some courses designed for laypeople were deemed too basic and likely would not be challenging enough for the medical students who were used to studying complex pathology at a high level of difficulty. Ultimately, it was determined that the Advanced Wilderness Life Support (AWLS) curriculum, developed by Wild Med U and the University of Utah, possessed the necessary academic rigor to adequately challenge preclinical students. Additionally, it would educate learners on topics pertinent to certification examinations, allow for incorporation of diverse methods of engagement, and remain affordable for medical students. Of note, since initiation of this curriculum, AWLS has now split and is also known as Wilderness Life Support for the Medical Professional as a revised course under the AdventureMed banner.
The revised curriculum for this program has been crafted to optimize students’ learning experience. It incorporates established learning theories and proven methodologies to enhance knowledge retention effectively. The experiential learning theory is one such framework that the course was designed around, based on the concept of learning by doing. 3 In essence, this theory emphasizes the necessity of active engagement, reflection, and hands-on experiences to ensure that learning occurs.
Further planning ensured that the proven concepts of spaced repetition and interleaving were incorporated into activities to create durable learning. Spacing refers to the concept of reviewing topics at spaced intervals, initially more frequently and then at increasingly longer intervals, to ensure that long-term learning occurs. Interleaving involves weaving together different concepts and topics throughout the learning process rather than concentrating on a single topic at a time. 4 In a longitudinal course, where topics are covered sequentially and often weeks apart, it is crucial to incorporate subsequent spacing and interleaving of subjects. This approach helps to ensure that the materials covered are not forgotten after each instructional session.
Methods
Participants
The Wilderness Medicine Interest Group (WMIG) at the University of Louisville School of Medicine (ULSOM) was organized by elected second-year medical student (M2) leaders who have completed the AWLS certification course as a first-year medical student (M1). The target audience is a mix of M1 and M2 students of varying annual proportions. The nature of the course often attracts students with a prehospital background, but most interested parties have no prior significant clinical exposure. The student leaders work closely with the faculty advisor to coordinate activity logistics, with the advisor carrying the responsibility for curriculum delivery. Although AWLS content is complex and tailored for advanced medical knowledge, the longitudinal course aims to deconstruct concepts to suit preclinical students. It includes hands-on sessions and reviews to support their learning and enhance understanding.
Development
For the ULSOM course, I organized what I believed to be among the first of its kind: a longitudinal course designed to certify preclinical medical students over a 1-y period. Many AWLS or equivalent courses focus the material into a condensed 3 to 5 d, targeting a wide audience of healthcare professionals. A review of the literature and electives offered revealed that there is a multitude of wilderness medicine electives for senior medical students, often ranging from 2 to 4 wk. Other programs, such as those at Wake Forest University School of Medicine 5 and Rocky Vista University, 6 have created excellent 4-y longitudinal programs/tracks for a small cohort of selected students. UT Southwestern introduced a 3-mo preclinical elective for students covering topics of medicine in extreme environments, demonstrating both positive feedback from students and increases in medical knowledge. 7 The Wilderness Medicine Interest Group at the University of Iowa used the adventure race simulation method to grow their students’ wilderness medical knowledge and clinical experience skills. 8 At the graduate medical education level, some residency programs have implemented wilderness medicine tracks for their trainees. 9
In comparison, this course aims to be available to all preclinical students who are interested, to be completed in either M1 or M2. To complete the course and take the certification exam, students are required to attend at least 50% of the in-person didactics, review recordings of any missed didactics, and attend at least 1 hands-on skills session throughout the academic year. Because university policy dictates that affiliated interest group activities must remain open to all students, students who do not wish to complete the full course are still encouraged to engage for any portion of the course they find interesting. In this longitudinal format, the curriculum uses spaced repetition of terms, knowledge, and skills to better solidify the learning in the medical students in a free or low-cost, accessible manner.
Core Curriculum
The core AWLS topics include 12 didactic PowerPoints supplied by Wild Med U in partnership with the University of Utah School of Medicine. 10 These PowerPoints can be modified with additional pictures, explanations, or resources as needed to make the topics more easily comprehensible for the preclinical learners, to whom many of these terms, pathologies, and pharmacologic treatments are novel. Additional elective topics are covered each year at the ULSOM WMIG course depending on the interests of the cohort. The core topics include patient assessment, wound management, environmental exposures, drowning, altitude illness, dive medicine, lightning, ear, nose, and throat/dental, bites and stings, and avalanches. Some core topics, such as medical kits and water treatment, lend themselves easily to being used in small-group sessions with hands-on activities. These topics are most commonly presented in a 1-h lunchtime lecture format, with funding provided by the university's student organization association to supply lunch for participants. Guest faculty are invited to present didactic sessions on their subspecialty areas of expertise.
Implementation
Although foundational medical knowledge is an essential component of wilderness medical education, special attention is given to designing hands-on sessions to allow the medical students to problem solve and work together as a team to enhance their learning. These sessions are held 1 to 3 times per semester for 2 to 4 h in the evening at a local park. The first 1 to 2 h of the session are dedicated to learning new skills, such as splinting, tourniquets, joint-reduction techniques, and improvised litters and carries, and practicing patient assessment skills, including log rolling and cervical spine stabilization. The other 1 to 2 h are spent with learners rotating through scenarios in small groups of 3 to 5 students, preferably a mix of M1 and M2 students in each group. These sessions are led by volunteer residents or attending physicians.
Activities are designed to match the training level of the students, provide hands-on opportunities to learn skills, and reinforce those lessons in different patient care scenarios. The focus is on interleaving recently learned skills to solidify technique through spaced repetition. At each session, student groups encounter 1 to 3 simulated patients (SPs) who act out their various ailments and injuries. Students must designate roles among the team, assigning team leaders, primary survey assessors, secondary survey assessors, history takers, and proceduralists. Teams work together to assess, treat, stabilize, and extricate their patients in a manner as realistically as possible but with occasional guidance from overseeing faculty or prompting from the patient if the team is struggling. After each scenario, faculty lead reflective discussions to help students gain insights and prepare for high-stakes real-life situations. This includes reviewing the critical actions for case completion, important history and exam findings, and giving feedback on any procedures performed. The SPs also speak to their experience as patients, regarding compassionate care, comfort, and understanding of the situation as per the information relayed by the team to the patient.
Faculty volunteers are recruited and trained from those who have expressed an interest in wilderness medicine, prehospital medicine, or simulation. Several residents have previously completed wilderness medical education courses and have volunteered longitudinally with the WMIG's hands-on activities. Other residents volunteer as a part of their own wilderness medicine elective rotation. Most of the SPs are current or former WMIG student leaders or premedical undergraduate student volunteers. The medical student SPs do not lead sessions independently but are invited to provide their experiences, perspectives, or tips to the course participants during the debrief sessions.
Assessments
To standardize and guide faculty evaluations of student groups, I created scenario sheets (see online Appendix 1) and assessment checklists (see online Appendix 2) for each scenario. The scenario sheets are standardized for quick reference, helping faculty find key information for student teams and ensuring that no important sections are missed. These sections include background prompts to be given to the group, a story for the patient to share, physical exam findings for primary/secondary surveys, pertinent history, appropriate vital signs, and an overall flow of the case.
The assessment checklists are formatted into similar categories with actions for each, such as primary survey (e.g., assessing scene safety, obtaining consent, and massive hemorrhage, airway, respirations, circulation, and head injury/hypothermia [MARCH]/airway, breathing, and circulation [ABCs]), secondary survey (e.g., history and head to toe exam), and scenario-specific actions such as splinting with proper technique and neurovascular checks before/after splinting, recognizing significant hemorrhage, and improvising a tourniquet. Each scenario also has a few higher-level actions that would be expected of more senior clinicians, which students receive extra praise for completing and as additional actions to consider in the future if they did not. Checklists include discussion points, topics of conversation, and high-yield testing points to guide the debriefing portion and encourage reflection while reinforcing learning pearls. It should be emphasized because these are all preclinical medical students with potentially no prior patient contact skills, the environment of these scenarios and assessments are designed to be exceptionally inclusive and supportive. The students are advised that these assessments are designed to be frequent and low stakes, with formative feedback offered as an opportunity for growth and improvement, without concerns for failure.
Lunchtime sessions typically feature an opening activity that is deliberately crafted to incorporate the interleaving of previously learned skills and activities through spaced repetition. This approach aligns with best practices for promoting durable learning while providing formative feedback to the learners. These activities might be a scenario a small group would demonstrate working through for their peers, rapid-fire brief scenarios in rotation, or practicing a previously learned skill. Kahoot review quizzes are used to cover recent topics, with prizes such as a tourniquet, SAM splint (SAM Medical Products Inc, Tualatin, OR), or anaphylaxis kit. Throughout the year, students are encouraged to use the AWLS free online resources to supplement their learning, including a reference textbook, practice questions, and skills videos.
At the conclusion of the academic year, final testing for AWLS certification includes both written and practical assessments. Students work in groups of 3 to 4 to complete 4 scenarios formatted similarly to the previous practice scenarios. Teams are given a standardized box of limited supplies and are otherwise instructed to be creative and improvise from their own belongings or the environment. These scenarios are designed to incorporate the major skills students have learned throughout the year, emphasizing teamwork, leadership skills, and critical thinking. On completing the practical assessments, students are then given either a paper copy of the examination or a password to take the written examination through the Wild Med U AWLS online portal to complete the certification, at a cost of $30 per student. There is no cost for students who wish to participate in the course but decline to take the written certification exam. The medical school offers full support for this interest group and program but does not grant elective credit.
Results
Since the initiation of this longitudinal course, a total of 48 preclinical medical students have completed course requirements and AWLS certification at the ULSOM over 3 academic years, with another 20 students working toward certification this year (see online Appendix 3). These numbers exceed the initial goal of 5 to 10 students per year. On average, 20 to 25 students attend each skills/scenarios session, and 30 to 50 attend each lunchtime session. Many students who certified in previous years return to listen to didactic sessions again or to assist with teaching skills and scenarios. Overall, the course fosters a sense of belonging and camaraderie, with students forming social groups for hiking, white water rafting, and camping trips within the WMIG.
Anonymous postcourse surveys (see online Appendix 5) were emailed to participants both immediately following course completion and again after students had obtained further clinical experience as M3 and M4 students. The end-of-course survey, consisting of 8 questions, received responses from 20 of 48 participants, resulting in a response rate of 42%. Most of these replies consisted of 1- to 2-word replies or suggestions. The follow-up survey during the clinical years had 9 responses. This survey consisted of a single open-ended question, which led to longer, more reflective responses. The responses included positive feedback, with students reporting that they felt more prepared to perform an examination of patients and respond to and assess an unexpected medical emergency and that they had gained skills and confidence with common wilderness procedures. Sample responses can be reviewed in online Appendix 4 and include the following:
“I took it as an M1, prior to having any real clinical experience and before learning how to do complete physical exams and take patient histories. AWLS gave me both a method for collecting this information once I moved into M3/M4 year . . . as well as the confidence to do so.” “[The course] made me feel useful, like I could act in an emergency.” “The course was very useful and helped prepare me for clinicals. . . . In our curriculum, aside from a few SP encounters, there is very little opportunity to learn practical, hands-on skills in the first two years. AWLS . . . taught not only about medical scenarios that we might encounter in the wilderness, but also how to take a history, how to do primary and secondary assessments, how to splint. In M3, I created my assessment and interview style by integrating a lot of what I learned in the course.” “I felt the course was useful in teaching skills that are totally applicable to real-life scenarios.” “I really enjoyed learning practical skills during the first and second year of medical school when it feels like “real world” learning is a little lacking. . . . I absolutely felt a little extra prepared for third-year rotations, and I really appreciate how applicable the AWLS skills are in real life. As someone that enjoys the outdoors, I cannot imagine going out into the wilderness without some of the skills we’ve learned.” “The overwhelming amount of hands-on experience was very helpful and impactful for me. I thought that this program stood out from the others in how much is hands-on and useful versus simply lectures.” “I feel confident now in my abilities to treat someone outside of the hospital, even in a wilderness setting.”
Several students have reported using their course-learned skills on real patients in a prehospital environment, ranging from basic wound care and splinting on backpacking trips to one M2 student who performed their first shoulder dislocation reduction on another individual stage side at a Red Hot Chili Peppers concert. The course teaches that wilderness medical skills can be practiced anywhere—although reductions after a failed crowd-surfing attempt at a rock concert may be a novel application.
Discussion
Implementing a 1-y longitudinal wilderness medicine curriculum for pre-clinical medical students allows learners to gain valuable skills to apply to real world situations, enhances their medical knowledge on wilderness specific topics, allows for CV building as they can gain certification in AWLS, and fosters growth of an inclusive community between the M1 and M2 cohorts. The feedback from student participants has been positive, with some learners using skills learned in real-life wilderness medical situations within their first few months after course completion. Multiple courses could be adapted to a preclinical learning environment in a similar manner, such as Wilderness First Aid, Wilderness First Responder, Wilderness Upgrade for Medical Professionals, Wilderness Life Support for the Medical Professional, or Basic Wilderness Life Support. However, at only $30 per student with a wealth of open-access references and practice questions, AWLS is a proven low-cost option that can be adapted to fit almost any curriculum goals.
Aside from the benefits for the medical students, this format allows residents and faculty to engage with medical students from an early stage of their education. This fosters longitudinal relationships and mentorships, with multiple course graduates later pursuing residency in that specialty. At ULSOM, the Department of Emergency Medicine has met several preclinical students via this pathway, many of who have shadowed, volunteered with the department at community engagement events, and joined our research team. Several of those graduates of the course are now applying to or have matched into an emergency medicine residency, with some expressing interests in pursuing a postresidency wilderness medicine fellowship or a Fellow of the Academy of Wilderness Medicine.
A 1-y curriculum is ideal because it allows students to participate as either an M1 or M2. The trend after the first course has been heavily skewed toward M1 participants, but each year has included M2 participants who would not have been able to join if the curriculum were a multiple-year track. Keeping all sessions open to all interested preclinical students ensures an inclusive learning environment and allows students to continue to join throughout the year in some capacity, even if they choose not to pursue certification. The academic year timeframe allows for 1 to 2 activities each month, which is manageable for the busy students.
Although it is felt that the 1-y curriculum is optimal, the curriculum design can be modeled and revised to suit the needs of many learning institutions. It can be condensed into a 1-semester accelerated course or a 2-wk elective rotation for senior medical students or residents. It could be used in other health professions educational programs such as for emergency medical technicians/paramedics, registered nurses, physician assistants, and nurse practitioners. A simplified version (Basic Wilderness Life Support and Wilderness First Aid) can be taught to undergraduate-level students. It can be incorporated as a part of a 4-y wilderness medicine track for medical students, similar to what other institutions have offered.
Existing research has published examples of wilderness medicine scenarios that can be adopted and used by other programs, some of which contain critical action checklists or similar that were the inspiration for this course's scenario sheets and assessment checklists. 11 This course's assessment checklists are novel in that they include not only critical actions but also reminders of the mnemonics used in the course, are formatted following the primary/secondary survey method, include both procedural skills and team discussions, and include guidelines for debriefing for the faculty leaders. They are designed for cross-referencing with the scenario sheets, and both are easy to follow for first-time faculty assessors.
The implementation and review of this program were not without challenges and limitations. Most medical schools do not cover pathology and pharmacology until M2, with M1 focusing more on anatomy and physiology. As faculty, it was challenging to remember the level of the trainees and ensure that topics were covered at a level appropriate for the audience. Some topics, such as patient assessment and wound care, are easier to cover early in the academic year, whereas altitude illness and dive medicine are best taught after students have covered more of the M1 core curriculum. The skills sessions and scenarios are always the highlights of the course, and each year the course aims to incorporate more simulation and skills and fewer didactics. Because the material is novel to students, it can be challenging to find a balance between an appropriate amount of didactics to cover the core topics while keeping the course fun and engaging for the learners.
Another challenge was creating a collection of scenarios, formatted in an easy-to-follow fashion, with associated assessment checklists for faculty assessors. Despite using some open-access simulations, revisions were needed to match the skills of the learners and the format of the course. Building this library was time intensive, but it was worthwhile to have a host of scenarios from which to choose to match the objectives of a session. The hands-on sessions rely heavily on the willingness of volunteer faculty and residents to serve as station leads and students to serve as SPs. Recruiting and training faculty assessors and SPs were an essential aspect, but the assessment checklists provided standardization and enabled participants to manage multiple scenarios following the main briefing. Additional challenges pertained to scheduling, considering the M1 and M2 schedules and their capacity for accommodating extra activities.
The analysis of this program was limited by a lack of constructive feedback from learners. Postcourse surveys had open-ended questions and thus often were met with vague feedback such as “Great course” or “I liked everything.” More reflective replies were obtained on the clinical years follow-up survey, when the single question scaffolded learners’ thinking regarding the type of answers I was seeking. Although this may have introduced potential bias, these responses provide a more thorough reflection of the skills that students acquired and how they applied the material. Future survey revisions will include Likert-scale questions and inquire how many sessions learners attended, aiming to collect more quantifiable data. Attendance was recorded at events to verify 50% attendance for final testing, but these records were discarded at the end of each academic year. In follow-up studies, I plan to incorporate pre/post data collection to objectively track participants’ progress and measure skills learned during this course.
Conclusion
This curriculum demonstrates that educators can use the principles of medical education, merge them with and expand existing certification courses, and present these concepts to preclinical learners at an affordable cost. Implementing the curriculum as a 1-y longitudinal course has been demonstrated to effectively accommodate the time limitations of medical student participants. The material was enthusiastically received by participants, and learners felt that they gained medical knowledge and valuable hands-on experience that were both immediately applicable and beneficial during their clinical years.
Supplemental Material
sj-docx-1-wem-10.1177_10806032251338012 - Supplemental material for Blazing the Trail: A Novel Longitudinal Approach to Wilderness Medicine Education for Preclinical Medical Students
Supplemental material, sj-docx-1-wem-10.1177_10806032251338012 for Blazing the Trail: A Novel Longitudinal Approach to Wilderness Medicine Education for Preclinical Medical Students by Jennifer McGowan, MD in Wilderness & Environmental Medicine
Supplemental Material
sj-docx-2-wem-10.1177_10806032251338012 - Supplemental material for Blazing the Trail: A Novel Longitudinal Approach to Wilderness Medicine Education for Preclinical Medical Students
Supplemental material, sj-docx-2-wem-10.1177_10806032251338012 for Blazing the Trail: A Novel Longitudinal Approach to Wilderness Medicine Education for Preclinical Medical Students by Jennifer McGowan, MD in Wilderness & Environmental Medicine
Supplemental Material
sj-docx-3-wem-10.1177_10806032251338012 - Supplemental material for Blazing the Trail: A Novel Longitudinal Approach to Wilderness Medicine Education for Preclinical Medical Students
Supplemental material, sj-docx-3-wem-10.1177_10806032251338012 for Blazing the Trail: A Novel Longitudinal Approach to Wilderness Medicine Education for Preclinical Medical Students by Jennifer McGowan, MD in Wilderness & Environmental Medicine
Supplemental Material
sj-docx-4-wem-10.1177_10806032251338012 - Supplemental material for Blazing the Trail: A Novel Longitudinal Approach to Wilderness Medicine Education for Preclinical Medical Students
Supplemental material, sj-docx-4-wem-10.1177_10806032251338012 for Blazing the Trail: A Novel Longitudinal Approach to Wilderness Medicine Education for Preclinical Medical Students by Jennifer McGowan, MD in Wilderness & Environmental Medicine
Supplemental Material
sj-docx-5-wem-10.1177_10806032251338012 - Supplemental material for Blazing the Trail: A Novel Longitudinal Approach to Wilderness Medicine Education for Preclinical Medical Students
Supplemental material, sj-docx-5-wem-10.1177_10806032251338012 for Blazing the Trail: A Novel Longitudinal Approach to Wilderness Medicine Education for Preclinical Medical Students by Jennifer McGowan, MD in Wilderness & Environmental Medicine
Footnotes
Acknowledgments
Special thanks to Rich Ingebretsen and Wild Med U for their willingness to share resources and allow our Wilderness Medicine Interest Group to reformat the AWLS curriculum, to the faculty and Emergency Medicine residents at the University of Louisville School of Medicine Department of Emergency Medicine for their time volunteering to teach, and to my Wilderness Medicine Interest Group student leaders for their tireless dedication to bringing this course to their peers.
Funding/Material Support
The University of Louisville Student Activities Council provided funding to the Wilderness Medicine Interest Group that was managed exclusively by student leaders to provide food to participants for lunchtime sessions. Otherwise, no funding for this course, this study, or by this author was obtained.
Ethical Considerations
The postcourse feedback data were collected for informational purposes and were not initially collected with intent for research or publication. This paper was initiated without the intent of including qualitative data, but the final version does include student feedback comments. The University of Louisville Institutional Review Board classified this wok as program evaluation and non-human subjects research (IRB 25.0014) on January 21, 2025.
Consent to Participate
Students were verbally advised that consent in any portion of the course was voluntary, could be anonymous, and could be revoked at any time by the student by leaving the event or declining to participate in further course events. This included didactic lectures, hands-on sessions, and the anonymous optional postcourse feedback surveys.
References
Supplementary Material
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