Exploring the Role of Wilderness Medicine in Undergraduate Medical Education in India: Impact on Student Motivation and Self-Directed Learning

Abstract

Background

In India, emergency medicine is a developing specialty and is not yet integrated into undergraduate medical education (bachelor of medicine and bachelor of surgery [MBBS]). Against this backdrop, introducing wilderness medicine may seem premature, but its relevance is clear given the country's vast rural geography and limited prehospital care. This study evaluated the impact of a 1-d wilderness medicine elective on medical students’ motivation, self-directed learning, and satisfaction.

Method

This mixed-methods study involved 53 MBBS students from a tertiary care teaching institute divided into 3 independent batches that sequentially underwent wilderness medicine training across 3 curricular iterations. Data collection included pre- and post-tests, surveys using validated scales, and qualitative feedback from focus group discussions.

Results

Confidence improved significantly (P<0.001) in scene size-up (2.66±0.99 to 4.22±0.53), first aid (2.66±0.99 to 4.22±0.53), identification of life-threatening emergencies (2.66±0.94 to 4.20±0.51), and first aid kit preparation (2.39±1.07 to 4.29±0.72, all scores out of 5). The module was highly valued, with strong support from the learners for its inclusion in the curriculum (4.14±0.94 to 4.86±0.35; P<0.001) and reported high satisfaction and demonstrated intrinsic motivation.

Conclusions

The elective module enhanced students’ confidence and engagement, supporting its integration into undergraduate curricula. Further research is warranted to assess long-term impact and scalability. Further research is needed to validate these findings and assess the long-term effects on clinical practice.

Keywords

wilderness medicine education undergraduate medical students simulation training emergency medicine outdoor education wilderness education self-directed learning

Introduction

Emergency medicine, a relatively new specialty in India, has evolved rapidly to meet the critical need for organized and effective emergency care in the country.¹ The establishment of structured protocols and the training of specialists have contributed to the development of emergency departments that aspire to meet global standards. However, the scope of emergency medicine extends beyond hospitals, encompassing prehospital and remote medical care—areas that are particularly relevant given India's vast geographic diversity.²

Wilderness medicine draws on the traditional specialties of emergency medicine, family medicine, surgery, internal medicine, pediatrics, and psychiatry, integrating them into a framework that addresses the unique challenges of providing care in remote and austere environments where access to healthcare is delayed. This makes wilderness medicine particularly relevant for India, where large parts of the country routinely face logistical and environmental challenges to healthcare delivery. In India, the bachelor of medicine and bachelor of surgery (MBBS) program constitutes undergraduate medical education and consists of 4.5 y of academic training followed by a 1-y mandatory internship. Despite its contextual need, wilderness medicine remains largely absent from the Indian undergraduate medical curriculum.³ The educational value of introducing wilderness medicine early in this training remains underexplored.

The Snake Bite Life Support workshop was developed as a national initiative funded by the Indian Council of Medical Research to improve the knowledge, skills, and self-efficacy of healthcare workers managing snakebite and other emergencies in remote environments.⁴ The Snake Bite Life Support workshop is comprised of 2 core components: (a) snakebite assessment, venomous bite intervention, and optimal referral, which focus on clinical training for snakebite management including syndromic approaches, treatment protocols, and referral decision making, and (b) skills and awareness for first aid, emergency response, and wilderness training (SAFETi), which target practical prehospital and environmental emergency response skills in austere settings.^5,6 Building on this platform, we adapted SAFETi into a 1-d immersive elective for medical students to introduce wilderness medicine through structured theoretical content and hands-on simulation within the broader context of emergency care in resource-limited settings.

This intervention aligns with India's transition to a competency-based medical education (CBME) curriculum, which emphasizes outcome-driven learning, practical skills acquisition, and self-directed engagement over traditional time-based training.^3,7 This study aimed to evaluate the impact of the SAFETi elective on medical student motivation, self-directed learning, and curriculum satisfaction. By assessing learner engagement and perceived learning outcomes, we sought to determine whether a brief but immersive training experience could enhance preparedness for real-world emergency care in low-resource and wilderness settings.

Methods

Study Design

This study employed a sequential explanatory mixed-methods design in which quantitative data collection (ie, pre- and post-test assessments and structured surveys) was followed by a qualitative inquiry (ie, focus group discussions, written logbook reflections, and open-ended feedback).

Setting and Participants

The study was conducted at Jubilee Mission Medical College and Research Institute in collaboration with the Kerala Forest Research Institute, and participants consisted of MBBS students (eighth semester) who electively chose to enroll in the emergency medicine elective module.^7,8

Iterative Development of the SAFETi Course Across Batches

The SAFETi module was delivered to 3 independent batches of MBBS students, each representing a separate group based on academic scheduling. The term batch is used throughout to refer to these student cohorts. The course itself underwent iterative refinement based on participant feedback and faculty review—these course curricular changes are referred to as successive iterations of the module.

The study incorporated 3 curricular iterations, with modifications based on feedback and observations from preceding batches. The decision to conclude the study after 3 iterations was based on the stabilization of key learning outcomes, the convergence of qualitative feedback without new emerging themes, and practical feasibility in terms of resource allocation and course implementation.

Each batch participated only once, in a single version of the course; there was no crossover or progression between batches. Each batch thus corresponded to a specific iteration—Batch 1 received the first iteration, Batch 2 the second, and Batch 3 the final version. All eligible students who enrolled in the elective were included, and those who completed both before and after assessments were analyzed. The design of the first iteration was based on internal faculty discussions conducted prior to study initiation, drawing from collective experience to determine initial content and emphasis areas.

Batch 1 was taught within the medical college campus and focused primarily on the theoretical aspects of wilderness medicine, including snakebite first aid, environmental emergencies, and survival medicine. Students were given hands-on skills training in the campus setting. Their feedback indicated a strong preference for a more immersive, outdoor, and practical experience to reinforce learning.

Batch 2 received the second iteration of the course, which incorporated feedback from Batch 1. This curricular iteration introduced field-based training in a forest setting, integrating hands-on skill stations, scenario-based learning, and real-world applications of wilderness medicine. Although students valued the practical exposure, they expressed a need for a stronger theoretical foundation to support skills development.

Batch 3 combined interactive digital learning using gamification, structured theoretical instruction, and immersive outdoor training (Figure 1). Based on feedback from Batches 1 and 2, which indicated a need for stronger theoretical preparation before field-based sessions, a precourse digital learning component was introduced for Batch 3. In this version, the precourse learning component used a gamified online quiz platform (ie, Quizizz) that allowed students to complete a self-paced preparatory exercise composed of multiple-choice questions with detailed feedback for all options. These were not limited to a single-best-answer format; instead, explanations were provided for correct and incorrect responses, ensuring comprehensive content coverage. Students were allowed multiple attempts to reach a minimum accuracy threshold of 90% to pass the precourse, and incorrect answers prompted immediate feedback and opportunities to redo questions. Additionally, an abridged SAFETi textbook was provided in advance to facilitate structured prelearning. The field-based training incorporated first aid, environmental emergencies, and pre–hospital care scenarios, followed by a postcourse evaluation to assess knowledge retention, self-directed learning, and confidence in emergency care.

Data Collection

A combination of quantitative and qualitative methods was used to assess the effectiveness of the SAFETi module. For the quantitative component, data were collected using validated scales, including the Revised Dundee Ready Educational Environment Measure to assess perceptions of the learning environment using a 5-point Likert scale and the Self-Determination Theory Intrinsic Motivation Inventory to measure intrinsic motivation and self-directed learning using a 7-point Likert scale.

Additionally, structured feedback surveys were collected anonymously using Google Forms and in-person questionnaires. These surveys included Likert-scale ratings and open-ended questions evaluating student satisfaction, the perceived usefulness of the module, the effectiveness of gamified learning, and the overall training experience. A post-test multiple-choice questionnaire was administered after the module to measure knowledge, perceptions of the learning environment, and motivation. The post-test contained only 3 knowledge-based questions, designed under the assumption that students had no prior knowledge. For Batch 3 alone, a precourse assessment was conducted using a gamified quiz platform, allowing students to engage in self-paced learning while also serving as a baseline knowledge assessment.

For the qualitative component, focus group discussions were conducted at the end of each iteration to explore student experiences, engagement, and the challenges faced during the module. Discussions were audio recorded and transcribed verbatim for thematic analysis. Students also completed structured written logbook reflections documenting key insights in their clinical and simulation-based exposures, personal experiences related to procedural skills, communication and teamwork, critical thinking and decision making, and interdepartmental collaboration. The reflections also included motivational factors, self-directed learning habits, suggestions for improvement, and alignment with CBME objectives.⁹ Faculty members provided additional feedback on student performance as well as the strengths and weaknesses of the module.

Data Analysis

For quantitative analysis, pre- and post-test scores were compared using paired t tests for parametric data and Wilcoxon signed-rank tests for nonparametric data. Student performance in the precourse assessments was analyzed to determine engagement levels and the effectiveness of gamified learning. Mean scores with respect to teaching satisfaction and intrinsic motivation were compared across the 3 batches using the analysis-of-variance test or Kruskal-Wallis test as appropriate. Survey responses were summarized using descriptive statistics.

For qualitative analysis, transcripts from focus group discussions (FGDs), logbook reflections, and open-ended survey responses were subjected to inductive thematic analysis to identify recurring themes. The thematic coding system categorized findings into key domains, including clinical and simulation-based learning, interpersonal and teamwork skills, critical thinking and decision making, self-directed learning and career exploration, training effectiveness, CBME integration, scenario adaptability, and student confidence in emergency response roles. The combination of quantitative and qualitative findings provided a comprehensive assessment of the SAFETi module's impact on student learning and motivation.

Ethical Considerations

Ethical approval for the study was obtained from the institutional ethics committee (ref. no. 52/24/IEC/JMMC&RI). Participation was voluntary, and informed consent was obtained from all students before enrollment. Data were anonymized to ensure confidentiality.

Results

Participant Demographics

A total of 53 MBBS students participated in the SAFETi module over 3 curricular iterations in 3 batches (Figure 2). Quantitative data from 41 consenting individuals (77%) were analyzed, of whom 29 (70.7%) were female.

All eligible students from the eighth semester who opted for the elective were included, and batch assignment was determined by institutional scheduling. The course included 15 students in Batch 1, 15 in Batch 2, and 23 in Batch 3. Pre- and post-test assessments were completed by 14 of 15 students in Batch 1, 9 of 15 in Batch 2, and 18 of 23 in Batch 3.

Students’ Knowledge

Knowledge was assessed using a 3-question multiple-choice test (maximum score=3). Across the entire cohort (n=41) mean pretest score was 2.24±0.582, and the mean post-test score was 2.27±0.549 (P=0.800). Individual question analysis did not reveal statistically significant differences between pre- and post-test responses (Table 1).

Table 1.

Knowledge pre- and post test.^a

Batch	Pretest score, mean (SD)	Post-test score, mean (SD)	P value
Batch 1	2.07 (0.730)	2.21 (0.579)	0.435
Batch 2	2.44 (0.527)	2.22 (0.667)	0.447
Batch 3	2.28 (0.461)	2.33 (0.485)	0.579
Overall	2.24 (0.582)	2.27 (0.549)	0.800

All scores out of 3.

Although Batch 3 received a structured gamified precourse learning tool (Quizizz), post-test knowledge scores remained comparable across batches.

Students’ Confidence

Students’ belief that wilderness medicine should be part of the undergraduate medical education curriculum increased significantly (P<0.001). Confidence improved significantly in key domains, including scene size-up (2.66±0.99 to 4.22±0.53), first aid (2.66±0.99 to 4.22±0.53), identification of life-threatening emergencies (2.66±0.94 to 4.20±0.51), application of splints and bandages (3.20±1.01 to 4.54±0.55), and preparation of a first aid kit (2.39±1.07 to 4.29±0.72, all with P<0.001; Table 2).

Table 2.

Confidence and attitude assessment.^a

Batch 1 (n=14)			Batch 2 (n=9)			Batch 3 (n=18)			Overall
Pretest	Post-test	P value	Pretest	Post-test	P value	Pretest	Post-test	P value	Pretest	Post-test	P value
How strongly do you believe wilderness medicine should be part of routine undergraduate medical curriculum?
3.71 (0.914)	4.86 (0.363)	.001	4.44 (1.333)	4.78 (0.441)	.397	4.56 (0.616)	4.89 (0.323)	.029	4.24 (0.969)	4.85 (0.358)	<0.001
If my travel companion is injured in the wild, I will help them irrespective of what the scenario is.
3.79 (0.802)	3.57 (1.158)	0.630	4.22 (0.833)	4.11 (0.928)	0.729	4.22 (0.878)	3.89 (1.132)	0.138	4.07 (0.848)	3.83 (1.093)	0.193
How confident are you as emergency medical officer in performing scene size up and delivering first aid (performing initial assessment)
2.57 (1.016)	4.43 (0.514)	<0.001	2.33 (0.866)	4.00 (0.500)	0.002	2.89 (1.023)	4.17 (0.514)	<0.001	2.66 (0.990)	4.22 (0.525)	<0.001
How confident are you in identifying life-threatening emergencies?
2.79 (0.975)	4.43 (0.514)	<0.001	2.44 (1.014)	4.00 (0.707)	0.008	2.67 (0.907)	4.11 (0.323)	<0.001	2.66 (0.938)	4.20 (0.511)	<0.001
How confident are you in applying splints and bandages?
3.36 (0.842)	4.50 (0.65)	<0.001	3.11 (0.928)	4.33 (0.500)	0.002	3.11 (1.183)	4.67 (0.485)	<0.001	3.20 (1.005)	4.54 (0.552)	<0.001
How confident are you in preparing first aid/ medical kit pre-expedition?
2.57 (1.089)	4.50 (0.519)	<0.001	2.44 (0.882)	3.78 (0.972)	0.016	2.22 (1.166)	4.39 (0.608)	<0.001	2.39 (1.070)	4.29 (0.716)	<0.001
How challenging did you expect the module and how challenging did you find it?
4.21 (0.893)	3.93 (0.917)	0.218	4.22 (1.093)	4.22 (0.667)	1.0000	3.89 (0.832)	3.22 (1.114)	0.035	4.07 (0.905)	3.68 (1.035)	0.025
To what extent do you believe this module will help you achieve your learning objectives?
4.00 (0.679)	4.38 (0.65)	0.104	4.33 (1.118)	4.44 (1.014)	0.729	4.67 (0.485)	4.78 (0.428)	0.163	4.37 (0.767)	4.58 (0.675)	0.070
Do you feel confident in the extrication of these individuals?
—	—	—	2.78 (0.972)	4.56 (1.333)	0.028	2.22 (1.114)	5.00 (0.000)	<.0001	2.41 (1.083)	4.85 (0.77)	<0.001

All scores out of 5.

Confidence in extrication of individuals increased significantly (2.41±1.08 to 4.85±0.77; P<0.001) among Batches 2 and 3. Confidence in wilderness medicine as part of the undergraduate curriculum increased in Batch 1 (3.71±0.91 to 4.86±0.36; P=0.004) and Batch 3 (4.56±0.62 to 4.89±0.32; P=0.029), with no significant change in Batch 2 (4.44±1.33 to 4.78±0.44; P=0.397).

Student Perceptions

On a 5-point scale, instructor enthusiasm was rated 4.90±0.37, clarity of presentation 4.83±0.44, encouragement of active learning 4.83±0.54, peer learning 4.78±0.52, and real-world applicability 4.73±0.55. The overall Revised Dundee Ready Educational Environment Measure score on a 5-point scale was 4.8±0.4. No difference in teaching perceptions across batches was noted (P>0.005). Satisfaction with real-world applicability was highest in Batch 3 (4.9±0.4; Table 3). Perceived difficulty of the module decreased after training in Batch 3 (P=0.035), whereas no significant change was observed in Batches 1 and 2. (Table 2).

Table 3.

Teaching method evaluation.

Statement	Batch 1 (n=14)	Batch 2 (n=9)	Batch 3 (n=18)	P value	Mean score (SD)
Teachers in this module were enthusiastic about the subject they taught.	4.86 (0.363)	4.78 (0.667)	5.00 (0.000)	0.305	4.90 (0.37)
The material was presented in a clear and concise way.	4.79 (0.426)	4.78 (0.667)	4.89 (0.323)	0.755	4.83 (0.44)
The teaching methods used in this module encouraged me to participate actively in learning.	4.79 (0.426)	4.67 (1.000)	4.94 (0.236)	0.437	4.83 (0.54)
The elective modules provided opportunities for me to learn from my peers.	4.79 (0.426)	4.78 (0.667)	4.78 (0.548)	0.999	4.78 (0.52)
The modules provided opportunities for me to apply what I learned to real-world situations.	4.79 (0.426)	4.78 (0.667)	4.67 (0.594)	0.806	4.73 (0.55)
Total score (DREEM)	4.800 (0.3595)	4.756 (0.7333)	4.856 (0.2255)	0.837	4.815 (0.4157)

DREEM, Dundee Ready Educational Environment Measure.

^a All scores out of 5.

Intrinsic Motivation and Engagement

On a 7-point scale, students rated module topics as interesting and enjoyable (6.80±0.56), personally important (6.54±1.14), and relevant to their future careers (6.76±0.54; Table 4). A total of 87.8% of students reported that the module difficulty matched their expectations. Interest in module topics was highest in Batch 3 (6.89±0.323), followed by Batch 1 (6.77±0.439) and Batch 2 (6.67±1.000). All batches were equally motivated, with no significant difference found in curiosity to learn beyond course requirements (P=0.649) or career relevance (P=0.941).

Table 4.

Intrinsic motivation.

Statement	Batch 1 (n=14)	Batch 2 (n=9)	Batch 3 (n=18)	P value	Mean score (SD)
I found the topics covered in the module to be interesting and enjoyable.	6.77 (0.439)	6.67 (1.000)	6.89 (0.323)	.622	6.80 (0.56)
Learning the material covered in the module feels important to me personally.	6.71 (0.611)	6.33 (2.000)	6.50 (0.924)	.735	6.54 (1.14)
I feel a sense of accomplishment when I successfully learn something new in the module.	6.79 (0.426)	6.44 (1.667)	6.78 (0.548)	.604	6.71 (0.87)
I am curious to learn more about the topics covered in the modules even beyond the requirements of the course.	6.71 (0.469)	6.44 (0.882)	6.61 (0.698)	.649	6.61 (0.67)
I believe that learning the material covered in the modules will be helpful for my future career.	6.71 (0.469)	6.78 (0.667)	6.78 (0.548)	.941	6.76 (0.54)

^a All scores out of 7.

Students in Batch 1 reported the highest confidence in applying knowledge and skills to real-world emergency medicine scenarios (4.38±0.506), followed by Batch 3 (4.22±0.428) and Batch 2 (3.78±1.093), with no significant difference across batches (P=0.106). Satisfaction scores were consistently high across groups, with Batch 3 reporting the highest satisfaction (4.78±0.428), followed by Batch 1 (4.62±0.506) and Batch 2 (4.56±1.333), with no significant difference (P=0.721).

Effectiveness of Precourse Learning

The precourse quiz was administered exclusively to Batch 3 as a structured learning tool. A total of 23 students participated, completing 31 attempts, with an overall class accuracy of 92%. Students demonstrated high engagement, with immediate feedback and reattempts improving accuracy across key topics.

Thematic Analysis: Key Themes from FGDs

The FGDs provided deep insights into how students perceived the module, with the following key themes emerging. The detailed themes and subthemes including the transcript are available as online Supplementary Files 1–4.

Clinical and Simulation-Based Learning

Students reported acquiring essential first aid and wilderness-specific skills through structured skill stations and real-world simulations. Many entered the module with minimal exposure to practical techniques such as splinting and patient transport but gained confidence in applying them under simulated field conditions. Several students reflected on how simulation-based exercises helped translate theoretical knowledge into action during scenario-based drills. Advanced tasks—such as cardiopulmonary resuscitation in rugged terrain and prioritizing patients for triage—challenged learners to adapt to real-world constraints. Ethical dilemmas also emerged, including difficult decisions about resource allocation and continuing resuscitation efforts, prompting reflection on the realities of field-based emergency care. One student reflected: “If we don’t get ROSC [return of spontaneous circulation], should I stay with her, or should I leave her and go to the next victim?” (Transcript 2).

Confidence and Role Perception

Students described a significant boost in their confidence to act during emergencies and recognized the importance of clearly defined roles during rescue scenarios. Active participation, rather than passive observation, was perceived as critical to building this confidence. The module not only improved technical competencies but also reshaped students’ perceptions of their capabilities and professional responsibilities, preparing them to take on more proactive roles in prehospital and disaster settings. One student reflected: “Now I know doctors also have a role to play in this . . . [not just first responders]” (Transcript 5).

Interpersonal and Teamwork Skills

The SAFETi module enhanced students’ abilities to function collaboratively in high-stress scenarios, reinforcing role clarity, coordination, and communication. Participants learned to assign and adapt roles dynamically, manage team logistics, and respond to unpredictable external factors—such as uncooperative bystanders or environmental distractions. The simulation context helped highlight the importance of structured teamwork, communication loops, and scene control. A faculty member reflected: “When you’re standing there, you survey the scene from the top . . . then you come and report . . . [and] reallot personnel accordingly” (Transcript S).

Critical Thinking and Decision Making

The SAFETi module challenged students to adapt theoretical knowledge to unpredictable field conditions, fostering real-time decision making and situational awareness. Participants grappled with ethical dilemmas, terrain-specific challenges, and resource limitations, which sharpened their problem-solving skills and prompted deeper self-reflection on their preparedness. One student reflected: “Even though we prepared for one scenario, when we went there . . . the scenario was different” (Transcript 8).

Self-Directed Learning and Career Exploration

Exposure to wilderness medicine sparked student curiosity and expanded their understanding of the physician's role beyond the hospital. The module encouraged self-directed learning and inspired interest in research, interagency collaboration, and career opportunities in emergency settings. Several students reflected on the novelty of the experience and advocated for broader inclusion of such training in the curriculum. Their comments indicated that the SAFETi module not only enhanced practical emergency skills but also cultivated a proactive, reflective learning mindset. One student reflected: “At least now I have an introduction that there's something like this. And I can learn more about this in the future” (Transcript 5).

Strengths and Weaknesses Identified

Students responded positively to the immersive and hands-on nature of the SAFETi module, appreciating how real-world scenarios deepened their learning beyond theoretical instruction. However, they also highlighted limitations such as uneven role distribution, limited time for environmental adjustment, and a desire for all teams to participate equally in rescue simulations. These reflections offer valuable direction for improving the module's structure and delivery. One student reflected: “We saw a lot of things we couldn’t anticipate with just the theory” (Transcript 15).

CBME Integration

The SAFETi module reflected key principles of CBME by emphasizing practical skills, interdisciplinary learning, and self-directed development. Students highlighted a gap between conventional theory-based postings and the applied nature of this module. Many felt better prepared for emergency roles and strongly advocated for integrating wilderness medicine into the formal curriculum. One student reflected: “More than elective, it [wilderness medicine] should be part of the curriculum. . . . These things can happen to anyone any time” (Transcript 11).

Content Analysis of Transcripts of Written Feedback

A content analysis of the written feedback from the hybrid wilderness medicine module was coded using 8 key themes developed inductively from the focus group findings; no additional codes emerged. Detailed coding and additional quotes are available in online Supplementary Files 5 and 6.

Students consistently valued the hands-on learning and realistic simulations that bridged theory and practice. One candidate noted, “Techniques like splinting, hemorrhage control, and wound management became much more clear when practiced on a person” (Transcript 12), whereas another highlighted the engaging nature of simulation training that tested their teamwork (Transcript 1) and provided a vivid, eye-opening perspective on managing critical situations (Transcript 8).

Communication and role clarity were recurring themes. One respondent remarked on the “need for proper role assigning” to avoid miscommunication (Transcript 2), and another noted that faculty mentorship significantly enhanced learning: “I could actually see that good mentors make a big difference” (Transcript 6).

Students also described how the module fostered critical thinking and rapid problem solving, as evidenced by reflections on the necessity of improvising with limited resources in nonhospital settings (Transcripts 3 and 6). Moreover, the module sparked curiosity and motivated further self-directed learning and career exploration (Transcript 1), whereas another student mentioned that they began reading more about wilderness medicine (Transcript 5). Suggestions for improvement included offering all teams equal opportunity in simulations and extending the module duration to allow more time for skills consolidation (Transcript 20).

There was strong support for curricula integration, with students noting the module's contribution in enhancing competencies and real-world decision making (Transcripts 11 and 16). The module also encouraged critical thinking and improvisation, especially in managing unpredictable scenarios with limited resources (Transcript 8).

Finally, the module significantly boosted self-confidence and reshaped professional identity, with students reporting increased confidence in handling emergencies and a renewed understanding that “doctors also have a role to play in this” (Transcripts 5, 11, and 16).

Iteration Outcomes

Confidence improvements in core competencies such as scene size-up, first aid application, and patient extrication were consistently observed in Batches 1 and 2. However, no substantial additional gains were noted in Batch 3, suggesting a plateau in measurable outcomes across successive cohorts. Qualitative analysis of FGDs and reflections revealed no emergence of novel themes after the third iteration, indicating conceptual saturation. Each batch of students participated in a single version of the course, with the curriculum revised iteratively between batches. This study was concluded after the third iteration due to stabilization of key outcomes and practical feasibility. The qualitative analysis of Batch 3’s FGD highlighted areas for further improvement, suggesting potential avenues for future curriculum enhancements beyond the scope of this study.

Discussion

The SAFETi module significantly improved student confidence, teamwork, and emergency response skills, with marked gains in scene size-up, first aid, patient transport, and extrication. Confidence scores improved across all skill domains, and students highly rated the module for hands-on learning, real-world relevance, and applicability to prehospital care, disaster response, and remote medicine. In Batch 3, precourse interactive learning reinforced key concepts with 92% accuracy, whereas training aligned with CBME objectives.⁷ By integrating wilderness medicine into MBBS training, students develop critical thinking, adaptability, and problem-solving skills essential for austere and resource-limited settings.

Global Perspective

Given India's geographic diversity, frequent natural disasters, and healthcare access disparities, prehospital emergency preparedness is a crucial competency. Wilderness medicine could help bridge that gap and prepare students for real-world medical challenges. Many developed nations have recognized wilderness medicine as an essential component of undergraduate and postgraduate medical education worldwide.

In the United States and Canada, wilderness medicine has been integrated into medical school curricula through medical school electives, structured simulation-based programs, and postgraduate fellowships.^10-13 In the United Kingdom, student-led initiatives have proposed low-cost, immersive weekend courses as a potential solution to the lack of centralized national wilderness medicine teaching. These courses emphasize scenario-based instruction and real-time patient management.¹⁴ In response to growing interest in wilderness medicine among medical trainees, the Wilderness Medical Society published consensus guidelines outlining core curriculum recommendations for wilderness medicine electives.¹¹ These include domains such as survival skills, patient evacuation, environmental injuries, improvisation, and field-based leadership, aligned with core competencies in medical education. Among our students, only 1 had heard of wilderness medicine prior to the elective. India lacks formal integration of emergency medicine into undergraduate medical education, let alone wilderness medicine. The SAFETi module addresses this critical gap by providing a locally adapted, resource-conscious, and simulation-rich course designed specifically for undergraduate MBBS students. Unlike many international programs that are typically offered as standalone certifications or electives and often delivered outside formal curricula, SAFETi is embedded within undergraduate training, tailored to resource-limited settings, and developed iteratively based on learner feedback. It introduces wilderness and prehospital skills early in training, an approach that may help cultivate both relevance and retention.

This study demonstrates strong student interest and feasibility for curriculum inclusion, reinforcing the need to plan for structured wilderness medicine education in emergency medicine training programs in the future.

Impact on Knowledge, Confidence, and Student Engagement

The SAFETi wilderness medicine module significantly enhanced student confidence and practical skill acquisition, aligning with global trends in experiential learning for medical education.^15-18 Confidence levels improved across all key skills, reinforcing the role of simulation-based training in bridging theoretical knowledge with real-world emergency response, as demonstrated previously.¹⁴ Notably, Batch 3, which received a precourse interactive learning intervention, demonstrated the highest confidence gains, supporting the effectiveness of structured prelearning strategies. Interestingly, Batch 1, which underwent only indoor training, reported the highest confidence in self-assessed real-world application of skills, suggesting that self-reported confidence may not always align with actual field readiness. In contrast, Batch 2, which participated in an outdoor event, demonstrated lower confidence levels, likely due to direct exposure to real-world challenges that highlighted the complexities of emergency response. Batch 2 also exhibited a slight decrease in post-test scores, which may be attributed to increased cognitive and logistical demands, absence of structured precourse reinforcement (introduced later in Batch 3 based on their feedback), and recalibration of self-perceived knowledge following immersive learning. Given the small sample size (n=9), this trend is best interpreted as nonsignificant and exploratory. Batch 3, incorporating both precourse theoretical materials and practical exposure, showed improved postcourse confidence in real-life skill application, indicating that the hybrid model combining structured preparatory materials with outdoor training may be the most effective approach in the short duration available. Interestingly, confidence in responding to a travel companion's injury showed a slight decline across batches, which we believe reflects an increased emphasis on rescuer safety taught during the module. This was particularly evident in students who underwent simulation-based training, where hands-on exposure likely reinforced the complexities of real-world scenarios and encouraged more cautious self-assessment.

Student satisfaction was high, with the module rated highly for engagement, relevance, and hands-on training effectiveness. These findings are consistent with findings from other simulation-based wilderness training programs elsewhere that have emphasized active learning and trainer preparation^19,20 Although most students were encountering wilderness medicine for the first time, intrinsic motivation remained consistently strong across batches, suggesting its intrinsic appeal and practical relevance.²¹ Although little change was observed in knowledge scores, confidence and practical skills improved—likely reflecting the benefits of simulation-based learning, which enhances decision making and self-efficacy even when factual recall is unchanged.²² The lack of significant improvement in knowledge scores also may reflect the limited sensitivity of the brief 3-item post-test, which was designed under the assumption that students had no prior exposure to wilderness medicine.

The One Health Framework

Beyond skill building, the SAFETi module also introduced students to broader public health perspectives. Notably, wilderness medicine aligns with the One Health framework, which emphasizes the interconnection between human, animal, and environmental health. With increasing climate-related health emergencies, zoonotic disease outbreaks, and challenges in healthcare delivery to remote regions, such training is gaining global importance.^23-25 The integration of prehospital and austere environment training into undergraduate medical education is supported by international recommendations for competency-based wilderness medicine curricula.²⁶ The SAFETi module provided valuable exposure to zoonotic diseases, envenomations, and climate-related health emergencies, further reinforcing its applicability beyond traditional hospital-based medical training.

Early exposure at the undergraduate medical education level provides a malleable stage for students, allowing them to develop competency in prehospital care, improve adaptability, and enhance preparedness for real-world emergency scenarios.²⁷ By integrating wilderness medicine into the undergraduate medical education curriculum, future physicians may be better equipped to handle medical crises in both urban and remote settings, reinforcing the importance of emergency care training despite its removal from the CBME curriculum.

Limitations and Future Directions

The knowledge-assessment questionnaire was originally designed for Batch 1, where students had no prior exposure to wilderness medicine. It contained only 3 questions, which may not have adequately captured knowledge improvement in Batch 3, which had access to a precourse gamified reinforcement and assessment. Batch 3 demonstrated significantly higher post-test confidence in scene size-up (P=0.001), emergency response roles (P=0.001), and extrication (P<0.001) compared with Batches 1 and 2. However, knowledge scores remained comparable across all batches (P>0.05), suggesting that although interactive learning improved confidence, the post-test was not sensitive enough to detect knowledge gains. If a standardized or more comprehensive questionnaire had been used across all groups, or if Batch 3 had been assessed with the same precourse quiz questions in the post-test, differences in knowledge acquisition may have been more apparent.

This study was conducted within the constraints of fixed batch sizes and voluntary participation, which precluded a formal a priori sample size calculation. Although post-hoc analysis confirmed adequate power for within-group pre-post evaluation, the study was underpowered for formal interbatch comparisons. Trends across iterations should be interpreted as exploratory rather than inferential.

The number of iterations conducted in this study was data driven rather than predetermined, leading to potential variability in instructional modifications across batches. Although iterative refinement allowed for progressive improvements based on student feedback, the absence of a predefined stopping criterion limits standardization and comparability of findings across groups. Future studies should establish a predefined iteration framework, such as a threshold for knowledge gains or qualitative theme saturation, to ensure controlled modifications and consistency in data collection.

Although this study demonstrated the effectiveness of the SAFETi module, future iterations may benefit from refinements based on student feedback. Key recommendations included extending the module duration, structuring role assignments to enhance team coordination, and incorporating faculty-led presession demonstrations to improve technical precision and reinforce decision making in field conditions. Implementing these refinements in future studies could further optimize skill acquisition, confidence, and the real-world applicability of wilderness medicine training.

This study serves as a methodologic model by demonstrating a clear, replicable approach to evaluating educational interventions. It uses a sequential explanatory mixed-methods design, integrating quantitative assessments (ie, pre- and post-tests, surveys, and validated scales) with qualitative insights (ie, FGDs and content analysis). Iterative modifications based on feedback illustrate continuous refinement, and detailed documentation of participant selection, data collection, coding, and analysis offers a blueprint adaptable to similar training programs, especially in resource-limited settings.

Conclusion

The SAFETi module improved student confidence, practical skills, and engagement in wilderness medicine. Participants demonstrated gains in scene size-up, first aid application, extrication, and teamwork, highlighting the gap between theoretical knowledge and real-world emergency response. Interestingly, the highest self-assessed confidence was seen in students who underwent only indoor training, whereas those exposed to outdoor, real-world simulations reported lower confidence—suggesting that field-based experience may recalibrate perceived readiness by exposing students to greater complexity. This highlights the importance of combining both instructional modes. High satisfaction and strong intrinsic motivation suggest the relevance of structured wilderness medicine training in medical education. Future studies should focus on standardizing assessment methods, evaluating long-term skill retention, and exploring curriculum integration to maximize training effectiveness.

Supplemental Material

sj-docx-1-wem-10.1177_10806032251368236 - Supplemental material for Exploring the Role of Wilderness Medicine in Undergraduate Medical Education in India: Impact on Student Motivation and Self-Directed Learning

Supplemental material, sj-docx-1-wem-10.1177_10806032251368236 for Exploring the Role of Wilderness Medicine in Undergraduate Medical Education in India: Impact on Student Motivation and Self-Directed Learning by Siju V. Abraham, Aravind Sreekumar, Appu Suseel, Deo Mathew, Punchalil Chathappan Rajeev, Collin Raju George, Sonali Sunil Chammanam, Vijay Chanchal Attuvalappil Bharathan, Amayoor Variyam Raghu, Jyothi Antony, Arin Eliza Sunny and Cheru Kandiyil Kassyap in Wilderness & Environmental Medicine

Footnotes

Acknowledgments

The authors express their gratitude to Babu Urumese Palatty, head of the department of Emergency Medicine and Paul Chalissery, assistant director-medical education, at Jubilee Mission Medical College and Research Institute, for their invaluable support in overseeing and facilitating the conduct of the study. Special thanks to Unnikrishnan U.G. for his assistance in developing the statistical analysis plan. The successful execution of the course field work would not have been possible without the dedicated efforts of Cyril Santhosh, Edwin Tom, and Dyanchand P.S., who played a crucial role in the physical conduct of the training. Their collective contributions have been instrumental in the completion of this study.

Author Contribution(s)

Siju V. Abraham: Conceptualization; Methodology; Project administration; Investigation; Resources; Writing – original draft; Writing – review & editing; Data visualization; Supervision; Funding acquisition.

Aravind Sreekumar: Data curation; Formal analysis; Methodology; Validation; Writing – review & editing.

Appu Suseel: Conceptualization; Methodology; Project administration; Writing – review & editing.

Deo Mathew: Investigation; Methodology; Project administration; Writing – review & editing.

Punchalil Chathappan Rajeev: Project administration; Resources; Supervision; Writing – review & editing.

Collin Raju George: Project administration; Visualization; Writing – review & editing.

Sonali Sunil Chammanam: Project administration; Writing – review & editing.

Vijay Chanchal Attuvalappil Bharathan: Project administration; Writing – review & editing.

Amayoor Variyam Raghu: Project administration; Resources.

Jyothi Antony: Project administration; Writing – review & editing.

Arin Eliza Sunny: Project administration.

Cheru Kandiyil Kassyap: Conceptualization; Project administration; Resources.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The study was funded in part by an Indian Council for Medical Research extramural grant for clinical training of healthcare workers (No. 3/1/3/Clinical training/HRD/ 2023).

Ethical Considerations

The study was approved by the institute's ethics committee (Ref. 108/24/IEC/JMMC&RI). All participants provided informed consent for their results to be recorded and used for research purposes. Demographic or personal data collected from individuals who declined to participate in the study were not used, in adherence with ethical research practices.

Role of the Funding Source

The funding sources had no role in the study design, data collection, analysis, interpretation of the data, writing of the manuscript, or the decision to submit it for publication.

ORCID iDs

Siju V. Abraham

Aravind Sreekumar

Appu Suseel

Deo Mathew

Punchalil Chathappan Rajeev

Collin Raju George

Sonali Sunil Chammanam

Vijay Chanchal Attuvalappil Bharathan

Amayoor Variyam Raghu

Jyothi Antony

Arin Eliza Sunny

Cheru Kandiyil Kassyap

Supplemental Material

Supplementary material associated with this article can be found in the online version at

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Supplementary Material

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