4.1 Narratives of the nurturing stage
In the first stage, medical students scrupulously chose their topics and waited for others’ learning experience, therefore, lots of them were “lurkers” or “observers”. As the topics gradually expanded, they found anonymity was comfortable and were willing to share knowledge to help the confused. The salient features are that the mentor played a critical role in guiding and mediating the dialogues, and there were more lurkers than active members. The following three excerpts illustrate how the students tried to solve difficulties together to build hidden and unrecorded knowledge, and how they built relationships with other group members.
Excerpt 1
Student ID07: Back in my childhood, doing experiments was my lifelong dream but every time I lifted the rabbit out of the cage and injected it with anesthetic, it struggled so violently that the seeds of fear grew rapidly. Every scream and struggle made me feel extremely uncomfortable. I realized my dream was not cool but cruel. Though I’m not a freshman any more, it still makes me under pressure. (2020-11-08)
Dan: We’ll find its significance later probably because we can’t experiment on human in such cases.
Student ID14: Maybe you can find peace in your heart as long as you use the expertise to help more people when you become a real doctor.
Student ID38: It has much in common with Biology that we’ve learned in the senior high school. It can remind you of your past school life. You’ll have a growing interest.
Student ID07 faced a huge conflict between his childhood dream of becoming a doctor and his inability to accept the loss of life. He tried to resolve this contradiction, seeking a way to gain courage and restoring confidence in doing experiments. After the mentor’s comment, some offered their tried solutions while one student expressed similar confusion. He agreed with Student ID38 and decided to give it a try. It is noteworthy that later he admitted he spoke more in the group than before, as if he wanted to return the kindness of others.
Excerpt 2
Student ID13: To study medicine requires memorizing many complex conceptions and elusive knowledge. It fits all my stereotypes. But it wasn’t long before I realized that it was just my prejudice. (2021-03-29)
Dan: How have your views changed?
Student ID13: I took part in a research project, working with other medical majors.
Dan: What impressed you most?
Student ID13: I just didn’t expect to work with people who were not majors of clinical medicine. It’s challenging.
Dan: Does anybody have similar experience? Working with other majors?
Student ID26: You can always believe in teamwork. The psychological drama “Blue Balloon” was performed by us from different majors. We’ve insisted on communication and made so many compromises.
Student ID05: Attending elective courses is a good choice. There were lots of different majors in the same class. I met some talented people who shared similar interests with me. I hope someday I’ll work with them.
Student ID13 had a sense of belonging to his major and trusted his classmates, but had less experience with teamwork. He was confused about what kind of relationship to have with his teammates of other majors, such as partnership, competition, or a remain-unchanged relationship. Under Dan’s guidance, he made his difficulties explicit, got advice from the community and figured out how to balance the relationships later.
Excerpt 3
Student ID28: I just don’t understand why you work so hard. Passing all examinations and getting credits are my goals. Perhaps I am not as capable as you. (2021-06-07)
Dan: If you want to be a good doctor, you need to be wary of such feeling.
Student ID28: Why༟
Dan: Lack of confidence is a stumbling block to becoming a doctor. Also, just getting a diploma is a betrayal of what you were meant to be. You still have a dream, don’t you?
Student ID28: Yes, it’s true. Perhaps I know why I often come here to read the messages. Some of you are really excellent. I am just an ugly duckling.
Student ID49: Doctors are senior intellectuals who are the smartest. You are a future doctor. How can you be an ugly duckling? You are a swan.
In this excerpt, Student ID28 seemed to show fatigue with his studies. The knowledge and experience shared by the members made him feel inadequate and doubtful about his approaches and goals of studying medicine. But he found that the community was an anonymous place, so he boldly “complained” about the efforts and hardships of medical students. Dan’s constant listening and timely response allowed the participants to express themselves openly while Dan gave instructions and encouragement along the path of their growth.
It is worth noting that the metaphor of “ugly duckling” was mentioned by another member later in the interviews but appeared in a new appearance. As Student ID57 put it:
I read the messages every day, and I find that some of what I read is what I am experiencing, and I’ve applied it to my actual study. But I rarely post ... and only contribute when I need to ask a question. For now, I’m still an ugly duckling, waiting for growth. (2021-06-29)
Such members learned by “lurking” at first. As Whittaker et. Al (1998) asserted, lurking allows members to participate in community activities legally, and there exists “transition mechanism” for members to learn about new knowledge or social milieu. In this case, such lurkers indirectly experienced being a future doctor, gaining the group identity.
Thus it can be seen that the knowledge-sharing community of medical students has the originating events (Craig, 2007) of drawing future doctors together in one group to perceive reciprocity and similarity with other community members. When the students feel their problems were respected and responded to, they were more willing to participate in community activities, trying to be a seeker or a giver of information (Shelly & Chen, 2017). Under the circumstances, the knowledge-sharing community provides them with guidance and self-growth through a more attractive channel – anonymous and invisible – which allows individuals gradually gains adaptation and identification of being a doctor, finally being conducive to self-affirmation after dialogues and negotiations.
4.2 Narratives of the active stage
In July 2021, there was a noticeable increase in the number of dialogues as the students moved to hospitals and officially entered internship programs. The heated discussions centered around new surroundings and interns’ experience, lasting about five months until internship assessments and back-to-school arrangements had been put on the agenda from May to June 2022. In June 2022, the interns returned to campus for the graduation ceremony and gathered for three days, with all the community members attending two consecutive days of discussion.
Through the quantitative analysis of chat records and discussions, the following conclusions can be drawn: (1) 79% of the participants were active in the online dialogues while 12% of them admitted they were lurkers but constantly on the lookout for messages. (2) As shown in Fig. 1, the number of chat records in this stage were significantly more than those in the other two stages. The record number reached 788 and 706, being the two highest points in the two-year establishment of the community; (3) In the two offline meetings, 7 participants who claimed they were lurkers, were active because their speaking time accounted for about 18% of the total meeting time (8 hours). In terms of the average speaking time of all members, they spoke 29 minutes longer than expected.
The above analysis helps us summarize the factors contributing to an active online community: (1) Participants come together as a community to identify learning goals in the social networking environment, such as accumulating new knowledge during the transition from medical students to interns. (2) They connect with others by using habitual tools and by agreeing to complete certain tasks, such as sharing observation from workplace learning (788 pieces of chat records), or organization of activities for the return to school (704 pieces of chat records), which initiates the cognitive process of social mediation (Gunawardena et al., 2009). (3) Online community is not equivalent to online instruction, for it needs the stimulus of face-to-face interaction to augment communication to continue their learning (Gray & Tobin, 2010).
The field texts show that one obvious catalyst for the community’s development is the emergence of memories reconstruction (Kerby, 1991). Memory is not an exact copy of the original experience, but a way of how to perceive acquired knowledge from working and learning experience. Events of study and work remain in memory and are open to interpretation over time, not just a single correct version. Through knowledge sharing, participants construct and reconstruct, at the level of both individual reflection and group resonance, to reunderstand the past and establish other possibilities for the future. In this process, memories are fused with collective communication in the virtual space. It’s obvious in the following dialogues among the members.
Excerpt 4
Student ID26: In the orthopaedic operating room, the nurse and I covered the patient with the quilt, fixed the patient and helped to make preoperative preparation. The nurse said the temperature of the operating room was low, so do not let the patient catch cold before operation. I immediately thought of the sterile sheets for use in the room. At first, I thought all of these were just to keep the surgical requirements aseptic and protect patients and doctors. Now I realized I had been neglecting the patient’s feeling. (2021-10-27)
Student ID52: I am so envious that you have such deep thinking.
Student ID31: This is what we learned about “humanistic care”.
Student ID26: I believe we can find opportunities for deep thinking in daily work.
Dan: This warm doctor-patient relationship is one of the concerns of general practice.
Student ID02: Sure. One impressive detail in my workplace learning was that my teacher always warmed the stethoscope before using it.
Student ID06: Really? It’s a lot better than doctors showing their compassion for the patients. Sometimes so-called “caring” turns out to be a strange kind of compassion.
In above field texts, Student ID26 didn’t present his recollection of the operating room experience as a paraphrase of general knowledge, but rather as a point of inquiry to retell what he had learned. Other participants tried to reconstruct more or less coherent stories about the event, recalling knowledge about humanistic care and the medical behavior of the internship mentor. This coherence may depend more on the reflective things that community members add to the memories than on the basic materials of the memories themselves. As Freeman (2009) explained, they placed past experiences in relation to everything that had happened ever since, understanding and reunderstanding from the perspective of the present with the benefit of “hindsight”. Such memories reconstruction triggered medical students’ views on the doctor-patient perspective, as well as their reflections on the empathy and compassion of doctors.
Apparently, another catalyst is the multi-layered interactions which may bring reflection on experience. Participants shared medical knowledge as a way of introspection and discussed it with the mentor and peers as part of the “becoming a doctor” process. Multi-layered interactions are often fraught with uncertainty, complexity and tension, which evoke group resonance. Here’s another trigger story:
Student ID21: When inserting a gastric tube into an old man who had received percutaneous gallbladder drainage, my teacher paused and comforted him several times. I did not think too much at that moment. But later when I was having my dinner, I suddenly had a feeling: in the face of disease and pain, the doctor should be the patron saint of patients. Patient’s feelings should also be taken into account. (2021-12-13)
Although this excerpt took place at a different time, it is highly likely that Student ID21 was influenced by the previous multi-layered interactions, which enabled this intern to not only recall his observation on the medical behavior of his teacher, but also reinterpret the responsibilities of doctors by hindsight. He even used the metaphor of the “patron saint” to interpret the image of doctors, reflecting his anticipation for the future. The online resonance between the members occurs when a variety of experiences meet medical knowledge in a particular context.
Therefore, we believe that community members maintain a relational space (Clandinin, 2015) – a space with a reciprocal and caring attitude. This space is given by the active virtual community which is open and safe. It brings with itself responsibilities in which it is important for medical students to pay attention to peers’ internship stories, to be present in the telling of their experiences, and to respond to or empathize with what they share with hindsight. If participants only put themselves in the position of solving problems and try to wait for others’ sharing, the active online space will decay prematurely. In short, multi-layered interactions and memories reconstruction are equally important for the maintenance of the active stage.
4.3 Narratives of the sustainable stage
From July to October in 2022, participation has decreased gradually, as the focus of chats shifted to the unified recruitment exams from assigned hospitals, with occasional discussions on preparation for future career development or small talks to maintain relationships. At this stage, all the participants were interviewed and confirmed with the researcher the accuracy of the original field texts. The interview used semi-open questions, including their future plans and feelings.
When our participants described current work and life, their feelings most closely resembled those of Erickson’s “generativity” (Erikson, 1959) in this life stage, where students gradually identified the people and things they wanted to devote their passion and energy to, and were prepared to invest in them continuously, forming a professional identity from interns to doctors. These include establishing a sense of belonging through communities, actively acquiring more information to help clinical decision-making, reflecting on learning experience, and improving consultation techniques from patients’ perspective. The following excerpt illustrates the specific manifestation of “generativity” through a medical student’s experience of trying to change roles.
Student ID07: Now I’m in a couple of online work groups that keep me informed, but I miss when our group was lively. In those days I was afraid of doing animal experiments, but some of them recommended relevant books, some gave advice, and some even shared videos. They’re not talking now. I miss them. During my internship, I got into the habit of reading the messages to see what they were doing. Whether I am suitable to be a doctor is not the most important question for me. To be a good doctor is what I really want. (2022-08-18)
It can be seen that integrating into the identity of a doctor is carried out through a series of participation. The online community provides a broader platform and help for Student ID07, which also applies to other members. Students draw on the experience of others, resort to observation, and then gradually identify with their own profession as they engage in supported practice. But how often and how they use online communities depend on long-term patterns of interaction between this e-group and individuals, and are influenced by many factors that extend well into the future. These include the pressure to further study, assessment of professional fundamentals and clinical competence, community dynamics, the mentor’s enthusiasm and responsibility, and whether each individual is respected. These were rarely revealed publicly, but found in students’ reflection journals:
Student ID34: Anonymity helps me to reduce pressure, so I’ve learned to communicate with Dan, but you know, I usually do not initiate any contact with teachers. Plus, it’s interesting that everyone in the group has their own learning perspectives and experiences. I got more or less a response from them. It’s important to me. Now I’m in an online group including my old classmates and a few new colleagues. I’ll try to communicate with them in a similar fashion. (2022-09-16)
Use of terms such as “getting a response” or “communicate” suggest that the students were often pretty sure that what they want from an online knowledge-sharing community is the accumulation of knowledge conducive to career growth. Students can be seen as active learners in such a non-competitive environment. The need for professional progress will facilitate the integration of the spirit of online knowledge-sharing communities into the career of new doctors, thus helping them to improve clinical thinking ability and learning initiative. The interview data revealed that after becoming newly qualified doctors, all of the participants took the initiative to search knowledge-sharing communities to discuss clinical practice issues; 62% recruited trusted people and became the founders of knowledge-sharing communities; 59% said that knowledge-sharing communities would become one of their research topics; 76% considered improving their professional level so as to become future mentors.
Through above ways of spreading knowledge-sharing communities, the online community had been divided into multiple subgroups after medical students officially worked and integrated into the social atmosphere of hospitals. According to Albion and Weaver’s concept of online communities (Albion & Weaver, 2006), when a class is broken into smaller groups to form subgroups, the size and makeup of these subgroups have a marked impact on group dynamics. The ties between members weakened. Therefore, the current community was reduced too far and its activity actually became too low to maintain the momentum, which led to the gradual disappearance of motivation, so it entered the phase of dissolution. The researcher believe that dissolution of the community precedes its spread because medical students seemed no longer anxious about their professional identity and knew how to utilize knowledge-sharing communities to further professional growth. As Student ID39 reflected:
I want to go to a community with a stronger sense of academic knowledge, and get in touch with the knowledge that will help me in continuing education. This community has helped me grow, but I have bigger goals. (2022-10-08)
With the establishment of professional identity, the students lacked continuous motivation to stay in the current community, but their integration and spreading of the knowledge-sharing community are like establishing a “dense network of relationships” (Dholakia et al., 2004) for the sake of career development, during which they expanded existing relationships to achieve broader career goals. Online knowledge-sharing communities support students’ professional growth in another way.