Wilderness Medicine Physician Education: How an Elective Can Spark a Fire

Background Wilderness medicine (WM) electives offer an opportunity for medical trainees to learn an additional skillset outside of the traditional medical education curricula. Prior literature has yet to detail how participation in WM electives during medical training informs future training (i.e., master’s degree, fellowship) or career involvement in the field. Methodology A 25-question survey was completed by former participants of 25 WM electives based in the United States. Survey questions focused on the demographics, motivations, current involvement, and additional WM training among those who participated in WM electives. The survey was completed by 102 eligible participants. Results Of the 102 participants, 53% had been engaged with WM since completing their elective; 18% of the participants had completed additional formal training in WM (i.e., master’s degree, fellowship). Further, 95% of participants felt that the elective enhanced their resilience and critical thinking. Of those currently most involved in WM (n = 26), half (46%) were unsure about integrating WM into their careers prior to their elective. Among the uncertain yet highly engaged cohort, 98% cited the elective as the reason they stayed involved in WM. Conclusions These findings underscore the importance of WM electives in fostering interest among medical trainees in WM, and suggest that participation in WM electives may promote further involvement after medical school and residency.


Introduction
Wilderness medicine (WM) broadly encompasses the delivery of medical care in austere and/or low-resource environments. Opportunities for medical students and resident training in wilderness medicine have multiplied in recent years [1]. Medical students and residents (hereafter referred to as "medical trainees") have demonstrated a desire for exposure to and education in WM, with such experiences primarily being divided between nonelective experiences and elective courses [2,3]. Popular nonelective experiences include conferences, lectures, interest groups, weekend retreats, and wilderness races [4][5][6]. Many of these nonelective experiences offer an accessible opportunity to expose medical trainees to WM; however, because these programs are often short in duration, they typically provide limited exposure to the field.
For medical trainees seeking a more comprehensive WM experience, WM electives have become an increasingly popular option [2]. While there were only eight US-based WM electives in 2005, this number grew to at least 26 in 2014 [1]. Most electives either serve as broad introductions to various WM topics or specialize in a particular WM subfield (e.g., hyperbaric and dive medicine); because of their prehospital focus, they are particularly popular among emergency medicine (EM) trainees [7]. Exposure to WM via electives may spark an interest that promotes postresidency fellowship training, often after EM-based training programs, or career involvement in the field [7]. It is important to understand how WM electives influence participant career involvement, and studies have yet to examine such postelective involvement.
Prior research in a diverse set of medical specialties has demonstrated that medical school elective participation is a key factor in clarifying student decisions about future education and career choices in those fields [8]. Thus, the current study aims to: (i) outline professional demographics among past participants, (ii) identify how past participation in a WM elective by medical trainees influences their future involvement in the field of WM, and (iii) for those who are currently highly engaged in WM, understand the extent to which their elective experience influenced their current, active participation in WM.

Materials And Methods
The authors developed a survey to address these aims and included pilot testing with content experts in the field. A list of all medical school-sponsored WM electives in the United States (n = 25) was compiled using the Society for Academic Emergency Medicine's (SAEM) online WM program directory. The decision to restrict our study to only medical school-based electives was made in order to examine the impact of elective programs on future physicians; many WM programs are not affiliated with medicals schools and do not require participants to be physician trainees. The survey was emailed to each of the WM elective directors (n = 25), who then distributed the survey to former elective participants. The survey consisted of 25 questions divided into three sections based on (i) demographics, (ii) elective benefits, and (iii) WM interest and involvement following an elective.
Inclusion criteria included having taken one of the 25 WM electives as a medical student or resident. Exclusion criteria included any participant who was a current medical student at the time of survey completion.

Results
A total of 246 individuals received the survey, with 110 participants completing all 25 questions (45% response rate). Of the 110 participants, eight current medical students were excluded from the analysis, leaving 102 participants.
Attending physicians made up the greatest percentage of survey participants (41%), while 35% were early residents (postgraduate year [PGY]-1 or PGY-2), and 24% were late residents (PGY-3 through PGY-6). The most common specialty among participants was EM (45%), followed by family medicine (9%), and internal medicine (6%). Among all participants, 89% completed their WM electives during medical school, 5% during residency, and 6% during both medical school and residency (  Participants were divided into one of three subgroups for data analysis based on current involvement: high, moderate, and low engagement ( Figure 1). Overall, 25% of the total participants were in the high engagement subgroup (n = 26), 25% were in the moderate engagement subgroup (n = 27), and 48% were in the low engagement subgroup.
The majority (98%) of the participants reported that they benefited from participation in a WM elective. In total, 76% cited a new skillset and knowledge acquisition as the greatest perceived benefits of their elective, while 11% described "fun" as the greatest benefit. Further, 95% of the participants felt that the elective improved their resilience, critical thinking, and problem-solving. The following themes were cited as ways in which participants benefitted from WM electives: exposure to a new field, building confidence as a physician, developing knowledge and skills, gaining resource-limited training, networking, and hobby/personal interest fulfillment.
Among all participants, 78% reported an increased interest in WM following their elective. In total, 53% of participants had been engaged with WM since the completion of their elective; of those 53% of participants still involved, 47% cited their elective as a positive influencing factor in their decision to stay involved. Further, 80% of participants expressed that they were unsure about career WM involvement prior to their elective; of those uncertain participants, 37% cited the elective experience as the reason that they continued to stay involved.
A subgroup analysis allowed for a better understanding of high engagers' participation in the field following the elective. Before the elective, 54% of high engagers planned on integrating WM into their career; the remaining 46% were uncertain whether they would stay involved. Of the uncertain participants, 98% cited the elective as the primary influencing factor that fueled their decision to stay involved. For those participants who were previously uncertain about future involvement, their elective experiences were sufficiently meaningful to ignite a desire for future WM engagement despite initial indifference.
In total, 60% of high engagers (18% of all participants) completed a WM fellowship or related master's after their elective; among this supplemental training, 44% was in general WM, 8% in disaster medicine, 4% in global health, and 4% in hyperbaric medicine. Among those with supplemental WM training, 61% were EM physicians. This supports prior research suggesting that the majority of formal training programs in WM are linked to those who practice EM, though fellowship opportunities in other specialties are growing [7].

Discussion
These results have implications for both trainees and curriculum developers in the fields of WM and EM. The vast majority of participants reported benefit from their elective, improving both subjective critical thinking and leadership skills along with objective low-resource medical management skills. The influence of electives appears to be long-lasting as many participants (53%) stay involved in WM in a variety of ways (teaching courses, fellowships, conference attendance, etc.) after they complete the elective.
Furthermore, our results demonstrate that there are a number of elective participants who, despite low initial interest, have their WM interest sparked by their elective course and subsequently become highly involved in the field. Overall, 80% of participants were unsure prior to their elective whether they would pursue long-term WM involvement; of that 80%, half pointed to their elective experience as the strongest motivating factor for their continued WM involvement. This observation is particularly salient among current high engagers, the most active current participants in WM: 96% of high engagers who were previously uncertain about future involvement indicated that their elective experience influenced them to pursue future WM participation. Of note, three high engagers who had no intention to pursue a career in WM prior to their elective eventually went on to complete additional fellowship training and are now WM fellowship program directors.
These findings should be considered in light of study limitations. As a retrospective study with self-reported outcomes, participants who remain invested in WM may have been more likely to complete the study survey. This may have resulted in an overestimation of the response rate. The time interval between elective completion and survey collection was not gathered because the authors believed making inferences on this data may have biased the analysis. As a cross-sectional study, we cannot comment on changes in WM engagement over time. Future research should consider follow-up questionnaires to monitor involvement in WM over time. Further, future studies should more closely track time since elective to establish a concrete temporal understanding of career involvement.
These data highlight the impact that WM electives can have on a participant's career trajectory, even among those who were not initially considering further involvement in the field. This study illustrates that even those who are skeptical about future participation can have meaningful elective experiences which encourage sustained career involvement. For those individuals, the elective metaphorically sparked their fire of interest in WM.

Conclusions
This study is the first to outline the professional demographics of past WM elective participants and examines how past participation in an elective influences future educational and career involvement in the field. These results demonstrate that most WM elective participants perceive benefit from their experience, with electives fostering interest for future involvement in the field. For many individuals, their elective experience is a strong motivating factor for sustained high engagement. Wilderness medicine electives encourage medical trainees to embrace low-resource medical training, serving to inspire those who may have never otherwise considered involvement in the field.

Appendices Questionnaire
Year of medical school graduation