What students learned from “Thai medicine seminar”: Implication for education in medical communication

Nowadays, the use of complementary and alternative medicines by people is becoming more popular as an additional therapy to western medicine. Traditional medicine, which is a part of complementary and alternative medicines, is utilized complementarily with the dominant health-care model in Thailand. In Thailand, Thai traditional medicine is considered as one of the most valuable in their practice as an additional therapy. In terms of influence on university students, Thai traditional medicine seems to benefit university students’ mental health. However, little is known about what university students in multidisciplinary specialty learn from Thai traditional medicine, especially students outside Thailand. We aimed to study the learning impact of Thai Medicine Seminar, especially focused on the lesson of Thai traditional massage, for university students in Japan. Thai Medicine Seminar was conducted as an elective course for students of the University of Tokyo. Post-class reports from 26 students were analyzed qualitatively by thematic analysis. Nineteen codes were generated which were integrated into four categories: [Learning about Thai traditional medicine], [Learning about one’s own mind


PUBLIC INTEREST STATEMENT
This research investigates what university students learn from Thai traditional medicine especially with interest in communication education. Traditional medicine, which is a part of complementary and alternative medicines, is utilized complementarily with the dominant health care in many countries. Thai traditional medicine is one of them, and it is characterized by the massage technique. We aimed to study the learning impact of Thai Medicine Seminar for university students in Japan. Highlighted results are (1) students learned Thai traditional medicine with improvement of learning motivation; (2) students also learned aspects of mind-body awareness and relationships with others; (3) Thai traditional medicine learning could nurture mindfulness and compassion.
and body], [Learning about relationships with others], and [Improvement of learning motivation for diverse studies]. From Thai Medicine Seminar, students learned not only the nature of Thai traditional medicine but also aspects of mind-body awareness and relationships with others.

Background
Nowadays, the use of complementary and alternative medicines (CAMs) by people is becoming more popular as an additional therapy to western medicine. CAMs refer to a broad range of healthcare practices including those not introduced into dominant healthcare system in each country (World Health Organization, 2000). Thai traditional medicine, which is one of CAMs, has been widely transmitted in Thailand as a traditional medicine for conditioning the mind and body (Ratarasarn, 1986;Salguero, 2016). Thai traditional medicine has historically been influenced by Indian and Chinese medical knowledge and Buddhism teaching. It is a medical procedure in relation to examination, diagnosis, therapy, treatment or prevention of disease. Thai traditional medicine is regarded as embracing those traditional philosophies, constructing the knowledge and modes of practice to care for the health of Thai people. This is congruent with Thai culture and society based on the principles of Buddhism. Thai traditional medicine uses various forms of practices to complement each other, for instance, medication, Thai herbal pharmacy, massage, midwifery, maternal and child health care, Buddhist rites and meditation (Subcharoen, 2001).
Thai traditional medicine is used complementarily as prevention and disease treatment including cancer and Parkinson's disease (Lumlerdkij et al., 2018;Miyahara et al., 2018), and some hospitals in Thailand have integrated Thai traditional medicine into the modern medical model (Fakkham, Sirithanawutichi, Jarupoonpol, Homjumpa, & Bunalesnirunltr, 2012). In addition, Thai traditional medicine is applied to assist the development of physical and mental condition of infants and children (Watpho Thai Traditional Medicine School (Wat Pho), 2018). Previous studies show that it would be effective for children's emotional and behavioral disorders, particularly for autistic children (Piravej, Tangtrongchitr, Chandarasiri, Paothong, & Sukprasong, 2009). Moreover, lessons of Thai traditional massage are occasionally provided as optional events at elementary and junior high schools in Thailand in order to enhance children's self-esteem and compassion to others from Buddhism thought. Wat Pho Thai Traditional Medical School, the oldest Thai traditional medical school in Thailand, suggests that Thai traditional massage can train us to learn the awareness of breathing and attention, which leads to the learning of care and compassion for others. During massage, the practitioner is required to be calm, stable and maintain a peaceful mind and concentrate on the present. This demonstration of mindfulness and compassion is associated with Buddhism practice. Therefore, it is significant to note that Thai traditional massage can be helpful not only for the receiver but also for the practitioner (Briciu & Prompitak, 2016).
In terms of the psychological influence on university students, Thai traditional medicine seems to benefit their mental health as an instrument for self-care. Thai massage and meditation exercises were applied to reduce their stress levels (Inphrom et al., 2018). However, little is known about what university students learn from Thai traditional medicine, especially outside of Thailand. In Japan, adolescents have been noted to be weaker in building deeper relationships than adults; this is analyzed into three categories such as "staying in crowds not to be distinguished", "paying attention not to hurt each other" and "being away from deep relationships with others" (Matsushita & Yoshida, 2007;Okada, 1995). It is also suggested that the mental health status is lower in adolescents of indifferent and independent groups, compared to close relationship groups (Matsunaga & Iwamoto, 2008). Thus, we hypothesized that the lessons of Thai traditional medicine could help university students to strengthen their emotional and mental conditions and smooth their relationship with others.
The research question of this study is whether learning Thai traditional medicine, especially through the lesson of Thai traditional massage, affect physical and mental condition and the relationship with others in Japanese university students. We held an elective course on Thai medicine, called Thai Medicine Seminar, to teach the practice to multidisciplinary students of the University of Tokyo in Japan. The purpose of this study is to analyze qualitatively what Japanese students learn from Thai medicine and how that affects their physical and mental health.

Intervention
Thai Medicine Seminar was organized as an intensive course for a total of 23 h for 4 days in 2018, as an elective course for first-and second-year students of College of Arts and Sciences, the University of Tokyo. The main teacher was one of the authors, Yuka Miyahara, the certified instructor at Wat Pho Thai Traditional Medical School (Wat Pho), the first traditional medicine school approved under Ministry of Education, Thailand. The class consisted of 19 h of hands-on training, in which students practice Thai traditional massage with each other, 2 h for lectures on Thai traditional medicine, and 2 h for lectures by guest speakers.
In the lecture part by the guest speakers, case histories of applying Thai traditional medicine in day care centers in Thailand were introduced. They also covered aspects ranging from the relation between muscular stiffness research and Thai traditional medicine to the policy making applying Thai traditional medicine in Bangkok. The practice session of the course focused on Thai traditional massage, a field of Thai traditional medicine. It is characterized by relaxing rhythm, stretching of the entire body, and acupressure that the therapist's body weight is used to apply pressure. It is usually demonstrated for the entire body as much as possible. The acupressure technique is notably characteristic of infiltrating gradually into the center of the physical parts, where it is applied with a stable certain rhythm. Acupressure was practicsed mainly with palm during the seminar. In the class, after explaining the basic movement of Thai traditional massage, we set a lot of time for students to actually practice with each other. We practiced safe movements with the techniques for postures: prone, lateral, supine and sitting. The contents of the practical skills are taught in Wat Pho's "General Thai Massage" course, and the teaching in our class was conducted according to Wat Pho's method. We tried to secure time to touch the body by taking as much practical time as possible and enhance communication between the students by changing the pair of students in practice, using loose music and Thai herbs to create a peaceful space (Figure 1).

Research design and procedure
The study design applies a descriptive qualitative method. The students' post-class reports were analyzed to answer the research question. Sample size was identified by more than 20 people, in line with general criteria of qualitative research. The purpose of the study was explained to 33 students who attended the school-wide seminar and submitted post-class reports, and consent was obtained from 26 students for analysis in this study. We explained that personal information would be anonymized after removing any identification. The report consisted of mainly free description for what they learned from the seminar and what was the impression about the Thai traditional massage.

Data analysis
The authors applied thematic analysis to examine texts of the students' reports (Braun & Clarke, 2006). Themes were extracted from initial coding by two authors (TK and DS) and categories were made after three authors discussed and integrated similar themes (TK, DS and YM).

Ethical consideration
Ethical procedures were followed according to "Ethical Guidelines for Medical and Health Research Involving Human Subjects" by the Ministry of Education, Culture, Sports, Science and Technology (MEXT), and Ministry of Health, Labor and Welfare (MHLW) in Japan. Formal ethical approval is not mandated for this type of study under the guideline.  (Table 1).

Results
In the category [Learning about Thai traditional medicine], learning occurred in physical aspects such as "Importance of adjusting power according to the structure of the other's muscle" and "Importance of putting weight, not massaging muscles". In addition, respect for or sense of closeness to Thai traditional medicine was observed such as "Respect for Thai medicine tradition" and "Fostering a sense of closeness to Thailand". An example of the text is cited below.

Respect for Thai medicine tradition
"I know that Thai traditional therapy is a long-lasting practice and consists of a number of elaborate techniques under the idea of energy lines, etc., which was a very interesting point for me." In the category [Learning about one's own mind and body], awareness of one's own physical and psychological state and reflection on one's own life were mentioned, such as "Awareness of the state of mind and body of the self", "Experience of mindfulness", "Reflecting daily life and learning stress coping skills". Examples of the text are cited below.
3.2. Awareness of the state of mind and body of the self "I received more than 60 minutes of massage in the class, and after that I was able to improve my posture and move my body easily for a while."

Figure 1. Class of Thai Medicine Seminar
"I recognized that expected effects of Thai massage included the adjustment of the balance between body and mind, and awareness of our own physical and mental condition."

Experience of mindfulness
"By facing the partner's body and touching it in practice, I was able to feel calm and have peaceful time I would not get in my everyday life." "After experiencing it, I felt that my body and soul was purified. My mind was clearer, and it brought me to a peaceful feeling like after meditation." The category [Learning about relationships with others] included "Learning about caring and compassion for others" and "Building trust relationships with diverse people through practice". An example of the text is cited below.

Learning about caring and compassion for others
"I wondered if we would hesitate to say to partners that it hurts when we were strangers to each other. I asked in words, 'Is it not hurting?', and also looked at the partner's face, as well as trying to check whether there was any extra force on the buttocks or toes of the foot." "During the lesson of Thai traditional massage, I performed considering whether the receiver felt much pressure and pain or not, and I felt that these procedures led to matching the rhythm of breathing with my partner." The category [Improvement of learning motivation for diverse studies] included learning such as "Acquisition of social medicine perspective" and "Opportunity to consider complementary and alternative medicines". An example of the text is cited below.

Discussion and conclusion
The analysis of our study suggests that students who participated in the Thai Medicine Seminar learned not only the traditional medicine but also a sense of one's own physical and psychological condition and trusting relationships with others. As a basis of those findings, it seems relevant that Thai traditional medicine has physical techniques using body contact such as massage, acupressure and stretching with a stable certain rhythm combined with breathing that is similar to yoga to unwind the body and mind. The coding included "Experience of mindfulness" and "Reflecting daily life and learning stress coping skills", which suggest that it helps to relax one's mind and focus on the present time. It means that they could sense their own mental condition and communicate within themselves better than before. In addition, it is interesting that a mindset of caring for others was also cultivated, which was found in the themes such as "Learning about caring and compassion for others" and "Building trust relationships with diverse people through practice". The remarkable point is the deep awareness of self-esteem and care for others could be recognized for both the practitioner and receiver. It seems to be caused from the aspects of non-verbal communication of Thai traditional massage. Students' comments suggest that they had to concentrate on the receivers to catch their feelings as accurately as possible to make them relax and comfortable. The practitioners, in fact, were also supposed to control their own mental condition to conduct the massage. Therefore, the lesson seems to teach students two aspects of Thai massage training: (1) to concentrate and recognize their own mind and body, and (2) to care for the receiver with compassion. In addition, it was also noteworthy that they recognized the importance of the characteristics of Thai traditional massage techniques which the strength of acupressure and stretching are supposed to be gradually increased and decreased with the certain rhythm. This would pertain to the awareness of their breathing (Salguero, 2004).
It is also described in the previous study that mindfulness and caring for others would be nurtured by Thai traditional massage (Briciu & Prompitak, 2016). Mindfulness refers to the practice that cultivates present moment awareness, disengaging oneself from strong attachment to beliefs, thoughts, or emotions, thereby developing a greater sense of emotional balance and well-being (Ludwig & Kabat-Zinn, 2008). The findings prove that Thai traditional massage is useful as a touching therapy method, not only for children's emotional education but also for adolescent education in Japan. According to these results, Thai traditional massage might be applied for education for medical professionals. For example, in the medical education, the act of "touching" in physical examination is considered as important for medical trainees as it helps to build caring and trusting relationship with the patient (Iida, 2013). It is also reported that medical students learn non-verbal communication skills through touch therapies to enhance doctor-patient relationship (Ortiz et al., 2018), and it is compatible with the findings of this study.
This study seems to be the first report of university students' learning of Thai traditional medicine outside Thailand. Meanwhile, the limitation of this study is that we only analyzed free description of post-class reports, and the sample size is rather small.
In the future, we hope that learning from Thai traditional medicine will be widely introduced as a method of communication education in the curricula for various health-care professionals, especially for focusing on nurturing mindfulness and compassion.