Beyond homogenization discourse: Reconsidering the cultural consequences of globalized medical education

A meta-study analysing the discourses of discourse analysis in health professions education

INTRODUCTION

Discourse analysis has been used as an approach to conducting research in health professions education (HPE) for many years. However, because there is no one 'right' interpretation of or approach to it, quite what discourse analysis is, how it could or should be used, and how it can be appraised are unclear. This ambiguity risks undermining the trustworthiness and coherence of the methodology and any findings it produces.

METHOD

A meta-study review was conducted to explore the current state of discourse analysis in HPE, to guide researchers engaging using the methodology and to improving methodological, analytical and reporting rigour. Structured searches were conducted, returns were filtered for inclusion and 124 articles critically analysed.

RESULTS

Of 124 included articles, 64 were from medical education, 51 from nursing and 9 were mutli-disciplinary or from other HPE disciplines. Of 119 articles reporting some sort of data, 50 used documents/written text as the sole data source, while 27 were solely based on interview data. Foucault was the most commonly cited theorist (n = 47), particularly in medical education articles. The quality of articles varied: many did not provide a clear articulation what was meant by discourse, definitions and methodological choices were often misaligned, there was a lack of detail regarding data collection and analysis, and positionality statements and critiques were often underdeveloped or absent.

DISCUSSION

Seeking to address these many lacunae, the authors present a framework to facilitate rigorous discourse analysis research and transparent, complete and accurate reporting of the same, to help readers assess the trustworthiness of the findings from discourse analysis in HPE. Scholars are encouraged to reflect more deeply on the applications and practices of discourse analysis, with the ultimate aim of ensuring more breadth and depth when using discourse analysis for understanding and constructing meaning in our field.

Medical students' views on what professionalism means: an Ubuntu perspective

Medical training has become a global phenomenon, and the Physician's Charter (PC), as a missionary document, is key to training those outside the Global North. Undergraduate and postgraduate students in the medical profession are sometimes trained in contexts foreign to their social and ontological backgrounds. This might lead to confusion and blunders, creating an impression of what might look and feel unprofessional to those unfamiliar with the local context. Understanding the cultural backgrounds of the trainees is crucial, and the reverse is also as important. It is essential for clinicians and trainees to understand the cultural backgrounds of their patients to avoid miscommunication. In this phenomenological study, we recruited participants in 2020 who were in their first to fourth year of study of medical training during the #FeesMustFall protests. We used data from this extensive study looking at students' experiences during their training amidst protest and social upheavals in a South African tertiary institution. For this paper, we examined what professionalism means to the student participants using an African Ubuntu lens. Ubuntu and the Collective Finger theory were used to investigate what professionalism means to participants. The Ubuntu philosophy was compared to the PC. In the findings, the clinical space is hierarchical, silencing and the opposite of what Ubuntu means. In comparison to the PC, respect is overarching while compassion and responsibility are the most comparable to the Charter. This study adds an African voice to the professionalism discourse while showing African elements that could be aligned to the PC to challenge the current global discourses.

Are we teaching the health impacts of climate change in a clinically relevant way? A systematic narrative review of biomechanism-focused climate change learning outcomes in medical curricula

PURPOSE

Introducing biomedical approaches to the health impacts of climate change can improve medical student engagement with relevant climate-related issues, improve the development of medical schemas, and minimise displacement into crowded medical curricula. This paper aims to systematically review the medical education curricula related to climate change, with a particular focus on systems-based biomechanisms for the health impacts of climate change. We do this to provide a clear agenda for further development of learning outcomes (LOs) in this area to maximize the clinical applicability of this knowledge.

MATERIAL AND METHODS

A systematic review was undertaken following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA; Liberati et al. 2009) guidelines for both the published and grey literature. Five databases (PubMed, SCOPUS, ERIC, Open Access Thesis and Dissertation, and Proquest Global Dissertation and Theses) were searched for works published between 2011 and June 2023. Full texts that contained LOs were the main inclusion criteria for the final review. Descriptive and content extraction guided the final narrative synthesis.

RESULTS

Analysis indicated that biomechanism-related LOs represented about 25% of each published LO set, on average. These outcomes were primarily at the "understand" level of Bloom's taxonomy and were spread across a range of body systems and climate-change aspects. Infectious diseases and extreme heat were strong focuses. Authorship analysis indicated that the majority of these sets of published LOs are from Western contexts and authored by researchers and educators with medical and population health qualifications.

CONCLUSIONS

Biomechanism-focused teaching about the health impacts of climate change is relatively rare in published curricula. Of the available sets of LOs, the majority are sourced from Western authors and are focused on a fairly circumscribed set of biomedical topics. There is scope to both broaden and deepen curriculum in this area, and we would recommend the field prioritise collaboration with medical educators from the Global South, where the effects of climate change are already the most acutely felt.

Embracing different languages and local differences: Co-constructive patient simulation strengthens host countries' clinical training in psychiatry

BACKGROUND

Global education in psychiatry is heavily influenced by knowledge from Western, high-income countries, which obscures local voices and expertise.

AIM

To adapt a human simulation model to psychiatric education in a context that is specific to local languages and cultures.

METHODS

We conducted an observational study consisting of six human simulation sessions with standardized patients from two host countries, speaking their native languages, and following an adaptation of the co-constructive patient simulation (CCPS) model. As local faculty became increasingly familiar with the CCPS approach, they took on the role of facilitators-in their country's native language.

RESULTS

Fifty-three learners participated: 19 child and adolescent psychiatry trainees and 3 faculty members in Türkiye (as a group that met online during 3 consecutive months); and 24 trainees and 7 faculty in Israel (divided into 3 groups, in parallel in-person sessions during a single training day). Each of the six cases reflected local realities and clinical challenges, and was associated with specific learning goals identified by each case-writing trainee.

CONCLUSION

Human simulation has not been fully incorporated into psychiatric education: The creation of immersive clinical experiences and the strengthening of reflective practice are two areas ripe for development. Our adaptations of CCPS can also strengthen local and regional networks and psychiatric communities of practice. Finally, the model can help question and press against hegemonies in psychiatric training that overshadow local expertise.

Ethics without borders: an analysis of national and international guidelines on ethics in basic medical education

BACKGROUND

It has been widely recognized that ethics is central to the practice of medicine. Since physicians' identities are heavily influenced by their basic medical training, education in ethics during this period would facilitate their professional development. To enable this, some global and national organizations have published guidelines detailing the aspects of ethics that need to be taught to medical student. However, it is not known how many such guidelines exist and to what extent they concur or differ.

AIM

This study aims to identify and examine the content of existing national or international guidelines on the inclusion of ethics in basic medical education, in the English language. By doing so, it hopes to explore and highlight the similarities and differences regarding their pedagogical goals and their prescribed content, thereby contributing to a more holistic understanding on the state of medical ethics education.

METHODS

Data collection was performed through systematic searches on Google and on scientific databases. The guidelines that fulfilled the inclusion criteria were thematically analyzed using the method proposed by Braun and Clarke (2006). The resulting themes and sub-themes were grouped and characterized.

RESULTS

Thirteen guidelines (ten national and three international) fulfilled the inclusion criteria. Among these, two major approaches can be discerned: value-based and norm-based. Value-based guidelines tend to be more globally applicable, because they endorse more abstract and universal principles. Norm-based guidelines, on the other hand, are more context-specific and have a practical focus. Understanding this distinction could facilitate discussions on different perspectives in ethics education.

Clinician educators' conceptions of assessment in medical education

In pursuing assessment excellence, clinician-educators who design and implement assessment are pivotal. The influence of their assessment practice in university-run licensure exams on student learning has direct implications for future patient care. While teaching practice has been shown to parallel conceptions of teaching, we know too little about conceptions of assessment in medical education to know if this is the case for assessment practice and conceptions of assessment. To explore clinician-educators' conceptions of assessment, a phenomenographic study was undertaken. Phenomenography explores conceptions, the qualitatively different ways of understanding a phenomenon. Data analysis identifies a range of hierarchically inclusive categories of understanding, from simple to more complex, and the dimensions that distinguish each category or conception. Thirty-one clerkship convenors in three diverse Southern settings were interviewed in three cycles of iterative data collection and analysis. Four conceptions of assessment were identified: passive operator, awakening enquirer, active owner and scholarly assessor. Six dimensions were elucidated to describe and distinguish each conception: purpose of assessment; temporal perspective; role and responsibility; accountability; reflexivity and emotional valence. Additionally, three characteristics that appeared to track the progressive nature of the conceptions were identified: professional identity, assessment literacy and self-efficacy. These conceptions encompass and extend previously described conceptions across different educational levels, disciplines and contexts, suggesting applicability to other settings. There is some evidence of a relationship between conceptions and practice, suggesting, together with the hierarchical nature of these conceptions, that targeting conceptions during faculty development may be an effective approach to enhance assessment practice.

The Crisis of Medical Education in the Arab World: A Student's Perspective

Medical education is an important and ever-changing profession that determines the future of healthcare and public health in any nation. It is also a complicated and difficult process that needs ongoing adaptation and innovation in order to satisfy the changing demands and expectations of health systems and communities. However, several challenges and limits impede the growth and quality of medical education in the Arab world, preventing it from reaching its full potential. In this article, we will highlight some of the major difficulties affecting medical education in the Arab world from our own experience as a medical student in one of the Arab nations.

Perspectives on Medical Education in an Increasingly Globalized Society: Recognizing and Embracing Our Diversity

Medical curricula around the globe are diverse, accommodating the social, political, cultural, and health needs in each country. Every medical school has the responsibility to educate graduates capable of providing quality medical care to their communities. Yet true globalization of medical education is a challenge. Little is known about the intrinsic variations which impact curricula in countries around the world. There are unique, often historical reasons that explain the challenges in attaining a genuine globalization of the medical curricula. This perspective provides a glance and general comparison of traditions, economic, and socio-political influences on medical education across seven countries.

Applying North American medical education accreditation standards internationally in the United Arab Emirates

OBJECTIVE

Health care and health professions education are becoming increasingly global, yet no formal international accrediting body exists for medical education. Among the challenges in developing international standards for medical education is the variation in program models, with some regions offering six-year bachelor's degrees and others, including North America, customarily requiring a bachelor's degree prior to admission to a 4-year graduate-level degree program. This study sought to determine the applicability of the USA Liaison Committee on Medical Education (LCME) accreditation standards internationally as the foundation for program development, quality improvement, and program evaluation in a program that follows the North American medical education model in the United Arab Emirates (UAE).

METHODS

Using a qualitative political, economic, sociocultural, technological, legal, and environmental (PESTLE) analysis framework, we systematically assessed the applicability of each of the 93 LCME accreditation elements to the nascent doctor of medicine (MD) degree program at Khalifa University.

RESULTS

All 93 elements in the most current LCME accreditation standards were deemed applicable internationally in a program developed in accordance with the North American model of medical education. Of these, three elements were deemed applicable with caveats in the legal or regulatory processes required to achieve comparable compliance outside of the USA. No elements were deemed not applicable in an international setting.

CONCLUSIONS

Our analysis demonstrates that the LCME accreditation standards are model-specific and can be effectively applied internationally in programs that follow the North American model of medical education. Countries in which no specialized medical education accrediting body exists can apply the LCME standards and achieve international benchmarks of quality in medical education through rigorous self-assessment and continuous quality improvement.

Hyperglobalist, sceptical, and transformationalist perspectives on globalization in medical education

PURPOSE

Globalisation has been hotly debated in recent decades and has seemingly had a profound impact on medical education. This review synthesises the medical education literature using key perspectives from globalisation theory by Holton (Making globalisation).

METHODS

Holton (Making globalisation) recognised three key perspectives in globalisation theory-hyperglobalist, sceptical, and transformationalist. This article critically reviews the literature on globalisation in the field of medical education using this theoretical framework.

RESULTS

Hyperglobalist and sceptical perspectives dominated early periods of medical education literature on globalisation, projecting it either as a mainly positive or mainly negative force, respectively. Most forecasts grounded in these perspectives have not materialised in medical education policy and practice. Since 2010, the volume of scholarship about globalisation has increased and has been predominantly transformationalist in perspective, recognising a reality that has both positive and negative consequences.

CONCLUSIONS

The medical education literature has mirrored the broader social science literature, in moving over time from hyperglobalist and sceptical positions, towards a 'third wave' of globalisation thinking that is transformationalist. Medical education practitioners and policymakers should be mindful of these perspectives and trends as they navigate the opportunities and challenges presented by globalisation.

An international study on the implementation of programmatic assessment: Understanding challenges and exploring solutions

INTRODUCTION

Programmatic assessment is an approach to assessment aimed at optimizing the learning and decision function of assessment. It involves a set of key principles and ground rules that are important for its design and implementation. However, despite its intuitive appeal, its implementation remains a challenge. The purpose of this paper is to gain a better understanding of the factors that affect the implementation process of programmatic assessment and how specific implementation challenges are managed across different programs.

METHODS

An explanatory multiple case (collective) approach was used for this study. We identified 6 medical programs that had implemented programmatic assessment with variation regarding health profession disciplines, level of education and geographic location. We conducted interviews with a key faculty member from each of the programs and analyzed the data using inductive thematic analysis.

RESULTS

We identified two major factors in managing the challenges and complexity of the implementation process: knowledge brokers and a strategic opportunistic approach. Knowledge brokers were the people who drove and designed the implementation process acting by translating evidence into practice allowing for real-time management of the complex processes of implementation. These knowledge brokers used a 'strategic opportunistic' or agile approach to recognize new opportunities, secure leadership support, adapt to the context and take advantage of the unexpected. Engaging in an overall curriculum reform process was a critical factor for a successful implementation of programmatic assessment.

DISCUSSION

The study contributes to the understanding of the intricacies of implementation processes of programmatic assessment across different institutions. Managing opportunities, adaptive planning, awareness of context, were all critical aspects of thinking strategically and opportunistically in the implementation of programmatic assessment. Future research is needed to provide a more in-depth understanding of values and beliefs that underpin the assessment culture of an organization, and how such values may affect implementation.

The Terms of "You(s)": How the Term of Address Used by Conversational Agents Influences User Evaluations in French and German Linguaculture

Background: Conversational agents (CAs) are a novel approach to delivering digital health interventions. In human interactions, terms of address often change depending on the context or relationship between interlocutors. In many languages, this encompasses T/V distinction—formal and informal forms of the second-person pronoun “You”—that conveys different levels of familiarity. Yet, few research articles have examined whether CAs' use of T/V distinction across language contexts affects users' evaluations of digital health applications.

Methods: In an online experiment (N = 284), we manipulated a public health CA prototype to use either informal or formal T/V distinction forms in French (“tu” vs. “vous”) and German (“du” vs. “Sie”) language settings. A MANCOVA and post-hoc tests were performed to examine the effects of the independent variables (i.e., T/V distinction and Language) and the moderating role of users' demographic profile (i.e., Age and Gender) on eleven user evaluation variables. These were related to four themes: (i) Sociability, (ii) CA-User Collaboration, (iii) Service Evaluation, and (iv) Behavioral Intentions.

Results: Results showed a four-way interaction between T/V Distinction, Language, Age, and Gender, influencing user evaluations across all outcome themes. For French speakers, when the informal “T form” (“Tu”) was used, higher user evaluation scores were generated for younger women and older men (e.g., the CA felt more humanlike or individuals were more likely to recommend the CA), whereas when the formal “V form” (“Vous”) was used, higher user evaluation scores were generated for younger men and older women. For German speakers, when the informal T form (“Du”) was used, younger users' evaluations were comparable regardless of Gender, however, as individuals' Age increased, the use of “Du” resulted in lower user evaluation scores, with this effect more pronounced in men. When using the formal V form (“Sie”), user evaluation scores were relatively stable, regardless of Gender, and only increasing slightly with Age.

Conclusions: Results highlight how user CA evaluations vary based on the T/V distinction used and language setting, however, that even within a culturally homogenous language group, evaluations vary based on user demographics, thus highlighting the importance of personalizing CA language.

Medical Students' and Trainees' Country-By-Gender Profiles: Hofstede's Cultural Dimensions Across Sixteen Diverse Countries

Purpose

The global mobility of medical student and trainee populations has drawn researchers' attention to consider internationalization in medical education. Recently, researchers have focused on cultural diversity, predominately drawing on Hofstede's cross-cultural analysis of cultural dimensions from general population data to explain their findings. However, to date no research has been specifically undertaken to examine cultural dimensions within a medical student or trainee population. This is problematic as within-country differences between gender and professional groups have been identified within these dimensions. We address this gap by drawing on the theoretical concept of national context effects: specifically Hofstede's six-dimensional perspective. In doing so we examine medical students' and trainees' country profiles across dimensions, country-by-gender clustering, and differences between our data and Hofstede's general population data.

Methods

We undertook a cross-cultural online questionnaire study (eight languages) containing Hofstede's 2013 Values Survey. Our questionnaire was live between 1st March to 19th Aug 2018, and December 2018 to mitigate country holiday periods. We recruited undergraduate medical students and trainees with at least 6-months' clinical training using school-specific methods including emails, announcements, and snowballing.

Results

We received 2,529 responses. Sixteen countries were retained for analyses (n = 2,307, 91%): Australia, Chile, China, Hong Kong, India, Indonesia, Ireland, Israel, Japan, Malaysia, New Zealand, Pakistan, South Africa, South Korea, Sri-Lanka, Taiwan. Power distance and masculinity are homogenous across countries. Uncertainty avoidance shows the greatest diversity. We identified four country clusters. Masculinity and uncertainty are uncorrelated with Hofstede's general population data.

Conclusions

Our medical student and trainee data provides medical education researchers with more appropriate cultural dimension profiles than those from general population data. Country cluster profiles stimulate useful hypotheses for further research, especially as patterning between clusters cuts across traditional Eastern-Western divides with national culture being stronger than gendered influences. The Uncertainty dimension with its complex pattern across clusters is a particularly fruitful avenue for further investigation.

"Glocalization" in medical education: A framework underlying implementing CBME in a local context

BACKGROUND/PURPOSE

The implementation of competency-based medical education is a social construction process within a local and cultural context. However, little is known about the process of adaptation to different systems, known as "glocalization". We analyzed the documents in the development of a milestone project from adapting global standards into a local context and identified a framework underlying this process.

METHODS

Taiwan Society of Emergency Medicine (TSEM) had developed learning milestones based on the ACGME's version through series of consensus methods including committee work, nominal group technique (NGT), and a modified Delphi method. We applied qualitative content analysis to characterize the evolution of the three versions of TSEM and the original ACGME milestones documents and to explore the meaning behind the differences revealed by the glocalization process.

RESULTS

We found 48 differences between ACGME and TSEM milestones. Among these differences, one was made by committee work, 44 came from NGT, and 3 were from the modified Delphi process. Two themes and seven sub-themes emerged from the coding process to explain the contextualization process of the milestones.

CONCLUSION

We identified a framework that incorporates local expression and local needs into the process called glocalization through which global models of competency-based standards could be optimally implemented in a local context with different systems and cultures.

The World Health Organization and the global standardization of medical training, a history

BACKGROUND

This article presents a history of efforts by the World Health Organization and its most important ally, the World Federation for Medical Education, to strengthen and standardize international medical education. This aspect of WHO activity has been largely ignored in recent historical and sociological work on that organization and on global health generally.

METHODS

Historical textual analysis is applied to the digitalized archives and publications of the World Health Organization and the World Federation for Medical Education, as well as to publications in the periodic literature commenting on the standardization of international medical training and the problems associated with it.

RESULTS

Efforts to reform medical training occurred during three distinct chronological periods: the 1950s and 1960s characterized by efforts to disseminate western scientific norms; the 1970s and 1980s dominated by efforts to align medical training with the WHO's Primary Healthcare Policy; and from the late 1980s to the present, the campaign to impose global standards and institutional accreditation on medical schools worldwide. A growing number of publications in the periodic literature comment on the standardization of international medical training and the problems associated with it, notably the difficulty of reconciling global standards with local needs and of demonstrating the effects of curricular change.

Editorial diversity in medical education journals

BACKGROUND

In recent years, the field of medical education has sought to amplify the voices of those from traditionally marginalised groups and medical education journals have sought to become more accessible and diverse. This study sought to examine the gender and geographical representation of editors and editorial board members in medical education journals.

METHODS

Information about individual editors and editorial board members of 10 medical education journals was retrieved from their websites in January 2021, including their gender and the country in which they were based. Countries were categorised according to World Bank Income Classification and World Bank Geographical Regions. We then calculated the Composite Editorial Board Diversity Score for each journal.

FINDINGS

Of 488 editors and editorial board members, 283 (58.0%) were male, 452 (92.6%) were based in high-income countries and 322 (66.0%) were from the four countries with greatest representation (the United States, the United Kingdom, Australia and Canada).

DISCUSSION

The composition of medical education journals' editorial leadership teams remains dominated by males and those from higher income and Western countries. Strikingly, little change has taken place since this was last examined 17 years ago despite the field becoming apparently more globalised. As medical education strives to become a more inclusive and diverse discipline, developing policies to create more globally representative editorial leadership teams should now be an urgent priority.

Solutionism across borders: Sorting out problems, solutions and stakeholders in medical education internationalisation

Just whose problems are being solved when we internationalize medical education? Here Brouwer et al. reflect on the misalignment between the challenges of globalization and solutions of internationalization.

Cultural awareness and competence of pharmacy educators and learners from the perspective of pharmacy students at Qatar University: A mixed-methods approach

BACKGROUND

Since healthcare professional educators and practitioners in Qatar are culturally diverse, the impact of this diversity on the education and training of healthcare students should be evaluated. This study, therefore, aims at examining pharmacy students' perspectives on the level of cultural awareness and competence of pharmacy educators and learners at Qatar University and the influence of cultural diversity on pharmacy education in Qatar.

METHODS

A convergent mixed-methods design was adopted. The Cultural Awareness Scale (CAS) was utilized in the quantitative phase, which was administered on 122 pharmacy students at Qatar University College of Pharmacy (QU CPH), of whom 70 responded. The qualitative phase comprised four focus groups with a total of 23 students. The quantitative and qualitative data were collected concurrently, and the results were integrated.

RESULTS

The findings suggest that the QU CPH is an institution of a culturally diverse community. Educators and students alike are generally culturally aware and sensitive; however, demonstration of a holistic awareness was hindered by a few barriers. This study suggests curricular changes to reinforce cultural competence, cultural inclusiveness, and the preservation of Qatar's cultural identity and values in the educational environment.

CONCLUSIONS

The internationalization of pharmacy education in Qatar has inspired students and educators alike to achieve new dimensions of cultural awareness. To infuse passion and enthusiasm in learning while maintaining Qatar's cultural values and identity, healthcare professional educators, researchers, and policymakers are required to collaborate to promote culturally sensitive pharmacy education.

Implementing a collaborative medicine and pharmacy educational activity in two countries

BACKGROUND

To promote better collaboration for patient care, interprofessional education (IPE) is required in many health professions courses. However, successful IPE implementation at scale can be challenging because of complicated logistics and competing priorities. Implementing across multiple geographies adds further complexity.

OBJECTIVE

This paper describes the implementation of a full cohort IPE activity for medical and pharmacy students delivered at both the Australian and Malaysian campuses of Monash University.

DESIGN

We designed a 150-minute, blended learning activity centred around asthma care for second-year medical and pharmacy students. Student perceptions were measured with a pre- and post-activity survey using the validated ten-item, three-factor, SPICE-R2 instrument. Analysis focused on differences between professions and countries.

RESULTS

All second-year medicine (N = 301 in Australia and N = 107 in Malaysia) and pharmacy students (N = 168 in Australia and N = 117 in Malaysia) participated in the learning activity. A total of 326/693 (47%) students participated in the associated research by completing both the pre- and post-activity surveys. The pre-activity survey showed significant differences in four items between medicine and pharmacy students in Australia and two items in Malaysia. Post-activity, we observed significant changes in 8/10 items when the two professions were combined. Specifically, we noted changes across the countries in perceptions of roles and responsibilities for collaborative practice and patient outcomes from collaborative practice.

CONCLUSIONS

IPE across different professions and countries is feasible. Positive outcomes in role understanding and perceived patient outcomes are achievable through a context-sensitive, locally driven approach to implementation. Longitudinal experiences may be required to influence perceptions of teamwork and team-based care.

Long-term contribution of international electives for medical students to professional identity formation: a qualitative study

OBJECTIVES

Globalisation has given medical university students the opportunity to pursue international electives in other countries, enhancing the long-term socialisation of medical professionals. This study identified the long-term effects of international electives on the professional identity formation of medical students.

DESIGN

This is a qualitative study.

SETTING

The authors interviewed Japanese medical professionals who had completed their international electives more than 10 years ago, and analysed and interpreted the data using a social constructivism paradigm.

PARTICIPANTS

A total of 23 medical professionals (mean age 36.4 years; range 33-42 years) participated in face-to-face, semistructured in-depth interviews.

RESULTS

During the data analysis, 36 themes related to professional identity formation were identified, and the resulting themes had five primary factors (perspective transformation, career design, self-development, diversity of values and leadership). It was concluded that international electives for medical students could promote reflective self-relativisation and contribute to medical professional identity formation. Additionally, such electives can encourage pursuing a specialisation and academic or non-academic work abroad. International electives for medical students could contribute to medical professional identity formation on the basis of cross-cultural understanding.

CONCLUSIONS

This study addressed a number of issues regarding the long-term impact of international elective experiences in various countries on the professional identity formation of Japanese medical professionals. This study offers some guidance to mentors conducting international electives and provides useful information for professional identity formation development in medical professionals.

Accreditation Improves Quality of Oncology Education in Low- and Middle-Income Countries: Perspectives of African Oncologists

The purpose of this study is to understand the perspectives of African Oncologists on the role of accreditation and on global standards. We developed a survey that addressed African oncologists' opinions on the role of accreditation. The survey also included 187 standards from World Federation of Medical Education Postgraduate medical education (PGME) standards, American Council of Graduate Medical Education (ACGME)-I standards for hematology/oncology, and the Royal College of Physician and Surgeons of Canada Medical Oncology standards. A 3-point scale was employed for each standard: 1 = not important, 2 = important but not essential, 3 = essential. The survey was sent to 79 physicians, 38 responded. Eighty-seven percent agreed that accreditation ensures quality. Forty-five percent agreed it will not increase migration of qualified doctors. Twenty-two individuals who completed the entire survey were analyzed for the standards. Five standards received the highest ratings of 3 (essential) from all respondents. One standard received a rating of < 2.0. The majority of standards had ratings between 2.6 and 2.94 indicating African oncologists found most standards to be useful. Ratings < 2.6 were mostly related to resource constraints. Most African Oncologists believed that accreditation ensures quality of education, and most standards were considered important. This data is useful for developing and adapting accreditation standards in resource-constrained settings.

'Being international is always a good thing': A multicentre interview study on ethics in international medical education

CONTEXT

Internationalisation in medical education raises ethical concerns over, for instance, its for-profit orientation, the potential erosion of cultural diversity and the possibility that standardised education may not meet the needs of patients everywhere. These concerns fit into a broader debate on social responsibility in higher education. This study aims to explore how academic staff in international medical education experience and act upon the ethical concerns that pertain to their programmes. By adding their perspectives to the debate, this study helps us understand how theory-based ethical concerns are reflected in practice.

METHODS

We conducted a multicentre instrumental case study across three international medical programmes, all of which were characterised by an international student intake, an internationalised curriculum and international partnerships, and all of which used English as the medium of instruction. We conducted 24 semi-structured interviews with purposively sampled curriculum directors and teaching staff. Participants shared their personal experiences and responded to ethical concerns expressed in the literature. Our multidisciplinary team performed a template analysis of the data based on theoretical frameworks of ethics and social responsibility.

RESULTS

Participants primarily experienced the internationalisation of their institutions and programmes as having a positive impact on students, the university and the future global society. However, they did face several ethical dilemmas. The first of these involved the possibility that marketisation through international recruitment and the application of substantial tuition fees might widen access to medical education, but might allow weaker students to enter medical schools. The second concern referred to the homogenisation of education methods and content, which offers opportunities to expose students to best practices, but may also pose a risk to education quality. The third issue referred to the experience that although student diversity helped to promote intercultural learning, it also jeopardised student well-being.

CONCLUSIONS

In the eyes of teaching staff in international medical education, internationalisation can benefit education quality and society, but poses ethical dilemmas through the forces of marketisation, homogenisation and diversification. The findings reflect a tension between the views of scholars and those of practitioners. The critical perspective found in academic debates is largely missing in practice, and theoretical frameworks on ethics possibly overlook the benefits of international education. To facilitate ethical decision making, we propose that scholars and practitioners globally try to learn from each other.

Humanism in global oncology curricula: an emerging priority

Introduction

Training in humanism provides skills important for improving the quality of care received by patients, achieving shared decision-making with patients, and navigating systems-level challenges. However, because of the dominance of the biomedical model, there is potentially a lack of attention to humanistic competencies in global oncology curricula. In the present study, we aimed to explore the incorporation of humanistic competencies into global oncology curricula.

Methods

This analysis considered 17 global oncology curricula. A curricular item was coded as either humanistic (as defined by the iecares framework) or non-humanistic. If identified as humanistic, the item was coded using an aspect of humanism, such as Altruism, from the iecares framework. All items, humanistic and not, were coded under the canmeds framework using 1 of the 7 canmeds competency domains: Medical Expert, Communicator, Collaborator, Leader, Scholar, Professional, or Health Advocate.

Results

Of 7792 identified curricular items in 17 curricula, 780 (10%) aligned with the iecares humanism framework. The proportion of humanistic items in individual curricula ranged from 2% to 26%, and the proportion increased from 3% in the oldest curricula to 11% in the most recent curricula. Of the humanistic items, 35% were coded under Respect, 31% under Compassion, 24% under Empathy, 5% under Integrity, 2% under Excellence, 1% under Altruism, and 1% under Service. Within the canmeds domains, the humanistic items aligned mostly with Professional (35%), Medical Expert (31%), or Communicator (25%).

Conclusions

The proportion of humanistic competencies has been increasing in global oncology curricula over time, but the overall proportion remains low and represents a largely Western perspective on what constitutes humanism in health care. The representation of humanism focuses primarily on the iecares attributes of Respect, Compassion, and Empathy.

Educating universal professionals or global physicians? A multi-centre study of international medical programmes design

Introduction: Medical schools increasingly offer curricula that specifically aim to prepare students for an international medical career. This is challenging as well as controversial: curriculum designers must balance specific local healthcare requirements with global health competencies doctors need in our globalised world. By investigating how international medical programme designers experience this balancing act, this study aims to contribute insights to the debate on local versus global medical education.Methods: We conducted a multi-centre instrumental case study across three universities with international medical programmes in three countries. The study involved 26 semi-structured interviews with key curriculum designers recruited through purposive sampling. Additionally, we performed a curriculum document analysis. Data were thematically analysed within a multidisciplinary team.Results: Participants described two profiles of international medical programme graduates: 'a global physician', equipped with specific competencies for international practice, and 'a universal professional', an overall high-level graduate fit for future practice anywhere. These perspectives presented different curriculum design challenges.Conclusions: International medical programmes teach us how we can rethink graduate profiles in a globalising world. Yet, educational standardisation poses risks and securing equity in global health education is challenging, as is preparing students to be adaptable to the requirements of a rapidly changing future local healthcare context.

Workplace-Based Assessment in Cross-Border Health Professional Education

Construct: The globalization of healthcare has been accentuated by the export of health professional curricula overseas. Yet intact translation of pedagogies and practices devised in one cultural setting may not be possible or necessarily appropriate for alternate environments. Purposeful examination of workplace learning is necessary to understand how the source or "home" program may need adapting in the distributed or "host" setting. Background: Strategies to optimize cross-border medical education partnerships have been largely focused on elements of campus-based learning. Determining how host clinical supervisors approach assessment in experiential settings within a different culture and uphold the standards of home programs is relevant given the influence of context on trainees' demonstrated competencies. In this mixed-methods study, we sought to explore assessor judgments of student workplace-based performance made by preceptors sharing a pharmacy curriculum in Canada and Qatar. Approach: Using modified Delphi consensus technique, we asked clinical supervisors in Canada (n = 18) and in Qatar (n = 14) to categorize trainee performance as described in 16 student vignettes. The proportion of ratings for three levels of expectation (exceeds, meets, or below) was calculated and within-country group consensus achieved if the level of agreement reached 80%. Between-country group comparisons were measured using a chi-square statistic. We then conducted follow-up semi-structured interviews to gain further perspectives and clarify assessor rationale. Transcripts were analyzed using thematic content analysis. Results: The threshold for between-country group differences in assessor impressions was met for only two of the 16 student vignettes. Compared to Canadian clinical supervisors, relatively more preceptors in Qatar judged one described student as meets rather than exceeds expectations and one as meets rather than falls below expectations. Analysis of follow-up interviews exploring how culture may inform variations in assessor judgments identified themes associated with the profession, organization, learner, and supervisor performance theories but not their particular geographic context. Clinical supervisors in both countries were largely aligned in expectations of student knowledge, skills, and behaviors demonstrated in patient care and multidisciplinary team interactions. Conclusions: Our study demonstrated that variation in student assessment was more frequent among clinical supervisors within the same national context than any differences identified between the two countries. In these program settings, national sociocultural norms did not predict global assessor impressions or competency-specific judgments; instead, professional and organizational cultures were more likely to inform student characterizations of performance in workplace-based settings. Further study situated within the specific experiential learning contexts of cross-border health professional curricula is assuredly warranted.

The case for plural PBL: an analysis of dominant and marginalized perspectives in the globalization of problem-based learning

The globalization of problem-based learning (PBL) in health professions education has been both celebrated and criticized. Using a critical narrative review approach, underpinned by our archive of global PBL literature and a targeted literature search, we analyze these dominant global discourses of PBL in health professions education. More precisely, we explore what is missed when the globalization of PBL is theorized either as a positive consequence of standardization, or a problematic spread of Western educational ideals and values around the world. We make visible how two dominant global discourses, a universalist and culturalist discourse, have emerged in the global proliferation of PBL. We also discuss the limitations of the two discourses by demonstrating how they either ignore contextual and cultural diversity or see it as problematic. We then turn to a perspective that has been marginalized in the PBL literature that emphasizes the global origins of PBL, transcending the dichotomy between West and non-West. We make a case for relating to PBL as a plural construct in order to learn from the cultural and situational nuances of educational activities labeled PBL around the world. We argue that PBL as a singular and universal concept has no global future, yet versions of PBL may continue to thrive locally. Finally, we propose avenues for future research that may help elucidate the global and local values that underpin our curricula, as well as the socio-political factors that perpetuate neo-colonialist views and practices in the uptake and implementation of PBL approaches across the globe.

A qualitative study on harmonization of postgraduate medical education in Europe: negotiating flexibility is key

INTRODUCTION

International harmonization of postgraduate medical education is gaining importance in the globalization of medical education. Harmonization is regarded as the establishment of common standards in education, while maintaining regional or local freedom to adapt training to contexts. During the development of a harmonized curriculum, tensions between standardization and contextualization may surface. To allow future harmonization projects to recognize these tensions and deal with them in a timely manner, this study aims to gain insight into tensions that may arise when developing a harmonized curriculum for postgraduate medical education in Obstetrics and Gynaecology in Europe.

METHODS

Focus groups were held with international curriculum developers to discuss challenges that resulted from tensions between standardization and contextualization when developing a harmonized European curriculum for postgraduate medical education in Obstetrics and Gynaecology. Data were analyzed through conventional content analysis, using the principles of template analysis.

RESULTS AND DISCUSSION

Tensions between standardization and contextualization in the development of a harmonized curriculum were apparent in two domains: 1) Varying ideas about what the harmonized curriculum means for the current curriculum and 2) Inconsistencies between educational principles and the reality of training. Additionally, we identified ways of dealing with these tensions, which were characterized as 'negotiating flexibility'. Tensions between standardization and contextualization surfaced in the development phase of harmonizing a curriculum, partly because it was anticipated that there would be problems when implementing the curriculum.

National survey of international electives for global health in undergraduate medical education in Japan, 2011-2014

Interest in global health in medical education is increasing in Western countries, whereas data from non-Western countries is scarce. Here, we conducted a nationwide study of international clinical electives at Japanese medical schools from 2011 to 2013. We constructed a 28-item cross-sectional survey in Japanese to investigate the rate and characteristics of both Japanese students going abroad and international students coming on exchange to Japan. The surveys were sent to the administrative offices of all 80 Japanese medical schools in each of the three years, through the Japan Medical Education Foundation. All 80 medical schools responded to the questionnaire (response rate, 100%). An average of 70 of the 80 medical universities provided exchange programs across the three years to allow students to travel abroad as part of the school curriculum and obtain academic credit. The schools provided support in the form of in- and outside-class preparatory programs, tuition fee exemptions and housing. The most popular destinations for Japanese students going abroad were Europe and North America, which may reflect the desire of Japanese students to acquire medical knowledge or experience through exposure to the English language. In contrast, the most common countries of origin of international exchange students coming to Japan were Asian countries such as South Korea, Thailand and Taiwan, with pediatrics being the most popular elective. Foreign exchange programs are becoming increasingly incorporated into the Japanese medical education curriculum and can help to strengthen international partnerships and collaborations.

The "Glocalization" of Medical School Accreditation: Case Studies From Taiwan, South Korea, and Japan

PURPOSE

In an age of globalized medical education, medical school accreditation has been hailed as an approach to external quality assurance. However, accreditation standards can vary widely across national contexts. To achieve recognition by the World Federation for Medical Education (WFME), national accrediting bodies must develop standards suitable for both local contexts and international recognition. This study framed this issue in terms of "glocalization" and aimed to shine light on this complicated multistakeholder process by exploring accreditation in Taiwan, South Korea, and Japan.

METHOD

This study employed a comparative case-study design, examining the national standards that three accreditation bodies in East Asia developed using international reference standards. In 2015-2016, the authors conducted document analysis of the English versions of the standards to identify the differences between the national and international reference standards as well as how and why external standards were adapted.

RESULTS

Each country's accreditation body sought to balance local needs with global demands. Each used external standards as a template (e.g., Liaison Committee on Medical Education, General Medical Council, or WFME standards) and either revised (Taiwan, South Korea) or annotated (Japan) the standards to fit the local context. Four categories of differences emerged to account for how and why national standards departed from external references: structural, regulatory, developmental, and aspirational.

CONCLUSIONS

These countries' glocalization of medical accreditation standards serve as examples for others seeking to bring their accreditation practices in line with global standards while ensuring that local values and societal needs are given adequate consideration.

Development of culture-sensitive clinical teacher evaluation sheet in the Japanese context

AIM

Many instruments for evaluating clinical teaching have been developed, albeit most in Western countries. This study aims to develop a validated cultural and local context sensitive instrument for clinical teachers in an East Asian setting (Japan), Japanese Clinical Teacher Evaluation Sheet (JaCTES).

METHODS

A multicenter, cross-sectional evaluation study was conducted. We collected a total of 1368 questionnaires on 304 clinical teachers, completed by residents in 16 teaching hospitals. The construct validity was examined by conducting a factor analysis and using structural equation modeling (SEM). We also assessed the reliability using generalizability analysis and decision study.

RESULTS

Exploratory factor analysis resulted in three-factor (role model, teaching activities, and accessibility) model including 18 items. Confirmatory factor analysis was performed, using SEM. The comparative fit index was 0.931 and the root mean square error of approximation was 0.087, meaning an acceptable goodness of fit for this model. To obtain a reliable dependability-coefficient of at least 0.70 or higher, 5-8 resident responses are necessary.

DISCUSSION AND CONCLUSION

JaCTES is the first reported instrument with validity evidence of content and internal structure and high feasibility in Japan, an East Asian setting. Medical educators should be aware of the local context and cultural aspects in evaluating clinical teachers.

Describing student performance: a comparison among clinical preceptors across cultural contexts

CONTEXT

Health professional student evaluation during experiential training is notably subjective and assessor judgements may be affected by socio-cultural influences.

OBJECTIVES

This study sought to explore how clinical preceptors in pharmacy conceptualise varying levels of student performance and to identify any contextual differences that may exist across different countries.

METHODS

The qualitative research design employed semi-structured interviews. A sample of 20 clinical preceptors for post-baccalaureate Doctor of Pharmacy programmes in Canada and the Middle East gave personal accounts of how students they had supervised fell below, met or exceeded their expectations. Discussions were analysed following constructivist grounded theory principles.

RESULTS

Seven major themes encompassing how clinical pharmacy preceptors categorise levels of student performance and behaviour were identified: knowledge; team interaction; motivation; skills; patient care; communication, and professionalism. Expectations were outlined using both positive and negative descriptions. Pharmacists typically described supervisory experiences representing a series of these categories, but arrived at concluding judgements in a holistic fashion: if valued traits of motivation and positive attitude were present, overall favourable impressions of a student could be maintained despite observations of a few deficiencies. Some prioritised dimensions could not be mapped to defined existing educational outcomes. There was no difference in thresholds for how student performance was distinguished by participants in the two regions.

CONCLUSIONS

The present research findings are congruent with current literature related to the constructs used by clinical supervisors in health professional student workplace-based assessment and provide additional insight into cross-national perspectives in pharmacy. As previously determined in social work and medicine, further study of how evaluation instruments and associated processes can integrate these judgements should be pursued in this discipline.

How does culture affect experiential training feedback in exported Canadian health professional curricula?

OBJECTIVES

To explore feedback processes of Western-based health professional student training curricula conducted in an Arab clinical teaching setting.

METHODS

This qualitative study employed document analysis of in-training evaluation reports (ITERs) used by Canadian nursing, pharmacy, respiratory therapy, paramedic, dental hygiene, and pharmacy technician programs established in Qatar. Six experiential training program coordinators were interviewed between February and May 2016 to explore how national cultural differences are perceived to affect feedback processes between students and clinical supervisors. Interviews were recorded, transcribed, and coded according to a priori cultural themes.

RESULTS

Document analysis found all programs' ITERs outlined competency items for students to achieve. Clinical supervisors choose a response option corresponding to their judgment of student performance and may provide additional written feedback in spaces provided. Only one program required formal face-to-face feedback exchange between students and clinical supervisors. Experiential training program coordinators identified that no ITER was expressly culturally adapted, although in some instances, modifications were made for differences in scopes of practice between Canada and Qatar.  Power distance was recognized by all coordinators who also identified both student and supervisor reluctance to document potentially negative feedback in ITERs. Instances of collectivism were described as more lenient student assessment by clinical supervisors of the same cultural background. Uncertainty avoidance did not appear to impact feedback processes.

CONCLUSIONS

Our findings suggest that differences in specific cultural dimensions between Qatar and Canada have implications on the feedback process in experiential training which may be addressed through simple measures to accommodate communication preferences.

The discomfort of an educator's critical conscience: the case of problem-based learning and other global industries in medical education

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