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

Abstract

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.

Keywords:

• International medical education
• medical education research
• trends

Introduction

Although the concept of globalisation has been ubiquitous in the early 21st century, it originated relatively recently and was first systematically developed by the sociologist Roland Robertson (1992). It has, though, been widely popularised by scholars from a variety of different disciplinary backgrounds, fervently debating its intended and unintended consequences for nations, organisations, and individual citizens. Although definitions have varied according to the field and topic of interest, it fundamentally deals with the widening, deepening, and speeding up of ‘worldwide interconnectedness’ (Held et al. 1999). Whilst some commentators have noted that many observations about globalisation have been based on the dominant economic framework, social scientists have examined it in much broader terms, encompassing global social, cultural, and economic interdependence and interconnectedness (Sengupta 2001; Dreher et al. 2008).

Practice points

• The earliest scholarship about globalisation within medical education was dominated by hyperglobalist perspectives that emphasised the inevitability and benefits of globalisation, and sceptical perspectives that emphasised its harms.

• In the last decade, the dominant perspective about globalisation in the medical education literature has been transformationalist, recognising positive and negative consequences through a lens of complexity and multidimensionality.

• Medical education practitioners and scholars can draw on these perspectives as they approach international and global activities, recognising the shifting perspectives in recent years.

Within medical education, there has been a long history of medical professionals moving between countries, patients travelling overseas to receive medical care, students studying at medical schools outside of their own countries, and public health and research collaborations across nations (Ibrahim and Abdel-Razig 2021). In recent decades, more tangible manifestations of globalisation have included the transnational transfer of medical curricula (Waterval et al. 2018), the global migration of doctors and medical students (Toader 2020), the establishment of international branches of medical schools (Kassim et al. 2016), and the development of global regulatory practices, such as those of the World Federation for Medical Education (Sjöström et al. 2019). One might conceptualise these trends within medical education as what Sengupta (2001) described as ‘pointing towards the globe as a single inclusive place.’

In response to the volume of globalisation research and the number of disciplines from which it arises, Holton (2005) has presented three key perspectives in globalisation theory—hyperglobalist, sceptical, and transformationalist.

Globalisation theory is widely seen to have started in the 1980s and was characterised in this early period by admiring accounts of the globalisation of economy, politics, and culture and the sweeping away of the significance of territorial boundaries and national economies, states, and cultures (Martell 2007). In simple terms, it argued that if governments allow organisations the freedom to ‘do business,’ wealth will be generated, which will trickle down to everyone. This perspective is described by Holton (2005) as ‘hyperglobalist’ in that it argues that national governments have much less socio-political influence or even none at all. It sees globalisation as a unique, entirely lawful, and progressive process of unification. It conceptualises globalisation as a ‘leveller’ that helps to create economic and social opportunities that would otherwise have not existed.

A more sombre set of accounts reacted by arguing that globalisation is neither new nor progressive. This ‘sceptical’ perspective is concerned with the abstract nature of globalist ideas, which seem to be thin on empirical substantiation and make sweeping claims about processes as if they affect all areas of the world evenly and with the same responses (Martell 2007). It draws on evidence of the continuing role of nations and the ongoing importance of national borders. Sociologists Beck et al. (2003) have highlighted that cultural globalisation essentially refers to the overwhelming dominance of one culture, that of the U.S., as they argue in their exploration of the term ‘Americanisation.’ The sceptical perspective also highlights that the world has seen greater, rather than lesser, nationalism in many places, often in response to the perceived and real threats of globalisation (Milner 2020). Seabrook (2004), meanwhile, argues that integration into a single global economy is a ‘declaration of cultural war’ upon other cultures and societies and that it often results in profound social disruption. The sceptical perspective, then, challenges the consequences, ubiquity, and sustainability of globalisation.

A third perspective recognises some validity of both the hyperglobalist and sceptical perspectives that emerged in the earliest periods of globalisation analysis. This ‘transformationalist’ perspective has sometimes been referred to as the ‘third wave’ of globalisation theory (Martell 2007). It suggests that whilst a critical assessment of the claims of globalisation is needed, one should not ‘throw out the baby with the bathwater’ (Held and McGrew 2003). The outcome of this has been the recognition of a more complex picture of globalisation, as described by the prominent sociologist, Anthony Giddens (1990). Globalisation is seen as occurring but without just sweeping all away before it, as hyperglobalists might have it. Instead, transformationalists argue that cultural exchange is not unilateral from West to East but rather a two-way exchange in which Western culture is also changed and influenced. Randeria (2007) proposes that through this process, a new and complex social order is appearing in the world. The transformationalist perspective frames the process of globalisation as uneven and uncertain, insisting on its multidimensionality.

These three perspectives have subsequently been widely used to help provide social scientists with a framework for thinking about globalisation. As the literature on globalisation in medical education has grown rapidly in recent years (Hodges et al. 2019), this article seeks to apply this analytical framework to it, to help identify shifting patterns and ideas, and to guide educators and policymakers seeking to respond to the ongoing and dynamic challenges and opportunities arising from globalisation.

Methods

Database searches (PubMed and Google Scholar) in February 2020 using a combination of search terms around the terms ‘Globalisation’ and ‘Medical Education,’ for articles of all types between 1980 and 2020, were combined with hand-searching of reference lists and citation searches of key papers. These searches identified 1537 articles in total, which were subsequently screened using titles and abstracts to identify those relevant to the aims of this study, which were, in turn, analysed and synthesised using the framework described above.

Results

A summary of the findings is presented in Table 1.

Table 1. Summary of findings.

Globalisation perspective	Example in medical education	References
Hyperglobalist	International consensus on ‘core competencies’ in global health	Brewer et al. 2009
	Global adoption of problem-based learning methodology	Khoo 2003; Ju et al. 2016
	Widespread use of English language	Wang and Zhao 2004; Huang 2009
	Using technology to interconnect	Harris et al. 2001; Smothers et al. 2008
	Globally agreed medical school learning outcomes	Harden 2002, 2006; Schwarz and Wojtczak 2002
	Universal definition of medical professionalism	Medical Professionalism Project 2002; Creuss et al. 2010; Jha et al. 2015; Brouwer et al. 2020
Sceptical	Global standards as a means to enable Westward migration	Banerji 1981; Zaidi 1987; Solanki and Kashyap 2014
	Uneven power balances in the global community	Gao 2015; Gosselin et al. 2016
	Commercial and economic framings of engagement	Slaughter and Leslie 1997; Green 2007; Hodges et al. 2009; Martimianakis and Hafferty 2013
	One-sided benefits from partnerships	Edwards et al. 2004; Khan et al. 2017
	Emulation of approaches from Western countries	Huggan et al. 2012; Nemr et al. 2012
Transformationalist	Combining global and local approaches	Bates et al. 2019
	Complexity of adopting teaching and learning approaches in different cultures	Tabulawa 2003; Greveson and Spencer 2005; Hussain et al. 2007; Jippes and Majoor 2008; Tavakol and Dennick 2010; Frambach et al. 2012; Stevens and Goulbourne 2012
	Modifying models and approaches for the local context	Zaini et al. 2011
	Multiplicity of definitions of medical professionalism	Hodges et al. 2011; Ho et al. 2011; Al-Eraky et al. 2014; Nishigori et al. 2014
	Central importance of recognising local culture	Rees et al. 2009; Wong 2011; Fan et al. 2013
	Respectful international partnership approaches	Whitehead et al. 2018; Rashid et al. 2019
	Benefits and drawbacks of using the English language	Yang and Xi 2009; Al-Kadri et al. 2013

Hyperglobalist perspectives in medical education

Hyperglobalist perspectives have been manifest through approaches to what is taught, how it's taught, and the products of, medical education. Perhaps unsurprisingly, teaching about global health has been analysed in the context of globalisation, although much of this has come from the global health community and not the medical education community (Bateman et al. 2001). For example, a collaborative statement from several global health agencies urges medical schools to dedicate the necessary resources to ‘embrace’ international health (Evert et al. 2006), projecting it as a progressive and morally right course of action. There has also been a call for an international consensus on what constitutes core competencies in global health (Brewer et al. 2009), hyperglobalist in that it suggests a single statement could be universally applicable globally.

In recent decades, medical schools in Western countries have moved towards a student-centred learning model that has fundamentally changed both the philosophical basis of, and the practical implementation of, undergraduate medical education (Lemos et al. 2014). Problem-based learning (PBL) was a particularly widely adopted example of this new educational paradigm (Wood 2003). Although it began as a Western model of teaching medicine, it was adopted by medical schools in all parts of the world with great enthusiasm (Ju et al. 2016). Much of this adoption was based on hyperglobalist ideas, including the apparent ubiquity of medical school education environments. Early adopters from Eastern countries suggested that PBL could be used just as effectively in Asian countries as it could in the West (Khoo 2003).

The English language has also been promoted in a hyperglobalist way in the context of medical education. Wang and Zhao (2004) encourages the use of English in China, arguing that it is needed to allow scholars in the country to ‘contribute’ their share to globalisation. Huang (2009) argues along similar lines in the Japanese context, presenting data that shows the dramatic move towards publication of textbooks and articles in English over two decades.

Technology has also been a part of the hyperglobalist perspective in medical education. Harris et al. (2001) celebrated how their ‘academic centre in an English-speaking country’ could use the internet to provide low-cost medical training to doctors around the world. The ‘eViP’ (electronic Virtual Patients) project, which involves interactive computer programs that simulate real-life clinical scenarios for educational purposes (Smothers et al. 2008), can also be considered hyperglobalist, in that it seeks to enable the ‘exchange’ of virtual patients across countries.

Another popular idea in medical education in recent decades has been ‘outcomes-based education,’ where the orientation moves from process to ‘product.’ In 2002, the Institute for International Medical Education developed a set of core competencies which represent the minimum essential core competencies that all physicians must have (Schwarz and Wojtczak 2002). As a widely-cited editorial by Harden (2002) from this time makes clear, there was great excitement about the prospect of the learning outcomes developed by this project being widely used by countries in the ‘East and West.’ Harden (2006) later develops this further, quoting Friedman’s vision of globalisation ‘flattening’ the world and using it to suggest not only universally agreed learning outcomes, but also a ‘transnational’ approach to the entire medical school curriculum, culminating in his vision of a truly hyperglobalist idea: an ‘international virtual medical school.’

In the early part of the 21st century, the Medical Professionalism Project sought to ‘promote an agenda for the profession of medicine that is universal in scope and purpose’ (Medical Professionalism Project 2002). In their ‘Physicians Charter,’ the project team argued that despite wide variations in the practice of medicine, they were able to identify ‘fundamental principles’ as a set of definitive professional responsibilities. This homogenisation of the professionalism of medicine is hyperglobalist in that it seeks to transcend national and cultural differences. In a report of an international medical education conference meeting, Cruess et al. (2010) suggested, similarly, that there exist only ‘minor differences’ between countries and cultures, and that professionalism is ultimately universal. Jha et al. (2015) also suggest that it would be both possible and desirable for the medical education community to develop a framework of professionalism as a ‘global construct.’ Work exploring apparently ‘international’ programmes have also raised similar suggestions. A study that investigated the experiences of curriculum developers of ‘international’ medical school programmes in Hungary, the Netherlands, and Malaysia, found a clear desire in the group to produce doctors who were ‘universal’ professionals who could practice anywhere in the world after graduation (Brouwer et al. 2020).

Sceptical perspectives in medical education

There are also many examples of sceptical perspectives in the medical education literature. The migration of doctors is a politically contentious topic because of the implications for healthcare services as well as medical education systems. In critical reviews of medical education in India (Banerji 1981; Solanki and Kashyap 2014) and Pakistan (Zaidi 1987; Shaikh and Humayun 2012), the Western influence has been problematised by local educators. Not only does the dominance of the English language cause doctors to become alienated from ‘the masses’ of local populations (Banerji 1981), the focus on hospital-based teaching that arises from adopting an English approach to medical training limits interaction with rural communities (Zaidi 1987), and the overall effect is to cater either for the elite of the country or to maintain foreign standards by assisting migration to the West (Banerji 1981; Zaidi 1987; Solanki and Kashyap 2014). Experiences in Sub-Saharan Africa are similar and at one stage, there were found to be more Malawian doctors practising in the city of Manchester in the UK than in the whole of Malawi (Broadhead and Muula 2002). This is an example of ‘medical brain drain,’ a term which has been used to describe doctors moving from developing countries to developed countries, and has been argued to be profoundly impactful across all health professions (Pang et al. 2002). This fits within the sceptical perspective in that it focuses primarily on the harms that globalisation causes to local communities.

Although Segouin et al. (2007) and later Hodges et al. (2009) lament the lack of cross-cultural research within the field of medical education, a small number of studies have explored the impacts of globalisation in a critical way. For example, Xu (2007) describes noticeable incongruence between Chinese beliefs and Western concepts, so much so that they argue that adopting Western practices could be both harmful and unethical. Meanwhile, Gao (2015) challenges the motives of promoting the notion of a global medical education ‘community,’ suggesting that the pursuit of networks or connections by elite research universities is likely to be to achieve the academic accolade. A systematic review of medical education articles published between 2006 and 2014 showed that only 8.7% of medical education research takes place in non-Western countries, although the overwhelming majority of education practice occurs in these settings (Gosselin et al. 2016). The authors of this review argue that the resource differences that lead to such disparities may be further compounded by the tendency of non-Western stakeholders to be hesitant to express disagreement. In challenging the motivations and assumptions of a global medical education ‘community,’ these studies fit within the sceptical category.

Given that the term originated in the field of economics, it comes as little surprise that globalisation in medical education has been examined in economic terms. Reductions in governmental funding for medical schools have been cited as a key reason for the rapid development of ‘academic capitalism’ in medical schools (Slaughter and Leslie 1997). An early and oft-discussed example is Weill-Cornell Medical School’s branch campus in Qatar, which was established in 2005. As Green (2007) noted, this was conceptualised from the outset as a ‘revenue stream,’ and as Marginson and van der Wende (2007) stated, this new venture took place amidst a perfect storm of factors that led to the ‘global marketisation’ of higher education. Academic capitalism has continued to be examined in this context, including in the United Arab Emirates (Al Serhan and Houier 2020). In a seminal paper outlining the influence of economic discourses in medical education, Hodges et al. (2009) unpicked the trends towards commercial dominance in the field. They noted, for example, the now-routine conceptualisation of physicians being ‘imported’ and ‘exported,’ and the packaging and trading of educational materials as commodities. Martimianakis and Hafferty (2013), meanwhile, demonstrate that in efforts to attract medical tourism, institutions are keen to advertise the fact that their physicians have trained in the U.S., suggesting that such marketing promotes the idea that only Western education connotes quality. In focusing primarily on the harmful consequences of globalisation, these views can all be classed as sceptical as they project globalisation as a destructive force.

Further sceptical viewpoints can be seen in studies that explore international medical education collaborations. In the context of Sub-Saharan Africa, for example, Alemu (2014), has outlined how more powerful universities quickly adopt the role of ‘supplier’ of knowledge, leaving weaker and poorer institutions with no choice but to be ‘consumers.’ Tan and Macneill (2015) have also challenged the business activities of medical schools in Western countries, who commercialise branding and prestige, and for whom often ‘the main driver is to maximise profitability across national boundaries rather than concern for human well-being’ (p. 850). It is not just medical schools that have been examined with a sceptical outlook though. Khan et al. (2017) have outlined concerns about Western medical students potentially representing ‘destructive forces’ when conducting overseas electives, echoing concerns previously raised about this model contributing to a medical education ‘inverse care law’ (Edwards et al. 2004).

Using a case study of the Pakistani medical school circuit, Zaidi (1987) drew parallels between the economic dominance of developed countries over developing ones and the ideological dominance that takes place within medical education. She noted that such dominance, which is often by an ex-Colonial country, typically overshadows the different disease patterns and resource limitations of developing countries. Marginson and van der Wende (2007) highlighted that such power imbalances are commonplace and result from a desire from some countries to match the apparent superiority of others. Hong et al. (2010) pointed out the great ‘esteem’ that Chinese medical educators hold for any Western education research, Nemr et al. (2012) noted that medical schools in Lebanon want to ‘keep up’ with practices in Europe and North America, and Huggan et al. (2012) mourned that the most pressing question in medical education in Singapore is whether the British or American system is more suitable for adaptation. Each of these articles expresses concerns about the intellectual harms caused by globalisation and thereby fits into the sceptical category.

Transformationalist perspectives in medical education

The transformationalist perspective recognises arguments from both sceptical and hyperglobalist perspectives. In the context of medical education, it has been the most widely adopted viewpoint. It is perhaps most clearly embodied in a Canadian literature review that argued that both ‘standardisation’ and ‘contextualisation’ each have a role in the design and delivery of medical education systems, which in turn should seek to fulfill both global and local needs (Bates et al. 2019).

As described in the ‘hyperglobalist’ section of this article, PBL became a popular method in Western medical education that was initially thought to be widely transferrable. Although earlier views of it were hyperglobalist, these soon changed to a more transformationalist position, with the recognition that challenging peers or the tutor, a key element of PBL practice, was ‘culturally inappropriate’ in some settings (Hussain et al. 2007). A study that used empirical case studies of PBL adoptions at medical schools in the Netherlands and Jamaica noted that people do not just ‘naturally’ work well together and that the import of instructional designs to different cultures requires deep reflection and adaptation (Stevens and Goulbourne 2012). Indeed, Jippes and Majoor (2008) have shown that the propensity of a country to adopt PBL curricula actually correlates quantitatively with national culture, as defined by various numerical cultural parameters.

The idea of learner-centred pedagogy has also been challenged based on both values and technical grounds. It has been suggested, for example, that such strategies are underpinned by neoliberal ideologies that are deemed important for the operation of free-market economies (Tabulawa 2003), and rely strongly on western ideals of democracy, individualism, and egalitarianism (Greveson and Spencer 2005). It has also been argued that such approaches ignore the importance of ‘losing face’ and the focus on achievement and competition that characterises some non-Western cultures (Frambach et al. 2012). Although much of the literature has focussed on the export and replication of educational approaches, a British study of Asian international medical students’ learning styles’ suggested that they were not just rote learning as stereotyped, but rather adopting a Confucian-inspired, effort-focussed, learning attitude (Tavakol and Dennick 2010). These studies all point out the complexities of implementing teaching and learning approaches across different cultures, emphasising the inherent complexity of this process. In that they still ultimately argue that such adjustments are possible, they are transformationalist rather than sceptical in their outlook.

The outcomes-based educational approach outlined in the hyperglobalist section of this review was the ideological basis for another movement known as ‘competency-based medical education’ (CBME), with a focus on ‘competence’ and ‘competencies’ that need to be achieved (ten Cate 2017). CBME has become widely popular over the last two decades. Perhaps nowhere has it been more dominant than in Canada, where the launch of the CanMEDS framework in 2005 cemented a clear move towards conceptualising physician practice, and therefore training, in terms of distinct roles (Whitehead 2011). Although some have framed this as the ‘modernisation’ of medical education (Stevens and Goulbourne 2012), the movement has also been met with criticism. Grant (1999), for example, described the way in which it can oversimplify and depreciate the profession of medicine. Whitehead et al. (2013) also exposed unintended consequences of competency frameworks, especially in their compartmentalisation of the role of a physician and marginalisation of the importance of values. In the adaptation of the Canadian CanMEDs framework for Saudi Arabia, resulting in the SaudiMEDs framework, adaptations were needed although it did not differ ‘significantly’ (Zaini et al. 2011). In noting the challenges but possibilities of such modifications, this outlook can be seen as transformationalist.

In the hyperglobalist section of this article, it was noted that at an international medical education conference workshop in 2009, it was decided that professionalism was ultimately universal with only ‘minor differences’ between cultures (Cruess et al. 2010). Just a year later, a second such conference workshop, this time focussing on the assessment of professionalism, had a quite different conclusion. It suggested that there were likely to be multiple different ways of conceptualising the idea of professionalism around the world, and suggested a move towards a ‘multi-dimensional, multi-paradigmatic approach’ to account for these differences (Hodges et al. 2011). The contrast between the findings of these workshops is stark, as it seems unlikely that the differences between the teaching and assessment of professionalism could explain such opposing conclusions. It is noteworthy in that it demonstrates both the limitations of such consensus statements and also the differences in opinion from amongst the medical education ‘community.’ Whilst the former was hyperglobalist in outlook, the latter is firmly transformationalist.

In the decade since these two conference workshops on professionalism, the medical education literature has taken on a transformationalist perspective on this topic, noting that universal definitions of professionalism are problematic. Ho et al. (2011) produced a country-specific professionalism framework for Taiwan, grounded in Confucian cultural traditions, and challenging the ‘universal applicability’ of the Western framework. Similarly, Al-Eraky et al. (2014) adapted a North American framework for the Arabian context and later used a Delphi method to propose a ‘four gates model’ for Arabian medical professionalism, which includes as one of the four gates, a series of Islamic faith-based principles about accountability to God. Comparable studies have developed professionalism frameworks in Japan (Nishigori et al. 2014) and China (Pan et al. 2013), both producing models that differ from the Western, Hippocratic tradition. These ideas about professionalism are transformationalist, rejecting both the universal definition of professionalism promoted by hyperglobalist scholars, as well as the notion from sceptical scholars that the adaptation of western frameworks is invalid.

The rector of King Fahd University in Saudi Arabia once said: ‘some countries have sacrificed the soul of their culture to acquire the tools of Western Technology. We want the tools but not at the price of annihilating our religion and cultural values’ (Reynolds 1980). Although culture is of relevance to globalisation in the broadest sense, it is explicit within parts of the medical education literature. In a study examining medical students’ anxieties about peer examination, it was found that Middle Eastern students characterised more body regions as intimate than their Western counterparts (Rees et al. 2009). Similarly, a study comparing residency programmes in Canada and Thailand found that although the technical and scientific basis of education was similar, its enactment was significantly influenced by ‘culture and context’ (Wong 2011). In China, meanwhile, a study noted that the profession of medicine was itself evolving due to the fusion of Western and Eastern cultures, and that medical schools should match this by promoting exchanges, both of students and of ideas, to reach ‘harmonisation’ (Fan et al. 2013). Given that these studies portray culture as a consideration and not as an insurmountable barrier to globalisation, they can be framed as transformationalist.

As was established in the hyperglobalist section of this review, much of the economic language in medical education has focussed on international relationships that have been transactional in nature. There are, though, examples of activities that buck this trend. The Toronto Addis Ababa Academic Collaboration is a longstanding, wide-ranging partnership that is framed entirely in terms of respectful and reflexive engagement (Whitehead et al. 2018). Other international collaborations in medical education are starting to follow suit and are seeking to recognise cultural differences and complexities and form educational partnerships that are grounded in respect and building local capacity (Rashid et al. 2019; Rashid et al. 2020). There are, then, transformationalist perspectives in the context of international education partnerships as well as the hyperglobalist ones outlined previously.

As with cultures and traditions, the languages of the world influence the process of globalisation. International scientific publishing is one important aspect of this, and English is widely considered the ‘lingua franca’ of academic publication (Steger 2017). In a nuanced analysis of potential ‘trade-offs’ between local and international publications, Flowerdew and Li (2009) noted that there are important ideological implications of writing in English. Within medicine, the use of English as a language of instruction is widespread, and as a number of scholars have highlighted, potentially problematic. Zaidi (1987) highlighted the important consequences this has on selection, as a preference for English shows a bias towards the elite and westernised urban-based minority. Not only does it limit the diversity of students, but it further entrenches the differences between them and the largely illiterate public that they are training to serve. As Yang and Xi (2009) point out, studying in English may also mean that additional effort is needed to understand the language, distracting from the content of the medical curriculum itself. Al-Kadri et al. (2013) found that the use of English added an additional layer of complexity, as faculty members were making adjustments and taking more lenient views when teaching and assessment were done in English rather than Arabic. Whilst each of these articles draws attention to some of the disadvantages of using English, they do all recognise some benefits, primarily related to accessing medical knowledge. In acknowledging this complexity, they fit within the transformationalist category of thinking on globalisation.

Discussion

The academic literature examining globalisation in the field of medical education is highly variable in its form, content, coverage, and findings. Notably, there is a growing body of evidence that is comparative, reflexive, and grounded in empirically tested hypotheses. This work has particularly been generated in the last decade and has been predominantly transformationalist in its perspective. The medical education literature has then, mirrored the broader literature across the social sciences (Martell 2007), in moving over time from hyperglobalist and sceptical positions, towards a ‘third wave’ of globalisation thinking that is transformationalist in its perspective.

Hyperglobalist ideas that suggest and promote universality and homogenisation have been proposed, as have sceptical ideas that reject them. What is noteworthy, though, is that these ideas have generally not come to fruition from a policy and practice perspective. For example, the notion of using universal learning outcomes across medical schools in the world has not been realised, less still the idea of an ‘international virtual medical school,’ which seems even more remote an idea now, 15 years after it was first suggested, despite the advances in technology that may make it seem more possible to implement. In the same way, many sceptical ideas have not been realised. The suggestion that western educational approaches cause outright harm in eastern countries is not consistent with the fact that many years on, approaches like PBL continue to be enthusiastically used all around the world, albeit often with adaptations (Musa et al. 2020). Likewise, sceptical criticisms about the transactional and financial basis of medical education international partnerships have not led to the end of these relationships (Wu et al. 2020). In fact, they seem to be getting more popular, although as mentioned in the transformationalist section of this chapter, their nature of them is changing.

What is also clear from this literature, though, is that there have been no major, overt policy decisions that have successfully ‘globalised’ medical education. The movement of ideas and practices has instead been more organic and uneven, through choices made by individual educators and institutions rather than through compulsion, and have been tempered by sceptical, and eventually transformationalist, perspectives.

This study builds on, and aligns with, previous work on globalisation in medical education. Bleakley et al. (2008) critically examined how medical education has responded to globalisation, drawing on post-colonial theory to examine how medical schools in non-Western countries struggle with the ingrained cultural assumptions of some curricular innovations. Similarly, Hodges et al. (2009) described how globalisation is ‘dramatically transforming’ what medical schools do and called for a greater understanding of its ‘cultural, political, and sociological’ impacts on medical education. Meanwhile, in their examination of PBL across different countries, Stevens and Goulbourne (2012) highlight that Western approaches require ‘deep reflection and adaptation’ to ensure they can be used in different environments. Through the framework applied in this review, these studies collectively emerge as an important landmark as the literature in medical education moved towards a transformationalist position, which has remained the dominant perspective in the decade since they were published. This is exemplified, for example, in a recent examination of medical schools in Hong Kong that describes the ‘multi-layered complexities of a trilingual globalised city’ (Wong and See 2020).

The strengths of this study are the application of a widely used framework that has been applied across various disciplines and the analysis by a team immersed in international medical education practice professionally. A limitation of this study was that relevant articles may have been overlooked. The study only looked at English language articles, which limits the breadth of ideas, and the database search strategy relied on the term ‘globalisation,’ and scholars may have examined this notion without tagging it or adding it as a keyword. In addition, this was not a systematic review, But as Greenhalgh et al. (2018) note, narrative reviews provide interpretation and critique, helping to deepen understanding rather than to summarise data in the way that systematic reviews do. In that this study examines the period up to 2020, it does not capture articles about the COVID19 pandemic, which may have altered perspectives on globalisation within the medical education community. Given the profound and universal impacts of this event, it is worthy of separate study altogether.

The medical education literature has evolved over time and has recognised both pros and cons of globalisation. Those engaged in international partnerships, collaborations, and policymaking in medical education could reflect on these changing perspectives as they plan ahead for the future, noting that scholarship has moved towards a recognition that globalisation is multifaceted. In particular, the importance of cultural and linguistic sensitivity is a clearly important practice and policy focus area emerging from this literature, as well as the inevitable tensions of prioritising both ‘global’ and ‘local’—amalgamated by some scholars in medical education through the hybrid term ‘glocalisation’ (Ho et al. 2017).

Future research could build on this framework to examine particular aspects of medical education, such as teaching and learning methods, assessment, or accreditation, or else to examine particular world regions in depth. Moreover, an in-depth analysis of the perspectives highlighted in this review using different lenses, such as those offered by post-colonial theory, may help to highlight the global power imbalances and inequities that have may have contributed to the dominance of some cultures and countries over others, as scholars from the field are starting to uncover (Wondimagegn et al. 2020; Naidu 2020).

In summary, the medical education literature has responded to globalisation with a range of opinions and outlooks that eventually moved from more polarised positions to a more moderate perspective. Earlier, more radical, ideas and suggestions have generally not materialised. As medical education practitioners and policymakers approach the global challenges of tomorrow, they should be mindful of these trends and recognise the inherent complexity and multidimensionality of globalisation.

Glossary

Transformationalist: Is a perspective in globalisation theory that recognises both positive and negative impacts of globalisation on the world (Holton 2005).

Acknowledgements

The author would like to thank Professor Deborah Gill and Professor Ann Griffin for comments on an earlier version of this manuscript, which was conducted as part of a post-graduate research degree in Medical Education at UCL that they both supervised.

Disclosure statement

The author reports no conflicts of interest. The author alone is responsible for the content and writing of the article.

Correction Statement

This article has been corrected with minor changes. These changes do not impact the academic content of the article.

Additional information

Notes on contributors

Mohammed Ahmed Rashid

Mohammed Ahmed Rashid, MBChB, MSc, MD, MRCGP, PFHEA, UCL Medical School, GF/664, Royal Free Hospital, London, NW3 2PR, UK.