Becoming Agents of Change: Contextual Influences on Medical Educator Professionalization and Practice in a LMIC Context

Abstract

Phenomenon

Medical educators are particularly needed in Low- and Middle-Income Countries (LMIC), where medical schools have grown rapidly in size, number, and global outlook in response to persistent health workforce shortages and increased expectations of quality care. Educator development is thus the focus of many LMIC programs initiated by universities and governments of high income countries. While signs of medical educator professionalization such as postgraduate qualifications, specialized units, and professional associations have emerged in LMIC, whether these relate to programs originating from outside LMIC contexts is unknown. This study investigated the contextual influences on the long-term impact of an international faculty development program a decade after its delivery in a LMIC context – Vietnam.

Approach

Ten years after an international aid program to develop clinical skills teaching expertise in Vietnam, we conducted in-depth qualitative interviews with eight medical educators from all eight participating medical schools. Selected for their leadership potential, each participant had completed the Maastricht Masters in Health Professions Education during the program. Interview transcripts underwent thematic analysis, using the Theory of Practice Architectures as a conceptual lens to highlight the contextual influences on professional practice.

Findings

Four themes were identified: Careers and Practices before, during, and after the program, Unrecognized and Unseen practice, Structural Restraints on individual advancement and collective activity, and the Cultivation of Connections through social traditions. Participants reported being in well-established teaching delivery roles. However, the absence of professionalizing discourses and material resources meant that practice was restricted and determined by institutional leadership and individuals’ adaptations.

Insights

Informed by the theory of practice architectures, we found that change in medical education practice will falter in contexts that lack supporting discursive, material-economic, and socio-political arrangements. While there were emerging signs of individual agency, the momentum of change was not sustained and perhaps unapparent to Western framings of educational leadership. Practice architectures offers a framework for identifying the contextual features which influence practice, from which to design and deliver sustainable and impactful interventions, and to advance context-relevant evaluation and research. Our findings suggest that faculty development delivered across diverse contexts, such as in distributed or transnational medical programs, may have more effect if informed by a practice architectures analysis of each context.

Keywords:

• medical educator
• professionalization
• low- and middle-income country
• practice architecture
• faculty development

Introduction

Medical educators are needed to train graduates who will meet the continuing demand for quality medical care, particularly in Low and Middle Income Countries (LMIC) where health professional shortages persist.¹ Globally, the public expects well-trained medical graduates from high quality curricula, teaching, and assessment systems. In response, LMIC medical schools have rapidly grown in number, size, and global outlook.² Some have adopted international accreditation standards,³ which require teacher expertise through staff recruitment, professional development, and performance appraisal.⁴ The demand for medical education expertise has been met by migration of medical educators,⁵ transnational medical program partnerships,^6,7 and international aid, such as faculty development projects initiated by universities, governments, and non-government agencies from high income countries.^8–10 Signs of increasing professionalization of medical educators in the Indo-Pacific include specialist qualifications such as masters degrees, regional communities of practice, medical education units and professional associations.^11–15 But whether such developments arise from changes initiated by international faculty development projects developed for other, usually high income, contexts is unknown.¹⁶

Definitions of medical educator continue to evolve alongside growing acceptance of medical education as a professionalized, specialist practice requiring formal qualifications. In 2013, the UK Academy of Medical Educators offered an inclusive definition of medical educators as “those who have committed a significant amount of their time, energy and professional development to medical education and can demonstrate that this has become an important component of their career”,^{5(p. 8)} incorporating educators with qualifications in medicine with those from other disciplines. Three specialist roles of clinician educator, research scientist, and administrative leader have been proposed.¹⁶ While teaching responsibilities are integral to university academic staff and medical practitioners’ roles, further personal and institutional investment in professional development is needed to professionalize the field.¹⁷ A recent review highlights how professionalization can be traced to the development of a teaching professional identity,¹⁸ manifested as a presentation of the self within the workplace, but variations between workplace contexts were not considered. Other indicators of professionalization such as professional standards,¹⁹ postgraduate qualifications, and dedicated units and departments²⁰ have been studied. With few exceptions^21,22 little professionalization work has been reported from LMIC contexts.

LMIC medical educators experience greater service demand and increased tensions between teaching, scholarship, and patient care, diminishing their opportunities for training and development.²³ Although research to date has focused on the barriers to professionalization of medical education due to limited resources and limited recognition of the field, there also may be strengths and affordances that are unique to LMIC contexts. To explore these possibilities, and how contextual features may influence the transferability of professionalizing practices and concepts, we explored the experiences of medical educators in an LMIC context – Vietnam – a decade after their completion of a faculty development project initiated through international aid.

Practice architectures and medical education

This study re-orients and extends earlier studies on the development of medical education careers and practice in non-LMIC contexts^16,24,25 and adds a novel theoretical framework to recent studies conducted in other very different LMIC contexts.^26,27 Distinct from other studies, our study examines context itself and the impact of context on practice. Accordingly, we sought a theory that would highlight, rather than sublimate, contextual features, but without any judgment of quality between contexts. The Theory of Practice Architectures can reveal what shapes practice and professionalization within contexts,²⁸ and also informed a related study in another LMIC context.²⁷ Context in medical education is variably understood;²⁹ our focus was on meso and macro level influences on professional practice through discursive-cultural “sayings” (i.e. professional and organizational discourses and values), material-economic “doings’ (i.e. institutional physical resources and activities), and socio-political “relatings” (e.g. institutional and professional relationships and roles). These features constitute the arrangements which “hang together” to form the practice architectures for a particular context. Practice arrangements are dynamic; continually formed and re-formed to influence, and in turn be influenced by, the enactment of practice.^30,31

In health professions education, practice architectures have provided insights on professional identity development in new graduates,³² interprofessional simulation,³³ and interprofessional practice.³⁴ By taking a theoretically informed approach, we aimed for insights into the professionalization of medical educators in a LMIC context that would be potentially transferrable to practice and research in other contexts.

Our research questions were:

• What practices and professional development do medical educators undertake in Vietnam?

• How is medical educator practice shaped by discursive-cultural, material-economic and socio-political contextual arrangements in Vietnam?

Methods

For our interview study, we adopted a constructivist qualitative research approach,³⁵ recognizing the socially constructed and multiple nature of knowledges and perspectives within contexts.

Study context—medical education in Vietnam

In recognition of Vietnam’s critical shortage of health professionals compared to recommended international thresholds,³⁶ growth and diversification of Vietnam’s medical schools has occurred.³⁷ At the time of this study, there were eleven government funded university-based medical schools within general or dedicated medical universities, each geographically distributed across all Vietnamese regions. Centralized state control through national policy requires all medical programs to be authorized and approved by the Ministry of Education and Training (MoET), and if within a medical university, also by the Ministry of Health (MoH). All schools must deliver the 6-year national curriculum for generalist medical doctors^36,38 with some institutional customization allowed. Academic position descriptions, designations—and promotions—are also determined by MoET. Some medical schools also deliver nursing, pharmacy,

and public health programs and their teaching faculty are considered “medical educators.” There is no national system of medical school accreditation, but Vietnamese medical schools are expected to reform curricula, training, and assessment systems^38,39 to meet state aspirations for regional leadership and community expectations for doctors with the clinical and communication skills to deliver patient-centered care.

The NUFFIC program

In 2004, NUFFIC, a Dutch government international aid program,⁹ funded the Ho Chi Minh City University of Medicine and MUNDO, Maastricht University’s international educational development division,⁸ to deliver a program aimed at increasing expertise in teaching clinical skills to Vietnamese medical schools.⁴⁰

All eight of the then existing university-based medical schools participated. Using their own internal selection processes, each school selected two staff who were seen as potential leaders in medical education to undertake the Master of Health Professions Education (MHPE) at Maastricht University. This was delivered according to the established Dutch format, a two-year part-time distance course, supported by annual, short residential courses when the candidates traveled as a group to Maastricht. The only modification was that candidates were to choose an educational issue within the Vietnamese context on which to base their major assessment, an educational quality improvement project report or a research-based dissertation. In 2007, 15 medical educators graduated.

Reflexivity

To authentically embed our research in local knowledges and build research capacity, our study was co-designed and conducted by authors within and/or familiar with the study context (WH, VATN, NTN), in collaboration with established medical education researchers (WH, RS). Two authors are of Vietnamese origin: VATN, a medically trained career medical educator and graduate of the Masters program, and NTN, a higher education academic. Both brought their knowledge and lived experience of Vietnamese medical and higher education, language, and culture to collect and interpret data. (WH), a medically trained career medical educator with experience in faculty development in Vietnam, and (RS), an educational scientist who served and subsequently stepped down as the coordinator of the Masters program well after the aid program had ended, brought their expertise in cross-cultural and qualitative research, relating findings to international research conversations.

Data collection

Ten years after the program concluded, we conducted semi-structured, in-depth interviews with eight Masters graduates, one from each school in the program. These interviewees comprised all of the original aid program participants who were still working in medical schools. Of the other program participants, one moved overseas, two left medical school employment and five returned to their substantive university role within their original disciplines (e.g. Public Health). Interview questions covered professional backgrounds, teaching and professional development activities before and after completing the program, the structure and function of any units they worked in, and influences on medical education practice within their university and Vietnam (see Supplementary online material). Questions were adapted from an international research program on medical education careers in Canada, USA, Australia, New Zealand, and Sri Lanka.^25,27,41 The Vietnamese researchers (VATN, NTN) revised these questions following an established procedure for bilingual research in higher education, translating, back-translating,⁴² and piloting drafts.

Interviews of up to 60 minutes were conducted in Vietnamese by (NTN), who had no prior relationship with the participants, audio recorded and transcribed verbatim in Vietnamese. Ethical approval for this project was obtained from Hanoi Medical University, ID No. 00003121.

Data analysis

Informed by practice architectures as a conceptual lens, preliminary analysis was conducted in Vietnamese by the bilingual researchers (VATN, NTN), using an inductive process to independently identify and then collaboratively confirm recurrent themes. These themes, their descriptors and illustrative quotes were translated into English by one researcher (VATN), then back translated by another (NTN) to reach an agreed and accurate translation. The translated findings were read anew by the other researchers (WH, RS). Findings emerged from iterative discussion between all authors to interrogate, revise, and confirm the themes and their descriptors.

Results

At the time of the interviews, the educators were 38–62 years old, six were female, and all had worked in medical education for at least 12 years. Six were medical graduates, one a nursing graduate and one had dual medical and nursing qualifications. Five had been promoted to leadership positions, as department heads and vice heads, two had retired. After completing their Masters, five had commenced PhDs but only one was researching education, and only one had completed, in public health.

Four key themes were identified:

• The first, Careers and Professional Practices describes the career trajectories of the participants on being selected and thus recognized as educators, and subsequently being appointed to teaching roles. The following three themes were identified using cultural-discursive, material-economic, and social-political practice arrangements as conceptual lenses.

• Unrecognized and Unseen Practice illustrates how an absence of official recognition conferred invisibility, impacting on promotion and the motivation to continue. Structural Restraints relates to resource limitations and underdeveloped institutional structures. Cultivating Connections describes how, in the absence of a career pathway, hierarchical traditions and social connections could establish educator roles and enable leaders to direct educators’ practice.

• These themes and their associated subthemes are explained below with illustrative quotes using pseudonyms. Shorter quotes are integrated in-text and indicated with quotation marks to enhance the narrative.

Careers and professional practices

The educators vividly described participating in the program as energizing and revelatory. Subsequently there were opportunities to apply newfound knowledge and inspire others. A decade later, they were well-established in teaching and curriculum development roles.

Becoming an educator and being “mind-opened”

Most had not purposively sought teaching careers and were opportunistic recruits. Before the program, they were not known for their teaching in their departments and medical school community. When selected, and on commencing masters studies, they began to see themselves as “pioneers” and future “change agents”. The program experience cemented career commitment to medical education, bringing new “opportunities to work in this area”:

At first everything I did is voluntary; after [the course], results from my work persuaded the managing board of my school about my important role…and it really motivate me to continue. (Ba)

The course provided “knowledge, skills of medical education”; some thought they could “apply almost everything from the course to my work”.

…I am a doctor but I love to teach…After studying Master, I love even more… By studying international literature, I realised that medical education in Vietnam is so out of date…I apply many new things in my job and also train many other teachers in my school and in other organizations. (Dao)

Their experience “changed many things”, with one participant describing their learning as revelatory:

Actually, I think all medical schools in Vietnam had been ‘mind opened’. (Man)

Appointed to teach

Their newfound status was recognized by appointments to program delivery roles, such as leading the new clinical and simulation skills labs, also built with international aid.

…gradually, I was promoted to be the head of Skills Lab and the leader of medical education core group in my school. (Tuyet)

A decade on, their roles had taken two paths; most were responsible for teaching core course components such as clinical skills, assessment, and in teacher education; a few had diverted into central university quality assurance positions. None had been promoted to professorial positions and none described research or scholarship as part of their roles.

Discursive-cultural: unrecognized and unseen practice

This lens revealed a persistent absence of professionalizing discourses to legitimize the educators’ practice and new qualifications. A decade on, most participants continued to lack institutional visibility and some became demotivated.

Unrecognized and invisible

Most did not have job descriptions or job titles which recognized their specialist expertise. Despite the cachet of an international qualification with no Vietnamese equivalent, their degree was not recognized by the Ministry as meeting the Masters criterion for promotions. The degree was thus worth “nothing more than a piece of a blank paper”. Some lobbied for their new qualification to be recognized.

Our degrees were not recognized by the Ministry. Some of us had to collect evidences…to gain the recognition. So how can others recognise our contribution and the work in this field? (Mo)

Consequently, for advancement and recognition, some undertook further qualifications in specialist areas with identified positions and career paths.

Most of us put the degree of MHPE aside and took another postgraduate course in different specialties…to work and earn money. This degree seems to be worthless because this field [Medical Education] hasn’t been recognised here. (Tuyet)

Without formal recognition, their initial enthusiasm to renew educational practice waned. They felt “restricted”, “demotivated”, and “sad”. A decade on, medical education practice lacked the legitimacy of other medical specialties, was not visible to higher education authorities and did not relate to education disciplines outside medicine.

It is critical to have a defined recognition for this field, like giving it a name…we are not professional, even medical educators haven’t figured out who they are and what they do. (Mai)

The absence of a government approved position meant that a career in medical education was invisible, so appointment to medical education roles remained opportunistic. Some did not see medical education as a career to which promising educators should aspire.

I would not recruit graduates with a medical degree to work as medical educators. Although I know they have high capacity, they wouldn’t stay for long. (Ba)

To these participants, professionalization of medical education was in stasis with no future.

Material-economic: structural restraints

This pessimism was partly explained by the absence of sustaining material-economic arrangements to enable practice. The invigoration and motivation to change practice following the injection of material resources from outside Vietnam soon waned without structural changes in salaries and established units.

Divided careers, divided labor

Absence of in-kind and financial support for professional development indicated to participants that medical education was not seen as a professional career. This undervaluing was heightened by low university incomes compared to medical work. Public salary stagnation amidst a growing economy and aspirational middle class accentuated the impact, leading many to take on additional paid employment to supplement their wages and earn a living wage:

Working as a medical educator is very hard and we don’t get enough money from doing this job. All of us have to…find other sources of income. We have to get money from other jobs to survive and be able to continue with medical education. (Ba)

As a consequence, nearly all worked part-time in their university roles, but the personal effect was gendered. A university appointment brought respect for both men and women, but traditional divisions of labor meant that flexible hours resulted in women taking up childcare and domestic duties instead of an additional, clinical job. However, men were not expected to undertake childcare and domestic duties, so clinical work provided greater financial security. As Hanh, a female educator explained:

Those who don’t work full-time in my unit are clinicians. Their income from clinical work is high enough to guarantee their living expenses. They stay in our unit [because] the title of a ‘lecturer’ at Hanoi Medical School is a really good thing to have, especially for a man. (Hanh)

Lacking cohesion and isolated

Despite the centrality of undergraduate teaching to Vietnamese medical schools, only one school had a medical education unit, staffed by part-time educators. But hours were not fixed, with much teaching done by staff reporting to other units. The lack of cohesion greatly affected commitment to education practice:

Our group of medical education is a small unit, we are all part time staff…staff from other units get involved on request…being casual, staff are not very committed to this area of work. (Hanh)

Reflecting this fragmented practice, the unit was positioned in the periphery of the medical school, its practices unseen and unheard.

My department play such an important role in the school…but our ‘voice’ is not heard and my department has not a link to other departments in my school. (Hanh)

In other schools, educators were placed in clinical medicine or public health departments for administrative convenience. Most worked as isolated individuals, disconnected from like-minded peers. In sum, participants were yet to be regarded as scholars in a specialist practice. There was little collective activity, either as units within medical schools, or through any external professional networks.

Socio-political: cultivating connections

Relationships and connections determined practice and career trajectory, from entry onwards. While family and social connections were instrumental to finding employment opportunities, subsequent career advancement depended on the ability to negotiate and manage relationships with the school leadership.

Opportunistic connections

In the absence of a recognized career path, social and chance connections were instrumental for finding and being offered medical education opportunities:

….one of my mother’s colleagues who was the Head of Skills lab offered me a position…Although it is a very new unit with not so much work for me, there was an opportunity for me to study abroad. It sounded very promising and attractive. (Hanh)

Agents within a dominating leadership

After career entry, participants’ practice, and subsequent path was dominated by the leadership. All participants strongly and repeatedly cited leadership, at ministry, university, and in particular, medical school levels as instrumental for establishing new practices. School leader endorsement was critical to the success of educators’ proposals and to setting “expectations and forms of medical education”. But the leadership’s vision and support for education varied greatly, as these contrasting examples from different schools show:

Leaders in my school don’t actually understand what medical education is, they think I am like a general educator…we learnt by ourselves, we do by ourselves, we continue to work because of our own interest…(Mo)

Luckily, our new leader understands the importance of it and he requested more work… (Tuyet)

From the ministry level downwards, a strict hierarchical “top-down management approach” meant participants saw “rules, regulations, agreements from the leaders” as essential to any change. Otherwise, “no one cares even if they know how important it is.”

Everyone, academic staff, management staff are always resistant to us. If we have strong support from our leaders, it would be fine to fight for it. If the leaders do not support enough, we will become ‘trouble makers’. (Ba)

Without formal authority or approval from the formal leadership, resistance to “new things” and “change” was inevitable. Yet, despite this deferral to authority, there were emerging signs of a new agency by resourceful individuals. Some educators discovered affordances from within their institutional positions to cultivate connections:

We don’t have a formal unit, only a core group in medical education, it works informally, it doesn’t belong to the organization and doesn’t have any resource. (Mai)

One participant, who had secured a role within the Ministry, called on educators to exercise agency and instigate change.

…we medical educators need to be the agents, the active person to propose what we need to do in this field. (Tuyet)

Discussion

Our study traces how context shaped the trajectory of medical education practice in Vietnam through the experiences of educators who were positioned as potential medical education leaders. Ten years after their postgraduate training, the educators inhabited intra-institutional roles in teaching, assessment, curriculum and faculty development, and many had been appointed as heads of teaching units. But contextual influences, such as the absence of professionalizing discourses, meant their practice remained unseen and unrecognized. Educators practiced in isolation, limited to unit and institutional boundaries, so sought recognition and reward outside the field of medical education. Without contextual arrangements and structures to redress insufficient material resources and traditional social values, individual motivations receded. Change became slow, incremental, and for some, in stasis. Rather than professionalization centered on expertise and a visible career path, educators’ practice deferred to contextual arrangements dominated by leadership and serendipitous social connections.

Nonetheless, there were signs of an emergent agency, different to that observed in medical educators in North America, Australia, and New Zealand⁴³ or in graduates of other international health professions postgraduate programs.⁴⁴ We examine this phenomenon in relation to the distinctive Vietnamese contextual arrangements described in our findings.

Impact of absent professionalizing discourses on individual and collective practice

For individuals, the energizing effect of being chosen, engaging in international exchange, and achieving a significant qualification by world standards was short-lived on returning to a context where neither their experiences nor certification were recognized. This devaluing led some to seek qualifications – at the same level – in other disciplines, further erasing any nascent medical education discourse.

Postgraduate qualifications are increasingly expected of medical educators and can be instrumental in developing educator professional identity and networks in other international and LMIC contexts.⁴⁴ Such outcomes were not evident in our study, suggesting that important re-contextualisation and/or co-design work was missing from the MHPE program to make an arguably internationalized degree relevant to settings such as Vietnam.

Our finding of invisible work is similar to findings from studies on clinician educators in UK, USA, and Australia,^17,45,46 but with much greater impact in Vietnam, where most if not all medical educators have medical or health professions backgrounds. A new educator identity and agentic repertoire must emerge and integrate with a preexisting and valued professional identity as a clinician. This embryonic identity may remain weak or be temporary; our participants did not describe roles where these identities converged. In contrast, formal clinician educator career paths in contexts such as USA and Canada are visible,⁴⁷ reinforced by practice arrangements such as educator promoting workplace cultures,¹⁸influential professional associations, documented scholarly activities and outputs,⁴⁸ and conceptualized as a distinctive professional identity.¹⁶

Positions not sanctioned by the authority are less likely to attract resources, an effect which is compounded in LMIC contexts. Out of material necessity, many clinician educators pursued clinical work, and prioritized university time to teaching delivery rather than scholarship activities, or even required curriculum reform.³⁹

Reluctance to teach and to conduct research due to lower salaries is reported in medical graduates from high income countries,⁴⁹ but in Vietnam the effect is absolute. Despite reforms to higher education policy during our study dictating that public university academics allocate 33% of time to research activities,^50,51 none of our participants mentioned research as part of their roles, and the requirement is often not enforced.⁵¹ With public university salaries unable to sustain a living wage, a thriving informal economy of academic salary supplementation through private tutoring has emerged,⁵² or for the male educators in this study, clinical work, leading to curtailment of potentially more fulfilling education work.

The absence of professionalizing discourses was also associated with under-development of collective practice and collaboration. Intra-institutional communities of practice were rarely described, with one informal unfunded group and one marginalized unit. Furthermore, limited extra-institutional networking reflected weak professional ties. Despite all administrative regions participating, there was no subsequent sharing and expansion after completion of the NUFFIC program.⁵³ Drivers such as international aid (e.g. conferences, teaching innovations) and ministry directives³⁹ can initiate cross-institutional collaboration and intra-institutional change, but often end, as in our study, with short term project-focused outcomes. Other Indo-Pacific LMIC with comparable state control of higher education, such as Nepal and Myanmar, have national medical education professional associations, and platforms for exchange between medical educators within their own country and around the world.¹⁴ Resource constraints are thus not the only explanation; our findings suggest that the NUFFIC program did not create or promote the practice architectures needed for collegial and collaborative practice within the Vietnam context.

Participants recounted a controlling hierarchy with centralized governance of curriculum, staff appointments, employment, and promotion. While not unique to Vietnam,⁵⁴ the many layered bureaucratic control of higher education with limited institutional autonomy, particularly over staff recruitment, professional development, and promotion, is a feature.^50,55 Without state approval and alignment of policy with resources it is unlikely that professional associations, dedicated academic journals, professors in medical education or other signals of professionalizing discourse will appear. While some individuals could navigate these socio-political arrangements and negotiate with the authority (e.g. to attain recognition of their MHPE, or to pursue doctoral studies), such agentic maneuvers did not coalesce into sustained and collective professionalizing practice.

Influence of historical and social context on leadership and agency

Participants repeatedly cited the power of formal authority, as invested in the medical school dean by the Ministry,⁵⁶ to determine their scope of practice. In earlier studies, medical education leaders in high income contexts also cite school leadership, particularly the dean’s influence, as critical to survival of dedicated roles and units.^25,41 In Vietnam, this leadership is experienced differently; participants repeatedly emphasized an impenetrable power differential and the forceful influence of school leaders to induce - or prevent – change. Notably, one participant called for a new agency, but none described enacting agency, such as by being “institutional entrepreneurs” who, in the absence of formal structures, assemble coalitions and create narratives to promote and create medical education units, as found in Canada, USA, Australia, and New Zealand.^16,24,25 Such western constructs of leadership and agency rest arguably on individualism and individual endeavor but also assume contextual arrangements which do not exist outside these settings.

Our findings of limited professionalization in medical education can be viewed as an exemplar of higher education development in Vietnam. Influenced by Confucian traditions which value learning and respect for teachers⁵⁷ and evidenced by references to “honouring the teaching profession” in contemporary national law,⁵⁰ teaching practices are also foregrounded by a history of resistance to foreign intrusion⁵⁷ and by adaptation and resourcefulness to meet new expectations. For example, other educators in the NUFFIC program repurposed basic equipment to successfully deliver enriched clinical skills programs to large cohorts of medical students.⁴⁰

Since the 1980s, successive waves of policy reforms have dismantled many elements of the historical centralized state model of education in order to deliver ambitious expansions of basic and secondary education, which are yet to be translated to higher education.^50,58 Emerging from a tradition of university appointments based on social connections and patronage, with senior appointments dependent on allegiance to the dominant political party,⁵⁷ teacher development has lagged, with the only mandatory professional development being attendance at courses to increase knowledge of political philosophy and pedagogy. There is a persistently low rate of professorial appointments (4.8% in 2016, including associate and full professors) and a slowly improving proportion of academic staff with doctoral qualifications (21.4% in 2017).⁵⁹ Quality assurance departments are a relatively new phenomenon, and despite increasing expectations to do research, faculty developers in particular have resisted, and been called “reluctant researchers”.⁵⁰ Their professional identification with teaching is strong, but it is not an identity that incorporates interactions with the international community of scholars and with scholarship.⁵⁰ Despite recent policy to decentralize, change is limited, with MoET retaining control over: key appointments such as the rector; endorsement of board recommendations for deans; determination and provision of base salary levels; and setting promotion criteria,^50,55,57 reflecting the experiences recounted by our participants to have their qualifications recognized. “Leadership” and agency looks very different under such conditions, and our participants’ achievements can thus be seen as remarkable within their contexts.

Like Singapore, it is argued that a contemporary model of Confucian higher education⁵⁴ operates in Vietnam. However, in contrast to Singapore, professionalization in Vietnam is stalled by the absence, rather than by dominance, of state involvement. In a functional state system, patronage and resources flow through hierarchical arrangements to enable forms of agency which outsiders can misconstrue as passive deference to authority. Our study suggests that the absence of collective practice should not be interpreted as a lack of agency or initiative; rather, the actions of some of our participants can be better understood as those of effective change agents, adept at working within and with their unique practice architectures, and choosing to remain invisible in the absence of official sanction.

Limitations

Our findings directly relate to the Vietnamese context; while some of the identified practice architectures may be recognizable in other contexts, the arrangements in Vietnam are unique to its context. This study was informed by studies in other settings but we asked different research questions and used a novel theory of practice to interpret our data. For this study, we assumed that there is no common path toward professionalization of medical education and did not find one. Faculty development practice inevitably differs between contexts and should be fit for purpose.⁶⁰

We did not wish to repeat an evaluation of the NUFFIC international initiative.⁴⁰ Evaluations of international programs tend to be commissioned reports which lack detail or rigor⁶¹ due to time constraints.⁶² Our findings add to the evaluation perspective by being long-term and theoretically informed. A comprehensive evaluation or in-depth case study would thus include interviews with participants who discontinued their medical education careers, and other stakeholders.

In the decade or more since this program began, the importance of co-design and co-delivery to ensure contextual relevance and to differentiate between host and donor country expectations in internationalized programs has become recognized.^6,63 Concurrent and multisource data collection and analysis could improve contextual relevance and thus the likelihood of long-term knowledge translation in such programs.

One finding suggests that practice adaptations are highly gendered with part-time roles being combined with family duties for women and with paid medical practice by men, despite both being medically qualified. Previous studies suggest that feminization of medical education has influenced career development,⁴¹ a phenomenon seen across higher education. Our study was not, however, designed to investigate gender effects. Recent research on women higher education leaders in Vietnam⁶⁴ suggests a promising avenue for future research relevant to the dominant educational leadership model in this LMIC context.

Finally, the research team’s intersecting positions as participants, observers and educators both inside and outside the study context have inevitably sharpened some lenses with which we interpreted our findings and dulled others; for example, we did not view teacher standards as the way forward. Our diverse perspectives have led to other insights, united by our desire to see Vietnamese medical educators grow their own, unique, forms of professional practice.

Conclusion

Our study supports the notion of practices and professionalization of medical education as situated phenomena, influenced more by contextual features than by qualifications and standards about medical educator skills, knowledge and capabilities. We found that while professional practices may take new directions through external aid, without supportive architectures the trajectory of change will not be maintained. By adopting context-sensitive theory, our study offers an approach for investigating whether our findings and method are transferrable to different contexts, from settings where professionalization is visible and established, to resource-constrained contexts where professionalization is nascent and emerging. Knowing the practice architectures which constitute the unique arrangements for that context may lead to more impactful and sustainable program design and implementation.

Acknowledgments

We thank Dr. Asela Olupeliyawa for his careful reading and advice on earlier drafts.

Disclosure statement

The authors have no other interests to declare.

Data availability statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to their containing information that could compromise the privacy of research participants.

Additional information

Funding

The Authors acknowledge the Association for Medical Education in Europe Faculty Development Research Grant 2019 for supporting the wider program of research in LMIC contexts.