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

Abstract

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.

Introduction

Higher education institutes introduce new internationalisation modalities to prepare their students for careers in the globalising world (Altbach and Knight 2007; Wit 2013; Waterval et al. 2015). In medical education, these modalities typically target specific curriculum elements such as global health education or electives (Battat et al. 2010). Yet, medical schools are increasingly offering curricula specifically targeting international students (Hodges et al. 2009; Mayberry 2013). In an attempt to estimate the scope of this phenomenon, we found over 200 medical schools globally with international programmes that aim to prepare students for a medical career abroad. These programmes were mainly located in Europe, Asia and the Caribbean (Brouwer et al. 2017). The advantages of internationalisation to universities are manifold and may range from economic and academic to political and social gains, such as enhanced research capacity and increased cultural understanding (Altbach and Knight 2007). Yet, designing a curriculum for a diverse student group whose future work context might be anywhere in the world is challenging and raises questions about curriculum content and requirements of global and local practice (Leask 2015).

In the higher education literature, curriculum internationalisation has been defined as a process of ‘incorporating international, intercultural and global dimensions into the content of the curriculum as well as the learning outcomes, assessment tasks, teaching methods and support services of a programme of study’ (Leask 2015). However, a wide variety of interpretations of curriculum internationalisation exist across disciplines, institutes and individuals (Leask and Bridge 2013). This raises the question of how those involved in preparing students for practice or training abroad interpret curriculum internationalisation. An answer to this may help us better understand their approaches to curriculum design.

Practice points

• International medical programmes are a rapidly growing phenomenon with different graduate profiles guiding curriculum design.

• Educating ‘global physicians’ requires additional global health training and international exposure.

• Preparing ‘universal professionals’ involves a globally competitive curriculum emphasizing international standards.

• It remains challenging to balance local and global requirements in curriculum design.

• Adaptability is a key competency for future international medical practitioners.

Research outside medical education has pointed to the complexities of curriculum internationalisation (Leask and Bridge 2013; Green and Whitsed 2015). It will inevitably meet with competing interests between local, national and global contexts, which requires critical choices (Leask and Bridge 2013). Medical schools designing international programmes are likely to face similar challenges. Most international medical programmes are English-language copies of a local curriculum (Mayberry 2013; Yang et al. 2016). But can a literal translation of a locally contextualised medical curriculum, focusing on local epidemiology and healthcare systems, work effectively for international students? Critics of international education have questioned the appropriateness of such curricula for healthcare contexts elsewhere in the world (Hodges et al. 2009; Frenk et al. 2010; Crisp and Chen 2014) and believe that students must be recruited from and trained in the area in which they will work (Celletti et al. 2011; Miller et al. 2011). Also, literature on international medical graduates’ integration into North American and British healthcare systems has reported difficulties in adaptation to local organisations, communication practices and disease patterns (Pilotto et al. 2007; Zulla et al. 2008; Sockalingam et al. 2014). At the same time, many scholars believe that, in a time of globalisation, all medical students must be adequately prepared for globalised healthcare practice by exposing them to intercultural communication, health system analysis and global epidemiology (Mckimm and McLean 2011; Rowson, Smith, et al. 2012; Brown 2014). The rising phenomenon of international medical programmes thus reflects a global-local tension in medical education, where responses to globalisation at times conflict with calls for social accountability locally (Prideaux 2019). It is imperative that international medical curriculum designers take account of future work contexts. How they balance these different local and global contexts in designing curricula, however, has yet remained unclear.

We therefore set out to investigate how international medical programme designers experience these questions of balancing contexts. Our research questions were: ‘What are the challenges experienced in international medical programme design?’ and ‘Which potential curriculum strategies can be identified?’ The answers to these questions will not only increase our understanding of this rapidly growing, yet under-researched international medical education phenomenon, but may also provide lessons for medical programme design generally in an era of globalisation and contribute to the debate on local versus global medical education.

Methods

We conducted a qualitative multi-centre instrumental case study (Stake 2005) using semi-structured interviews and document analysis. Its main purpose was integrative rather than comparative. By investigating cases holistically and in detail, this design allowed an in-depth understanding of the variety of experienced challenges and potential curriculum strategies.

Setting

The study was set in three universities in different countries that offer international medical programmes, defined as actively recruiting foreign students and designing or adapting a curriculum specifically for practice or training abroad. We sought to draw a sample that differed in curriculum structure, teaching methods, geographic location, programme age, annual student intake and student backgrounds, since we expected this miscellany to yield diverse, rich insights regarding the research questions. After an online search and document analysis (Brouwer et al. 2017), we found over 200 schools to be eligible globally, from which we selected the three international medical programmes presented in Table 1.

Table 1. Overview of the participating institutes and characteristics of their international medical programme.

Institute	Location	Programme start date	Student intake/year	Student background	Teaching methods	Curriculum structure and language
University of Pécs	Pécs, Hungary	1984	180	50% European (not Hungarian); 50% other	Mixed, mostly lectures, subject-based	6-year MD programme in English or German (patient contact in Hungarian) in parallel to Hungarian programme
International Medical University (IMU)	Kuala Lumpur, Malaysia	1993	2 × 100	± 70% Malaysian; 30% other (mostly South East Asian)	Mixed, integrated	First 2.5 years in Malaysia, then either transfer to partner medical school abroad for MD degree (UK, Australia, Ireland, Canada) or stay in Malaysia for MBBS track
Maastricht University	Maastricht, the Netherlands	2009	60	± 30% Dutch; 30% European; 30% Middle Eastern; 10% other	PBL, integrated	3-year BSc programme in English in parallel to Dutch programme, followed by 3-year MSc in English abroad or in Dutch in the Netherlands

Participants and sampling

Prior to sampling, we broadly defined international medical education designers as anyone who had been involved in developing curriculum materials for the international medical programme. This included current and past curriculum directors, module coordinators, lecturers, student bodies and support staff. To identify key informants at each institute, we used a purposive sampling approach, aiming for diversity in positions, years of experience, disciplinary background and views of the programme (supportive/opposing). A local co-researcher in each institute invited potential candidates by email, yielding 26 participants across the three research contexts, with experience in their international programme ranging between 2 and 26 years. Seventeen participants combined teaching with curriculum design, seven had curriculum leadership roles, one was an administrator and one was a student.

Data collection and analysis

One researcher (EB) conducted the semi-structured interviews in all contexts. The interview guide included open questions on the interviewees’ roles in the curriculum, their vision for the international programme, their main challenges in curriculum design and implementation as well as some specific probes on requirements for international practice, balancing local and global contexts and student diversity approaches. Interviews lasted between 45 and 75 min and took place in English or Dutch. All interviews were audiotaped and transcribed verbatim. The language used for the coding and data analysis process as described below was English. A professional language editor translated the quotations used in this paper from the Dutch transcripts.

Data analysis followed the thematic analysis method as described by Braun and Clarke (2006). In each setting, two researchers (EB and a local co-researcher) independently coded the first three interviews, after which they discussed codes and emerging themes to create an initial codebook. When all interviews were coded, the investigators (EB with KS in Pécs; EB with VDN and NHM in Kuala Lumpur; EB with JF and ED in Maastricht) discussed the key issues, challenges and strategies that curriculum designers reported. They then shared the summaries of data interpretation with the other team members. These summaries served as a basis for the integrative analysis with the aim to find the main parallels and dissimilarities across contexts. All authors met regularly to further review and refine the overall themes and key issues. We conducted a member check by collecting participants’ feedback on the summaries of data interpretation per institute, which did not lead to adjustments.

To triangulate the findings from the interview data, we performed a curriculum document analysis. We collected and screened 125 module descriptions across the three programmes, and coded the international dimensions that we encountered in them. In identifying these dimensions, we focused on curriculum elements that explicitly discussed international competencies as suggested in the literature, such as cross-cultural communication, global health and epidemiology (Mckimm and McLean 2011; Rowson, Willott, et al. 2012; Brown 2014; Leask 2015). Prompted by the interviews, we also looked for more implicit examples of curriculum adaptations to fit the needs of the international student group and their future global practice.

Research team and reflexivity

We also sought to achieve variation in geographic and disciplinary perspectives in the research team. This project originated at Maastricht University where EB, JF and ED are all involved in educational research and in the international programme as teachers. EB is a medical doctor trained in Maastricht, JF has a background in social sciences and ED in educational sciences. KS, who has a background in linguistics, works at the University of Pécs as researcher and alumni coordinator for the international programme. VDN is a biochemist trained in the educational sciences and currently the Dean for teaching and learning at the International Medical University (IMU), and NHM is a lecturer with a background in psychology. Both teach in the international programme. Throughout the project, the team have been aware that their background and experiences shaped their assumptions and the research itself. Continuous input from all members helped to balance all these perspectives.

Ethics

The study was approved by the Ethical Review Board of the Netherlands Association for Medical Education (ref no. 00929), the Regional Ethics Committee of University of Pécs (ref no. 6746), and the IMU Research and Ethics Committee (ref no. IMU412/2018). All participants gave their informed consent and could withdraw from the study at any moment.

Results

A global physician or a universal professional

A major finding of this research was that participants had markedly different perspectives on what defines an international programme and what it aims to achieve. Some believed the mere presence of international students made a curriculum international, while others considered all current medical education international. The programme aims participants described roughly fell into two categories: (1) to educate ‘global physicians’: a distinct group of future doctors with specific qualifications that made them fit for international practice; or (2) to educate ‘universal professionals’: high-level graduates who, regardless of their origin or destination, were fit for future practice anywhere. When the aim was to educate global physicians, there was an explicit focus on differentiation in the international programme and, consequently, there was a clear distinction between the international curriculum on the one hand and the parallel curriculum in the local language on the other.

We want to add and (…) spot all the international relevant topics and where to integrate them (…). To say at the end, you’re really prepared for an- To be a doctor with an international background and not a doctor for [a local] patient. [Participant07]

When medicine was understood to be a universal profession, the programme’s focus was clearly on keeping all education content equal for all students.

International, in my point of view it means that if someone gets their diploma general medicine [here], they can go to anywhere in the world. The human body is the same (…) Everyone in each language must be trained the same way, must have the same knowledge. [Participant10]

However, this definition or aim was not always clear to all teachers and students, nor was it consistent with the institutional aims, which complicated curriculum design strategies.

The global physician perspective: Adding an international flavour

The main curriculum strategy employed by participants using ‘a global physician’ to characterise their perceived graduate profile was to add an international flavour to pre-existing curriculum materials. These additions mainly concerned specific learning activities such as extra topics to be discussed in seminars or specific assignments for the international programme. In the curriculum materials, we found themes such as global epidemiology, health systems varieties and socio-economic determinants of health. Examples included a table showing the distribution of stroke risk factors for women of different ethnic backgrounds or extra assignments, such as the one below belonging to a case study on mood regulation:

Discuss cross-cultural differences in the prevalence and conceptual models of depression. Are there different views on causes, manifestations, perception, and treatment of depression? What are the consequences of these differences in terms of treatment-seeking behaviour and stigma? [Document22]

Notably, while most participants explained ‘global’ in ‘global physician’ as ‘any place international’, upon closer inspection of the interviews and documents this qualifier often referred to ‘low- and middle-income’ or ‘tropical’ settings. Many of the specific curriculum additions addressed knowledge and skills needed in resource-constrained settings with high infectious disease rates, for example.

This strategy to add international elements, however, was challenging for participants. Many curriculum designers felt that, in order to raise awareness of the differences in disease patterns, health systems or cultures that students could meet when practising in another country, they needed to incorporate specific features of potential practice locations. As the following quote demonstrates, it was not feasible to fit in the particularities of all potential destinations:

Of course you don’t know where they will go then. It is impossible to [include] hundreds of settings. And if you happen to show the settings that aren’t the ones, will it be of use to them? That’s what the question is, really. You wish you could somehow equip them, so to speak, so they are able to make this transition themselves. (…) But how to do that, that’s a really good question. [Participant03]

Several participants added that it was difficult to meet all the different student expectations of the ‘global physician’ concept. Some students expected to be prepared for humanitarian work, others for global policy-making and yet others ‘just wanted English’ [Participant09].

The universal professional perspective: Being globally relevant

The approach to curriculum design taken by participants who perceived medicine as a universal profession was essentially to make the curriculum globally competitive. They mainly did so by benchmarking their programmes against other education and healthcare systems or through quality assurance. For instance, curriculum designers aligned their course content with recent versions of the United States Medical Licensing Exam (USMLE) or with entrance requirements applicable in their students’ destination countries, used global frameworks for medical education and invited foreign authorities to assess the curriculum:

[Foreign medical schools] recognise [our] students’ capability, recognise students’ training or students’ education so that (…) they are at par with [their] locally trained students. So when the medical schools overseas look at this, it is a very important aspect and we’ve been able to maintain this year after year. So that is the important thing. [Participant19]

Another way to become globally relevant, as some participants described, was to strongly emphasise skills and professionalism, following the shift of focus from knowledge to skills and attitudes they saw in the US, UK and Australia:

Clinical skills have been given very much importance here and while practising clinical skills, students automatically become professionals. Professionalism automatically comes, isn’t it? I mean these components I told which is universal for all medical doctors’. [Participant19]

This group of curriculum designers too, however, felt it was challenging to balance the different requirements of potential future work contexts. Although they believed it would not harm students if they learned about the needs of a country they would eventually not go to, they were concerned that the curriculum would become overcrowded with additional objectives and activities. This problem was solved, in part, by the view that a curriculum’s responsibility should be limited to teaching students basic knowledge and generic skills. Participants trusted students to develop further based on the local context where they would eventually work in. Hence, as one participant indicated, the aim of delivering ‘lifelong learners’.

As long as you cover the basic important areas, the student will be able to learn more. Because what we want is for the students to be able to… they must have the basic things and certain things they need to tweak when they have to be in that country. [Participant26]

In this connection, we observed that participants of both perspectives shared a similar goal, which was to incorporate the competency of adaptability in the curriculum. This need to prepare students in international programmes for the transfer to another location of practice that almost all participants mentioned was considered supplementary to the traditional set of learning outcomes for medical students.

We also put that competency alongside: you have to be adaptable, is our wish, that is the extra competency. Because all knowledge might be correct, but you shouldn’t be able to apply that in one context only. [Participant02]

Participants noted that achieving this was challenging. One strategy that participants discussed was to as much as possible expose students to different situations, aiming to train the adaptability competency like a skill. Examples of such different situations included exposure to patients from different cultural backgrounds (at home or abroad), to public, private and community based health care, and to different teaching and assessment methods – followed by reflective sessions or reports.

Discussion

This study explored the challenges international medical curriculum designers faced when balancing local and global relevance and the strategies they used to overcome these. Participants in our case study of three different programmes described two potential graduate profiles: a global physician specifically fit for international practice, and a universal professional or an overall high-level graduate who is fit for practice anywhere. The ways in which curriculum designers set the requirements for global medical practice and considered future local work contexts varied in accordance with each perspective.

Considering Leask’s work on and definition of curriculum internationalisation (Leask and Bridge 2013; Leask 2015), our study underlines the variety of interpretations of curriculum internationalisation across institutes and individuals. Although it was beyond the scope of this study to explore the origin of these variations, it is possible that national historical and political factors influence the appearance of curriculum internationalisation, as Stütz and colleagues demonstrated to be the case in Germany and Australia (Stütz et al. 2015). Our study further illustrates how these interpretations affect curriculum design choices and, ultimately, graduate profiles.

Characteristic of the ‘universal professional’ perspective was a strong sense of global applicability of the curriculum, rather than pursuing an internationalised curriculum: any current curriculum that was ‘up to global standards’ could prepare a doctor for practice anywhere. This thinking is in line with for example the Institute for International Medical Education (IIME)’s efforts to establish a set of globally applicable standards for student performance (Stern et al. 2005) and the World Federation for Medical Education (WFME)’s initiative to ensure that accrediting agencies are at an internationally accepted standard (Karle 2007). The concept of a universal professional was also identified as the most established vision of global medical competency in a large discourse analysis of the topic (Martimianakis and Hafferty 2013).

Standardisation of approaches and outcomes in medical education has also received criticism and raises questions about power dynamics in medical education globally (Bleakley et al. 2011). It is argued that the ‘global’ standards for medical education are largely derived from norms and traditions in Western countries that dominate medical education research and development, thereby potentially suppressing local needs and cultural values (Bleakley et al. 2008; Hodges et al. 2009; Bleakley et al. 2011). Several studies have suggested alternative responses to the globalisation of medical education in non-Western settings, such as more hybrid models that allow for cross-cultural exchange and adaptation or contextualisation of educational content or methods (Gosselin et al. 2016; Bates et al. 2019), sometimes referred to as ‘glocalisation’ (Ho et al. 2017). These alternative approaches might not fit one-to-one to international medical programmes because of the variety in destinations, yet, considering the risks of standardisation when designing international curricula might increase awareness of local values and potential inequities among future universal professionals. We encourage further research into the question of how global standards can be adapted to fit a diverse set of future work contexts.

Participants who shared the ‘global physician’ perspective, on the other hand, considered curriculum internationalisation a goal in itself, to produce a special kind of medical graduate: one with additional skills and competencies to be able to practise globally. Yet, what this global practice exactly entailed was unclear to many designers who held this perspective, although they often took it to mean work in humanitarian or tropical contexts, rather than truly globally. The few previous publications about similar international medical programmes also describe offering students extra global health-related education to prepare them ‘for practice anywhere’, while concentrating on resource-constrained settings (Margolis 2013; Teichholtz et al. 2015). This view is also found in the literature on ‘global health education’, which often refers to overseas electives in low- and middle-income countries (Battat et al. 2010; Liu et al. 2015).

This narrow interpretation of global health has recently received criticism from scholars in the field who, moreover, question the ethical implications of electives in low-income settings (Adams et al. 2016; Peluso et al. 2017; Khan et al. 2017). They call for a broader and more balanced approach to global health education, where global health refers to health equity for all people worldwide (Koplan et al. 2009) and where students can develop their global health competencies in vulnerable communities closer to home, for example (Khan et al. 2017; Peluso et al. 2017). If international medical programmes aim to educate truly global physicians, they may benefit from a similar broadened way of thinking, starting by clearly defining their interpretation of the global physician for curriculum designers and current and prospective students.

The two perspectives in this study affected curricular choices that differed mainly on the level of teaching content. Participants across perspectives emphasized including the competency of adaptability in the curriculum to prepare students for international practice. This idea resonates with studies analysing transitions in medical education – both in international contexts (Koehn and Swick 2006; Sockalingam et al. 2014) as well as in early career transitions generally (Murdoch-Eaton and Whittle 2012; Cutrer et al. 2017). In a rapidly changing world where globalization and artificial intelligence are only two of many developments to consider in curriculum design, adaptability could be a valuable competency for all future doctors, regardless their location of study or practice. Participants in this study mentioned a few approaches to teach this competency. Exploring additional strategies and their effect could be subject of further study.

Limitations

This study was purposively designed to include three geographically and curriculum structure-wise diverse institutes to ensure a broad range of perspectives on the topic under scrutiny. This selection did not include all potential appearances of international medical education that currently exist globally, meaning we may have missed relevant additional perspectives or strategies in international curriculum design. We therefore invite future studies to expand the case study approach to include schools within and across different countries and programme characteristics. We mainly focused on pre-clinical curriculum design, as in two of the institutes students did most of their clinical placements abroad. As a result, the data on programme design in the clinical phase of international medical education is limited. Also, we based our results mainly on designers’ perspectives, which we triangulated with curriculum documents to limit bias. It would be of value to study the perspectives of other stakeholders too, such as the students and graduates from these programmes, as these could provide insights into the perceived alignment between curriculum and career requirements.

Conclusion

International medical programmes are on the rise around the world, educating a new generation of future doctors that could practise globally – in current curricula depicted as universal professionals or as distinct global physicians. Being explicit about the selected graduate profile not only helps teachers in their curriculum design choices, it also helps managing prospective students’ expectations. International standardisation of educational content and methods to achieve universal professionalism promotes degree comparability, but contextualisation or ‘glocalisation’ should be considered to secure awareness of cultural differences and values in local healthcare contexts. Adding global health content and skills can serve to prepare distinct global physicians, but curriculum designers should adopt a broad and equitable interpretation of global health that goes beyond tropical medicine. It remains challenging to prepare students to be adaptable to the requirements of a rapidly changing future local healthcare context.

Glossary

International medical programmes: Those programmes characterized by an international student intake, curriculum internationalisation, international partnerships, and using English as a medium of instruction (this paper)

Adaptabiliy: Balancing the efficiency of routine expertise with more effortful learning and innovative problem solving (Cutrer et al. 2017; doi 10.1097/ACM.0000000000001323)

Acknowledgments

The authors wish to thank all participants in this project. We also thank Angelique van den Heuvel for her help with manuscript editing and Miriam Wijbenga for her contribution to interview coding.

Disclosure statement

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.

Additional information

Notes on contributors

Emmaline Brouwer

Emmaline Brouwer, MD, MPH, is a medical doctor trained at Maastricht University, the Netherlands, where she works as an assistant professor in educational research and international collaboration.

Erik Driessen

Erik Driessen, PhD, is a Professor of medical education and Head of the Department of Educational Development and Research at the Faculty of Health, Medicine and Life Sciences at Maastricht University, the Netherlands.

Norul Hidayah Mamat

Norul Hidayah Mamat, M.Ed., is a psychologist by training and works as a lecturer at the International Medical University in Malaysia.

Vishna Devi Nadarajah

Vishna Devi Nadarajah, PhD, has a background in biochemistry and is the Dean for teaching and learning at International Medical University in Malaysia.

Klara Somodi

Klara Somodi, MA, works as a researcher and alumni coordinator for the international medical programmes at Pécs University, Hungary.

Janneke Frambach

Janneke Frambach, PhD, is assistant professor at the School of Health Professions Education, Maastricht University, the Netherlands. Her research interests are globalization, internationalization and cultural diversity in health professions education.