High- and low-achieving international medical students' perceptions of the factors influencing their academic performance at Chinese universities

China has become an attractive destination for international medical students, particularly those from developing countries in Asia and Africa. These students are known to face difficulties in adapting to Chinese medical universities and they tend to score poorly on subsequent examinations to enter the medical profession in their home or in a third country. To date, limited research concerning the factors that affect the academic performance of this group of students in China has been conducted. In particular, there have been very few comparisons between high and low achievers to identify the factors that high- and low-achieving international medical students in all years of study perceive as affecting their academic performance. A qualitative research approach was implemented at two medical universities. Semi-structured interviews were conducted with 18 high achievers and 22 low achievers in their second, third, fourth, fifth, sixth, and post-graduation years. Interviews were audio-recorded, transcribed, and coded using a thematic analysis approach.A few key overlapping factors were identified: social support, learning motivation and interest, exam preparation and strategies, time management, and coping. The high achievers manipulated these strategies successfully while the low achievers did not. The high achievers demonstrated efficient learning methods (efficient use of class time, good note-taking habits, preview and review strategies, expanded learning, self-study and group learning, deep learning, choosing an appropriate study location, and focusing on basics and concepts). They also achieved a good balance between studying and leisure. The low achievers mentioned learning challenges, health issues, English language barriers, and problems with online classes. This study allowed us to identify important factors that international medical students at Chinese institutions perceive to influence their performance. The findings contribute to the literature on the topic and provide a solid basis for practice and policy development.

Consistency and quality in written accreditation protocols for pediatrician training programs: a mixed-methods analysis of a global sample, and directions for improvement

BACKGROUND

The World Federation for Medical Education (WFME) defines accreditation as 'certification of the suitability of medical education programs, and of…competence…in the delivery of medical education.' Accreditation bodies function at national, regional and global levels. In 2015, WFME published quality standards for accreditation of postgraduate medical education (PGME). We compared accreditation of pediatric PGME programs to these standards to understand variability in accreditation and areas for improvement.

METHODS

We examined 19 accreditation protocols representing all country income levels and world regions. For each, two raters assessed 36 WFME-defined accreditation sub-areas as present, partially present, or absent. When rating "partially present" or "absent", raters noted the rationale for the rating. Using an inductive approach, authors qualitatively analyzed notes, generating themes in reasons for divergence from the benchmark.

RESULTS

A median of 56% (IQR 43-77%) of WFME sub-areas were present in individual protocols; 22% (IQR 15-39%) were partially present; and 8.3% (IQR 5.5-21%) were absent. Inter-rater agreement was 74% (SD 11%). Sub-areas least addressed included number of trainees, educational expertise, and performance of qualified doctors. Qualitative themes of divergence included (1) variation in protocols related to heterogeneity in program structure; (2) limited engagement with stakeholders, especially regarding educational outcomes and community/health system needs; (3) a trainee-centered approach, including equity considerations, was not universal; and (4) less emphasis on quality of education, particularly faculty development in teaching.

CONCLUSIONS

Heterogeneity in accreditation can be appropriate, considering cultural or regulatory context. However, we identified broadly applicable areas for improvement: ensuring equitable access to training, taking a trainee-centered approach, emphasizing quality of teaching, and ensuring diverse stakeholder feedback.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

"Design and implementation challenges of massive open online course on research methods for Indian medical postgraduates and teachers -descriptive analysis of inaugural cycle"

BACKGROUND

In view of the growing popularity, reach and access for Massive Open Online Courses (MOOCs), India's apex body for medical education, the National Medical Commission (NMC) mandated uniform foundational course on research methods for the medical post graduates (PGs) and faculty members of the medical institutions under NMC as MOOC. This course is a pioneering effort in the field of India's PG medical education. NMC entrusted Indian Council of Medical Research (ICMR)-National Institute of Epidemiology (NIE) to design and offer the MOOC, named as Basic Course in Biomedical Research (BCBR). We describe the experience of designing and that of implementation challenges in the inaugural cycle of the course.

METHODS

The course objective was to inculcate the fundamental concepts in research methods covering epidemiology and biostatistics in the form of video lectures, resource materials, discussion forum, assignments, feedback and a final proctored examination. The course was delivered over 16 weeks through MOOCs platform under the Indian Ministry of Education. We reviewed records, documents and faculty notes and described the course conceptualization, development, design and implementation process. We abstracted information from course portal on enrolment profile of the participants, self-reported course feedback (structured and open-ended on format, lectures and quality of contents), examination registration form, scores obtained in the assignments/examination and that of the participant queries. We described quantitative data using descriptive statistics. We presented the thematic analysis of qualitative data from open-ended questions in the feedback system and that of email interactions.

RESULTS

The inaugural cycle (September-December 2019) was taken by 24,385 participants. Majority, 15,879 (65%) were from medical background. 13,242 (54%) were medical postgraduates and 2637 (11%) were medical teachers. Among the enrolled, 14,720 (60%) cleared the assignments. A total of 11,392 (47%), 8,205 (62%) medical PGs and 896 (34%) faculty members successfully completed the course. Feedback from 1305 (5%) participants had mean score of 4.5/5 (±0.7) for quality of teaching. We faced challenges in customizing the course for medical participants, unawareness among target group, digital illiteracy and the ongoing pandemic.

CONCLUSIONS

During the inaugural cycle of the online Basic Course in Biomedical Research course, nearly half of the enrolled participants successfully completed and received the certificate. India's MOOC for enhancing research capabilities of future medical researchers encountered successes and challenges. Lessons learnt from the inaugural cycle will guide future directions and to address larger issues in terms of sustainability and replication by stakeholders in medical education in India or elsewhere.

Twelve tips for students who wish to write and publish

Stepping into the world of research can be an overwhelming task, especially for those with relatively little experience, such as medical students. This article aims to provide students with tips for writing and publishing in all fields. The 12 tips are as follows: (1) find your why; (2) play to your strengths and be realistic; (3) be well read; (4) revisit missed opportunities; (5) talk to the doctors around you; (6) broaden your horizons; (7) get to grips with the submission process early; (8) pay attention to the details; (9) remember that submission is not the end; (10) the process can't be rushed; (11) consider the alternative paths to presenting research; (12) start writing. This writing is derived from personal experience with supporting evidence and is not designed to be encyclopaedic, simply a reference to help students alleviate any concerns and begin their own journey into the world of research.

Medical education in Italy: Challenges and opportunities

Italy is a country of 60 million citizens with a high life expectancy, an increasing prevalence of chronic multi-morbidity and a public healthcare system. There are 61 medical schools and more than one thousand postgraduate programs for 50 different specialisations. In this article, we describe the Italian medical educational system and its most recent evolution towards a process of internationalization, alongside pedagogical and cultural changes. The main challenges are in the process of students' selection, which is still only based on the assessment of basic knowledge, and in the reform of the post-graduate education, which lacks an official, formal definition of the learning outcomes and the aligned methods of assessment. The opportunities come from the increasing awareness of the importance of faculty development programs. The pandemic itself acted as a catalyst of innovation, pushing toward more student-centered teaching-learning activities. Finally, an increase in international collaborations in medical education research could be effective to foster the development of medical education in the country.

Twelve tips for point-of-care ultrasound teaching in low-resource settings

Point-of-care ultrasound (POCUS) has become the standard of care for many emergency department evaluations. Low-resource settings are ideal for POCUS to help improve access to imaging for a number of indications that are obstetric, disease or trauma related. The following twelve specific tips are aimed toward organizations and individuals who aspire to initiate POCUS training in a low-resource setting.

Investing in scholarship for health professions education: Learning from the past to move into the future

There have been recent discourses of what scholarship means for health professions education (HPE) and how it may need a rethink during the pandemic. One key take home message from these discourses is the role of institutions in nurturing and investing in scholarship. Given the current challenges faced by both higher education and healthcare, there is a risk that activities and resources for scholarship in HPE may be neglected. How do institutions make a case for continuous investment in HPE scholarship? Despite being a relatively new and small private university with no public funding, IMU has made fairly significant progress in delivering a unique model of HPE programmes with HPE scholarly output. This commentary discusses the importance of investing in scholarship for HPE with the International Medical University (IMU) in Kuala Lumpur, Malaysia as a case study. Examples of institutional initiatives that support and enhance scholarship are presented based on the recent AMEE guide (142) on redefining scholarship.

A SWOT analysis of Italian medical curricular adaptations to the COVID-19 pandemic: A nationwide survey of medical school leaders

BACKGROUND

There is a growing literature on how medical education adapts to the COVID-19 pandemic. However, there is a need to examine the facilitators and barriers of these adaptations. This study explores the strengths, weaknesses, opportunities, and threats (SWOT) of how Italian medical schools adapted their curricula to the COVID -19 pandemic.

METHODS

The authors conducted an online survey of directors of medical curricula in Italy. Free-text responses to open-ended questions about curricular adaptations and reflections on these adaptations were analysed using qualitative thematic analysis.

RESULTS

Twenty out of 60 Italian medical school directors completed the survey. Strengths identified were rapid responses and a spirit of cooperation. Weaknesses included dependency on clinical facilities, teachers' limited skills to use technology, and lack of mental health support for staff. Opportunities highlighted were clear government rules, new ways of teaching and a renewed focus on underrepresented topics. Threats expressed included impaired relationships, difficulties related to online assessment, lack of IT access, and legal and insurance issues.

CONCLUSIONS

This study, in documenting the curricular adaptations of Italian medical schools during an active global pandemic, and recording the perspectives of medical education leaders, offers important lessons for the future.

Development and Implementation of an Objective Structured Clinical Examination (OSCE) of the Subject of Surgery for Undergraduate Students in an Institution with Limited Resources

This article was migrated. The article was marked as recommended. Aim: To develop and to test the feasibility of conducting an objective structured clinical examination (OSCE) of the subject of surgery for third-year medical students in a limited-resources institution. Methods: To planning the OSCE following the Kane Validity framework. A blueprint based on curriculum was developed to design stations. A specific checklist/rubric (using google forms) was elaborated for each station. The pass/score was determined using the Modified Angoff Approach. Cronbach's alpha was used to determine the reliability. The whole process was evaluated by assessing students' and professors' satisfaction using a survey. Results: It was feasible to develop and implement an OSCE in an institution with limited resources. 28 students and 10 examiners participated. Both considered that the OSCE allows evaluation of the clinical competencies of the subject. They consider that this kind of assessment changed their way of studying, placing more emphasis on clinical skills. In the same way, they consider that it is, more objective, and less stressful when compared to other traditional methods. Similarly, the implementation of this strategy encourages teachers to improve teaching strategies. Conclusion: It's possible to implement un OSCE in an institution with limited resources. The incorporation of this tool has a positive impact on learning.

Residency training in the time of COVID-19: A framework for academic medical centers dealing with the pandemic

BACKGROUND

As cases of COVID-19 climb worldwide, academic medical centers (AMCs) are scrambling to balance the increasing demand for medical services while maintaining safe learning environments. The scale and nature of the current pandemic, limitations on key resources, risks of transmission, and the impact on trainee wellbeing pose additional challenges to AMCs. We propose a framework for AMCs to utilize in facilitating health system, organization and program-level adjustments to meet the needs of medical trainees during the pandemic.

APPROACH

In February 2020, we developed a three-level approach to the pandemic response of training programs at our AMC. The first level involved AMC alignment and engagement with regulatory stakeholders. The second level utilized the graduate medical education committee and leveraged organizational functions such as human resources, finance, and clinical departments. The third level of intervention focused on common approaches used by programs to ensure continuity of learning in the context of dynamic changes in workflows and service operations.

EVALUATION

Outcomes at each level are reported. These include the co-development of a national framework on medical trainee responses to COVID-19, the composition of an operational guidance document, organizational protocols to accommodate novel challenges posed by the pandemic, and multiple program-level interventions.

REFLECTION

This methodical approach, employed during a global crisis, was critical in facilitating interventions required to fulfill the mission of AMCs. Future steps include assessing the impact of these changes on trainee performance and the applicability of the approach in diverse settings.

Capturing the impact of cultural differences in residency

BACKGROUND

Postgraduate training is a period in which residents develop both their medical competency and their professional identity in an environment of apprenticeship. As situated learning suggests, a critical dimension of such apprenticeship is the mode through which trainees can legitimately participate in the practice before they become experts, in this case physicians. One source of barriers to participation is cultural difference between learner and the clinical environment.

OBJECTIVE

To assess the extent cultural differences create barriers for residents, particularly but not exclusively for international medical graduates (IMGs).

METHODS

In 2014-15 a questionnaire was developed with subscales assessing areas such as sense of hierarchy, individuality versus teamwork, and risk tolerance. We refined the instrument by subjecting it to a review panel of experts in postgraduate education followed by "think aloud" sessions with residents.

RESULTS

Piloting this instrument yielded a Cronbach's alpha of 0.675. When administered to a larger group of residents and faculty representing many specialties, the Impact of Cultural Differences on Residency Experiences (ICDRE) questionnaire revealed a few items for which the Canadian Medical Graduates and International Medical Graduates differed in their mean opinion. The groups were not substantially different overall, but we did observe an interesting diversity of cultural beliefs within each group.

CONCLUSIONS

We suggest that the ICDRE may be useful in identifying beliefs which may present challenges to an individual resident or in capturing trends in a resident population so that a specialty program can address the trends proactively. The instrument also provides language with which to anchor preceptors' evaluations of residents' professionalism and may serve as an interventional coaching tool.

Radiology residency training in China: results from the first retrospective nationwide survey

Objectives

This was the first study to systematically landscape and examine China’s nationwide standardized residency training in radiology.

Methods

In this retrospective cross-sectional study, we used data from the 2019 national survey of the first two cohorts of 3679 radiology residents who completed training in 2017 and 2018 across all 31 provinces in China. A total of 1163 (32%) residents participated in the survey. Multivariable logistic regression was used to examine the implementation frequency of 24 identified training tasks (categorized into six competencies) by region, demographics, and other residency information.

Results

Among the 1163 respondents, 592 (51%) were trained in the more developed eastern region. Of the 24 identified training tasks, 15 were implemented significantly differently across regions, while the frequency of the most frequently conducted tasks (e.g., CT, MR, and radiograph interpretation and reporting) was consistent. The top 10 tasks all fell into the patient care and medical knowledge competency domains, while other competencies tended to be neglected. We found region and marital status were the most influential factors of training task implementation frequencies. Respondents trained in the northeast and the west were more likely to report, for instance, radiological examination recommendation (OR = 1.91, 95%CI = 1.27–2.88), as “very frequent.” Married respondents were more likely to report first-line night shift as “very frequent” (OR = 1.71, 95%CI = 1.29–2.26).

Conclusions

Despite the fast-win achievements of developing a national radiology residency training program, there is a gap to train quality and homogeneous radiologists across regions. Future improvement should be more tailored to residents’ personal characteristics and emphasize some “soft” competencies (e.g., communication skills).

Faculty Development in Basic Science Disciplines for Clinical Teachers: Results of a Cross-Cultural Workshop in the Dominican Republic

BACKGROUND

Faculty development programs, studied both within the USA and internationally, have been shown to be helpful for enhancing scholarly and academic work for academic faculty in teaching institutions. This project investigates the impact of a well-studied faculty development program applied to basic science teachers in an academic medical center in the Dominican Republic.

METHODS

A faculty cohort of physician educators in the Basic Sciences at Universidad Iberoamericana (UNIBE) School of Medicine in the Dominican Republic underwent training in the Stanford Faculty Development Center (SFDC) model of teaching through a sequence of seven workshops that were adapted for basic science content. A validated retrospective pre- and post-test instrument was used to measure study outcomes on specific teaching behaviors at the end of the workshops, at 3-month and at 12-month post-intervention. Thematic analysis of specific teaching techniques and barriers to their teaching were compiled.

RESULTS

Fourteen faculty participants completed the study. All participants found the workshops valuable. Significant improvement in self-reported teaching abilities was seen comparing the mean pre-intervention scores of 106.21 (maximum score = 145, standard deviation [SD] = 12.70) with mean immediate post-intervention scores of 138.28 (SD = 6.12), the 3-month post-intervention scores of 129.79 (SD = 11.12) and the 1-year post-intervention scores of 131.86 (SD = 11.26). Several consistent themes were found among participants.

CONCLUSIONS

Faculty development for improving teaching of basic science concepts by clinicians can be performed across the cultures of the USA and the Dominican Republic.

Student learning about UK health services in a cross-border curriculum partnership; the London-Cyprus experience

This article was migrated. The article was marked as recommended. Purpose of the article Cross border partnerships require curricula, faculty and students to negotiate challenges associated with national regulatory frameworks, contexts and cultures. This study investigated student attitude and behaviours when encountering learning about health services in host and home students in the context of problem based learning. Materials and Methods First year graduate entry students' health systems interest and exposure and their perceptions of the dynamics of learning in PBL were investigated via a questionnaire comprising open and closed questions. Results and Conclusions Results showed a difference between home and host students in the ways they learned about home health systems and their attitudes to the value of learning about home and international health systems. There was no difference in the quantity of health service related learning objectives generated. Both groups reported noticing differences between the PBL cases and clinical practice, however, perceptions of the reasons for the differences varied between home and host students. We are interested in the way in which this perception of difference was reported as either a stimulus or a barrier to learning.

Cross-Cultural Interprofessional Faculty Development in Japan: Results of an Integrated Workshop for Clinical Teachers

BACKGROUND

Faculty development programs, studied both home and abroad, have been shown to be helpful for enhancing the scholarly and academic work of nonacademic clinicians. Interprofessional education and faculty development efforts have been less well studied. This project investigated the effect of a well-studied faculty development program applied in an interprofessional fashion across health profession educators in medicine and nursing.

METHODS

A faculty cohort of nurse and physician educators at The University of Tokyo underwent training in the Stanford Faculty Development Center (SFDC) model of clinical teaching through a sequence of 7 workshops. The workshops were performed in English with all materials translated into Japanese. A validated, retrospective pretest and posttest instrument was used to measure study outcomes on global assessment of teaching abilities and specific teaching behaviors (STBs) at 1 and 12 months after intervention. Successful completion of Commitment to Change statements were also assessed at 12 months.

RESULTS

In total, 19 faculty participants completed the study. All participants found the workshops valuable. For global assessment, significant improvement in self-reported teaching abilities was seen comparing the mean pretest scores of 27.26 (maximum score = 55, standard deviation [SD] = 8.61) with mean scores at both 1 month (36.81, SD = 7.48, P < 0.001) and at 1 year (34.67, SD = 7.32, P < 0.001). For STBs, significant improvement was also seen comparing the mean group pretest score of 82.11 (maximum score = 145, SD = 15.72), to the posttest mean score of 111.11 (SD = 14.48, P < 0.001) and the 1-year mean score of 103.76 (SD = 12.87, P < 0.001). In total, 27/42 Commitment to Change statements were successfully completed at 1 year.

CONCLUSIONS

Faculty development for improving clinical teaching can be performed across the cultures of medicine and nursing, as well as across the cultures of the United States and Japan.

"Location is surprisingly a lot more important than you think": a critical thematic analysis of push and pull factor messaging used on Caribbean offshore medical school websites

BACKGROUND

Offshore medical schools are for-profit, private enterprises located in the Caribbean that provide undergraduate medical education to students who must leave the region for postgraduate training and also typically to practice. This growing industry attracts many medical students from the US and Canada who wish to return home to practice medicine. After graduation, international medical graduates can encounter challenges obtaining residency placements and can face other barriers related to practice.

METHODS

We conducted a qualitative thematic analysis to discern the dominant messages found on offshore medical school websites. Dominant messages included frequent references to push and pull factors intended to encourage potential applicants to consider attending an offshore medical school. We reviewed 38 English-language Caribbean offshore medical school websites in order to extract and record content pertaining to push and pull factors.

RESULTS

We found two push and four pull factors present across most offshore medical school websites. Push factors include the: shortages of physicians in the US and Canada that require new medical trainees; and low acceptance rates at medical schools in intended students' home countries. Pull factors include the: financial benefits of attending an offshore medical school; geographic location and environment of training in the Caribbean; training quality and effectiveness; and the potential to practice medicine in one's home country.

CONCLUSIONS

This analysis contributes to our understanding of some of the factors behind students' decisions to attend an offshore medical school. Importantly, push and pull factors do not address the barriers faced by offshore medical school graduates in finding postgraduate residency placements and ultimately practicing elsewhere. It is clear from push and pull factors that these medical schools heavily focus messaging and marketing towards students from the US and Canada, which raises questions about who benefits from this offshoring practice.

Learner perception of oral and written examinations in an international medical training program

Background

There are an increasing number of training programs in emergency medicine involving different countries or cultures. Many examination types, both oral and written, have been validated as useful assessment tools around the world; but learner perception of their use in the setting of cross-cultural training programs has not been described.

Aims

The goal of this study was to evaluate learner perception of four common examination methods in an international educational curriculum in emergency medicine.

Methods

Twenty-four physicians in a cross-cultural training program were surveyed to determine learner perception of four different examination methods: structured oral case simulations, multiple-choice tests, semi-structured oral examinations, and essay tests. We also describe techniques used and barriers faced.

Results

There was a 100% response rate. Learners reported that all testing methods were useful in measuring knowledge and clinical ability and should be used for accreditation and future training programs. They rated oral examinations as significantly more useful than written in measuring clinical abilities (p < 0.01). Compared to the other three types of examinations, learners ranked oral case simulations as the most useful examination method for assessing learners’ fund of knowledge and clinical ability (p < 0.01).

Conclusions

Physician learners in a cross-cultural, international training program perceive all four written and oral examination methods as useful, but rate structured oral case simulations as the most useful method for assessing fund of knowledge and clinical ability.

Electronic supplementary material

The online version of this article (doi:10.1007/s12245-009-0147-2) contains supplementary material, which is available to authorized users.