Learning in Tension: A Case Study Examining What Internal Medicine Residents Learn in the Ambulatory Care Setting.

Introduction: Medical care of patients with complex conditions has shifted to the ambulatory setting, whereas current knowledge of resident learning is primarily based on studies from inpatient settings. Preparing trainees to adapt to this shift necessitates an understanding of what internal medicine (IM) residents currently learn during ambulatory rotations. The aim of this study is to identify what residents learn during their ambulatory care experience. Methods: Using a qualitative instrumental case study design, the authors conducted separate focus groups with IM trainees (n = 15), supervisors (n = 16), and program directors (n = 5) from two IM programs in New York City, USA in 2019. Participants were invited via email, and focus group sessions were complemented by document analysis of ambulatory syllabi. Results: Based on focus group commentary and document analysis, content learned in the ambulatory setting encompassed three domains; 1) patient needs, 2) the resident's role within a healthcare team, and 3) health system opportunities and limitations. Residents also learned about tensions within and between these domains including the skills needed to care for patients versus the skills acquired, a desire for ownership of patient care versus fragmented care, and time allotted versus time required. Discussion: This study revealed two outcomes about what residents learn during their ambulatory care experience. First, learning content largely fell into three domains. Second, residents learned about the tensions between ideal care delivery and the realities of practice. These results highlight the imperative to better align curricula with clinical environments to meet the learning needs of residents.

Early career experiences of international medical program graduates: An international, longitudinal, mixed-methods study.

INTRODUCTION: Increasingly medical students pursue medical education abroad. Graduates from International Medical Programs (IMPs) practice globally, yet how to prepare students for an unknown international environment is complex. Following IMP graduates throughout their early careers, this study offers insights into gaps in current undergraduate education. METHODS: In this international, longitudinal, mixed-methods study, 188 graduates from seven IMPs completed baseline surveys on career choice and job preparedness. Forty-two participants completed follow-up until three years after graduation. Nine graduates participated in semi-structured interviews on individual experiences and the evolution of their perspectives. The multiphase, sequential design allowed data collected at baseline to inform further data collection instruments. RESULTS: Two typical student profiles emerged. The first depicts a student who, despite the challenges of studying abroad, pursues a medical degree 'anyhow', with a common aim of practicing in their home country. The other deliberately selects an IMP while envisaging an international career. Two years after graduation, the majority (> 70%) of our participants were practicing in a country other than their country of training. They reported challenges around licensing, the job application process and health system familiarization. Participants' experiences point towards potential curriculum adaptations to facilitate cross-border transitions, including career guidance, networking and entrance exam preparation. DISCUSSION: IMP graduates lack support in practical aspects of career orientation and international exposure. Most IMPs essentially prepare their graduates for a career elsewhere. Gaps and challenges that IMP graduates experience in this cross-border career transition entail a responsibility for preparation and guidance that is currently lacking in IMP curricula.

The 'exotic other' in medical curricula: Rethinking cultural diversity in course manuals.

Introduction: Implementation of cultural diversity training in medical education faces challenges, including ambiguity about the interpretation of 'cultural diversity'. This is worrisome as research has demonstrated that the interpretation employed matters greatly to practices and people concerned. This study therefore explored the construction of cultural diversity in medical curricula.Methods: Using a constructivist approach we performed a content analysis of course materials of three purposefully selected undergraduate curricula in the Netherlands. Via open coding we looked for text references that identified differences labelled in terms of culture. Iteratively, we developed themes from the text fragments.Results: We identified four mechanisms, showing together that culture is unconsciously constructed as something or someone exotic, deviant from the standard Dutch or Western patient or disease, and therefore problematic.Conclusions: We complemented earlier identified mechanisms of othering and stereotyping by showing how these mechanisms are embedded in educational materials themselves and reinforce each other. We argue that the embedded notion of 'problematic stranger' can lead to a lack of tools for taking appropriate medical action and to insecurity among doctors. This study suggests that integrating more attention to biological and contextual differences in the entire medical curriculum and leaving out static references such as ethnicity and nationality, can enhance quality of medical training and care.

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

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

Crossborder curriculum partnerships: medical students' experiences on critical aspects.

BACKGROUND: The past decade has witnessed an upsurge in medical curriculum partnerships established across national boundaries to offer students at the foreign institution (host) a learning experience comparable to that of students at the exporting institution (home). However, since the learning environments and national healthcare contexts differ greatly between institutions, concerns have been raised in the literature about potential low quality of curriculum delivery, inadequate preparation of students to practice in the host country healthcare setting, and a culture shock for host students having to study a home curriculum.. The experiences and opinions of medical students related to these concerns have not been investigated. This study takes an explorative approach on key challenges faced by host institution students. METHOD: Three hundred sixty-one host students recruited from 3 partnerships completed a survey about their motives, transition from high school, language, preparedness for practice, future career planning, and general satisfaction. Descriptive statistics of closed-ended items and thematic analysis of open-ended items were performed. RESULTS: Findings revealed that students generally held positive views of the education they received. Switching to a new language of instruction (English) and learning environment was not perceived as a major obstacle. However, a significant portion of students who as non-nationals did not speak the language of the patient population felt this complicated effective workplace-based learning. CONCLUSION: Despite differences in learning experiences, host students felt the partnership afforded opportunities to acquire unique academic competencies and boost their career. Further adaptation of the home curriculum to the host country healthcare system may be beneficial, without losing sight of medical curriculum partnerships' potential to offer graduates an international outlook on global healthcare.

Twelve tips for crossborder curriculum partnerships in medical education.

Crossborder curriculum partnerships are a relatively new and fast-growing form of internationalization in which the curriculum that has been developed by one institution (the home institution) crosses borders and is implemented in another institution (the host institution). These partnerships aim to provide comparable learning experiences to the students in both institutions and are driven by a variety of motives, such as strengthening international networks, increasing financial gains, and stimulating research spinoffs. Although popular, crossborder curriculum partnerships are also criticized for their potentially low educational quality, failing to address fundamental differences in teaching and learning between the home and host institutions, and not addressing the educational needs of the host country's health care system. Our aim is to provide guidance to those considering or engaged in designing, developing, managing, and reviewing a crossborder curriculum partnership or other forms of international educational partnerships in medical education. Drawing from research, personal, and institutional experiences in this area, we listed twelve tips categorized into four themes, which contribute to the establishment of sustainable partnerships that can withstand the aforementioned criticism.

Connected, attracted, and concerned: A Q study on medical crossborder curriculum partnerships.

INTRODUCTION: A new form of internationalization has been trending upward in the medical education realm: crossborder medical curriculum partnerships established to deliver the same, or adapted, curriculum to groups of geographically separated students. This study aims to investigate crossborder medical curriculum partnerships by exploring the experiences of teachers at the recipient institution who have a key role in delivering the program. METHODS: From four pioneering recipient medical schools, 24 teachers participated in a Q-sort study. Each participant rank-ordered 42 statements about teaching in a crossborder medical curriculum on a scale from -5 (indicating strong disagreement) to +5 (indicating strong agreement). The authors conducted a "by-person" factor analysis to uncover distinct patterns in the ranking of statements, using the statistical results and participants' comments about their Q sorts to interpret these patterns and translate them into distinct viewpoints. RESULTS: Three viewpoints emerged, reflecting: (1) a feeling of connectedness with the partner institution, trust in the quality of the curriculum, and appreciation of interinstitutional relationships; (2) the partnership's attractiveness because of the career opportunities it offers; and (3) concerns over the quality of graduates because of doubts about the appropriateness of the didactic model and insufficient attention to local healthcare needs, and over the practical feasibility of such partnerships. CONCLUSIONS: The three viewpoints identified revealed a pallet of views on how host teachers might experience their work. It shows the heterogeneous features of this group and seems to counterbalance reports that they are feeling "deprived" from their role as teacher. Two viewpoints featured an appreciation of interinstitutional relationships and of the partnership, especially when perceiving a degree of autonomy. Partners can capitalize on all different viewpoints by deploying procedure and policies to raise the quality of education delivery.

How innovative and conventional curricula prepare medical students for practice in Sub-Saharan Africa: A comparative study from Mozambique.

BACKGROUND: Medical education in Sub-Saharan Africa is in need of reform to promote the number and quality of physicians trained. Curriculum change and innovation in this region, however, face a challenging context that may affect curriculum outcomes. Research on outcomes of curriculum innovation in Sub-Saharan Africa is scarce. We investigated curriculum outcomes in a Sub-Saharan African context by comparing students' perceived preparedness for practice within three curricula in Mozambique: a conventional curriculum and two innovative curricula. Both innovative curricula used problem-based learning and community-based education. METHODS: We conducted a comparative mixed methods study. We adapted a validated questionnaire on perceived professional competencies and administered it to 5th year students of the three curricula (n = 140). We conducted semi-structured interviews with 5th year students from these curricula (n = 12). Additional contextual information was collected. Statistical and thematic analyses were conducted. RESULTS: Perceived preparedness for practice of students from the conventional curriculum was significantly lower than for students from one innovative curriculum, but significantly higher than for students from the other innovative curriculum. Major human and material resource issues and disorganization impeded the latter's sense of preparedness. Both innovative curricula, however, stimulated a more holistic approach among students toward patients, as well an inquiring and independent attitude, which is valuable preparation for Sub-Saharan African healthcare. DISCUSSION: In Sub-Saharan Africa, risks and benefits of curriculum innovation are high. Positive outcomes add value to local healthcare in terms of doctors' meaningful preparedness for practice, but instead outcomes can be negative due to the implementation challenges sometimes found in Sub-Saharan African contexts. Before embarking on innovative curriculum reform, medical schools need to assess their capability and motivation for innovation.

An exploration of crossborder medical curriculum partnerships: Balancing curriculum equivalence and local adaptation.

CONTEXT: Worldwide, medical schools have entered into crossborder curriculum partnerships (CCPs) to provide equivalent curricula and learning experiences to groups of geographically separated students. Paradoxically, this process also involves adaptation of curricula to suit local contexts. This study has focused on challenges faced by medical Crossborder curriculum programme directors and strategies they employed to overcome these. METHODS: We conducted a qualitative study on six CCPs using document analysis and semi-structured interviews with 13 programme directors from 12 medical schools. Interview transcripts were coded iteratively, followed by cross-case analysis. RESULTS: The challenges faced by CCP programme directors are four-fold, springing from differences in health care systems, legislation and political interference, teaching and learning environments, and partnership. Deliberate strategies, such as intensifying interactions between partners in all academic echelons, can help to overcome these. Partnerships vary in their setup and collaboration strategy. CONCLUSION: Medical CCPs are challenging though seem feasible. Partnerships with more solid integration of academic operations appear robust in terms of ownership and provide, besides financial, also academic advantages to both institutions. However, more research is needed on the long-term effects on quality of graduates and impact on the host health care system.

Students' and junior doctors' preparedness for the reality of practice in sub-Saharan Africa.

BACKGROUND: Evidence tailored to sub-Saharan Africa on outcomes of innovations in medical education is needed to encourage and advance their implementation in this region. AIM: To investigate preparedness for practice of students and graduates from an innovative and a conventional medical curriculum in a sub-Saharan African context. METHODS: Using mixed methods we compared junior doctors and fifth-year students from two Mozambican medical schools: one with an innovative problem- and community-based curriculum and one with a conventional lecture- and discipline-based curriculum. A questionnaire on professional competencies was administered, semi-structured interviews were conducted, and work diaries were collected. The findings were integrated in a conceptual model. RESULTS: Six areas of tension between global health care ideals and local health care practice emerged from the data that challenged doctors' motivation and preparedness for practice. Four elements of the innovative curriculum equipped students and graduates with skills, attitudes and competencies to better cope with these tensions. Students and graduates from the innovative curriculum rated significantly higher levels on various competencies and expressed more satisfaction with the curriculum and its usefulness for their work. CONCLUSION: An innovative problem- and community-based curriculum can improve sub-Saharan African doctors' motivation and preparedness to tackle the challenges of health care practice in this region.

Using activity theory to study cultural complexity in medical education.

There is a growing need for research on culture, cultural differences and cultural effects of globalization in medical education, but these are complex phenomena to investigate. Socio-cultural activity theory seems a useful framework to study cultural complexity, because it matches current views on culture as a dynamic process situated in a social context, and has been valued in diverse fields for yielding rich understandings of complex issues and key factors involved. This paper explains how activity theory can be used in (cross-)cultural medical education research. We discuss activity theory's theoretical background and principles, and we show how these can be applied to the cultural research practice by discussing the steps involved in a cross-cultural study that we conducted, from formulating research questions to drawing conclusions. We describe how the activity system, the unit of analysis in activity theory, can serve as an organizing principle to grasp cultural complexity. We end with reflections on the theoretical and practical use of activity theory for cultural research and note that it is not a shortcut to capture cultural complexity: it is a challenge for researchers to determine the boundaries of their study and to analyze and interpret the dynamics of the activity system.

Rethinking the globalisation of problem-based learning: how culture challenges self-directed learning.

CONTEXT: Medical schools worldwide are increasingly switching to student-centred methods such as problem-based learning (PBL) to foster lifelong self-directed learning (SDL). The cross-cultural applicability of these methods has been questioned because of their Western origins and because education contexts and learning approaches differ across cultures. OBJECTIVES: This study evaluated PBL's cross-cultural applicability by investigating how it is applied in three medical schools in regions with different cultures in, respectively, East Asia, the Middle East and Western Europe. Specifically, it investigated how students' cultural backgrounds impact on SDL in PBL and how this impact affects students. METHODS: A qualitative, cross-cultural, comparative case study was conducted in three medical schools. Data were collected through 88 semi-structured, in-depth interviews with Year 1 and 3 students, tutors and key persons involved in PBL, 32 observations of Year 1 and 3 PBL tutorials, document analysis, and contextual information. The data were thematically analysed using the template analysis method. Comparisons were made among the three medical schools and between Year 1 and 3 students across and within the schools. RESULTS: The cultural factors of uncertainty and tradition posed a challenge to Middle Eastern students' SDL. Hierarchy posed a challenge to Asian students and achievement impacted on both sets of non-Western students. These factors were less applicable to European students, although the latter did experience some challenges. Several contextual factors inhibited or enhanced SDL across the cases. As students grew used to PBL, SDL skills increased across the cases, albeit to different degrees. CONCLUSIONS: Although cultural factors can pose a challenge to the application of PBL in non-Western settings, it appears that PBL can be applied in different cultural contexts. However, its globalisation does not postulate uniform processes and outcomes, and culturally sensitive alternatives might be developed.