Harden, Ronald M. MD
The beginning of the 21st century will be remembered, Friedman1 argues, not for military conflicts or political events, but for a whole new age of globalization—a “flattening” of the world. For learning organizations, globalization is both a powerful challenge and an opportunity.2 Today, almost every country has three ambitions regarding higher education.3 The first is to provide greater access—that is, to admit more students to a university. The second is to improve higher education to compete in an international market. The third is to increase equity—to offer university education to students disadvantaged because of their social, cultural, or ethnic background. All three ambitions taken together are difficult to achieve in many countries. The answer may lie in viewing education from a more global perspective.
Few would disagree that we now live in a global village and that every sector of human endeavor is being affected and altered by globalization.4 “It really boils down to this:” argued Martin Luther King, Jr5 in 1968, “that all life is interrelated. We are all caught in an inescapable network of mutuality, tied into a single garment of destiny. Whatever affects one directly, affects all indirectly.” Education is not exempt. Global communication and the internationalization of education are now integral parts of higher education. In the largest international survey of its kind, the International Association of Universities6 found in 2005 that 73% of educational institutions gave internationalization of education a high priority. Internationalization is fast becoming one of the most important and increasingly complex forces in higher education. Internationalization means, however, different things to different people and different institutions. For some, it means a flow of students and teachers and a push for international activities such as branch campuses and franchise agreements outside their national boundaries. For others, internationalization means integrating or embedding an international dimension into a curriculum and into teaching and learning.
This paper looks at internationalization of higher education, particularly medical education, from the perspectives of the student, the teacher, and the curriculum. It argues that the future, facilitated by new learning technologies and pedagogical advances, lies in a move from an interconnected international approach that emphasizes mobility of students and teachers to a transnational or global approach in which internationalization is integrated and embedded within a curriculum involving collaboration among a number of schools in different countries. The paper examines first the factors driving and facilitating internationalization.
Factors Encouraging Internationalization
Pressures for change and factors supporting internationalization of medical education come from different directions. Each on its own may be of no great significance. Together, however, they constitute a powerful force that makes inevitable a move to greater internationalization in medical education.
Globalization of health care delivery
It is now accepted that globalization affects health as well as other aspects of human activity and that this has implications for medical education. Certain features of the international health care labor market have given rise to concern, and the maldistribution of health care workers is a near-universal problem.7 Migration of physicians from developing countries has created serious shortages of medical manpower in many parts of the world,8,9 and the physician to population ratio has stagnated or declined in nearly every Sub-Saharan country since 1960. This situation raises important international issues relating to medical education.
The need for internationalization in education is increasingly in the minds of leaders in government as part of a more general global awareness. In Europe, for example, the “Bologna process” has, as an objective, the creation of a European higher education area where learning outcomes, the educational process, and accreditation are shared by the member states. The aim is to increase the international competitiveness of the European system of higher education in the world market and to promote mobility within Europe by overcoming obstacles to working and studying in different countries for the graduate labor market and for students during their studies.10 In this top-down approach, higher-education institutions are seen as instruments of government policy, not as autonomous actors. The communiqué from a conference held in Prague in May 2001 stated explicitly that “higher education is perceived as a public good and governments are the agents in society that are responsible for providing public goods.”11
Improved channels of communication
In response to a perceived need to communicate or exchange views about the many exciting developments in medical education occurring around the world, an international meeting was held in Ottawa in 1985 on the assessment of clinical competence. Jake Epp, the Minister of National Health and Welfare for Canada, defined the aspirations of the meeting: “It is my hope that this meeting will encourage the development of international standards of medical education which will lead to further improvements in health care and health care delivery around the world.”12 There followed a series of international Ottawa conferences. The eighth conference was hosted by the National Board of Medical Examiners in Philadelphia; and the 12th conference, in May 2006 in New York, attracted about 1,000 participants from 55 countries. The annual international meeting on medical education organized by the Association for Medical Education in Europe (AMEE) now attracts about 2000 participants from more than 80 countries. The third Asia Pacific Medical Education Conference in Singapore in 2006 attracted more than 400 participants from the region. These and other international conferences have provided an international forum for exchanging ideas and developments in medical education.
International medical education journals, including Academic Medicine, Advances in Health Science Education, Medical Education, Medical Teacher, and Teaching and Learning in Medicine, have contributed to the internationalization of medical education. The journal Medical Teacher, for example, has readers in 86 countries; over the past two years, contributors from more than 34 countries have published articles in the journal (List 1).
The development of a common vocabulary
Similar issues in medical education concern educators in whichever country they are teaching. In problem-based learning, for example, the presentation of the problem, the role of the tutor, the application of new learning technologies, and the implementation in the curriculum were all issues discussed last year during meetings of the International Association of Medical Science Educators in Los Angeles, the Association for American Medical Colleges in Washington, DC, and the AMEE in Amsterdam and during the Asian Pacific Problem-based Learning Conference in Tokyo. Internationalization and communication across countries have been facilitated by the use of a common medical education vocabulary or terminology and by international collaborations such as the Best Evidence Medical Education collaboration (www.bemecollaboration.org), which publishes systematic reviews on medical education topics.13 The importance of common usage of terms in medical education was recognized by the International Institute of Medical Education (IIME). This led to the development and publication of a glossary.14
A relatively new online medical education information source and glossary, “MedEd Central” (www.mededcentral.org), has been developed by AMEE in collaboration with MEDINE, the European Union (EU) medical education thematic network. Thematic networks within the EU are cooperations between departments in higher education institutions whose aim is to enhance quality and to define a European dimension within an academic discipline. MedEd Central is a collaborative-writing, Wikipedia-like initiative and encourages the sharing of a common language for medical education.
Outcome-based education and standards
The move to outcome-based education,15 with more explicit statements and greater transparency about the product of medical schools and postgraduate training programs, has been another catalyst for internationalization in medical education. In Scotland, the five medical schools published learning outcomes that have now been adopted in a number of other countries in Europe.16 The competencies and learning outcomes set out by the Royal College of Physicians and Surgeons of Canada17 and the Accreditation Council for Graduate Medical Education in the United States18 have also had a significant international impact. IIME19 has identified the “Global Minimum Education Requirements” with the express purpose of defining the minimum competencies that all physicians must have regardless of where they receive their general medical education or practice.
The World Federation for Medical Education20 has played an important role in internationalization of medical education through its development, publication, and dissemination of standards in basic medical education, postgraduate medical education, and continuing medical education. In Europe, quality assurance systems and standards have played a vital role in facilitating the comparability of qualifications. The European Credit Transfer System was introduced to encourage a greater cross-recognition. Within Europe, the acceptance of the principle of “equivalence” of higher education programs has contributed to the pressures for globalization and the move toward a European higher education space.21 However, there have been diverse national policies regarding europeanization, internationalization, and globalization of higher education, particularly in medical education; Finland is often identified as widely accepting the supernational policies, and the United Kingdom and Greece are often considered least supportive.
In medical education, the link between internationalization and outcome-based education will be further strengthened by the MedBiquitous competencies working group.22 The mission of the group is to develop standards and supporting guidelines for competency data to enable educational resources and activities to be tied to a competency framework
There has been increasing recognition of the need for health care professionals to develop skills in medical education. Provision of programs to foster these skills has been seen as one function of departments of medical education.23 Participants enrolled in such programs frequently come from diverse international backgrounds, and exchanging views on medical education practices in different parts of the world is a valuable part of their studies. Currently enrolled in the diploma and master’s degree programs in medical education delivered by the Centre for Medical Education at the University of Dundee are participants from more than 70 countries.
Faculty development programs may be targeted particularly at teachers in developing countries, with the aim of strengthening medical education and the teachers’ career advancement in their countries. The Foundation for Advancement of International Medical Education and Research24 has had a significant impact in this area over the past five years through its faculty development programs; it is hoped that these efforts will help increase production of physicians in countries where there is an undersupply.
Competitiveness and commercialization
One cannot ignore as forces in the move to internationalization the competitiveness between higher education institutions and the drive to seek new markets and additional sources of income. Indeed, the IAU6 found competitiveness to be the most important factor driving internationalization in institutions of higher education—a major shift from earlier findings. Universities have discovered international students as an alternative source of income.25 In many countries, a shift has occurred from seeing international activities as aid to perceiving them as providing commercial advantage. In Australia,26 for example, education is now recognized as the nation’s ninth largest export earner and an industry of 4.2 billion (Australian) dollars.
Views of Internationalization in Education
Internationalization in education has traditionally been seen, and still is seen by many educators, as a movement of people—students to a different country to study, and teachers to a different part of the world to teach. Such boundary-crossing mobility traditionally has been highly esteemed in Europe. Staff members and students of the medieval European universities came together from many countries, and craftsmen walked around in Europe for some years early in their careers before they eventually settled.21 This view, however, represents only a restricted vision of internationalization.
In thinking about internationalization of medical education, three variables should be considered—the student, the teacher, and the curriculum—along with the interrelationships between these variables. Different models for internationalization of medical education, based on whether the student and the teacher are local or international, are shown in Figure 1. Including the curriculum as a third dimension, although adding to the complexity, provides an understanding of the opportunities that challenge us.
The insular model where students have only local experience and are taught only by local teachers is represented in the bottom left quadrant. It is almost universally accepted that, given the factors described in the previous section, this model is no longer appropriate.
Some students choose to complete their entire basic medical training in another country, either because they value the kudos of an overseas qualification or because finding a place in a medical school in their own country is too costly or too difficult. A model of internationalization of medical education based on student mobility corresponds with the bottom right quadrant in Figure 1. The UNESCO 199721 data confirmed that students from relatively poor or developing countries tended to opt for study in a relatively rich country, hoping to gain access to a more advanced quality of higher education and possibly access to the labor market of the host country. The problem of sending students from developing to developed countries for their education, however, has been stated by Broadhead and Muula27: “Sending young students abroad immediately after their secondary education and in their formative years risks their not coming back when they qualify. This proved to be the case. By the 1980s, the joke—ironically true—was that there were more Malawian doctors practising in Manchester than in the whole of Malawi.”
This movement of students also takes place between developed countries that are more or less on equal terms. Such movement may be motivated by desire to get to know a variety of regions, cultures, educational approaches and professional practices. Both the U.S. advocacy of a “junior year abroad” and the Fulbright program, established in 1948, were based on the hope that study abroad would enhance international understanding. Education was viewed as an important means to overcome mistrust. Many research projects, however, have shown that students become neither more internationally minded nor friendlier to their host country during a short period of study abroad.21
Within Europe, the EU has facilitated, as a matter or policy, greater mobility of medical students within Europe. Doctors with degrees awarded by an EU university can practice in Britain, and medical schools in Eastern European universities provide an alternative medical education for some British students. Many U.S. citizens study medicine abroad and return to the United States to practice.28 Currently, approximately 25% of all residents and 25% of practicing physicians in the United States obtained their medical degrees outside the United States or Canada. The Educational Commission for Foreign Medical Graduates (ECFMG) has defined an international medical graduate (IMG) as “a physician who received his or her basic medical degree or qualification from a medical school located outside the United States and Canada.” Studying abroad is not only an issue in the West. In China,29 it is estimated that 160,000 private students went abroad between 1978 and 1999 and that they studied in 103 countries. China has also tried hard to attract foreign students. In 2000, the number of foreign students in China was estimated as 44,711; the students came from 164 countries, with 71% of the students from Asia, 14% from Europe, 11% from America, and 3% from Africa.
Some students study overseas not to complete a course of study and gain a degree but as a formal part of their training in an institution in their own country. Curricula now often include blocks of time when students may opt to study overseas. Such overseas electives are popular with students and have educational merit.
The International Medical University in Kuala Lumpur offers an interesting model of international collaboration. Students complete the first two and a half years of their study in Malaysia. They then transfer to one of 22 partner schools in Australasia, Europe, and North America and are awarded the medical degree of the university in the country where they satisfactory complete their training.
There are exceptional situations too when students study overseas. An example in 2005 was the transfer of some students from Louisiana State University to Germany to continue their studies, which had been interrupted by Hurricane Katrina.
One established area of international cooperation in higher education has been the attachment of a scholar or teacher for a variable period of time to an institution in a different country. The academic may have responsibilities in the host institution for teaching students as a visiting professor, in addition to pursuing research. Such attachments have been long recognized as a valuable way to bring an international dimension to a curriculum. This movement of teachers corresponds to the concept of internationalization of medical education represented in the top left quadrant of Figure 1.
In the past, the concept of the international teacher was defined in terms of spatial location; the teacher was physically present in the host institution in the overseas country. Developments in information and communication technology, however, have made possible the virtual teacher and thus the international teacher located at a distance—even in a different country from the student. The contribution of teachers, through textbooks and other learning resources, to the learning of students in other countries is not new. From 2000 onward, large numbers of textbooks written in English were imported and introduced into China,29 and in 2002, 10 of the most famous universities in China decided to buy and use almost all of the textbooks, including medical ones, used at Harvard University, Stanford University, and MIT. Now networks of academic libraries covering universities in Europe, Asia, and North America through broadband Internet access are the norm. Indeed, rankings of universities may include the size of a university’s bandwidth, with universities with low bandwidths considered unable to compete in quality with universities with large bandwidths.3
The Internet and developments in e-learning have further fostered the use by students of learning resources in one country, provided and facilitated by teachers in another country. For example, in the International Virtual Medical School (IVIMEDS),30 schools in 16 countries share learning resources. The adoption by IVIMEDS of a learning objects approach to instructional design has facilitated this collaboration. Learning objects are small chunks of learning material—such as a diagram, a clinical photograph, or a short instructional sequence—that can be combined to make up a learning program. Hodgins,31 a leading innovator in e-learning, has compared this approach to the use of the toy Lego, in that small pieces of instruction (Lego blocks) can be assembled (stacked together) into a larger instructional structure (eg, a castle) and reused in other instructional structures (eg, a spaceship). Any learning object (Lego block) is combinable with any other learning object (Lego block), and the learning objects (Lego blocks) can be assembled however users choose to create educational programs (toys) to meet their needs.
Other important elements of IVIMEDS are a virtual practice and a curriculum map. Developed in collaboration with Stephen Smith of Brown University,32 the virtual practice, with more than 60 patients covering the key areas of medical practice, can be used as a basis or a framework for a curriculum, as a source of presenting problems for problem-based learning, or as a resource for interactive exercises or case studies to illustrate principles and concepts in more traditional learning approaches. The IVIMEDS curriculum map30 provides a useful user interface which has embedded in it a view of medicine across different cultures. The map enables and integrates student learning by displaying a series of nodes that link together and visualize the course content, the learning outcomes, and the related learning objects and virtual patients. The map can be used as a framework for storing and accessing learning resources and for identifying relationships between learning outcomes and learning objects.
We have looked at two aspects of internationalization in medical education: the student and the teacher. A third dimension is the curriculum. From an international perspective, there are three approaches to curriculum development and implementation. The first approach is the use of a local curriculum, a program of studies developed by local teachers for use by local students. This is the traditional approach to which most of us are accustomed.
The second approach is a curriculum developed for an institution in one country and exported for use in a different country. In the international expansion of universities, the development of the branch campus, franchised campus, satellite campus, or joint venture campus is perhaps the most intrusive international education activity.26 In the second approach, students typically complete their course of study in whole or in part at the branch campus; some of the instruction may be provided by staff members from the “main” university. Examples in medicine include joint programs in Malaysia with Monash University and with the Royal College of Surgeons in Ireland, in Qatar with Cornell University, and in Singapore with Duke University. Australia, particularly, has seen a dramatic increase in the number of offshore campuses and twinning arrangements, from about 50 in 1996 to more than 1,000 in 2001.26 The curriculum at the branch campus usually is designed to parallel that at the “main” campus, and often for the purpose of equivalence the program is made as indistinguishable as possible from that at the main campus. In China, by 1999, more than 70 institutions of higher education granted qualifications through some kind of international education in collaboration with foreign counterparts; overall, 25 foreign counterparts—in the United States, the United Kingdom, Australia, France, the Netherlands, Norway, Thailand, and Hong Kong—were involved.29 There is a third option for curriculum development. It is the development of a truly international— better described as transnational or global—curriculum that, while considering the local students’ needs relating to the topics covered, has a strong international basis. In such a curriculum, local issues are put into international context. This approach will be described in the section “Transnational Medical Education.”
A three-dimensional model
In the three-dimensional model proposed—based on the student, the teacher, and the curriculum—a range of international-education approaches or combinations can be identified. The traditional model of education is characterized by a local teacher, a local student, and a local curriculum. The overseas student or IMG model is characterized by an international student, a local teacher, and a local curriculum. Other international combinations are possible. A transnational or global model corresponds to the upper right quadrant of Figure 1 and is characterized by an international student, an international teacher, and an international curriculum.
Transnational Medical Education
Globalization and internationalization of medical education can be seen as much more than a faster flow of teachers or students from one country to another, enabled by technologies such as aircrafts, television, satellites, and even e-learning. Transnational or global education goes well beyond spatial mobility. The future lies in extending the concept of internationalization of medical education to that of transnational medical education. In a transnational approach, medical education is disembedded from its spatial context. Although local needs are considered in educating individual students, the overall focus of the curriculum is on globally agreed learning outcomes and a range of planned international experiences, many of these virtual, with students taught by teachers from different countries. Transnational education is a move from seeing international education as simply interconnected arrangements across the territories of two or more countries to a transnational approach including closely integrated arrangements that extend beyond national boundaries.
In transnational education, medicine is exemplified in the global context rather than that of a single country or locality. The common problems facing medicine and health care professionals internationally, as well as locally, become part of the learners’ experience. The students are immersed in international medical practice and thereby derive the broader aims and goals of the curriculum. Also, the curriculum transcends the curricula of individual schools, with international aspects of medicine becoming part of the mindset of the learner rather than being taught as an additional subject in a traditional curriculum. The key differences between international and transnational medical education are summarized in List 2.
What makes all of this possible is the rapid development of the Internet and new pedagogical approaches. “Web and Internet technologies,” Horton33 has said, “are transforming our world, presenting opportunities we could only imagine a few years ago. Nowhere are these opportunities greater than in training and education.” In the text The Virtual University, Ryan and colleagues34 describe the breaking down of the distinction between traditional forms of education and distance learning and call for one or more global university systems. “There is no question,” argues Roberts,35 “that information technologies make the world smaller, overcoming boundaries of time and space, connecting communities around the globe. International efforts have much to gain from these new capabilities.” Ready access to a Web environment and its multimedia content, Le and Stein36 have argued, has already had a significant impact on medical education. They have noted that in addition to facilitating the creation and distribution of innovative educational content, the Internet creates a virtual arena for instant global communication and collaboration.
The Internet has done much to improve international communication. A move has occurred from using the Internet primarily as a medium for distributing information to using global networks as social places to bring people together and support learning.37 This new use includes providing partnerships between teachers and learners that are not defined by spatial constraints. In transnational education, exclusive links between educators and a single institution will be broken. In keeping with this model, Squires37 has described the idea of “Peripatetic Electronic Teachers,” who act as information brokers, provide virtual asynchronous tutorials for groups and individuals, teach in a virtual classroom environment, and manage or moderate discussion lists or bulletin boards.
Experience with IVIMEDS30 has demonstrated how a transnational approach may be achieved. IVIMEDS components include:
* a curriculum map that identifies common areas of global interest (for example, health inequalities, smoking and other risk factors for cardiovascular disease) but that allows staff and students to customize programs to meet their local and individual needs;
* learning resources that include presentation of topics from an international perspective (for example, patterns of cardiovascular disease in different countries and the different priorities in managing hypertension as determined by socioeconomic backgrounds);
* student-led online discussions among students from different countries, who participate as part of a collaborative learning environment in an international community of learners;
* an “ask-the-expert” facility with online access to staff from different countries (Dr. Ira Gessner from Florida, for example, acted as a tutor for students in Dundee during a recent course on the cardiovascular system); and
* use of a bank of virtual patients, with emphasis on a holistic and patient-centered approach to medical practice that includes the ethnocultural and sociopolitical analysis of problems.
Such programs not only provide a global and multicultural perspective on medicine, but also encourage a deeper understanding of a topic, including recognition of the generalizability of underlying principles.
In the article “Medical education for a changing world: moving beyond cultural competence into transnational competence,” Koehn and Swick38 advocate moving from the current emphasis in the United States on cultural competence to a specified set of transnational competencies. The authors’ vision is limited, however, to implementation in curricula in U.S. medical schools rather than in a truly international context. The approach to transnational education proposed in the present paper adds an additional valuable dimension that can aid in achieving Koehn and Swick’s aspirations of preparing physicians better equipped to reduce health disparities and to care for ethnoculturally and socially diverse patients.
At present, transnational education is underresearched, and there is no common understanding, definition, or approach.39 There has been terminological as well as conceptual confusion about the term “transnational education.” A report from Council of Europe/UNESCO40 included in transnational education “all types of higher education study programmes, or sets of study, or educational services (including those of distance education) in which the learners are located in a country different from the one where the awarding institution is based.” In the current paper, a more ambitious and more precise view of transnational education has been proposed. It involves not only an international teacher and student, but also a curriculum with an international or global vision of medicine and medical education.
A controversial aspect of moving toward a transnational/global model of medical education is that it could lead to calls for the award and recognition of joint degrees. Joint degrees resulting from cooperation among several higher education institutions located in different countries, although appearing threatening to some institutions, have considerable potential.41 The EU has already moved in this direction. The Erasmus World program42 included the development of about 90 interuniversity networks to provide 250 joint master’s courses to students around the world.
To date, international activities in medical education have been at the periphery of a medical school’s activities. For the reasons given, this situation must inevitably change. As international activities come to occupy a more central and important position on the agenda, they will increasingly affect the core educational program in an institution.
Institutions will address the international dimension of higher education in ways that reflect their values, priorities, opportunities, and revenues.6 What is no longer sustainable is to educate students in such a way that their perspectives are limited to medical practice in the context of their own country. The United States, for example, has been criticized for its educational isolation as evidenced by the findings of a National Geographic Society survey.35 Among students from eight countries surveyed, those attending American schools were the second most poorly informed about world affairs and geography. Fortunately, in medical education we see a different picture, with the ECFMG providing leadership in what can be achieved internationally.
Wherever we practice, we must ask ourselves: Are we doing enough to prepare our students to succeed in a globalized world? Are we giving them the skills necessary to practice as clinicians and doctors within the 21st-century global village in which we live? We should be wary, however, of viewing international education from a narrow viewpoint or as a form of colonialism. We require a transnational approach to medical education that goes well beyond increased spatial mobility or transfer of curricula from one school to another. The ability to benefit from transnational education while maintaining a national character is a key challenge for higher education institutions for the future.29
This paper sets out a three-dimensional model that views internationalism from the perspectives of the student, the teacher, and the curriculum. The real challenges for the future of international medical education lie in transnational education as represented by the intersection of international students, international teachers, and an international curriculum customized to local needs. I have suggested that new learning technologies and pedagogies can do much to help meet this challenge and that we can look forward to a new world where there are educational collaborations not previously imagined and where students are members of an international community sharing their learning experiences and their teachers across the world. Is this just a dream or disguised science fiction? Writing on global perspectives on e-learning, Carr-Chellman43 challenged us that
progress over the next decade is likely to be slow, probably best described as plodding. The technology’s sceptics, emboldened by the fact that, to date, e-learning’s failures have been much more prominent than its limited successes, will challenge each new product and innovation. Ultimately, however, the lure of anywhere-anytime learning will prove irresistible— educationally as well as financially.
We have the technology and the pedagogy to deliver a transnational approach to medical education today, if we choose to do so. This can be a reality, not a dream. Within the lifetimes of students now enrolled in medicine, we will see a move from students studying in one medical school to a greater emphasis on jointly recognized collaborative programs and beyond this to larger international consortia with students not based for their studies in any one fixed physical location. The result will be physicians better able to serve patients and populations in their own communities and throughout the world.